Inclusion, Not Exclusion: Expanding Healthcare Access to Undocumented Immigrants in California

BY JADE HARVEY

With 2.55 out of the nation’s 11.2 million undocumented immigrants living in California, the Golden State is host to the nation’s largest percentage of undocumented immigrants in the country. While undocumented immigrants make up approximately 6.8 percent of the state’s residents, they also represent an overwhelming 24 percent of the uninsured population.¹ As debates in immigration and healthcare continue to lead current political discourse, the connection between the two topics is commonly either overlooked or misunderstood. Despite the fact that undocumented immigrants hold high employment rates—typically working more hours than the average documented non-immigrant to sustain vital industries such as farming, construction and maintenance—undocumented workers often find themselves between a rock and a hard place, not guaranteed employment-based health coverage, but also unable to afford private insurance. As of now, the Affordable Care Act (ACA) excludes undocumented immigrants from the expanded federal Medicaid coverage. Furthermore, although this measure would bear no additional cost to the government, the ACA also does not allow for undocumented immigrants to purchase insurance through the Marketplaces, even without subsidies, despite the clear financial and social consequences of denying coverage. California legislature should expand undocumented immigrants’ access to primary and preventive care to cut rates of avoidable acute care expenditures in the long term, improve the standard of life for residents contributing tirelessly to the state’s economy, and provide a more sustainable model of healthcare for the greater population.

Conservative political ideology often blames undocumented immigrants for high healthcare costs, claiming that undocumented residents over-consume healthcare, specifically in the form of emergency department and hospital services, leaving documented citizens to pick up the check. Additional conservative channels claim that undocumented immigrants travel to the United States specifically to receive free health care. Such myths could not be more false. In the current hostile political climate that seeks to capitalize on xenophobic fears to win conservative votes, vulnerable populations like undocumented immigrants tend to become victim to hateful propaganda and racially-driven, pseudo-economic policy backed by few facts.

Research shows that “most undocumented immigration occurs because of the search for higher wages by unskilled workers or for family reunification”—not because of the search for healthcare.¹ Furthermore, immigrants in the United States typically, to the detriment of their own health, under-consume services and face a variety of unique difficulties when trying to obtain healthcare services from an already limited pool of options. One study finds that undocumented immigrants in California, both insured and uninsured, have “lower rates of hospitalization for non-childbirth-related reasons, fewer visits to physicians, lower likelihood of receiving blood pressure and cholesterol checks, and lower overall healthcare expenditures compared to US citizens and other immigrant groups.” ¹ This goes to show that conservative accusations of undocumented immigrants abusing healthcare services are simply unfounded. Further, this study affirms that “undocumented immigrants have lower health care spending, estimated in one study at $15.4 billion in annual average spending compared to $1 trillion for US-born individuals.”¹ Thus, the rumor that undocumented immigrants have high healthcare costs proves to be false.

Evidence of undocumented residents’ limited use of healthcare services can also be seen in the contrast of access between undocumented versus documented immigrants. According to a Journal of Immigrant and Minority Health study, undocumented immigrants from Mexico are “27% less likely to have a doctor visit in the previous year” and “35% less likely to have a usual source of care compared to documented Mexican immigrants.”² Considering that undocumented immigrants from Mexico represent 57 percent of the majority of all undocumented immigrants in the United States, these findings have a significant application to the overall study of the disparity in healthcare access even between documented and undocumented immigrants.² Though understanding the current underconsumption of medical resources by undocumented immigrants is necessary to debunk myths on immigration and healthcare, the fact that so many undocumented, working residents in California receive little to no healthcare services is surely not a topic to applaud. Despite lower healthcare expenditures, undocumented immigrants are in no way less prone to illness or less in need of medical attention than the rest of the population, but instead face significant, sometimes prohibiting barriers to accessing care when needed.

When it comes to public coverage options for undocumented adults that do choose to seek out medical attention, Medicaid funds are limited to strictly emergency, condition-specific situations. For an undocumented adult to receive Medicaid coverage in California, the law requires an “emergency medical condition,” which must be “severe, acute, and life-threatening or lead to disability.”¹ Under current law, Medicaid is restricted to low-income, documented residents within targeted high-need groups as well as all adults less than 65 years old with incomes up to 138% of the Federal Poverty Level.³ In one study, researchers found that undocumented workers’ households are around “half as likely to use Medicaid as documented households.”⁴ In other words, the only public healthcare coverage option available to undocumented adults, i.e. emergency Medicaid, is also drastically underused. There are many factors that contribute to this stark underuse of healthcare services by undocumented immigrants, ranging from demographic factors, to English proficiency, to the number of years lived in the United States—all of which affect the health maintenance and well-being of community members.

