Immigration & Documentation

Written by: Harman Khokhar, MS4 Touro COM Harlem

Edited by: Payal Modi, MD

Immigration and documentation status can play a major role in whether a person chooses to access health and emergency services, and this can impact, not only themselves, but their immediate family as well. An undocumented immigrant may choose not to seek medical care for fear of deportation or being put into immigration detention, and they are more likely to forgo these services for their children as well. Other factors include limited experience with healthcare and insurance in the U.S., distrust of the healthcare system, and lack of understanding regarding eligibility of their children for certain programs, such as CHIP (Children’s Healthcare Insurance Program). (1) The way immigration status affects the immigrant population is unique; this is due to the existence of subgroups within this population. Non-citizens (permanent residents, undocumented immigrants, refugee/asylum seekers) come to mind first, but there are also naturalized citizens and U.S.-born citizens. Each subgroup accesses and utilizes  healthcare differently. Non-elderly undocumented immigrants are 4x more likely to not have health insurance compared to their U.S. citizens counterparts, and undocumented immigrant children are 5x more likely to be uninsured than U.S. citizen children. Whereas, legal immigrants were 2x as likely to not have health insurance compared to U.S. citizens. (1) In this article, I will discuss healthcare coverage for immigrant populations, historic events and health policies that have affected these populations, the effects on the children of immigrants, and provide resources for healthcare professionals to prepare them for encounters with these populations.   


MEDICAL COVERAGE AMONG IMMIGRANTS


It is important to note how immigration and documentation play a role in social determinants of health (SDoH). SDoH include economic stability, education access and quality, healthcare access and quality, neighborhood build and environment, social community and context. (2) Many immigrants lack regular care; they do not follow up for chronic conditions, they are less likely to engage in mental health services, and they may favor emergency services usage. The Emergency Medical Treatment and Active Labor Act of 1986 states that “all patients who present to the emergency department must receive appropriate medical screening and, if in need of medical emergency treatment, must be treated until stable.” This law is blind to immigration status or documentation and may be the life-line for many undocumented immigrants to receive medical care (3). Undocumented immigrants have lower rates of screenings for colorectal, cervical, and breast cancer than U.S. citizens. Immigrant children have decreased rates of immunization, higher prevalence of certain infectious diseases (Hepatitis A and Tuberculosis), and are less likely to receive preventative care for conditions like asthma compared to U.S. citizen population. Immigrants report feeling more sadness, depression, and loneliness several years after immigration due to migration stressors (physical violence, ethnic cleansing, imprisonment, rape, economic distress, and torture) and stressors in the U.S. including, but not limited to, lower income, decreased ability to obtain higher education, and discrimination. (1) Immigrants have a greater rate of occupational risks and injuries compared to the native population and they are less likely to report these risks and injuries due to fear of immigration enforcement. Significant factors that determine healthcare access and usage among immigrants are fluency of English, documentation status, and length of time within the U.S. The Affordable Care Act increased healthcare access and usage among legal immigrants but left out undocumented immigrants. It is estimated that 23% of legal immigrants and 45% of undocumented immigrants lack healthcare coverage compared to 9% of their U.S. citizen counterparts. Lack of healthcare insurance among immigrants is also due to other factors such as cultural, geographic, provider and health system based barriers. For example, immigrants located in states with unfavorable political environments or criminalizing laws have disadvantageous health outcomes. (4) There are many other barriers to access of healthcare that are specific to immigrant populations; legal barriers excluding undocumented migrants to accessing public health coverage programs, requiring documentation in order to apply for these programs, and resource limitations such as working in occupations with little support (low income jobs without employer insurance, inability to take off for medical reasons, etc.), lack of transportation and low “healthcare capacity” (decreased provider cultural competency and difficulties with communication as non-native speakers or decreased English proficiency) (5). 

Many states use local funds to cover immigrant populations not covered by federal programs, such as CHIP and medicaid, especially during the pandemic. California, Washington D.C., Illinois, Massachusetts, New York, Oregon and Washington have implemented health coverage plans for immigrant children that are equivalent to federally funded programs. Alternatively, California, Washington D.C., and Illinois have some form of adult health coverage. The Illinois program is meant to cover seniors (65 years and older) and California has health coverage for ages 19-25. Washington D.C. has health coverage for immigrants age 21 and older. Other states implementing similar plans for health coverage of immigrants that do not qualify for federally funded programs are Connecticut, Vermont, New Jersey and Colorado. There are a host of benefits that come along with health coverage; access to primary care and preventative services, improved health outcomes, and greater rates of attendance for school and work. Availability to healthcare coverage also means increasing revenue, increased provider capacity for care and decreased rates of uncompensated care. State-funded health coverage programs will likely decrease the use of emergency services as well. Two states, Oregon and Washington, employ community based outreach through organizations and community specialists within hospitals to get uninsured immigrants to enroll in state-funded insurance, which addresses the barriers these populations face in terms of access and fear of immigration enforcement due to immigration status (13).


