Dr. Mercado, Pediatrican: Atlanta
Grady Memorial Hospital

“As an American citizen, I
understand that you want to make
sure the resources are there for the
right people. Yet, how can you deny
someone health access? If we don’t
treat and prevent illness…our
community is going to suffer.”
Immigrants and Health
Care
Lynn Christiansen, MSW
New Mexico Title V CYSHCN Director
Susan Chacon, MSW
New Mexico Title V CYSHCN Program
Oklahoma Bill 1804

The State of Oklahoma finds that illegal immigration is causing
economic hardship and lawlessness in this state and that illegal
immigration is encouraged when public agencies within this state
provide public benefits without verifying immigration status. The
State of Oklahoma further finds that when illegal immigrants have
been harbored and sheltered in this state and encouraged to
reside in this state through the issuance of identification cards
that are issued without verifying immigration status, these
practices impede and obstruct the enforcement of federal
immigration law, undermine the security of our borders, and
impermissibly restrict the privileges and immunities of the citizens
of Oklahoma. Therefore, the people of the State of Oklahoma
declare that it is a compelling public interest of this state to
discourage illegal immigration by requiring all agencies within this
state to fully cooperate with federal immigration authorities in the
enforcement of federal immigration laws. The State of Oklahoma
also finds that other measures are necessary to ensure the
integrity of various governmental programs and services.
Penalties HB 1804
 A.
It shall be unlawful for any
person to transport, move, or
attempt to transport in the State of
Oklahoma any alien knowing or in
reckless disregard of the fact that
the alien has come to, entered, or
remained in the United States in
violation of law, in furtherance of the
illegal presence of the alien in the
United States.
Penalties HB 1804
 B.
It shall be unlawful for any
person to conceal, harbor, or shelter
from detection any alien in any place
within the State of Oklahoma,
including any building or means of
transportation, knowing or in
reckless disregard of the fact that
the alien has come to, entered, or
remained in the United States in
violation of law.
Felony Penalty
 D.
Any person violating the
provisions of subsections A or B of
this section shall, upon conviction, be
guilty of a felony punishable by
imprisonment in the custody of the
Department of Corrections for not
less than one (1) year, or by a fine of
not less than One Thousand Dollars
($1,000.00), or by both such fine
and imprisonment
Exceptions to the Law
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Newborn Screening Programs
Public laboratory services
Acute and chronic disease services
HIV/STD services
Terrorism response
Child, adolescent and women’s health (MCH)
Early Intervention program
Dental health program (excluding dental loan)
Child guidance program
WIC program
Immigrant Health Care
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Immigrants, on average, receive about half the health care
services provided to native-born Americans
Immigrants received an average of $1139 worth of care,
compared with $2564 for non-immigrants, according to 2005
study in AJPH.
A much higher percentage of immigrants lack a high school
education, which makes it difficult for them to navigate the health
care system
Immigrant children had fewer doctor visits, took less medication
and made fewer trips to the ER. But their ER costs were nearly
triple those for non-immigrant children.
Immigrant families are more likely to miss routine check-ups and
wait until a condition was more serious before seeking treatment.
They are less likely to receive standard immunizations and more
likely to let chronic problems go untreated.
Ceci Connolly, “Study Paints Bleak Picture of Immigrant Health Care,” 7/26/2005.
Washington Post Online, accessed 9/11/2008.
Immigrant Health Care Cont’d
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Notes contradiction in current policy: i.e. labor and delivery
costs for undocumented immigrant women are covered
under EMSA, but prenatal care and family planning are not
2005 study in American Journal of public Health showed
that annual per capita expenses for health care were 86%
lower for uninsured immigrant children than for uninsured
U.S.-born children; but emergency department
expenditures were more than three times as high.
Noncitizens make up 20% of the 46 million uninsured
people in the U.S.
2005 Deficit Reduction Act requires all persons applying for
or renewing Medicaid coverage to provide proof of identity
and U.S. citizenship.
Susan Okie, MD, “Immigrants and Health Care—At the Intersection of Two Broken Systems,”
New England Journal of Medicine.
Overview of Federal Regulations
and Funding
Immigrant Reform and Control Act/ IRCA1986
 Personal Responsibility and Work
Opportunity Reconciliation Act/PROWRA1996
 Examination and treatment for emergency
medical conditions and women in
labor/EMTALA-1985
 Emergency Services for Undocumented
Aliens/EMSA-1999
 Federal Payments to Hospitals for
Emergency Room Care-2005

