Running head: HEALTH CARE REFORM’S EFFECT ON IMMIGRANTS
Health Care Reform’s Effect on Immigrants:
New and Undocumented Immigrant’s Access to Care
Eden V. Thompson, RN
University of North Georgia
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Health Care Reform’s Effect on Immigrants:
New and Undocumented Immigrant’s Access to Care
The Patient Protection and Affordable Care Act (PPACA), signed into law in 2010 has
provisions intended to expand access to insurance coverage to uninsured people and improve
access to healthcare services to all residents of the U.S. The Law includes income-based
subsides, health insurance requirements, expansion of Medicaid and aims to achieve increased
enrollment and utilization of Medicaid and Children’s Health Insurance Program (CHIP)
coverage (Kenney & Huntress, 2012). Under current law, there is variation across states with
respect to eligibility requirements for those programs and no requirements of the state to
maintain coverage or prevent denial of enrollment. Under the ACA, eligibility expansions will
improve access to insurance, Medicaid, and CHIP coverage and states will be required to
maintain standards for adult and children’s coverage via the Maintenance of Effort (MOE)
provision (Kenney & Huntress, 2012). However, for the immigrant population, some variations
to these standards exist. Immigrants who have been legal residents for less than five years are
ineligible for Medicaid or CHIP coverage, except for emergency care, and are not subject to the
MOE provision but are allowed to purchase private insurance on state exchanges (Kenney &
Huntress, 2012). However, with the majority of these individuals living at or below poverty
level, they may still find it unaffordable and many are projected to remain uninsured. Research
indicates that immigrant children and native born children with non-citizen parents are less likely
to participate in Medicaid or CHIP and their parent’s lack of coverage becomes a barrier to them
receiving basic care (Kenney & Huntress, 2012). Illegal immigrants are ineligible for any
government assistance program or the purchase of unsubsidized coverage through state exchange
under the ACA, but they do remain eligible for emergency care under Medicaid which should
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help hospitals to provide services to this population. Because of the five year gap restrictions,
inability to afford privatized insurance due to income level, and the exclusion of all
undocumented immigrants, their access to care will likely depend on community health services
and safety net providers beyond emergency medical care, such as preventative and basic care
(Kenney & Huntress, 2012). The ACA provides a five year 11 billion dollar program for the
funding of community health centers to provide care to vulnerable populations which will be an
important source for those who remain uninsured after ACA provisions are fully implemented
(Kenney & Huntress, 2012). Although there are bans on immigrants obtaining federal
government assistance, it remains the decision of the state to expand CHIP and Medicaid
eligibility to pregnant women and children who have been residing legally for less than five
years or to fund charity and community health programs that address the needs of the immigrant
population despite documentation status (Kenney & Huntress, 2012). Without expansion of
insurance coverage to legal residents and some basic care and preventative services to the
immigrant population, despite documentation or residency status, a significant percentage of
individuals will still have little to no access to care due to low-income status and lack of funding
for programs that serve this population. This lack of coverage combined with access to
education, occupation and socioeconomic status, financial cost to hospitals, and lack of resources
for community health services and charity care impact the health of immigrants and their
children which affects the health of the overall U.S. population. In order to better understand the
effects of the PPACA on the uninsured immigrant population and gain support for providing
them with some access to basic and preventative care, one must gain public support for reform
on a state level through examination of the impact of the ACA’s exclusions on a financial and
ethical level as well as its impact on the health of the general U.S populace.
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According to Cunningham, Hibbard, and Gibbons (2011), differences in patient
activation, which refers to the knowledge, skills, and confidence people need to manage their
own health, are likely to contribute to disparities in healthcare between whites and minorities.
These differences in access to care and overall healthcare were evidenced by a 2007 study of
over 12,00 U.S. households in which overall activation levels for Hispanics were shown to be
lower than whites with 24.8% high level of activation in Hispanics vs. 45.3% of whites
(Cunningham et al., 2011). Lower activation among foreign born Hispanics may reflect cultural
differences, differences in education or income level, and/or differences in access to care.