COVID-19 PANDEMIC 


The Covid-19 pandemic highlighted the gaps in healthcare coverage and public health policy for immigrant populations. (4) For example, undocumented immigrants still faced barriers to healthcare access, despite inclusion in U.S. Federal policies related to relief aid for the Covid-19 pandemic. Relief aid left gaps in coverage for treatment, placing the financial burden on undocumented patients (5). The “public charge rule” states that the government can deny visas and change permanent status to non-citizens based on usage of public benefits for more than 12 months in a 36 month period while in the U.S. and/or for individuals who will be likely to use public benefits in the future (the public charge rule is no longer in effect, since March 09, 2021(6)). For pandemic relief and before the discontinuation of the public charge rule, the government stated that individuals seeking to use public health benefits for testing, treatment, or any associated preventative care related to Covid-19 would be exempt. Coronavirus Aid, Relief, and Economic Security Act and Families First Coronavirus Response Act are federal initiatives that provide free testing to uninsured and undocumented individuals, but not necessarily for the Covid-19 treatments. These policies are nuanced with “opt-in” requirements for those receiving treatments, which may not be well known among this population.Not every provider participated in this program, thus limiting it’s outreach. Reimbursement is an issue for the undocumented because they do not have social security numbers and, therefore, are left out of important relief aid and face higher costs of medical treatment than U.S. citizens. The language used in policies for relief aid are meant to help the uninsured and can be ambiguous leading to fear among noncitizen individuals. Rules like “public charge” and penalizing laws against non-citizens affect their ability to seek medical care and health insurance because these laws can impact their future in the U.S. (5) 

The public charge rule heavily impacted all immigrant populations, even though the rule focused on a noncitizen immigrant populations. Healthcare enrollment, including enrollment of children into medicaid, decreased over a three year period (2017-2020). Other programs including Temporary Assistance for Needy Families, and Supplemental Nutrition Assistance Program decreased for children in households with at least one noncitizen family member than their U.S. citizen household counterparts. At the state level, some states (Georgia and Alabama) require residents (children and pregnant women) to have a waiting period before receiving state aid (CHIP and medicaid), while other states (New York, California, etc.)  provide this assistance without regard to immigration status. (7) Immigration status and documentation affects all levels, individual, institutional and political aspects of seeking healthcare, this highlights the importance of implementing actions at all levels, such as dismantling policies that are punitive and providing easily accessible care through increase in cultural competency among providers, making healthcare physically accessible through public transportation, and disseminating public information regarding healthcare laws and programs in hospitals and other public domains. 

The Covid-19 pandemic is a public health emergency and the pandemic exacerbates issues for many immigrants, which includes receiving care (testing, treatment, and preventative care) and economic relief. This historic event demonstrates how vulnerable immigrants are in our system, as they are among the populations hit hardest in the U.S. population. As highlighted by Tia Taylor Williams, Director of American Public Health Association’s Center for Public Health, a “disproportionate burden of Covid-19 among communities of color and other marginalized groups is due inequitable policies and treatment at the individual, community and system levels.”  Many undocumented immigrants work in “essential” professions, often working in high risk Covid-19 exposure environments, are more likely to be uninsured, less likely to receive consistent medical care and, therefore, should be deemed one of the highest risk groups. Of note, the hispanic non-citizen population faced significant barriers to receiving health care access. They had higher rates of Covid-19 cases, hospitalizations, and death compared to White, Black, and Asian populations, as well as decreased vaccination rates (7). 

Refugees and asylees are another group of noncitizen immigrants that are at increased risk for access to healthcare, particularly after their short-term health insurance expires (Refugee Medical Assistance Program in Medicaid, for up to 8 months). Mental health is another risk factor for this group; they have increased incidences of post-traumatic stress disorder, depression, and anxiety. However, this population is less vulnerable to Covid-19 with regard to age, as about 44% are children and 25% are young adults. They face Covid-19 vulnerability in terms of living conditions, underlying medical conditions, work circumstances, and other such factors (7). 

