AbstractHow to provide good care to uninsured undocumented immigrants who are broadly excluded from federally funded health benefits in the United States can raise ethical challenges for clinicians. The chilling effect of current immigration enforcement policies on health care access affects other immigrant populations and US citizens in mixed-status families. In the current political environment, students in health professions, house staff and other early career professionals, and teachers and mentors in health care settings that serve low-income immigrant populations need a shared understanding of how to provide good care under changing and challenging conditions. This article suggests key resources for clinical teaching and learning and for self-directed learning and reflection, with special attention to the “public charge” rule and its effects on immigrant health.
Immigrants as Patients in Safety-Net Health Care Systems
Most immigrants throughout the world live in or near cities, which are sources of jobs and other resources. In the United States, most immigrants live in just 20 metropolitan areas.1 Health care professionals who work in safety-net settings in metropolitan areas are likely to see patients whose lives are shaped by immigration enforcement policies in ways that affect health care access. Safety-net settings include public hospitals and outpatient clinics, nonprofit community health centers, private nonprofit hospitals (also known as community or voluntary hospitals), and academic medical centers with emergency departments. Professionals who work in hospitals near immigrant detention facilities or shelters for child migrants in the custody of the Office of Refugee Resettlement (ORR) of the US Department of Health and Human Services (HHS) are responsible for the medical care of immigrants in detention or custody when a patient is transported to a hospital for medical treatment. Health care professionals who work in rural agricultural areas will also see low-income immigrant patients because nearly three-quarters of farmworkers are immigrants.2
Undocumented Immigrants and Barriers to Health Care Access
An undocumented immigrant is a person who crossed a border into the United States without authorization or who is living outside the terms of an entry visa or other authorization. (Other terms referring to this population’s immigration status include unauthorized, irregular, or out of status; illegal tends to be perceived pejoratively and connotes disrespect for persons.) Undocumented immigrants in the United States are broadly excluded from federally funded health-related benefits such as Medicaid, Medicare, the Children’s Health Insurance Program (CHIP), and the Supplemental Nutrition Assistance Program (SNAP, commonly known as food stamps) because they are not legally present in this country.3 Exclusions also apply to recently arrived immigrants who are legally present but not yet eligible for these benefits.3 This means that their access to health insurance is limited to state-funded provisions or to insurance provided by their employers. Under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986, all patients who present in an emergency department must receive an appropriate medical screening and, if in need of emergency medical treatment, must be treated until stable.4 This mandate covers emergency medical treatment regardless of insurance status or immigration status. EMTALA is not a funding mechanism, however. Hospitals that admit patients under EMTALA who are later determined to lack health insurance and to be ineligible for Medicaid or other public insurance can apply to state Medicaid programs for Emergency Medicaid reimbursement. Because Emergency Medicaid, whose provisions vary by state, covers specific services, hospitals often must contribute to the cost of emergency services that are uncompensated. The EMTALA provision, which provides health care access, and Emergency Medicaid provisions, which provide reimbursement, do not apply to many forms of nonemergent care. In some cases, these emergency provisions are the only means of access to life-sustaining treatment for conditions such as chronic kidney disease.5
Meeting the health care needs of uninsured patients who are undocumented and therefore ineligible for Medicaid and other federally funded programs calls for close collaboration between the clinician (physician, nurse-practitioner, physician assistant) with direct responsibility for patient care and medical social workers who are responsible for determining patients’ insurance eligibility and for identifying potential sources of aid for patients who are uninsurable due to immigration status or other reasons. These sources include a health system’s charity care provisions, which may, on a case-by-case basis, finance health care that is needed but not reimbursable under a state’s Emergency Medicaid provisions. Medical social workers are also often the link between inpatient services covered by Emergency Medicaid or charity care and referrals to affordable posthospital services. For example, federally qualified health centers and migrant health centers throughout the United States are federally funded to provide low-cost primary health care to medically underserved populations, including immigrants regardless of immigration status. In some cities, public health systems or community-based nonprofit organizations offer services to immigrants that include patient navigation and care coordination. These services vary greatly by locality and availability of financing.
Medical-legal partnerships (MLPs), in which attorneys aim to resolve legal barriers to health care access through a team approach by contributing expert knowledge of relevant law, are also a key educational resource for health professionals. All professionals who work in settings where they are responsible for the care of immigrant patients, including undocumented patients, should know whether their institution includes an MLP. The website of the National Center for Medical-Legal Partnership provides an interactive map of participating institutions nationwide6 and includes information on legal services in farmworker health programs.7 Attorneys with expert knowledge of health-related provisions in immigration law can be crucial sources of health care access for some undocumented patients. When a patient is undocumented, MLP attorneys can advise on the prospects for securing a change in a patient’s immigration status and assist with immigration filings that may provide access to public insurance. Even if an MLP does not offer immigration-related legal services to patients, it can be a helpful source of up-to-date, state-specific health law information that can support good practice and strengthen clinical teaching and learning.8
Immigration Enforcement and Its Chilling Effect on Health Care Access
Providing good care to patients whose legal status is uncertain or threatened is often experienced as an ethically fraught aspect of clinical practice. In clinical teaching and learning, it is important both to acknowledge the distress and other emotions that clinicians feel when they perceive that a patient or patient population is being treated in an unfair or inhumane way and to frame these situations in terms of justice and injustice.
