Immigrant Health

A NextGen Free-Standing Perspective Article

Currently in front of Congress stands a flurry of issues including the weighty topic of immigration, long overdue since its last reform in 1986. The overhaul in 1986 focused on controlling the immigration influx by making it illegal for US employers to hire undocumented workers, and offering amnesty to illegal immigrants who had been here for five years. (1) Ironically, the number of illegal immigrants has tripled since the passage of the 1986 legislation, putting the best estimates at 11 million for immigrants entering the US during the 1990s. (1) The Census Bureau projects that by 2050, immigrants will make up more than 13% of the total population (2) (with immigrants defined as "Aliens admitted for legal permanent residence in the United States"). Not only does this flux in population mean new strains on the already burdened medical system in the US, the special status and needs of those who have recently arrived also challenge the public health system in other ways.

In a poll conducted by TIME Magazine, 75% of Americans say illegal immigrants should not be allowed to obtain government services such as health care. (1) The same deep concern is echoed by local and state governments, which are already struggling with various costs related to the influx of immigrants. A large percentage of immigrants irrespective of status are uninsured and are forced to seek medical care in emergency departments. Currently, under the Emergency Medical Treatment and Active Labor Act (EMTALA), a hospital must provide an appropriate medical screening examination to any patient who comes to an emergency department requesting an exam or treatment for a medical condition. If the patient's condition proves to be an emergency, the hospital is obligated to stabilize the patient. However, the EMTALA does not include funding to reimburse hospitals for the cost of providing any emergency treatment. (2) In order to reduce the amount of government spending and hospital expenses used for immigrant emergency treatments, government and public health agencies can increase health care access to immigrants and provide them with basic preventive health care to avoid serious health problems in the future.

Access to healthcare coverage is one of the greatest health issues facing immigrants today. According to the Kaiser Commission on Medicaid and the Uninsured, recent immigrants are much less likely to have health insurance than US citizens. In addition, many children, usually US citizens themselves, living in low-income immigrant families have a higher uninsured rate than their counterparts living in native-born families. (2) The US has two large health care coverage programs available to immigrants, Medicaid and the State Children's Health Insurance Program (SCHIP). SCHIP is an enhanced program where the federal government matches funds to states in order to expand health insurance coverage to children. SCHIP serves about 5 million children providing coverage for children ineligible for Medicaid, and covers prenatal care regardless of immigration status. (2) With the passage of Personal Responsibility and Work Opportunity and Reconciliation Act (PRWORA) in 1996, the number of immigrants eligible for Medicaid and SCHIP has been drastically reduced. The PRWORA includes a "five year bar" that prohibits most legal immigrants from receiving Medicaid or SCHIP during their first five years residing in the US. Other barriers included in the PRWORA have deterred eligible legal immigrants from participating in the Medicaid and SCHIP programs. (2)

But even before PRWORA was passed, the Medicaid and SCHIP programs were not all inclusive. Medicaid, the largest publicly funded health care program in the US serves over 38 million members of low-income families including comprehensive health care coverage for 1 in 4 children in the US and about 12 million seniors and persons with disabilities. Medicaid is not available to illegal immigrants. (2) Some states have allocated funds in order to augment the coverage provided by Medicaid and SCHIP by addressing the coverage limitations the PRWORA have created and extending coverage to children and pregnant women of illegal immigrant status. With numerous restrictions and limitations in Medicaid, SCHIP, and state-funded programs, many immigrants are without health insurance. (2) Without health insurance, immigrants have less access to health care, are less likely to have a regular source of care, are less likely to visit a doctor, and are less likely to obtain needed health care.

Simply providing health insurance to immigrants does not eliminate many related health disparities that immigrants have when compared to US citizens. In a recent report published by the New York City Department of Health and Mental Hygiene titled "The Health of Immigrants in New York City," it was found that immigrants or foreign-born New Yorkers were less likely to be insured and as a result were less likely to have their blood pressure and cholesterol checked, experienced a greater amount of psychological distress, were less likely to receive colon cancer screenings, pap tests, and mammograms, were less likely to receive a immunizations for flu and pneumonia, have an increased rate of intimate partner femicide, have an increased rate of tuberculosis, and have a higher teen birth rate than US citizens. (3) In order to narrow the gap between immigrant and citizen health, government and public health agencies can work to reduce the enrollment barriers that immigrants are presented with in participating in Medicaid, SCHIP or other health programs, reduce language and cultural barriers, alleviate immigrant concerns about participation in government health programs, and provide education about the importance of seeking health care coverage and preventive health care.

