Resources
Kaiser Commission on Medicaid and the Uninsured
National Immigration Law Center
White paper: “National Immigration Policy and Health Care,” (PDF) by the American College of Physicians
Report: “Voice of Primary Care: Migrant Workers in the Southeast,” (PDF) by the Florida Association of Community Health Centers
By Grace Rubenstein
The simple answer to this session’s fundamental question is: very few people.
The rules about when and where the undocumented can get care are a complex thicket. For that reason, plus misinformation, cultural and language barriers and fears of deportation, these immigrants tend to avoid getting care until they reach a crisis. It’s also very hard to get good data on undocumented immigrants, as national surveys and health care providers generally don’t ask about immigration status (exception: the Pew Hispanic Center has some data).
The speakers in this session at Health Journalsim 2012 outlined the rules about care for the undocumented and offered up a wrenching case study of one adolescent girl.
First, they said, it’s important to be clear about who we are talking about when we say “immigrants.” Samantha Artiga, associate director of the Kaiser Commission on Medicaid and the Uninsured, presented data showing that, of the 38 million immigrants in the United States – legal and otherwise – just 7 percent are not citizens. Legal residents themselves are a diverse group including those on a path to citizenship, those with temporary work visas and no citizenship option, asylees and refugees and others.
Yet 19 percent of the uninsured people in this country are non-citizens. What does that tell us? That non-citizens (who include legal residents as well as the undocumented) are much more likely to go without insurance, often because they have lower incomes and are less likely to have private insurance via an employer, Artiga said. Non-citizens have much lower rates of using health care, and that pattern extends to citizen children of non-citizen parents. Of the 17 million children in this country, 86 percent are U.S.-born citizens with immigrant parents.
So how does an immigrant get medical care? Here are the nuts and bolts:
– If you’re a legal immigrant, you have a five-year waiting period from your arrival before you can qualify for government coverage via Medicaid or CHIP, though states have the option to waive this delay for children and pregnant women and cover them immediately via CHIPRA.
– If you’re undocumented, you can get public coverage only via Emergency Medicaid for genuine emergencies, life-or-death treatments, or labor and delivery (that is, of course, only if you meet the other qualifications for Medicaid, such as having a low income). This does not include prenatal care, leading to concerns about bad birth outcomes and the resulting high human and financial costs. States have the option to extend CHIP benefits to pregnant women, but only by declaring that the benefits are for the unborn (future citizen) child. Many states, fearing a slippery slope toward fetal “personhood” in the abortion debate, have balked at this. A handful of states fund their own programs to fill this gap in care. Sonal Ambegaokar of the National Immigration Law Center said that Washington, Illinois, New York, Massachusetts, Washington, D.C., and some California counties cover all kids regardless of status. (Interesting note: Since 2005, everyone has had to prove citizenship to get Medicaid. This roadblock has prevented or delayed some citizens from enrolling, Ambegaokar said.)
– The primary route for non-emergency care for undocumented immigrants in community clinics. One category of these clinics – the federally-qualified health centers – get federal money each year in exchange for serving all comers, regardless of income, insurance or immigration status, with a sliding-fee scale for those paying out of pocket. Many immigrants also get one-time care are health fairs, but this does not allow for ongoing monitoring or disease management. They may buy insurance on the private market, if they can afford it.
How does this typically play out in real life?
Flavia Mercado, a physician in a primary care clinic at Atlanta’s Grady Hospital, recalled an undocumented teenage girl complaining of suffering abdominal pain for a year. The girl was referred to her from a free clinic at another hospital, where clinicians were quite concerned about her but didn’t speak Spanish or know how to arrange care for someone without legal immigration status. She had been seen by a doctor somewhere a year earlier and received medication for constipation, but the pills ran out and the mother, who was also undocumented and spoke no English, didn’t bring her daughter back to the doctor.
By now, the girl was severely anemic. Mercado secured the Grady discount for the family, based on a raft of documentation including a birth certificate, passport, and utility bills to prove residency in the county. But before the girl came in for her scheduled testing, her condition acutely worsened and she went to the emergency room. Imaging tests showed a large mass on one of her ovaries. Surgery (covered by Emergency Medicaid) removed the mass, but now the girl may have fertility problems and may still need chemotherapy. She came back to the clinic to make arrangements for this follow-up care, but that was it – she disappeared, and Mercado hasn’t seen her since.
“She wouldn’t have had to have her ovary removed if she had come in sooner,” said Mercado, who sees similar problems with uninsured citizens and citizen children of undocumented parents.
What changes in 2014?
If upheld, the ACA would allow legal immigrants to receive tax credits and buy insurance on the exchanges, even before their five-year waiting period is up (provided they meet the standard requirements of income no higher than 400 percent of the federal poverty level). This could really expand options for legal immigrants, but it will need lots of enrollment and outreach work, said Artiga. Ambegaokar is also hopeful that the exchanges will expand coverage for small businesses and thus insure more low-income legal immigrants.
Undocumented immigrants, however, are explicitly barred from buying insurance (even without tax credits) on the exchanges. So, prospects for them get no better. The only potential boost is in the extra money the ACA allocates for community health centers – though legislators are busy now cutting that allocation away.
Grace Rubenstein is a public health reporter at The Sacramento Bee and was a 2012 AHCJ-California Health Journalism Fellow.