Increasing patient activation can be an important component of reducing racial and ethnic
disparities. Patients who reported that their providers gave them some access to self-management
programs were more compliant and involved in their own care and were more likely to
participate in programs providing peer support and skills development to manage any existing
health issues (Cunningham et al., 2011). Those patients who receive support tailored to their
level of activation are more likely to have improved health outcomes; therefore, reform will need
to include education and support of all patients to become more active in self-care. This is
especially important at the community health level where immigrants are more likely to seek
care because when information is provided about self-care management and avoidance of health
risks, there is a lower chance of this population requiring costly medical services that the
government may or may not compensate providers for depending on if the individual meets
federal requirements for coverage.
Newly-arrived immigrants represent a vulnerable population because they have lower
insurance coverage rates across the population and less access to care. Education and English
language proficiency may be important in shaping access to care and these both play a role in
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occupational status which influences how immigrants and their children gain access to care and
determine if healthcare is affordable (Kao, Park, Min, & Myers, 2010). With a large portion of
immigrants being low-income them having to meet residency requirements for five years before
being eligible for government assistance, many are unable to afford healthcare and have no
access to care even if they are here legally. Measures of assimilation such as education and
English language proficiency are important, especially with immigrant children or the native
born children of immigrants (Kao et al., 2010). Education assists these people and their children
in obtaining a position in an occupation that will increase their access to health care in the future
via income or an employer who provides insurance coverage. However, if these children cannot
be taken care of due to lack of access, they are more likely to miss school which is a barrier to
education. A lack of education and cumulative social disadvantages adversely affect the ability
of immigrant children and children of immigrants to become productive members of the
workforce (Pati & Danagoulian, 2008).
According to Pati and Danagoulian (2008), because children depend on their parents to
obtain necessary healthcare coverage and are their primary care takers parental immigration
status may influence a child’s health outcomes. A study was conducted in order to determine
whether immigrant children are becoming increasingly or decreasingly reliant on public health
programs. Immigrant children are increasingly likely to be uninsured as opposed to relying on
public health insurance and are less likely to participate in public or community health programs.
Also, foreign born children are more likely to live in families with incomes below the poverty
level which contributes to their inability to receive needed medical care (Pati & Danagoulian,
2008). Cost of preventative care is relatively small in comparison to other healthcare costs ,so
funding to provide for these services and basic care for children who are still uninsured after
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ACA provisions would be financially beneficial to hospitals and the government because it helps
to avoid more costly issues later in life. Large numbers of uninsured children raises concerns
about their long-term health and functional outcomes because they are more likely to have poor
health status and less likely to have access to education about maintaining their own health (Pati
& Danagoulian, 2008). Policies that assist in providing basic care and education to this
population have the potential to improve their socioeconomic well-being and lower
uncompensated emergency care costs.
Jerome-D'Emilia & Suplee (2012) argue that “health disparities and outcomes are
determined by socioeconomic class and education as much as by race and ethnicity” which adds
to the likelihood of immigrants, especially undocumented immigrants, to have lower access to
care. A study was conducted focusing on the use of safety net services before and after insurance
coverage for those eligible and those who would remain ineligible after the new ACA provisions,
based on their undocumented immigration status. This was done in order to determine the
frequency of use of charity care services and how important they will be in the future as a
resource to those who remain uninsured after the reform provisions are phased in (JeromeD'Emilia & Suplee, 2012). There is evidence that those who immigrant who are uninsured due
to the five year residency requirement are less likely to enroll in government assistance when it
does become applicable. Also, those who remained uninsured were less likely to enroll in
government assistance or to seek care until absolutely necessary; therefore, the ones who do seek
care at emergency rooms or community health services are those who are the most sick and have
the lowest incomes while also requiring more medical intervention (Jerome-D'Emilia & Suplee,
2012). Although there is a five year funding program in the ACA for development of
community health centers, the number of people who will still be uninsured due to residency
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requirements or illegal status indicates that these centers may lack the resources needed to meet
the needs of this population (Jerome-D'Emilia & Suplee, 2012). It is the state’s choice whether
or not to use funds to create some kind of program to provide minimal care to the uninsured after
ACA provisions are in effect and because of this, states should elect to find ways of increasing
funding to community health services and even charity care because the health of this population
will affect the overall health of the community in which that population lives.