A chilling effect refers to the behavioral effect of policy that interferes with a person’s ability to use a legal right that this person technically holds, often by inducing fear. For example, laws that require citizens to show identification to vote may have a demonstrable chilling effect on voting behavior by depressing turnout among populations who fear the consequences of being required to show identification. The immigration enforcement priorities of the Trump Administration and the US Department of Justice, which has broad responsibility for immigration courts, have created multiple chilling effects on health care access for undocumented immigrants, immigrants with legal status, and US citizens—often children—in mixed-status families. When immigrant patients are afraid to approach health care settings or disclose personal information to medical staff because they fear that interaction with perceived authorities (such as security guards) or a record of use of health services will result in detention, deportation, or other action against them or their families, their fears should be recognized as chilling effects of immigration enforcement priorities on health care access.
The announcement in late 2018 of a proposed rule that would change federal public charge policies is of greatest concern to health care professionals and organizations nationwide for the dramatic chilling effects it has induced.9 The effect of this rule, which would allow use of health-related programs for which immigrants or their family members are eligible to be counted against them in applications for permanent residency (green card) status, would be to discourage immigrants from enrolling in or using these programs out of fear of the consequences. As the public charge era unfolds, the long-standing health care access problems of undocumented immigrants, who are ineligible for federally funded programs, are likely to be mirrored among authorized immigrants who are eligible for but afraid to use these same programs, which include nonemergency Medicaid, the Medicare Part D Low-Income Subsidy Program, SNAP, and subsidized housing and rental assistance programs, among others.10-12
Three Resources for Clinicians
Three resources are valuable for helping clinicians understand and provide appropriate care under the public charge rule.
- The National Immigration Law Center (NILC) is an educational resource on the public charge rule and the legal rights of immigrant patients. The public charge rule is complex and requires expert guidance to understand its actual provisions and to communicate clearly and compassionately concerning the fears it triggers among immigrants. The website of the National Immigration Law Center (NILC) offers reliable, regularly updated information on the public charge rule that can support clinician education and professional practice.13 The NILC also offers guidance for health care professionals on discussing enrollment in public programs with immigrant families.14 A specific NILC resource, “Health Care Providers and Immigration Enforcement: Know Your Rights, Know Your Patients’ Rights,” offers detailed information and recommendations for health care professionals and organizations on how to safeguard rights in clinical practice and in interactions with immigration enforcement.15
- MLPs (discussed in the previous section) are another helpful educational resource on the public charge rule; professionals are encouraged to reach out to an MLP in their institution or community6 for guidance on this evolving issue.
- The American Academy of Pediatrics (AAP) is also a helpful practice resource. The AAP website offers an Immigrant Health Toolkit with practical information and resources for pediatricians and other health care professionals on topics such as medical screening and treatment recommendations for newly arrived immigrant children; access to health care and public benefits; immigration status and related health concerns; and mental, emotional, and behavioral care.16
Immigration Enforcement and the Health of People Crossing Borders
Policies of family separation, open-ended detention, and refusal of asylum to people fleeing violence are also associated with a range of threats and harms to health.17-19 These policies are technically distinct from the public charge rule but have unfolded during the same period and contribute to pervasive fears across immigrant populations that affect health-seeking behavior.
Whether or not a health professional is likely to care for immigrants in custody, understanding something of the experiences of these immigrants and their families is important for professional practice in the current political environment. Below are 2 resources for clinicians.
- The investigative journalism organization ProPublica and other partners have applied game technology to the challenges of learning about the conditions that drive asylum seekers and understanding the stress of the asylum-seeking process. The Waiting Game, an app for self-directed learning and clinical teaching about immigrants in detention,20 offers an engaging way for nonspecialists to learn about this aspect of migration through 5 cases. It can be used as an individual resource for learning and reflection and to support group teaching and learning on the political context of providing good care within the safety net.20
- The Undocumented Patients website, a project of the Hastings Center, offers a frequently updated searchable database of articles, reports, and other publications relevant to health care for undocumented immigrants in the United States that serves as a resource for clinical teaching on health care needs of immigrants.21 This database also includes a selection of recent literature on the emerging health consequences of immigration enforcement as it affects lawfully present immigrants, asylum seekers, and citizens in mixed-status households.
In a time of great uncertainty and fear for immigrant populations across this immigrant nation, professionalism in health care work calls for close attention to the political, social, and economic context of health care delivery. To treat immigrant patients as persons and members of families and communities, professionals should aim to understand the challenges their patients face, respond with compassion, and keep abreast of necessary knowledge. Clinical teachers and mentors should support these aspects of contemporary professional practice and offer opportunities for professionals to discuss ethical uncertainties even when ready solutions are not at hand.
