They are blending illegal aliens and immigrants together so this study.


Immigrant health care in the United States: What ails our system?
Katherine G. Footracer, MS, PA-C, CMTApril 13, 2009

Is everyone in the United States entitled to health care? If so, how much does each person deserve? If not, how should it be allocated? And, perhaps most crucially, who pays for it? These questions have been raised in presidential debates, editorial columns, and conversations around the country. The debate already bears the weight of failed proposals and personal frustrations, but it takes on additional intensity when applied to people who are in this country without documentation. The problem of undocumented immigration has broad economic, political, and cultural implications, but as health care providers, our primary concern is with the medical needs of our patients and communities.


THE SCOPE OF THE PROBLEM

Nearly 46 million people in the United States are currently estimated to be without health insurance, representing approximately 15% of the total population.1,2 For the native-born, the uninsured rate is 12.7%, but among noncitizens, a group that includes temporary workers, foreign students, permanent legal residents, and those here without documentation, the rate is 43.8%.1,3 This difference means that noncitizens are vastly overrepresented within the population of uninsured persons.2 Moreover, the number of immigrants without insurance, including those entering with or without documentation, is growing. Government estimates as of January 2005 place the number of undocumented immigrants at 10.5 million, representing 29% of the total foreign-born population.4,5


IMMIGRANT USE OF HEALTH CARE

Immigrants and the native-born use health care resources differently, with immigrants typically accessing them less frequently. Figure 1 compares health care access by citizens and noncitizens.6 The majority of health care received by undocumented immigrants comes through emergency departments (EDs), while most of the remaining care is obtained through public clinics and community health centers.3,4



A national study comparing health care expenditures between immigrants and those born in the United States found that native-born adults and their children consume statistically significantly more dollars per capita for health care.2 The one exception is that children of immigrants have a higher per capita expenditure for ED visits than do children of the native-born when adjusted to take into account age, ethnicity, poverty level, insurance status, and patientreported health status.2

A 2000 study uncovered additional differences between native-born and foreign-born residents regardless of their citizenship status. The study showed that immigrants were more likely to have no health insurance, report fewer medical conditions, spend less on health care, have fewer interactions with the health care system, and have lower household incomes.4 These differences were magnified when the nativeborn were compared with undocumented immigrants.7

Interestingly, immigrants in general and the undocumented in particular report lower levels of cancer, heart disease, arthritis, depression, hypertension, and asthma than do the nativeborn. Researchers attribute lower rates of health care usage and lower reported chronic disease to several factors. The first consideration is that compared with the native-born population, immigrants are relatively young, resulting in a healthier immigrant population. The second is that the process of migration itself, especially in cases of people entering without documentation, may positively select for health since the less healthy are unable to make the often arduous journey.7

A third possibility is that many immigrants, especially the undocumented, may avoid seeking health care for fear of being noticed by authorities. Immigrants are more likely to wait until they are acutely ill and then access emergency care rather than seek preventive care earlier in the disease process.3 Figure 2 shows a comparison of ED use by citizens versus noncitizens.6



Other reasons may be financial. Given the low number with health insurance and an average income approximately 25% that of the native-born, undocumented immigrants may not be able to afford preventive health care and may have chronic medical conditions that have yet to be diagnosed or treated.2 One of the reasons so few immigrants have health insurance may be that lack of health insurance is associated with lower education levels, higher poverty rates, and less-skilled jobs that are less likely to provide health insurance.8 The exception to this pattern is immigrants who are in the United States with refugee or asylum status. These individuals are more likely to have insurance because they are granted immediate access to welfare and Medicaid.9


GOVERNMENT POLICIES

Public funding for preventive and ongoing health care for the poor occurs primarily through Medicaid, the costs of which are usually split equally between federal and state governments.10 In 1996, as part of welfare reform, the Personal Work and Responsibility Reconciliation Act reduced immigrants' access to Medicaid by delaying eligibility for federal benefits until after they had attained permanent resident status for five years and denying benefits to undocumented and nonpermanent residents. The net effect of this policy change was to shift responsibility for immigrant health care from the federal government to state and local governments.3

Emergency medical care is treated differently. The Emergency Medical Treatment and Active Labor Act (EMTALA) of 1985 requires that anyone who enters a hospital with an emergency or in active labor be screened and treated until ready for discharge or stable for transfer, regardless of that individual's ability to pay. Emergency Medicaid does not require proof of citizenship or residency and thus can be used by anyone in the United States, including visitors, foreign students, and undocumented immigrants.11

Critics of the law have argued that “emergencyâ€