Due to the high cost of healthcare services for uninsured individuals in the United States and the limited service options for undocumented residents, poverty significantly affects access to care for immigrants. California Latino DREAMers—young undocumented immigrants who, through qualification for the Deferred Action for Childhood Arrivals (DACA), program are eligible for temporary legal status, but excluded from the Affordable Care Act’s Medicaid expansion and Health Care Exchanges—cite cost as a significant barrier to care access.⁵ When already faced with the tremendous challenges of making a life in a new country as a low-wage worker without English proficiency or financial support, young undocumented youth struggle to pay for daily necessities, let alone high fees for uninsured doctor visits. In the case of DREAMers, having insurance did not always eliminate the cost burden of seeking care. One youth explains, “I had insurance from my dad growing up. But, even then, you still had to pay five bucks… I tried avoiding going to the doctor or getting medicine because it’s so expensive.”⁵ Whereas lack of insurance can also be an obvious barrier for many undocumented immigrants, poverty’s impact on access to care is also significant.

The time it takes for undocumented immigrants to seek medical help also factors into care costs. In a 2013 case study on undocumented women, many participants reported high wait times as a deterrent from accessing health services.⁶ When individuals and families are struggling to make ends meet, there sometimes simply is not enough time to wait at overcrowded community clinics. Many safety-net healthcare systems are overburdened with patients seeing as for many uninsured, undocumented families, they are one of the only sources of help. Many low-wage, undocumented, working families do not have the leeway to take work off and see a doctor, thus not only the price of healthcare services, but also the opportunity-cost remains too high for many.

Along with financial difficulty, other factors such as immigration status, language, lack of familiarity with the healthcare system, and mistrust of providers due to fear of discrimination and deportation also prove to be critical barriers to care access for many immigrants. In a study titled “Fear of Discovery Among Latino Immigrants Presenting to the Emergency Department,” researchers show that one in eight of undocumented Latino immigrants seeking care in Emergency Departments in California express fear of discovery and consequent deportation.⁷ This fear comes in part from existing discrimination by medical providers—a widely expressed sentiment throughout many studies. One study shows that among the state’s uninsured, immigrants have higher odds of perceiving discrimination than non-immigrant populations and tend to postpone emergency room trips at higher rates.⁸ The “DREAMers” study quotes a youth on discrimination: “I think it’s related to like how we’re brown, and we’re undocumented, and we’re low income … They’re going to treat you differently.”⁵ The discussion continues: “because the majority of DACA-eligible young adults lack a regular provider, they have few opportunities to develop trusting relationships that might increase their comfort level.” ⁵ In addition to the commonly overlooked factor of lacking the comfort and support of a regular doctor, undocumented immigrants’ fears of discrimination may additionally stem from the current hostile, anti-immigration political climate, the country’s history of xenophobia and racism or lingering fear from previous anti-immigrant legislation, such as the notorious Proposition 187 that sought to restrict undocumented residents’ access to resources.

In 1994, California passed the controversial Proposition 187, which aimed to discourage undocumented immigration into California by denying education, health, and social services to people without legal immigrant status. The Proposition passed, but ultimately was never implemented; nevertheless, it still had notable effects on the undocumented immigrant population in the state. Community health care providers in California at the time “reported declines in visits from [undocumented Latino immigrants], despite the proposition never having taken effect.”⁷ Lasting fear and misunderstanding of the state’s current non-reporting practices discourages many undocumented immigrants from seeking care. This lack of familiarity with the current functioning of healthcare options for undocumented immigrants spreads beyond fear of being deported, but also includes a general health care illiteracy amongst many non-English speaking immigrants.

All of the aforementioned limited health opportunities for undocumented immigrants do not go without repercussions. Due to the fact that healthcare access is not a statistically significant factor for immigration to the United States, “including undocumented immigrants in the exchanges without subsidies is likely to have little effect on the size of the undocumented population, but denial of coverage may have important financial and social consequences.”¹ Financially, since California does not provide ample options for primary or preventative care for undocumented immigrants, the state ends up having to deal with sicker, more-expensive-to-treat patients. When it comes to public health, studies show that appropriate preventative care saves money. One study found that “if 90 percent of the population had access to tobacco cessation services, alcohol abuse screening, daily aspirin intake… and colorectal cancer screening, each of those four interventions alone would result in more than 100,000 years of life saved… if preventive care had been widely delivered in prior years, all without an increase in net cost.”⁹ Underutilization of medical services is associated with “poorer health outcomes such as longer stays in hospitals, more acute health crises, and higher mortality rates.”¹ When undocumented immigrants exhaust all options to avoid the perceived risks of seeking help in emergency departments, by the time that families do chose to seek help, individuals’ conditions tend to be more severe and costly. Increasing primary care options can reduce emergency department and acute-care costs while reducing the burden on safety-net providers.