- López G, Bialik K, Radford J. Key findings about US immigrants. Fact Tank. May 3, 2017. http://pewrsr.ch/2qz2zvx. Updated September 14, 2018. Accessed October 23, 2018.
National Center for Farmworker Health. Farmworker health fact sheet: demographics. http://www.ncfh.org/uploads/3/8/6/8/38685499/fs-migrant_demographics.pdf. Published September 2012. Accessed October 23, 2018.
Singer A. Welfare reform and immigrants: a policy review. In: Kretsedemans P, Aparicio A, eds. Immigrants, Welfare Reform, and the Poverty of Policy. Westport, CT: Praeger; 2004:21-34. https://www.brookings.edu/wp-content/uploads/2016/06/200405_singer.pdf. Accessed October 23, 2018.
Emergency Medical Treatment and Labor Act (EMTALA), 42 USC §1395dd (1986).
- Cervantes L, Fischer S, Berlinger N, et al. The illness experience of undocumented immigrants with end-stage renal disease. JAMA Intern Med. 2017;177(4):529-535.
National Center for Medical-Legal Partnership. The partnerships. http://medical-legalpartnership.org/partnerships/. Accessed June 29, 2018.
Farmworker Justice and Health Outreach Partners. Medical-legal partnership resource guide for farmworker-serving health centers and legal services organizations. https://www.farmworkerjustice.org/sites/default/files/Medical_Legal_Partnership_FINAL_WEB.pdf. Accessed June 29, 2018.
- Berlinger N, Guidry-Grimes L, Hulkower A. Knowledge is key for safety-net providers: undocumented patients may not know their health-related and legal rights.. Health Prog. 2017;98(4):9-14.
US Citizenship and Immigration Services. Public charge. https://www.uscis.gov/greencard/public-charge. Accessed October 23, 2018.
Katz MH, Chokshi DA. The “public charge” proposal and public health: implications for patients and clinicians [published online ahead of print October 1, 2018]. JAMA.
Artiga S, Garfield R, Damico A. Estimated impacts of the proposed public charge rule on immigrants and Medicaid. Henry J. Kaiser Family Foundation. https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-the-proposed-public-charge-rule-on-immigrants-and-medicaid/. Published October 11, 2018. Accessed October 23, 2018.
Henry J. Kaiser Family Foundation. Proposed changes to “public charge” policies for immigrants: implications for health coverage. https://www.kff.org/disparities-policy/fact-sheet/proposed-changes-to-public-charge-policies-for-immigrants-implications-for-health-coverage/. Published September 24, 2018. Accessed October 23, 2018.
National Immigration Law Center. Public charge: a new threat to immigrant families. https://www.nilc.org/issues/economic-support/pubcharge/public-charge-a-new-threat-to-immigrant-families/. Updated October 2018. Accessed October 23, 2018.
National Immigration Law Center. Access to health care, food, and other public programs for immigrant families under the Trump administration: things to keep in mind when talking with immigrant families. https://www.nilc.org/wp-content/uploads/2018/02/talking-to-immigrants-about-public-programs-2018.pdf. Updated April 2, 2018. Accessed October 23, 2018.
National Immigration Law Center. Health care providers and immigration enforcement: know your rights, know your patients’ rights. https://www.nilc.org/issues/immigration-enforcement/healthcare-provider-and-patients-rights-imm-enf/. Accessed October 23, 2018.
Meneses C, Chilton L, Duffee J, et al. Immigrant health toolkit. American Academy of Pediatrics. https://www.aap.org/en-us/Documents/cocp_toolkit_full.pdf. Accessed October 27, 2018.
Henry J. Kaiser Family Foundation. Key health implications of separation of families at the border (as of June 27, 2018). https://www.kff.org/disparities-policy/fact-sheet/key-health-implications-of-separation-of-families-at-the-border/. Published June 27, 2018. Accessed October 31, 2018.
Artiga S, Ubri P. Living as an immigrant family in America: how fear and toxic stress are affecting daily life, well-being, and health. Henry J. Kaiser Family Foundation. https://www.kff.org/disparities-policy/issue-brief/living-in-an-immigrant-family-in-america-how-fear-and-toxic-stress-are-affecting-daily-life-well-being-health/. Published December 13, 2017. Accessed October 23, 2018.
Berlinger N. Migrants’ lives, immigration policy, and ethics work. Hastings Bioethics Forum. June 20, 2018. https://www.thehastingscenter.org/migrants-lives-immigration-policy-ethics-work/. Accessed June 29, 2018.
Wei S, Fortugno N. The Waiting Game app. ProPublica. https://projects.propublica.org/asylum/. Published April 23, 2018. Accessed October 23, 2018.
Hastings Center. Undocumented immigrants and health care access in the United States. http://undocumentedpatients.org/. Accessed October 23, 2018.