By Tim Dang

[box]Complex Problems, Complex Solutions[/box]

On May 14, 2008, seventeen-year-old farm worker María Jiménez passed out from heat exhaustion in a Californian grape field. Her supervisors initially refused to take her to a hospital, and when they finally did, she was already comatose.¹ María passed away two days later, after her fiancé discovered that she was two months pregnant. Unfortunately, tragedies like these are not unique cases. Such preventable loss of life speaks to the failures of the health care system to address the needs of the immigrant population. Who is to blame? Was it the fault of greedy farm owners who feared governmental scrutiny? Was it the fault of María, who willingly faced risks by crossing the border? Actually, these are not the questions we should be asking. This kind of polarizing rhetoric oversimplifies the complexity of health care and immigration, fostering a hostile climate that discourages meaningful discourse.

The debate on these two issues must adopt a more holistic approach before it can possibly result in an agreement. This approach necessitates a shift from the current focus of citizenship status to the more pressing issue of health status. Medical needs of millions of undocumented immigrants are not met by the current system. Regardless of political attitudes on immigration, these are human tragedies that we cannot ignore. However, discussion must also acknowledge the distinction between different barriers to health services. Having access to care is to meet the qualifications to be able to receive it. Utilization is the actual decision to make use of care. Thus, access is like holding the key to a locked door, but utilization is the decision to walk through it.

This paper aims to inform political discourse to pave the way for comprehensive conversations on health care and immigration as a joint discussion. We must avoid analyzing either of these topics in a vacuum. By addressing the nature of the United States health care system and health crises of the immigrant population, it will become clear why the debate must prioritize health over citizenship. Once the primary importance of health status is evident, the differences between barriers to access and barriers to utilization of services will become more evident, demonstrating that health solutions in the immigrant community must emphasize use of care.

[box]Immigrants and Our Current Health Care System[/box]

Congressman John Carter of Texas commented that “working Americans […] earn their healthcare” and decried provision of “free healthcare to illegal aliens,”2 but these statements fail to acknowledge the mechanisms of the health care system that make “earning” access extremely difficult. Although many people have a basic understanding of how the system works, discussion on this topic has become very polarized and will benefit from clearer information and informed arguments. To have meaningful discourse, we must understand how the health care system works.

At the root of all health care systems is a method for connecting the patient population with health care providers. In the United States, private insurance companies largely play the role of the middleman. Most people with private insurance receive it through their employer, though some buy their own directly.3 Government insurance plans add an extra layer of complexity to the health care matchmaking game, particularly through programs like Medicaid, the joint federal-state plan for lower-income populations. All of these intermediaries collect funds from the population and pool them together to pay for medical costs. Essentially, sufficiently large groups can pool together their risks and money to replace the chance of a “difficult-to-predict, possibly large cost with a certain, known, lower cost.”3

However, costs for the undocumented immigrant population are still high because they cannot acquire insurance, making it impossible for them to “earn” health care benefits. The United States is an outlier among developed nations in that the role of government in health care is much smaller than the private sector’s role, resulting in a system that relies heavily on the socioeconomic status of patients. We have created a system where health relies on wealth. Even when the health care system can rely on government funding, patients must still meet some basic prerequisites. One of these requirements is legal residence, which creates the health care crisis for the undocumented population.  These immigrants cannot readily receive government or employment insurance without legal status, nor can they afford private insurance with the low wage-rates characteristic of illegal employment. Consequentially, undocumented immigrants face greater medical problems and issues with receiving treatment.

[box]Health Crises in the Immigrant Population[/box]

Mexican immigrants face greater health risks and complications compared to other ethnic groups,4 and these disparities illustrate the failure of the health care system to prioritize the well-being of this country’s residents.  Mexicans in the US have twice the risk of developing diabetes compared to non-Hispanic whites, and the incidence of diabetes in Hispanic children born after 2002 is roughly one out of three.5 One factor influencing these statistics is the lack of preventive care provided to the undocumented population, such as nutritional education and early detection. A 2006 study reported that high blood pressure, a preventable risk factor for cardiovascular disease, accounts for nearly eight million preventable deaths worldwide each year.6 These deaths are also associated with other morbidities like non-fatal heart attacks, which present a financial stress on the health care system that earlier preventive care could have reduced.

One cause of this financial stress is the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), which stipulates that hospitals must provide “examination or treatment for an emergency medical condition […] regardless of an individual’s ability to pay.”7 To the benefit of undocumented immigrants, these conditions do not make a distinction based on legal status, but EMTALA does not allow for preventive care. Thus, the undocumented instead must rely on corrective care administered after the development of a disease. For individuals with diabetes, this could entail waiting for devastating conditions like kidney failure instead of addressing the problem early on. These types of policies are shortsighted in creating a sustainable health care system for the general population and affect the undocumented population disproportionately.

[box]Access versus Utilization[/box]

Several studies argue that factors leading to poor access to health care include income, insurance status, English proficiency, and cultural values, but a distinction must be made between access and utilization. Income and insurance status are major barriers to access, but low-paying jobs have other effects that prevent undocumented workers from receiving health care. They often fail to provide sick-time hours “to see a provider or to recuperate from an illness.”4 Furthermore, the transient nature of jobs and lack of stable health plans affect rates of having a usual source of care. One-third of undocumented immigrants reported lack of access to regular health providers while over 90% of US-born whites report having such access.8 The undocumented population also has about half of the mean number of physician visits per year compared to US-born whites. To what extent can we attribute this differential use of care to barriers of access and to what extent do differences in utilization play a role? To investigate this question, we must consider immigrant use of accessible care and barriers like language differences that affect the decision to walk through the hospital door.

