Health policies addressing America's newcomers.

ABSTRACT

US Immigration and Naturalization Services estimates that 77 million illegal immigrants currently live in the country. Lack of health insurance is a major issue facing the immigrant population. Recently, there has been much debate and controversy over immigrant's rights. In the wake of Hurricane Katrina, Mississippi will likely be challenged with an influx of undocumented workers. As the number of undocumented immigrants in the United States increases, health policy issues must be addressed at the local, state and federal levels. The purpose of this article is to explore the socioeconomic impact these undocumented individuals have on our society and discuss health policy issues that may influence their access to health care.

INTRODUCTION

According to U.S. Census Bureau statistics, the number of uninsured in America has reached over 41 million people. This figure is expected to escalate over the next several years to greater than 60 million people. In 2000, there were over 32 million foreign born residents in the United States totaling 11 percent of the population (U.S. Census Bureau, 2004). Data from the Kaiser Family Foundation (2004) indicates that 27 percent of immigrants are in the United States illegally. There are six states that account for the largest populations of immigrants: California was home to almost a third of all immigrants and another 40 percent were from New York, Florida, Texas, Illinois, and New Jersey. Future predictions indicate that immigrants will migrate to other areas of the country and will become more dispersed in populations across the United States. The Hispanic ethnic group is now considered the largest minority group in the United States surpassing African Americans.

The impact of illegal immigration in Mississippi has considerable social and economic consequences. In 2004, the Census Bureau estimated that Mississippi's population was 2,902,966 (U.S. Census Bureau). According to U.S. Immigration and Naturalization Service, (INS) data, it is estimated that the illegal immigrant population of Mississippi was approximately 8,000 residents in 2000 which was double that of the last previous INS estimate in 1996 (U.S. Immigration and Naturalization Service, 2003). As a result of the Hurricane Katrina, these numbers have likely significantly increased. It is estimated that the annual fiscal costs to Mississippi Taxpayers for emergency medical care, education, and incarceration from illegal or "guest" workers are approximately $32 million dollars a year. It is projected to escalate to over $54 million in 2010 and 94 million in 2020 (U.S. Immigration and Naturalization Service).

There are few articles with reference to health policies and Hispanic immigrants. Barriers to access of care that are common among this minority group include language barriers, high rates of uninsurance, and low income levels (Bell, 2004; Smith, 2001). These barriers leave the Hispanic population in need of new health policies that will ensure the wellbeing of the individuals and the communities in which they live. This literature synthesis will examine the social, economic, ethical, legal and political factors surrounding undocumented Hispanic immigrants and their health care disparities.

Economic Factors

The effects of uninsurance are well documented and have been shown to produce profound negative outcomes for individuals, communities, and populations. Hispanic immigrants are a large and growing segment of American society and are considered disproportionately low income and uninsured. Hispanics continue to be the lowest insured of any ethnic group (Tieman, 2004). Recent immigrants have the highest uninsurance rate at 46 percent (Institutes of Medicine [IOM], 2001). Increasingly, hospitals across the nation are seeing similarly increasing numbers in uncompensated care for uninsured immigrants. The money from this uncompensated care comes from the government, philanthropic sources, as well as by funds generated from insured patients. The economic effects on communities with relatively high numbers of uninsured individuals ultimately results in raising taxes, higher costs for health services, and loss of philanthropic dollars for other purposes. Thus, health policies at the state and federal level addressing healthcare access of uninsured immigrants will have significant economic effects on American communities.

In 1996 the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) restricted federal and state benefits available to immigrants. PRWORA legislation excludes immigrants arriving in the United States after August 1996 from receiving benefits for the first five years upon arriving in the United States. Although PRWORA's provisions were intended to allow families to maintain health coverage after cash benefits ended, separate enrollment processes and confusion led to reduced enrollment in Medicaid programs (Smith, 2001). Changes in legislation from PRWORA have resulted in more difficulty for immigrants to obtain services. Moreover, states that wish to provide benefits to undocumented illegals must pass specific laws to do so (Berk, Schur, Chaves & Frankel, 2000). Most uninsured adults, 85%, either work or live in families where someone works at least part time (Thrall & Scalise, 2002). The high uninsured rate for Hispanics reflects the fact that Hispanic wage earners are much less likely than average to be offered employment based coverage. Minority and immigrant populations work at jobs that do not offer health insurance and have lower wage jobs that prevent them from purchasing insurance (Thrall & Scalise, 2002). Adults with lower incomes and level of education use fewer health services, are more likely to be uninsured, and have worse health outcomes than do better educated and higher income adults (IOM, 2002).