BORDER, HEALTH & SANCTUARY POLICIES


As mentioned above, U.S. immigration policies heavily impact immigrant populations’ healthcare decisions. During the Border crisis, many immigrants found themselves in detention centers, in close quarters with others, and with very little autonomy.  A climate of fear of deportation emerged as well, especially while traveling to hospitals or clinics to receive medical treatment. Complex health and insurance systems, lack of resources, and documentation requirements also deter many undocumented immigrants from seeking regular medical care. While there are policies that protect immigrants from being questioned at sensitive locations (hospitals), there are other ways for immigration policies to be enforced, such as staking out areas around these sensitive locations, decreasing the likelihood that undocumented immigrants would seek out regular medical care. Another aspect of SDoH is financial security and undocumented immigrants are often essential workers, are low-income and, therefore, have limited access to resources. There are centers for these specific vulnerable populations that provide access to healthcare at low-to-no cost to the patient and can be thought of as a “Sanctuary” (8). Sanctuary policies address immigration status as a SDoH and focus on immigrant health, well-being, and rights in different contexts, at local, state and national level. In fact, within a subset of sanctuary policies, which addressed supporting immigrants through anti-discrimination, trust and privacy, the aim was to create a health-promoting environment within these communities. The increasing prevalence of sanctuary policies was preceded by two high profile cases; Miranda Olivares v. Clackamas County (holding a woman in custody beyond her sentence) and Galarza v. Szalczyk (Puetro Rican citizen was held mistakenly as an undocumented immigrant). Another subset of reactive terminology sanctuary policies arose during the “national anti-immigrant rhetoric and punitive presidential executive orders” time-frame. While the correlation of political climate and the emergence of different types of sanctuary policies cannot be described in concretely as cause-and-effect, the creation and purpose of these policies served to promote good health outcomes for immigrant populations. There is research supporting protective mental health benefits for immigrants under Deferred Action for Childhood Arrivals (DACA); policies of this nature can decrease the psychological stressors associated with immigration status and documentation (9). 


IMMIGRANTS & THE ED 


Three different California EDs (San Francisco, Oakland, and Sylmar) with large immigration populations contributed to a study on strategies of how to reduce fear and increase trust among immigrant patients in the emergency department. Within the ED, two “long standing” policies are known to providers: 1) hospital staff are under no obligation to share immigration status with authorities and 2) patients are to be treated regardless of immigration status, especially if they require emergency services for stabilization. (Hospital staff refers to physicians, nurses, social workers and administrators.) Policy and practices within the ED evolve through time as the political climate changes. For example, with heightened immigration enforcement, protective policies (sanctuary policies) have emerged. Hospital staff in the ED tend to respond to the unique needs of the patients, instead of executing a system wide protocol for undocumented immigrants. Formal training based on knowledge and research regarding undocumented immigrants and health outcomes for healthcare professionals is limited. For example, hospital staff may rely on social workers for information regarding undocumented immigrants. Physicians may actively research these policies on their own time but this is variable and provider-dependent. As mentioned earlier, with no protocol in place, hospital staff face ambiguity regarding law, policies and their roles in how to approach care with undocumented immigrants. There is also inconsistency in documentation of immigration status. However, usually documentation status is not recorded unless clinically relevant, and even then in ambiguous terms. Hospital staff provided care to many undocumented immigrants who faced barriers in receiving medical care due to fears of discovery. Hospital staff considered their roles as protectors of undocumented immigrants, providing an environment of safety and trust. Some strategies that can be implemented to improve undocumented immigrants include increasing staff training on anti-racism, clarification of provider roles, include signage emphasizing that medical care can be received without disclosing immigration status, not documenting immigration status within medical records (using ambiguous verbiage to describe medically relevant information), and using surveys to assess success of different strategies for both providers and patients  (10). Another strategy to be considered is streamlining resources for healthcare services and access through creating a public network of individuals and organizations, which would increase the likelihood of immigrant populations receiving critical updates. 