[box]Barriers to Utilization of Care[/box]

Undocumented immigrants do not often utilize currently accessible health care due to unwillingness and cultural differences, and these factors are distinct from barriers to access. Fear has historically played a role in discouraging use of services.  In 1994, California voters passed Proposition 187, which stipulated that public employees must “verify the legal residency of an individual before providing services.”9 Though the proposition “was not being enforced” and federal courts struck down the law five years later, Spetz et al. determined that Proposition 187 had lasting effects on deterring undocumented immigrants from using available services. Some may have been unaware that the law was not enforced, feared its enforcement and subsequent deportation, or may have avoided health care “because of fear of reprisals [or] poor treatment.”9 Specifically, Spetz et al. reported that prenatal care use declined, despite the fact that California’s Medicaid program covers it. Unfortunately, other investigations have shown that farm workers often do not wish to seek medical attention because of job security concerns. 10 Finding and using health care services would force them to take time off work, and employers could easily replace their labor. Undocumented immigrants have reduced their participation in programs that they are eligible for because of a hostile climate discouraging their use of public programs.

Language and culture play major roles in facilitating the connection between health care providers and patients, and communication barriers have further discouraged use of care. Mexicans with limited English proficiency may be uncomfortable navigating the health care system, and this health illiteracy prevents effective communication. Existing laws mandate health care providers to provide verbal and written information in Spanish,11 but in practice, medically underserved areas have insufficient numbers of bilingual physicians.12 Cultural beliefs can also influence immunization rates, alcohol intake, and nutritional habits.4 Failure to understand and work with patients’ cultural backgrounds may prevent the development of strong relationships with health care providers. The variety of barriers to utilization indicates that we will not necessarily alleviate health disparities of undocumented immigrants by increasing access to care. Accordingly, political discourse on these complex topics must change.

[box]Reforming the Rhetoric[/box]

In contrast to the alienating rhetoric surrounding immigration issues, it is imperative that political discourse recognizes the human tragedy that the current health care system causes and acknowledges that solutions to these problems lie primarily in the realm of health policy. Undocumented immigrants may be voteless, but they are neither faceless nor nameless. Workers like María Isabel enter our country to labor for wages that US citizens would not accept, are treated in ways that US citizens would not stand for, and utilize eligible health resources far less than their US-born counterparts. Nevertheless, public concern about immigrant overuse of health care continues, despite evidence to the contrary.

One change that could relieve stresses on the health care system involves increasing emphasis on preventive care. Notably, this shift is not specific to undocumented immigrants. Anyone who receives emergency care for a previously treatable, unchecked condition requires costly treatments. We can avoid these costs by encouraging preventive care, which has the additional benefit of being much less invasive than corrective care. Interestingly, expanding programs like EMTALA to cover preventive care measures is actually in the interest of those who claim that undocumented immigrants present a financial burden. A short-term increase in funding could potentially save much more in long-term costs.

[box]Solutions and Limitations[/box]

Solutions to health problems in the immigrant community must circumvent barriers to access or target barriers to utilization. Community Health Centers (CHCs) that can receive federal and state funding are viable alternatives to emergency departments. One study on health disparities noted that low-income populations may actually find that these centers are “more affordable than a private physician.”4 For example, CHCs can alleviate barriers to prescription drug access by partnering with pharmaceutical companies, which have patient assistance programs that reduce costs of medications. Unfortunately, CHCs are not nearly as common as hospitals and private practices, but their current success provides a model that others can follow.

Promoting bilingualism of both patients and providers can also help build a foundation for cultural competency and medical literacy. Interpreters contribute a valuable service in bridging the communication gap between physicians and patients, but direct delivery of health information is necessary for developing a professional rapport that encourages immigrants to regularly see a physician. The Santa Clara Children’s Health Initiative in 2001 used direct, multilingual communication with parents and expanded coverage to 14,000 kids by Medicaid, demonstrating the results that community-based organizations can yield.13

These methods largely work within the established framework created by current immigration and health care policy but are limited by the extent of existing resources. If all undocumented immigrants readily utilized services that they are eligible for, the current health care system could be overwhelmed. In this sense, the undocumented population actually could present a large financial burden to the government. However, political arguments must come from an informed and researched background to maintain productive discussion. Arguments against increasing health care access for undocumented immigrants do not have substantial evidence to back up the claim that this would take away health care from naturally-born US citizens. Due to differences between barriers to access and utilization, increased access may not actually encourage use of services. This would neither improve health outcomes for the undocumented nor present a financial burden to health providers. The medical needs of millions of undocumented immigrants present a challenge to politicians and advocates. The 2010 Patient Protection and Affordable Care Act, one of the central pieces of legislation in Obama’s health care reforms, has largely sidestepped the issue of undocumented immigrants despite claims that it will expand coverage to them.  President Obama called these claims a “myth” and stated, “That idea has not even been on the table.”14 To develop solutions, it should be. Only by maintaining a holistic perspective on immigration and how it interacts with health care can we hope to develop sustainable solutions in the future.