It has been argued that health and social services are an incentive for immigration. It has been proposed that if services were eliminated, fewer immigrants would come to the United States, thereby removing the burden imposed on the health care delivery system. Promoting legislation that would deny access services to undocumented immigrants, policymakers may hope to decrease immigration. However, according to Berk et al. (2000) excluding immigrants from government health care services is unlikely to effect immigration. In a study of immigrants who applied for legal status under the 1986 Immigration Reform and Control Act, ninety four percent (94%) of respondents cited economic reasons for immigration. Similarly, Berk et al. found that social services did not influence Hispanic immigrants' intentions to remain in the United States. It appears that only substantial changes in economic opportunity on either side of the border will influence the flow of persons crossing to the United States.

Ethical Factors

Under current policy, access to emergency services is afforded to all persons who are within the United States borders. The United States does not guarantee its citizens or residents access to personal healthcare services beyond treatment to stabilize an emergency condition and care at childbirth. Minimum national standards of access to health services was established by the federal Emergency Medical Treatment and Active Labor Act (EMTALA), a provision of the Omnibus Budget Reconciliation Act of 1986. Medical screening, stabilization of an acute or life threatening condition and transfer are guaranteed universally by the EMTALA act (Bilchik, 2001). The promise of EMTALA that an uninsured person will at least be seen and medically stabilized, and the generally high quality of acute care and it's around the clock accessibility, make the hospital emergency department a logical choice for uninsured persons. However, uninsured persons with traumatic injuries are less likely to be admitted to the hospital, receive fewer services when admitted, and are more likely to die than insured trauma victims (IOM, 2002a). The gap in emergency care is particularly relevant because current federal policy allows noncitizen immigrants, including undocumented illegals to receive emergency Medicaid services, even if they are ineligible for full coverage. Findings from Berk et al. suggest that current policies are not effective and that states could do more to facilitate emergency Medicaid access for immigrants

How would providing care to the uninsured beyond emergency care improve their outcomes: 1) the uninsured would use more health care services; 2) the uninsured would receive more appropriate preventative care; and 3) the uninsured would better manage their chronic conditions? Most importantly if adults who now lack health insurance were to be insured on a stable and ongoing basis, their health status would likely be better than it would be without health insurance and their risk of dying prematurely could be reduced (IOM, 2002b). Health insurance is associated with better health outcomes for adults and with their receipt of appropriate care across a range of preventative, chronic, and acute care services. Adults without health insurance coverage die sooner and experience greater declines in health status over time than do adults with continuous coverage. Population groups that most often lack stable health insurance coverage and that have worse health status include racial and ethnic groups and lower income adults. These groups of people would benefit most from increased health insurance coverage. Increased coverage would likely reduce some of the racial and ethnic disparities in the utilization of appropriate health care services and may also reduce disparities in morbidity and mortality among ethnic groups.

Legal Factors

The legal duty of hospital Emergency Department's and trauma units to screen and medically stabilize all patients regardless of the ability to pay for services is one source of financial and legal liability for hospitals. A high uninsured rate over time or an increase in the number of uninsured patients is likely to reduce a hospital's financial margin or even result in losses. A significant source of stress on regional trauma centers is related to the high proportion of uninsured patients that they serve. In response hospitals may decline to open a trauma center or may decide to close an existing trauma center in response to the financial stress and legal liabilities associated with treating trauma victims (Berk, et al.; Ku & Matani). The Medicare Modernization Act of 2003 included a new reimbursement program for the cost of emergency health services for illegal immigrants. Section 1011 reimburses health care providers up to $250 million per year for years 2005-2008 and the highest amounts will be forwarded to the states with the most immigrants (Centers for Medicare and Medicaid Services, 2003).

The Civil Rights Act of 1964 prohibits groups and individuals receiving federal funds from discriminating based on national origin. Non-English speaking people who are seeing providers that receive federal funds such as Medicare and Medicaid must be provided access to an interpreter. Lawsuits have been filed over care administered to non-English speaking patients without an interpreter. Legally, medical treatment rendered to non-English speaking patients must be explained by an interpreter. With a growing population of Spanish speaking people in the United States, increased burden is placed on the healthcare facility to provide an interpreter for this patient population. A facility may be providing uncompensated care in addition to paying for an interpreter. In many cases, the cost of providing an interpreter may be higher than the reimbursement rate for the healthcare provider (Kaiser Family Foundation, 2003; Bell).