IMMIGRANT CHILDREN


Noncitizen children are more likely to live in poverty, far more likely to be uninsured, more likely to have delays in medical care, and slightly worse reported health outcomes than their U.S. citizen children. However, a majority of noncitizen children (69.5%) became naturalized citizens by age of thirty and an even larger percentage (83.6%) by the age of fifty (11). This highlights the importance of including noncitizen children in public health coverage programs across, local, state or national levels to help offset these negative health outcomes and decrease usage of emergency health services. California’s Health4all Kids expansion program increased overall coverage and public coverage, which translates into 34% decline in uninsured rates relative to pre-expansion rate among noncitizen children. Enactment of this program decreased low-income children coverage disparities due to citizenship by about half (12). Health insurance coverage for noncitizen children can decrease the use of emergency services by providing access to regular healthcare. These programs can help protect these vulnerable populations against adverse health outcomes due to decreased access to insurance and decrease distrust among immigrants. 


FUTURE CONSIDERATIONS

We can improve health outcomes for immigrant populations by focusing on SDoH. Low socioeconomic status, housing insecurity, transportation barriers, and low healthcare access are detrimental to these populations and they face these barriers in addition to migrant stressors, as mentioned above. Public health should consider other factors as well, such as health literacy, use of sanctuary policies, and cultural competency. Knowing your rights and understanding the U.S. healthcare system can help offset barriers to healthcare access. In the ED, creating informational packets and providing these populations with the resources during patient visits can help foster trust and provide a safe space. Connecting patients in the ED with other legal and health resources, such as health centers specifically for uninsured populations can help decrease the burden of providing medical care. Creating more sanctuary policies that include other locations (courthouses, foodbanks, etc.) which act as disaster relief centers will also foster trust in the immigrant population. In a previously hostile political environment, with the now dismantled public charge rule and increased immigration enforcement, we saw a decrease in health insurance coverage, which negatively impacted immigrant health (5). Without health insurance, immigrant populations are more likely to seek access to emergency health services to treat acute-on-chronic conditions and less likely to have regular care and follow up with a physician. Even certain legislation encourages the use of emergency services (EMTLA), even though the purpose of this legislation is to provide a certain standard of healthcare to each individual (4). Healthcare decisions are largely based on how the government responds to the immigrant population presence and their futures within the U.S. Classification of citizenship and immigration status has often excluded certain populations (undocumented immigrants) from relief programs. While certain policies were enacted during Covid-19 to help undocumented immigrants receive care, we know a large percentage of the hispanic population (which is one of the largest groups in undocumented immigrant population) still saw a rise in cases, hospitalization, and death compared to White, Asians and Blacks. Communities of color and vulnerable populations were hit hardest in the Covid-19 pandemic (7). While many states are covering healthcare for uninsured immigrant populations, a push into this legislative direction was caused by the immense burden Covid-19 placed on this population, due to being front-line/essential workers, with decreased access to regular healthcare. The absence of healthcare coverage for this population surely increased the use of emergency services in the pandemic and increased burden upon those who worked in the ED as patients they would likely utilize emergency services as a last resort, due to lack of healthcare access. The uninsured immigrant population will not disappear within the near future, and it is in the benefit of the nation to pursue strategies that incorporate and protect this vulnerable population (13).  


RESOURCES FOR HEALTH PROFESSIONALS


  1. Doctors for Immigrants: to help develop healthcare facilities policies regarding fear among immigrants due to immigration enforcement and promote positive health-seeking behaviors among these individuals:  https://doctorsforimmigrants.com/ourwork/#ourtoolkit

  2. Sanctuary Doctoring: An approach: ​​https://journalofethics.ama-assn.org/article/good-sanctuary-doctoring-undocumented-patients/2019-01?Effort%2BCode=FBB007

Demonstration Video: https://hsd.luc.edu/bioethics/content/sanctuary-doctor/

  1. National Immigration Law Center: HCPs and Immigration Enforcement: https://www.nilc.org/issues/immigration-enforcement/healthcare-provider-and-patients-rights-imm-enf/

Immigration Enforcement: https://www.nilc.org/issues/immigration-enforcement/

  1. National Center for Medical-Legal Partnership: Use of legal services to improve individual and population health:  https://medical-legalpartnership.org/resources/

  2. American Academy of Pediatrics: Immigrant child health resources/tool-kit: https://www.aap.org/en/patient-care/immigrant-child-health/

  3. Physician for Human Rights (PHR) Asylum Network Resources: resources and guides for advocacy and evaluators: https://phr.org/issues/asylum-and-persecution/asylum-network-resources-linked/

  4. The Hastings Center: undocumented immigrants and healthcare access in the U.S.: public database and projects resources: https://undocumented.thehastingscenter.org

