Healthcare Inequality for Unauthorized Immigrants Anushka Bhatia '24

Healthcare Inequality for Unauthorized Immigrants

BY ANUSHKA BHATIA '24

Cover image: People using mobile phones. Mobile computing and communication is one of the modern technologies driving innovation in developing and least-developed countries. Image Source: Wikimedia Commons An Introduction to the Impact of Unauthorized Status on Health

As immigration into the United States increases, so does the number of unauthorized immigrants. Immigrants make up over 43.2 million of the U.S. population, and over 10.7 million have unauthorized status (Fortuny et al., 2010). Over the last two decades, there has been an increased focus on immigration status, with Immigration and Customs Enforcement (ICE) officials heavily focused on enacting workplace raids, detention, and deportation. 77.1% of likely undocumented immigrants reported deportation fears on average from 2007 to 2018 (Asad, 2020). Immigrant families are already at a higher risk for health issues due to the inaccessibility of health insurance, but other factors resulting from their undocumented status play into their exacerbated risk such as lack of knowledge, confusion over regulations, and discrimination (Karp et al., 2007). has created an anxious climate for unauthorized immigrants, with fears of deportation manifesting themselves both physically and mentally. A study of providers who care for unauthorized immigrants found that over 40% of medical practitioners reported negative health effects of ICE activities on their unauthorized immigrant patients. This pervasive fear of ICE leads to healthcare avoidance, stress, and anxiety, which all contribute to mental health issues and physical manifestations of stress (Hacker et al., 2012).

However, ICE is not the only factor that may have negative effects on physical health. Unauthorized immigrants often work jobs with poor conditions, leading to injuries or long-term health issues like joint pain or chemical inhalation. They may also have to switch jobs often or face long commutes to get to work, increasing the amount of strain on their body. The fatality rate of agricultural farm workers, 55 percent of which are immigrants (“Farm Labor”, USDA), is over five times that of all workers, and conditions like chronic pain, heart disease, and many cancers are higher in this

population (Slesinger, 1992). For example, studies on agricultural workers in California reported rates of musculoskeletal disorder incidence ranking among the highest risk industries as well as 100 times greater than rates suggested by the National Institute for Occupational Safety and Health (Meyers, et al, 1998, 2000). Besides working conditions or deportation fears, underlying and structural inequality related to immigration status prevents access to healthcare and receiving high-quality treatment. As a result of the social, structural, political, and economic forces that act on unauthorized immigrants, researchers suggest that immigration should be considered a social determinant of health (Castañeda et al., 2015), among others such as socioeconomic status, education, and employment. This means that immigration status is a very significant factor that needs to be considered by healthcare workers to predict the chance of developing severe conditions like heart disease and others mentioned above.

Issues with Doctor-Patient Interaction and Hospital Structure

If unauthorized immigrants seek access to healthcare for physical or mental issues, as a result of their unauthorized status, there are often structural barriers within hospitals and clinics which limit the quality of care they are given. With doctor-patient interactions, language barriers pose a significant problem, with some clinicians needing a translator with foreign language-speaking patients. Many physicians do not have easy access to a translator or do not want to put in enough effort to call over a translator, thus resorting to conduct the appointment in English so the patient cannot understand or with an untrained interpreter like a patient’s family member or a Spanish-speaking medical student. Scheduling appointments is complicated as well due to a lack of flexibility in farm schedules for migrant workers and difficulty in missing work to visit the doctor. Unauthorized immigrants may also have patchy medical records if they need to travel to different locations for their jobs (Holmes et al., 2012).