Immigrant Reform and Control Act

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Restricts Medicaid and other Federal programs to
newly legalized immigrants
U. S. Attorney General Ruling allowed:
– Exceptions-”don’t ask, don’t tell” also considered not a
provider, a contractor for services
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Emergency Services
Services to pregnant women
National School Lunches
Vocational Education Act
Headstart Programs
Job Training
Public Health Programs as set forth in The Public Health
Service Act. “20 USC 1070”
Federally Qualified Health Centers
RPHCA and FQHC
 RPHCA and FQHC clinics are the safety net for immigrants
 RPHCA – Rural Primary Health Care Act provides state
funding that is supplemental – intent is to help keep their
doors open for people who are unable to pay – should
maximize resources with Medicaid and other insurance
billing NM puts $13 mill into clinics - rare
 FQHC – receive federal funds to operate primary care clinics
– determines payment mechanisms
 Consumer boards oversee compliance and establish
regulations. Board determines sliding scale fees based on
their understanding of their individual communities. Sliding
scale goes to 0 in some cases. Fee not always collected
 Provider shortages – limited resources
 All are 501c3
 93 clinics in NM: some don’t get federal funding
Personal Responsibility and Work
Opportunity Reconciliation Act
 Welfare
reform that restricted
immigrant access to all programs
receiving state and/or federal
funding such as Medicaid
 Required immigrants wait 5 years
after obtaining green card before
applying for benefits
 Shifted responsibility to the states
Title V PROWRA Opinion

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Many HHS programs are targeted to meet the needs of
certain populations such as children or pregnant women.
But unless the authorizing statutes require that the
characteristics of these groups form the basis for denial of
services or benefits, these are not benefits that go to
“eligibility units.” The authorizing statutes of these
programs identify populations with specific characteristics
to clarify the types of services that should be provided;
they do not contemplate that providers use variations in
individual characteristics as a basis for determining
eligibility, on a case by case basis.
Therefore a benefit targeted to certain populations based
on their characteristics, such as a benefit provided under
the Maternal and Child Health program, which provides
health services to women and children, is not a “Federal
public benefit.”
Response to PROWRA
Illinois, NY, D.C., and some CA counties
used own funds to expand health
insurance coverage for undocumented
immigrant children and pregnant women
with low income
 AZ, CO, GA, VA and OK passed laws
making it more difficult for noncitizens to
obtain health care
 AZ and OK criminalized provision of
services to immigrants

Examination and treatment for emergency medical
conditions and women in labor (EMTALA-1985)
– Medical screenings for those who come to the
ER with a complaint and a request to have
their condition evaluated
– Necessary stabilizing treatment for emergency
medical conditions and labor