Supporting Health Equity and Affordable Health Coverage for Immigrant Populations: https://www.rwjf.org/en/library/research/2021/10/supporting-health-equity-and-affordable-health-coverage-for-immigrant-populations.html


SOCIAL MEDIA CONTENT:


  1. TEDMED: Denisse Rojas Marquez - No longer afraid: and undocumented immigrant’s experience in American healthcare: https://www.tedmed.com/talks/show?id=730486


REFERENCES:


  1. Chang CD. Social Determinants of Health and Health Disparities Among Immigrants and their Children. Curr Probl Pediatr Adolesc Health Care. 2019 Jan;49(1):23-30. doi: 10.1016/j.cppeds.2018.11.009. Epub 2018 Dec 28. PMID: 30595524.

  2. Health People 2030: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. . (n.d.). Social Determinants of Health. Social Determinants of Health - Healthy People 2030. Retrieved January 18, 2022, from https://health.gov/healthypeople/objectives-and-data/social-determinants-health 

  3. Berlinger, N., & Zacharias, R. (2019, January). Resources for Teaching and Learning About Immigrant Health Care in Health Professions Education. AMA Journal of Ethics. Retrieved January 17, 2022, from https://journalofethics.ama-assn.org/sites/journalofethics.ama-assn.org/files/2018-12/medu2-1901_1.pdf

  4. Bustamante, A. V., Chen, J., Félix Beltrán, L., & Ortega, A. N. (2021). Health Policy Challenges Posed By Shifting Demographics And Health Trends Among Immigrants To The United States. Health Affairs, 40(7), 1028–1037. https://doi.org/10.1377/hlthaff.2021.00037

  5. Hill, J., Rodriguez, D. X., & McDaniel, P. N. (2021). Immigration status as a health care barrier in the USA during COVID-19. Journal of Migration and Health, 4, 100036. https://doi.org/10.1016/j.jmh.2021.100036

  6. Public Charge. (2021, November 29). USCIS. https://www.uscis.gov/green-card/green-card-processes-and-procedures/public-charge

  7. Department of Homeland Security, Office of Immigration Statistics, & Countering of Weapons of Mass Destruction Office. (2021, May). Covid-19 Vulnerability by Immigration Status. https://www.dhs.gov/sites/default/files/publications/immigration-statistics/research_reports/research_paper_covid-19_vulnerability_by_immigration_status_may_2021.pdf

  8. ICE in the ER: How U.S. Policies are Causing an Immigrant Health Crisis. (2018, December 7). Physicians for Human Rights. https://phr.org/our-work/resources/ice-in-the-er-how-u-s-policies-are-causing-an-immigrant-health-crisis/

  9. Ortiz, R., Farrell-Bryan, D., Gutierrez, G., Boen, C., Tam, V., Yun, K., Venkataramani, A. S., & Montoya-Williams, D. (2021). A Content Analysis Of US Sanctuary Immigration Policies: Implications For Research In Social Determinants Of Health. Health Affairs, 40(7), 1145–1153. https://doi.org/10.1377/hlthaff.2021.00097

  10. Ornelas-Dorian, C., Torres, J. M., Sun, J., Aleman, A., Cordova, E., Orue, A., Taira, B. R., Anderson, E., & Rodriguez, R. M. (2021). Provider and administrator-level perspectives on strategies to reduce fear and improve patient trust in the emergency department in times of heightened immigration enforcement. PLOS ONE, 16(9), e0256073. https://doi.org/10.1371/journal.pone.0256073

  11. Jewers, M., & Ku, L. (2021). Noncitizen Children Face Higher Health Harms Compared With Their Siblings Who Have US Citizen Status. Health Affairs, 40(7), 1084–1089. https://doi.org/10.1377/hlthaff.2021.00065

  12. Lipton, B. J., Nguyen, J., & Schiaffino, M. K. (2021). California’s Health4All Kids Expansion And Health Insurance Coverage Among Low-Income Noncitizen Children. Health Affairs, 40(7), 1075–1083. https://doi.org/10.1377/hlthaff.2021.00096

  13. Robert Wood Johnson Foundation. (2021, October). Supporting Health Equity and Affordable Health Coverage for Immigrant Populations. https://www.rwjf.org/en/library/research/2021/10/supporting-health-equity-and-affordable-health-coverage-for-immigrant-populations.html

John Purakal