According to Bustamante et al., 88% of health disparities between documented and
undocumented immigrants can be traced to socioeconomic and demographic characteristics such
as access to care, income level, and language barriers. “More limited healthcare access and
utilization among undocumented immigrants is likely to aggravate undiagnosed health problems”
(Bustamante, Fang, Garza, Carter-Pokras, Wallace, Rizzo, & Ortega,2012). The ACA will
increase funding to community health centers which could improve access to care for all
immigrants. However, a lack of public support of any type of preventative services provided to
undocumented immigrants limits the type of care that can be provided outside of charity
hospitals and community clinics as well as funding and resources for establishments providing
services to this population.
There is little support for including undocumented immigrants in state health care reform,
particularly when compared with other segments of the population such as the homeless and the
unemployed. The highest public support, at 85%, is for all children to be included while the two
subgroups for which the majority of the public does not support coverage are new foreign-born
residents and undocumented immigrants at only 4% of the public supporting it (Sanchez,
Sanchez-Youngman, Goodin, Santos, & Valdez, 2011). Public opinion plays an important role in
the policy making process because those attitudes influence implementation of policies such as
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the option for state level reform to provide basic care and preventative services to the
aforementioned populations. While controversy exists regarding coverage for pregnant women
and children despite immigration status, national health reform will fail to completely eliminate
health care access problems unless the immigrant population, including undocumented
immigrants, has some access to basic preventative care (Sanchez, et al., 2011). Due to the
provisions of the ACA, responsibility lies with the state to decide to fund programs for expansion
of community health services and charity services for this vulnerable population. However,
without support from the public, it is unlikely that reform on the state level will occur. More
limited access and utilization will aggravate health problems and undocumented immigrants who
arrive at the ED are more likely to have severe problems requiring more costly treatments and
interventions (Bustamante et al., 2012).
Viladrich (2012) states that the poor health in the immigrant population will have a
negative effect in the long run on emergency services and uncompensated care costs.
Consequently, providing preventative health services is seen as a cost effective strategy and
extending access to healthcare to all residents, including all categories of immigrants, is
beneficial from an economic and population health perspective. Viladrich (2012) explains that
because immigrants, regardless of legal status, tend to report less use of the U.S. health care
system; lower expenditures plus their contributions to the economy make it appear worthwhile to
provide minimal care to maintain their productivity in the workforce. Lack of immunizations and
basic care to immigrants pose a threat to the U.S. population, therefore, preventative measures
provided to all residents at the level of basic prevention and treatment services would decrease
the likelihood of disease transmission across the U.S. population (Nandi, Loue, & Galea, 2009).
Because immigrants without coverage often wait to obtain health care from clinics and
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emergency rooms until absolutely necessary, offering some degree of preventative care and
education can help to decrease the prevalence of complications from chronic diseases and can
reduce net costs from preventable conditions from an economic perspective (Nandi et al., 2009).
In addition, pregnant woman and children may be seen as needing access to care on an ethical
standpoint (Viladrich, 2012). Human rights and ethics framed with immigrant contributions,
emergency and chronic condition costs, as well as public safety through immunizations and
screenings may gain support for extending access to care for preventative measures to this
population from the public to initiate state reform.
According to Zuckerman, Waidmann, and Lawton, 2011, Only 1 in 10 undocumented
immigrants have regular access to public health care and the provisions of the ACA directly
disadvantage undocumented immigrant and legal immigrants who have resited in the U.S. for
less than five years relative to citizens of similar socioeconomic circumstances. Exclusions from
the Affordable Care Act may also serve as a barrier to the native-born children of undocumented
immigrants to receive health care. Increased funding for community health and more options for
using emergency Medicaid as specified by the ACA may help pay for those uninsured persons
(Zuckerman, et al., 2011). Safety-net providers and charity healthcare, which are decreasing
over time with a lack of incentive to healthcare professionals to provide these services and a lack
of resources, will serve the remaining immigrant population (Zuckerman, et al., 2011). Health
care reform could expand to pay for preventative care for undocumented immigrants and new
residents to reduce future healthcare costs if public opinion can be influenced at the state reform
level over time with by dissemination of information regarding the known benefits this reform
would have.