The social consequences to inadequate access to health services vary with certain undocumented immigrant demographic groups. Among working poor families, “immigrant children experience increased poverty and uninsurance and decreased access to care which may jeopardize their health and future productivity.”⁸ The American Academy of Pediatrics recommends a minimum of one annual physician visit for children. The lack of check-ups and continuity of care puts immigrant children at increased risk for missing vital preventive care opportunities, which is especially concerning given the increased health risks of living in poverty.⁸ In addition to dealing with the trauma and stress of their immigration, coming of age in a foreign country as an undocumented immigrant often results in significant mental health concerns that go largely unmet.⁵ Some pregnant women may receive government-sponsored insurance since care is often provided “to ensure the health of future U.S. citizen babies,” but even this conditional support raises the question of whether it is morally permissible to only support the health of an undocumented woman if she is raising a “future citizen” and calls into question why the health of an unborn American citizen in the womb is more worthy of protection than a working woman contributing to American society on her own.¹⁰ Seeing as increasing access to preventative services can improve the health of undocumented immigrant populations with little to no cost and failing to do so has serious social consequences, the points against expanding healthcare access pale in comparison to pro-expansion arguments.

The process of extending healthcare access to more undocumented immigrants could manifest in the form of both insurance and noninsurance solutions. One insurance solution could be to allow undocumented immigrants to find healthcare without subsidies in the new Marketplaces. Though less financially feasible, expanding Medicaid to allow for the inclusion of necessary preventive care beyond just emergency services for undocumented immigrants would also have tremendous positive effects. Non-insurance solutions include increasing language and culturally-competent staff, developing mutual-aid organizations, employing undocumented immigrant health promoters and mandating signage in public hospitals that reminds undocumented immigrants of California hospitals’ non-reporting policies to diminish fear of seeking help when needed. One study brightly suggests that “non-employer-based options for coverage could be sponsored or negotiated through unions, farm bureaus, churches or other immigrant organizations.”⁸ Politically, California can work to strengthen the enforcement of labor laws to improve conditions, raise wages and provide incentives for employers that use undocumented labor to provide workers with health insurance. These solutions, among many more, would have measurable success in improving community health standards while also decreasing acute healthcare costs.

Despite the proliferation of misinformation on the high costs of undocumented immigrants in the healthcare system, researchers continue to publish study after study dismantling such detrimental myths in favor of expanding access to health services in California. In all, there are a diversity of cost-effective options in addressing the issue of limited healthcare access for undocumented immigrants in California that will not only benefit marginalized communities, but also subsequently raise the health and well-being of the state as a whole. Although certain right-wing politicians continue to make inflammatory cries on the supposed burden that undocumented immigrants place on the national economy, the facts backing these hateful statements are simply not there. Instead of pushing policies to deny undocumented residents crucial services, the American public should recognize the value in investing in human capital and protecting the health of all residents. In a state whose economy and general function relies so much on the tireless work of undocumented immigrants in many low-wage industries, policy makers have a responsibility to recognize the legitimacy of undocumented immigrant health concerns to create a more healthy, productive and equal working population in a more economically-sensible healthcare model.

Jade Harvey is a senior in Ezra Stiles College majoring in Ethnicity, Race & Migration. She can be contacted at jade.harvey@yale.edu.

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References:

1. Assessing health care services used by California’s undocumented immigrant population in 2010. (2014). Health Aff (Millwood). Retrieved from
2. Vargas Bustamante. Variations in healthcare access and utilization among mexican immigrants: The role of documentation status. (2010). Journal of Immigrant and Minority Health, ##
3. Medicaid federal Policy Federal Policy Guidance.
4. “Medicaid Use by Documented and Undocumented Farm Workers.” J Occup Environ Med. (2015): n. pag. Web. 2 Dec. 2015.
5. Raymond-Flesch. ““There Is No Help Out There and If There Is, It’s Really Hard to Find”: A Qualitative Study of the Health Concerns and Health Care Access of Latino “DREAMers”.” Journal of Adolescent Health (2014): n. pag. Web. 1 Dec. 2015.
6. Deed-Sossa. Experiences of Undocumented Mexican Migrant Women When Accessing Sexual and Reproductive Health Services in California, USA: A Case Study.” Cad Saude Publica. (2013): n. pag. Web. 2 Dec. 2015.
7. “Fear of Discovery Among Latino Immigrants Presenting to the Emergency Department.” Official Journal of the Society for Academic Emergency Medicine (2013): n. pag. PubMed. Web. 2 Dec. 2015.
8. “Overcoming the Odds: Access to Care for Immigrant Children in Working Poor Families in California.” Maternal Child Health Journal (2010): n. pag. PubMed. Web. 2 Dec. 2015.
9. “Prevention Saves Lives as Well as Money, New Research Confirms.” Medscape. N.p., 2010. Web. 3 Dec. 2015.
10. “Undocumented Immigrants and Their Use of Medical Services in Orange County, California.” Social Science Medicine (2012): n. pag. PubMed. Web. 2 Dec. 2015.