Social factors

The facilities of states, counties, and municipalities are, often by default, providers of last resort of patients without the financial means to pay for their own care. Local agencies are more likely than state programs to be involved in the delivery of health services. For newcomers, difficulties with access to care include the pressures of diminishing state care budgets, infrastructure demands, and funding uncertainties that haunt policymakers (Smith). Without a source of public or private funds to cover the costs of uncompensated care for uninsured immigrants, hospitals may trim the hours and availability of services or close some or all of their operations entirely, leaving all residents to seek services elsewhere. Reimbursement for uncompensated care is provided differently across the nation. Some states reimburse local health departments, public hospitals, or clinics for the direct provision of care; some reimburse all hospitals in the state for a percentage of their expenditures; some finance state and county catastrophic care funds; and others subsidize packages of services that resemble an insurance plan (IOM, 2003). Some states explicitly assign responsibility for this role in their constitutions or by statute, while others acknowledge the obligation implicitly through annual budgetary appropriations for personal health care services. Although regulations about immigration are federal policy issues, health policies regarding payment for care afforded to uninsured immigrants are at the state and local level.

How does uninsurance affect the health services in the community? How does uninsurance within a community affect the availability of local health services? Any community resident may experience the results of decisions made about care for those without health insurance when they encounter the local public health infrastructure. Although insured and uninsured members of a community are likely to be adversely affected, members of medically underserved groups are particularly likely to suffer. These groups have fewer options for obtaining health services except for emergency departments who are required to see patients regardless of insurance (IOM, 2003). A high or rising uninsured rate within a community may result in allocation of public funds and staff resources away from public health programs that serve all members of the community and toward direct services delivery urgently needed by low income uninsured persons. The redeployment of public health agency resources away from population health activities to provide personal health care services to uninsured residents, along with the general underutilization of and limited access to care by uninsured members of the community can fuel the spread of disease and undermine communicable disease control efforts, prevention activities, such as immunizations programs. It is both mistaken and dangerous to assume that uninsurance affects only those who are uninsured. Further research is needed to adopt health policies that will address uninsurance due to its affects on all of the community population.

Political factors

Hispanics who identified themselves as noncitizens are more than twice as likely to go without health insurance (IOM, 2001). Being a noncitizen adult or the child of a noncitizen parent reduces access to ambulatory medical care and emergency room care, after factors such as health status, income, and race/ethnicity are controlled for (Ku & Matani, 2001). Noncitizen immigrants have large gaps in their health insurance coverage and access to health care, even when children are citizens (Bell, 2004). A review of the literature by Castle, Timbie, Sendersky, Curtis & Feather (2003), on the interaction of race, ethnicity, and socioeconomic status with health insurance, concluded that health insurance makes a positive contribution to the likelihood of receiving appropriate screening services, although racial and ethnic disparities persist independent of health insurance status. Approximately one-half of uninsured adults are non-Hispanic whites, more than a quarter are Hispanic and one out of six are African American. Almost 2/3 of uninsured fall below the federal poverty level.

From a policy perspective, immigrants' access and coverage disparities stem in part from specific policy changes that treat new legal immigrants differently from both existing immigrants and citizens when determining eligibility for Medicaid and public benefits. Even for immigrants who remain eligible for Medicaid benefits, fear and confusion create barriers to enrollment for fear and concern about becoming a public charge and thus ineligible for citizenship. The most recent immigration policy, proposed in January 2004 by President George W. Bush, allows more freely open borders for temporary workers in the United States. However, the healthcare of these new members of American society is not specified at the state level by the administration. Current policy denies government healthcare coverage benefits for the first five years immigrants are in the country. The jobs that the temporary workers may fill are usually low paying and are without insurance benefits. There may be advantages to having immigrants fill jobs that are unwanted by citizens of the United States but when they become ill or are in an accident the burden of care is placed on the local communities. With a prediction for even greater numbers of immigrants in more diverse populations across the nation, it is time for policy decisions to be made to account for the healthcare of immigrants. An increase in immigration to an area can raise the healthcare needs and costs to all in the community. Broad based health insurance strategies across the entire uninsured population would be more likely to produce benefits than would healthcare coverage provided only for trauma or Emergency care.