Restricts transferring of patients until patient is
stabilized
Emergency Services for
Undocumented Aliens (EMSA)
 Provides
Medicaid payments to
hospital emergency rooms on behalf
of undocumented immigrants
2005 Federal Appropriation
 Provided
funding to Emergency
Rooms and doctors for services to
undocumented immigrants/others
who do not have pay source
 Largest allocations went to: CA:
$70.8; TX $46; AZ $45; NY $12.3;
ILL: $10.3; FL$ 8.7 and NM $5.1
million the first year
“Dumping?”: Efforts to coerce undocumented
immigrants to leave U.S.
 Under
federal law, hospitals receiving
Medicare funds must transfer or refer
patients to “appropriate” posthospital care (NY Times)
 Some hospitals choose to return
immigrants to their home countries
 Advocates view practice as
international “dumping”
Immigrant Health Care Services in
New Mexico
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Title V CYSHCN Program – comprehensive care for those
with medical and fiscal eligibility
New Mexico Medical Insurance Pool
Service to immigrant families often begins with ER visit,
then referred to clinics and CMS for CYSHCN
FQHC and RPHCA funded community health care clinics
provide comprehensive primary care with sliding scale fees
Healthier Kids Fund provides primary care
Family Infant Toddler Program provides early intervention
Some counties provide county indigent coverage
Family Planning
Project ACCESS and Healthy Tomorrows Van in Santa Fe –
primary care – and some surgeries doctor donated
New Mexico Issues in Immigrant Care
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Families being divided by (ICE) Immigration and
Customs Enforcement Agency is deporting some
family members, leaving others. Primary income
provider may be deported; separation from
parents
Since 9/11, CYSHCN program no longer able to
use Angel Fight
Families fear deportation when flying or traveling
for care in other states
Immigration check points in NM bar access to
Albuquerque specialists
CYSHCN who are immigrants face funding and
citizen barriers when coordinating care for
kidney, liver transplants and cardiac surgery
New Mexico Issues in Immigrant Care
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Need for culturally competent response when immigrants
seek health care services
Lack of prenatal care – immigrant Moms covered at birth –
not pre or post-natal
Spontaneous and intermittent raids in certain areas of NM
create a culture of fear
Language – limited number of interpreters - often rely on
children to translate for health care
Difficulties in compliance with Federal Civil Rights Law
NM is a bilingual language and requires translation for all
written communication – still not always available
New Mexico Issues in Immigrant Care
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Fear of ability to meet health care sliding scale
fee
Education re: health and social service resources
is limited
Limited knowledge of immigrants rights
re: human rights issues i.e., housing, etc.
Transportation – no car for transport to work or
health care
Lack of resources – can’t apply for health
insurance No sick leave to go to doctor and/or
take children to doctor
Immigrants are not eligible for many social
programs
New Mexico Issues in Immigrant Care
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Response of health care system providers
Poverty – lower socioeconomic status
Little or no support system – family not present
Significant oral health problems – young adults
no oral health care and often lose teeth. Parents
less likely to go for preventive health care – will
take care of children instead
Elderly cannot apply for social security
Families share housing – often 2 or 3 in 1 house
or apartment
Comparing States: Arizona
 Title
V services do have a citizenship
requirement
 State law passed that restricts all
public services to immigrants
Comparing States: California
 Title
V services do not have a
citizenship requirement
 Low/no-cost non-profit or private
clinics provide health care
CA request for SCHIP for
Immigrants
Gov. Schwarzenegger’s health reform
proposal seeks health insurance through
Medicaid and SCHIP for all children at or
below 300% FPL
 Republican legislators response: “…do not
believe that state general fund revenues
should be invested in people who are here
illegally and that extends to children.”
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Comparing States: Florida
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Title 19 (Medicaid), Title 21 (SCHIP), are ineligible unless they
are qualified individuals
No state law or statute forbids utilization of funds, however Title V
CYSHCN follows operational policy of not providing care to
unqualified individuals
Title V may use Federal funds for care of unqualified individuals,
but MAY NOT use general fund match for unqualified individuals
Federal laws were extended to apply to state laws even though, it
may not be legally binding.
Some counties are” turning the other cheek” to operational policy
(not to serve unqualified individuals)
Political refuges are not seeking qualified individual status for fear
of deportation (kids go to public school, graduate and people
never become documented
Comparing States: Georgia
Law required immigrants to show proof of
legal residency resulted in fewer kids
going to the doctor
 Per Dr. Mercado, a Pediatrician: Many
clients are leaving and going to other
states, some back to their country
 Hispanics stopped offering health fairs
fearing police and immigration raids
 Media regularly blames illegal immigrants
for decline in health care system
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Comparing States: Iowa
 No
citizenship requirement for Title V
program; Title V services are direct
health care services
 Health and other assistance from the
refugee health program
 Private health clinics as available
Comparing States: Illinois
 Medicaid
available to all children with
no citizenship requirement
 Title V programs require that the
parent or the child be a citizen or a
legal resident of the US
Comparing States: Minnesota
Title V programs do not have a citizenship
requirement
 Community Health and Rural Health
Centers provide services without a
citizenship requirement
 CSHCN program provides a “health care
flow chart” for non-citizens that helps
identify avenues for treatment
 CSHCN program has compiled, with
community partners, a comprehensive list
of low/no-cost clinics statewide
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Comparing States: Texas
 Title
V programs do not have a
citizenship requirement
 Community Health and Rural Health
Centers provide services without a
citizenship requirement
 Some cities have low/no-cost clinics
available
Sources
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Directors of State Title V CSHCN Programs
Minnesota Department of Health:
http://www.health.state.mn.us/mcshn
Iowa Department of Public Health: http://www.idph.state.ia.us
EMTALA Online: http://www.medlaw.com/statute.htm
“Payments to Help Hospitals Care for Illegal Immigrants,” New
York Times, May 10, 2005. Accessed online 9/18/2008
Kaiser Commission on Key Facts: Medicaid and the Uninsured:
Health Coverage for Immigrants
http://www.kff.org/uninsured/upload/Health-Coverage-forImmigrants-Fact-Sheet.pdf
Susan Okie, MD, “Immigrants and Health Care—At the
Intersection of Two Broken Systems,” New England Journal of
Medicine. 8/9/2007, 357:525-529.
Ceci Connolly, “Study Paints Bleak Picture of Immigrant Health
Care,” 7/26/2005. Washington Post Online, accessed 9/11/2008.