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After review of the major provisions set forth in the PPACA that affect the immigrant
population’s access to care, the question of impact on the general population as well as future
generations of this vulnerable population versus the costs and benefits to state reform for
expanding preventative and basic health care services was explored. Due to a lack of education
and English proficiency as well as no substantial health care education, patient activation in their
own self-care is low in the immigrant population. The ACA provides standards that require
information distribution to be done in the individual client’s native language, however, that is
often not enough incentive to get a person to understand and comply to healthy habits and
management of current conditions. State reform on health should include education at the
community level so uninsured people have all the information required to make good choices
about their health. Children in this population are less likely to have access to care, do not quality
for insurance, and/or have parents who do not seek care due to low income and/or documentation
status. That, combined with those children being in public schools, missing class time and not
being immunized, indicates a need for change regarding access to basic and preventative care for
both the children and families. Because the uninsured wait longer to seek treatment, they are
more ill at time of visit and require higher uncompensated hospital costs so it is financially
beneficial to increase access to basic care at the state level to decrease costly emergency care
visits for exacerbated preventable health issues. They will still rely on community health services
and charity care, so funding to provide resources and possibly compensation to healthcare
professionals working in this area is very important to the success of state level healthcare
reform for the uninsured. Policy change cannot happen without public support, therefore,
information about the health benefits to the general public, financial benefits to healthcare
providers and local government, ethical dilemmas about right to healthcare and providing
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services , particularly to children and pregnant women, as well as public safety and the effects on
community healthy via preventative care such as immunizations is essential. Providing the public
with this information will hopefully garner more support for state level reform to include more
benefits for this vulnerable population after the PPACA is fully implemented.
References
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Bustamante, A., Fang, H., Garza, J., Carter-Pokras, O., Wallace, S., Rizzo, J., & Ortega, A.
(2012). Variations in healthcare access and utilization among mexican immigrants: The
role of documentation status. Journal Of Immigrant & Minority Health, 14(1),146155.
doi:http://dx.doi.org/10.1007/s10903-010-9406-9.
Cunningham, P. J., Hibbard, J., & Gibbons, C. B. (2011). Raising low 'patient activation' rates
among hispanic immigrants may equal expanded coverage in reducing access
disparities. Health Affairs, 30(10), 1888-1894.doi:http://dx.doi.org/10.1377/hlthaff.
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Jerome-D'Emilia, B., & Suplee, P. D. (2012). The ACA and the undocumented. American
Journal of Nursing, 112(4), 21-27.
Kao, D., Park, J., Min, S., & Myers, D. (2010). Occupational status and health insurance among
immigrants: effects by generation, length of residence in U.S., and race. Journal of
Immigrant & Minority Health, 12(3), 290-301.doi:http://dx.doi.org/10.1007/s10903-0089189-4.
Kenney, G.M., & Huntress, M. (2012). The affordable care act: coverage implications and issues
for immigrant families. ASPE Issue Brief. April 2012. Retrieved from http://aspe.hhs.
gov/hsp/11/ImmigrantAccess/Coverage/ib.shtml.
Nandi, A., Loue, S., & Galea, S. (2009). Expanding the universe of universal coverage: the
population health argument for increasing coverage for immigrants. Journal Of
Immigrant & Minority Health, 11(6), 433-436. doi:http://dx.doi.org/10.1007/s10903-0099267-2.
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Pati, S., & Danagoulian, S. (2008). Immigrant children's reliance on public health insurance in
the wake of immigration reform. American Journal of Public Health, 98(11), 2004-2010.
doi:http://dx.doi.org/10.2105/AJPH.2007.125773.
Sanchez, G. R., Sanchez-Youngman, S., R., Goodin, A., Santos, R., & Valdez,R.B. (2011).
Explaining public support (or lack thereof) for extending health coverage to
undocumented immigrants. Journal of Health Care For The Poor & Underserved, 22(2),
683-699.doi:http://dx.doi.org/10.1353/hpu.2011.0043.
Viladrich, A. (2012). Beyond welfare reform: Reframing undocumented immigrants’ entitlement
to health care in the United States, a critical review. Social Science & Medicine, 74(6),
822-829.doi:http://dx.doi.org/10.1016/j.socscimed.2011.05.050.
Zuckerman, S., Waidmann, T. A., & Lawton, E. (2011). Undocumented immigrants, left out of
health reform, likely to continue to grow as share of the uninsured. Health
Affairs, 30(10), 1997-2001.doi:http://dx.doi.org/10.1377/hlthaff.2011.0604.
I, _Eden V. Thompson_________, attest that none of the information used
in composing this assignment has been used in any assignment in this course,
any other course within the University of North Georgia system, or at any other
college or university.
"On my honor, I pledge that I have neither given nor received unauthorized help on this
work."
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