Despite eligibility for health care coverage by government programs, many immigrants are not enrolled due to a lack in support systems that help navigate the health coverage process for immigrants. Many immigrants do not know about Medicaid and SCHIP, do not know how to apply for benefits, fear that their children do not qualify for the government benefits, are deterred by the application process, and fear the adverse consequences of joining the government programs on their immigration status, such as deportation or difficulties gaining permanent residency. (2) Many immigrants do not know that they can receive health benefits from Medicaid or SCHIP without endangering their immigration status. Likewise, federal rules allow immigrants not to specify their immigration status or the Social Security numbers of family members not seeking benefits. (2) These federal rules and guidelines are unfortunately not widely known leading many government officials and agencies to unnecessarily request sensitive information. States can only require applicants who are seeking Medicaid or SCHIP for themselves to provide their Social Security numbers and immigration status information. In order to alleviate these concerns, many states have created organizations serving immigrant families. (2) For example, in Illinois, a coalition of 34 organizations known as the Outreach and Interpretation Project explain the availability of public benefits, provide assistance in applying, and provide interpretation and translation assistance to immigrant families. (2)

The change in demographics created by the continued influx of immigrants into the United States leads to increasing linguistic and cultural diversity in the medical field requiring increased sensitivities to language and culture between patients and doctors. According to the Kaiser commission, about fifty percent of all immigrants have come from Latin America and about twenty five percent of all immigrants have come from Asia. (2) The resulting language and cultural barriers reduce the quality of medical care that affects both immigrants and citizens not fluent in English. Language and cultural barriers create difficulties in communicating with a doctor, understanding the instructions given by a doctor's office, interpreting medical information that may lead to adverse health consequences, and obtaining a complete and accurate medical history. Language barriers also prevent immigrants and others who are not proficient in English from learning about available coverage, understanding how to apply for coverage, or even maintaining coverage. The difficulties caused by language and cultural barriers are not easily solved by relatives and friends serving as a translator, especially in the case of corresponding with a doctor, since the patient's condition and doctor's questions may become distorted by an untrained translator. To combat the problems caused by language and cultural barriers, many states, such as Minnesota have ensured that the state application for health care programs is offered in multiple languages. Similarly, many states are hiring outreach workers and trained translators and interpreters to avoid complications due to information lost in translation. Other hospitals are specifically reaching out to their non-English speaking population. For example, St. Vincent's Hospital Manhattan's new Chinese unit has adopted many Chinese cultural nuances, such as eliminating room number 1504 – the number 4 in Chinese sounds similar to the word for death – and including traditional Chinese foods in the menu. (4)

Another approach applied with much success in New York City to improve health care for immigrants is community outreach programs and specific immigrant community targeting to disperse health related information. As measured in 2000, the adult population of New York City is 44% foreign born with incredible diversity ranging from communities from the Dominican Republic to China. (3) In addition, as Dr. Thomas Frieden, Commissioner of the New York City Department of Health and Mental Hygiene, explained, within the immigrant population "each subgroup has a distinct health profile." As the report illustrates, Russians tend to be heavier smokers; Panama- and Honduras-born adults are likelier to be obese; adults with Ireland, Ghana, or Korean origins have higher levels of binge drinking; and New Yorkers born in China have the highest rate of death cased by liver cancer. (3)

Dr. Frieden described that "when designing [health] programs, [we] aim at the problems and try to cover the largest groups possible." Understanding health disparities between foreign-born and US born populations helps to identify groups that would most benefit from the targeted interventions, policies, and programmatic resources. With the targeted approach augmenting numerous services provided by New York City such as the New York public hospital program extending health care to undocumented immigrants and the Bureau of Tuberculosis Control, which provides treatment free of cost and without regard to immigration status, the city of New York hopes to promote health and curb avoidable illness and death to all New Yorkers.

The immigration issue still is an unresolved debate. Numerous proposals including the stringent Sensenbrenner Proposal would make giving even humanitarian assistance to an illegal immigrant a crime punishable by up to five years in prison have reached the floor of Congress. (1) But regardless of the final outcome of the immigration debate, the government has an obligation to protect the humanity of all that reside within its borders and that includes maintaining the health of both immigrants and citizens. The health needs of the immigrant population should be understood and considered in order to meet the unique needs of the US population as a whole. 

Eva Luo is a writer for the Next Generation and a member of the Harvard College Class of 2008.

Work Cited
  1. Tumulty, Karen. "Should They Stay or Should They Go?" TIME. 10 April 2006: 167, 15. (Text)
  2. United States. Kaiser Commission on Medicaid and the Uninsured. Covering New Americans: A Review of Federal and State Policies Related to Immigrants' Eligibility and Access to Publicily Funded Health Insurance. Shawn Fremstad and Laura Cox of the Center on Budget and Policy Priorities. November 2004. (Text)
  3. United States. New York City Department of Health and Mental Hygiene. The Health of Immigrants in New York City. June 2006. (Text)
  4. Fischman, Josh. "Bridging the Language Gap." US News and World Report. 17 July 2006. (Text)

» Back to Current Issue