Furthermore, there are cultural barriers that make it difficult for doctors to understand and make recommendations to their patients. For example, in Mexican culture, there are different beliefs about pain and medicine, and individuals often receive treatment from traditional healers near them. This can lead to problems with workers’ compensation, damages that must be paid to an employee for an injury occurring on the job, as doctors have to conduct tests assessing patients’ injuries that align with cultural norms that differ from those of unauthorized immigrants. Because of these differences in their view of pain, migrant patients often pull away during particular aspects of workers’ compensation tests, which can be “interpreted as faking pain, while in reality, it is fear of pain” (Holmes et al., 2012), causing them to receive less compensation for their injury. Racial bias can also play a role when clinicians have different perceptions of people based on their immigration status or racial makeup. In a study at migrant health clinics, a doctor mentioned that she sees a high rate of premarital pregnancy in the migrant population. Most couples that make up their patients, members of the Triqui tribe,

Figure 1: A world map showing the distribution of countries classified as developed, developing, and least-developed. Developed countries fall under the “advanced economies” and “in transition” labels (dark blue and light blue), developing countries fall under the “less developed,” (orange) and leastdeveloped economies fall under the “least developed” (red) labels respectively. Image Source: Wikimedia Commons

"immigration status is a very significant factor that needs to be considered by healthcare workers to predict the chance of developing severe conditions like heart disease and others mentioned"

Figure 2: Many unauthorized immigrants work jobs that increase the likelihood for physical issues like joint pain and chemical inhalation or have long hours that prevent workers from being able to reach clinics to receive treatment.

Image Source: Flickr, Creator: Bob Jagendorf

"In a systematic review of legislation, several laws were found to prohibit or restrict undocumented immigrants from accessing basic health services, including emergency care, HIV, and STI treatments"

engage in traditional practices distinct from a Church of state wedding, thus making premarital pregnancies more complex than the doctor stated (Holmes et al., 2012).

Within hospitals or clinics, there are resource constraints that make it harder for unauthorized immigrants to obtain proper care. In free clinics or reduced-price clinics especially, healthcare workers have heavy workloads and short appointment times that increase difficulty in communication, and there can be shortages of skilled psychotherapy or mental health workers to assist with issues more common to the unauthorized immigrant population. Besides a lack of quality interpreters, there is also a lack of diversity in the ethnic backgrounds of healthcare staff, contributing to the language and cultural issues mentioned earlier. Service guidelines in healthcare centers often contradict or do not match the attitudes and beliefs of migrant patients, such as practices concerning the disclosure of HIV status (Suphanchaimat et al., 2015). This can lead to increased stress and discomfort in patients and perhaps an increased likelihood that they will not return to these centers as frequently as they should.

Barriers to Healthcare Access Resulting from Immigration Policy

Regulation surrounding immigration places restrictions on unauthorized immigrant access to healthcare. Anti-immigration laws lead to changes in legal practice, which in turn lead to changes in social institutions and environments by decreasing available resources or reducing rights. These laws can affect health behaviors directly or shift environmental conditions to make certain behavioral choices more or less attractive, in the end leading to changes in health status. In a systematic review of legislation, several laws were found to prohibit or restrict undocumented immigrants from accessing basic health services, including emergency care, HIV, and STI treatments (Martinez et al., 2015).

General immigration policy bars access to healthcare through fear and isolation. Many unauthorized immigrants are afraid to receive healthcare, even from free clinics, as a result of fears of checking documentation and being deported (Martinez et al., 2015). Immigration policy can also have an impact on the attitude of healthcare providers when offering services. Anti-immigrant legislature and policies in certain geographic areas can cause healthcare workers to discriminate against unauthorized immigrants and deny or delay services. Multiple states continue to refuse to expand their Medicaid programs to provide insurance to all incomeeligible children, regardless of their immigration status.

Limited access to health insurance acts as a substantial barrier to receiving help. The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 placed significant restrictions on unauthorized immigrants, declaring them ineligible for “any…health… benefit for which payments or assistance are provided to an individual, household, or family eligibility unit by an agency of a State or local

government or by appropriated funds of a State or local government” except for in cases of emergency medical condition (Kullgren, 2003). This means that unauthorized immigrants are barred from participating in Medicare, Medicaid, and more. Some states are able to use funds to provide Medicaid coverage to income-eligible children regardless of immigration status, but many families continue to stay home due to fears of deportation (Gostin, 2019).