SUMMARY

The background of issues related to healthcare access has identified social, economical, ethical, legal and political aspects related to providing care for undocumented Hispanic immigrants. Stakeholders that would be affected by new health policies could be ethnic immigrants of any origin, members of communities where they reside and healthcare providers in those communities. Healthcare providers could benefit from health policies to address immigrants because they are currently treating many immigrants with no reimbursement resulting in economic hardship. Immigrants may benefit from health policies because it may improve their access to healthcare and diminish disparities in care to minorities. Communities would benefit from health policies because the individuals of the community may be in better health and may be more productive community members. Other stakeholders may include large corporations who are employing an increasing numbers of immigrants. Political policies may be needed to make them accountable for the provision health insurance coverage as part of their employment agreement obligations. Immigrants contribute to our American society in a number of ways. Because cultural diversity has been invaluable for the growth of this country, health care providers must approach newcomers with great respect and encouragement-versus disgust and authoritarianism (Smith, 2001). The nation was founded on beliefs of opportunity for all members. However, the current health policies are lacking in number and effectiveness because Hispanics immigrants are the most uninsured members of American society with poor health outcomes. If America continues to grow with large numbers of immigrants then we must research and begin to plan for the future growth.

Mississippi has an enormous stake in the provision of healthcare for Hispanic immigrants. In the wake of Hurricane Katrina and the rebuilding of large coastal communities, the influx of illegal and migrant workers has increased exponentially. The current price tag for this disaster in health care cost is projected to reach over $54 million within the next four years.

REFERENCES

Bell, M. T. (2004, September). Immigrants' Access to Quality Health Care. Retrieved July 4, 2004, from The Council of State Governments: http://www.csg.org

Berk, M. L., Schur, C. L., Chavez, L. R., & Frankel, M. (2000). Health care use among undocumented Latino immigrants. HealthAffairs, 19, 51-64.

Bilchik, G. S. (2001, May 12). No easy answers. Retrieved July 11, 2004, from Hospitals and Health Networks: http://www.hhnmag.com

Castle, L. D., Timbie, J. W., Sendersky, V., Curtis, L. H., & Feather, K. A. (2003). Toward estimating the impact of changes in immigrants' insurance eligibility on hospital expenditures for uncompensated care. BioMed Central Health Services Research, 3,1-10.

Centers for Medicare and Medicaid Services. (2003). Medicare Prescription Drug Improvement and Modernization Act of 2003. (Pub. L. 108-173). Retrieved May 2, 2006 from http://www.medicare.gov.

Institute of Medicine. (2001). Coverage matters. (National Academy Press No. 04258591). Washington, DC: U.S. National Academy of Sciences.

Institute of Medicine. (2002a). Care without coverage. (National Academy Press No. 49918281). Washington, DC: U.S. National Academy of Sciences.

Institute of Medicine. (2002b). Health insurance is a family matter. (National Academy Press No. 50805797). Washington, DC: U.S. National Academy of Sciences.

Institute of Medicine. (2003). A shared destiny. (National Academy Press No. 52043049). Washington, DC: U.S. National Academy of Sciences.

The Kaiser Commission on Medicaid and the Uninsured. (2004, November). Key facts: Immigrants' health care coverage and access. Washington, D.C., Henry J. Kaiser Family Foundation. Retrieved May 2, 2006 from http://www.kff.org.

The Kaiser Commission on Medicaid and the Uninsured. (2003, August). Key facts: Immigrants' health care coverage and access. Washington, D.C., Henry J. Kaiser Family Foundation. Retrieved July 23, 2005 from http://www.kff.org.

Ku, L, & Matani, S. (2001). Left out immigrants' access to health care and insurance. Health Affairs, 20, 247-256.

Lydersen, K. (2005). Some immigrants suffer doubly after hurricane Katrina. The New Standard, September 28.

Smith, L. S. (2001). Health of America's newcomers. Journal of Community Health Nursing, 18, 53-68.

Thrall, T. H., & Scalise, D. (2002, November 10). Americas uninsured rethinking the problem that won't go away. Retrieved July 11, 2004, from Hospitals and Health Networks: http://www.hhnmag.com.

Tieman, J. (2004, August 30). Unsure about the uninsured. Modern Healthcare, 34, 6-10.

U.S. Census Bureau (2004). Retrieved May 2, 2006 from http://www.census.gov.

U.S. Immigration and Naturalization Service. (2003, January). Estimates of the Unauthorized Immigrant Population Residing in the United States: 1990-2000, Office of Policy Planning, U.S. Immigration and Naturalization Service.

Brad Martin, Jean Walker, Tina Mitchell Martin, Lisa Haynie and Anne Norwood.

The University of Mississippi Medical Center 

Jackson, MS

Brad Martin corresponding author: [e-mail]