Disproportionate Impacts of COVID and Exacerbated Disparities for Unauthorized Immigrants

These gaps in access and treatment impact the current COVID-19 pandemic and the vulnerability that unauthorized immigrants face in particular. To begin with, many unauthorized immigrants work in jobs like essential services that have an increased exposure to COVID and crowded working conditions. These jobs could include inadequate access or inappropriate use of personal protective equipment or the need to continue working while sick due to economic pressures. This can also extend to living conditions, since unauthorized immigrants may live in crowded multi-generational households that have an increased risk of transmission (Greenaway et al., 2020). Unauthorized immigrants who continue to work are also more likely to use public transit to get to their jobs, increasing their risk of exposure.

The lack of access to healthcare for undocumented immigrants heavily affects them during the pandemic. Early diagnosis and monitoring of people with COVID are critical to optimize patient outcome and prevent further transmission. Unauthorized immigrants depend on free clinics or other safety-net public health systems that are underfunded and thus have limited resources to provide testing, management, and follow-up services. Also, a lack of access to preventive medicine in general leads to an increased risk of underlying health conditions like obesity, hypertension, and diabetes, which are linked to more severe COVID manifestations. Unauthorized immigrants also may be at risk for excessive stress due to fears of deportation, poverty, and trauma, which may be worsened during a pandemic, especially for those with limited healthcare, high risk of exposure, or high risk of job loss (Clark et al., 2020). Since unauthorized immigrants were excluded from the Patient Protection and Affordable Care Act, they are not able to receive primary care and thus needed to seek treatment in emergency rooms that are more crowded, increasing their risk or exposure to COVID (Greenaway et al., 2020). The increased vulnerability of unauthorized immigrants due to work and home conditions is exacerbated by the structural issues with access and quality of healthcare. This leads to increased health disparities for unauthorized immigrants among other minority populations, and the presence of COVID has revealed these disparities more clearly. Undocumented immigrants have increased barriers of access to vaccines because of these reasons, and although they are legally able to get the vaccine, the government has still needed to put out extra effort in order to encourage these "unauthorized immigrants are barred from participating in Medicare, Medicaid, and more."

Figure 3: Advocates rally for a bill to provide healthcare to undocumented (unauthorized) immigrants. Unauthorized immigrants receive limited access to health insurance as a result of specific immigration policy. Image Source: Hartford Courant, Creator: Hector Amezcua

individuals to receive their vaccines as a result of these barriers.

Potential Structural Changes and Recommendations

In terms of COVID, urgent actions should be taken to support disadvantaged communities like immigrants, especially those that are unauthorized. This needs to take place at the local, state, and national levels, especially through legislation and policy change. Healthcare facilities should be designated as locations where immigration enforcement is prohibited, thus being able to reduce fears concerning deportation or government association. Furthermore, COVID testing and vaccination appointments should be made widely available and accessible for unauthorized immigrants that have a hard time taking time off from work, and policy changes should be introduced to prevent large healthcare costs for uninsured patients with COVID. Ways to create safer jobs for low-income workers would reduce their transmission risk but also allow them to continue to support themselves or their families (Clark et al., 2020).

For doctor-patient communication, more materials and resources need to be allocated for translation services to ensure that proper communication is occurring and that unauthorized immigrants feel safe. There needs to be increased training on how to mediate cultural differences and understand potential bias by physicians, potentially including more intercultural mediators during appointments (Sandín-Vázquez et al., 2014). A study suggested that co-production, the concept of how to collaboratively create valuable healthcare service for the patient, with unauthorized immigrant patients can be successful if both the system and professionals are interested and prepared (RadlKarimi et al., 2020).

Healthcare policy in general should be modified so that more states opt into the Children’s Healthcare Insurance Program to have children considered for Medicaid regardless of their immigration status. Free clinics should be given more support and resources, especially in the number of interpreters required and the hours needed to stay open for unauthorized immigrants working long jobs throughout the day. This shows the need for collaboration between the healthcare system and NGOs, which provide help to disadvantaged groups in society (SandínVázquez et al., 2014).

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