UNAUTHORIZED MIGRANTS IN THE US HEALTH CARE SYSTEM Corey Sonnett, Spring 2008

1. UNAUTHORIZED MIGRANTS IN THE US HEALTH CARE SYSTEMCorey Sonnett, Spring 2008

2. Why should we care? • Legislation concerning unauthorized migrants is being passed at a rapid rate. Some of it affects delivery and payment of health care. • We will see this population in clinical practice • Understanding who they are and what their needs are helps us provide a higher quality of care. • Many claim that the health care system is near a state of collapse, that costs are climbing out of control. Often much of the blame is placed on the free health care provided to unauthorized migrants. Are they the problem? How much of the problem are they?*

3. Background: Who are they? • Terminology: Depending on where your information is coming from they may be referred to as illegal aliens, illegal immigrants, or unauthorized migrants • The population is composed of people who have clandestinely entered the country by illegally crossing the border without passing through immigration or customs, as well as those who entered the country legally, with a valid visa, but have since overstayed their allotted time.

4. Background: Population Characteristics • Where are they from? • 56% Mexican • 22% Other Latin American Countries • 13% Asian • 6% Canadian and European How many are there? 11.5-12 million with an influx of more than 500,000/year. In 1980 the population was approximately 3 million. In 25 years the population has nearly quadrupled! 67% of this population has been in the US less than 10 years and 40% less than 5 years…. Or 4.8 million in the last 5 years.

5. Background: Population Characteristics • Gender: 58% male, 42% female • Employment: 74% of males and 54% of females are employed • 31% work in the service occupations, 19% work in construction and extraction, 15% in production, 4% in farming, 8% transportation and material moving, 10% in management • Age: relatively youthful, 84% are under 45 • Education: 32% have 9th grade or less education, 49% have less than high school diploma, 74% have a high school diploma or less

6. Background: Where do they settle? • 2/3 of the population reside in just 8 states. In descending order of population they are California, Texas, Florida, New York, Arizona, Illinois, New Jersey, and North Carolina* • Prior to the 1990s immigrants favored settlement in regions with well-established, large foreign-born populations. Starting in the 1990s a new trend in immigration emerged as immigrants began to favor settlement in areas with smaller, less well established foreign-born populations

7. Legislation • Frequently mentioned legislation regarding health care and the unauthorized migrant • PWORA Personal Responsibility and Work Opportunity Reconciliation Act • EMTALA Emergency Medical Treatment and Active Labor Act of 1985 • 2005 Deficit Reduction Act • 2005 The Border Protection, Antiterrorism, and Illegal Immigration Control Act • California State Proposition 187

8. Legislation: PWORA • PWORA Personal Responsibility and Work Opportunity Reconciliation Act • Passed in 1996. • Made federally funded benefits i.e. Medicaid unavailable to legal immigrants for their first 5 years of residence • Required states inclined to provide publicly funded services to unauthorized migrants, already ineligible for Medicaid, to pass legislation specifically describing and affirming the eligibility of this population for state and local public benefits • Represented an attempt by the federal government to shift some of the burden of cost to the states

9. Legislation: 2005 Deficit Reduction Act • This legislation had a provision added on requiring all recipients of Medicaid to provide proof of citizenship or else risk losing coverage * • Before this legislation took effect there were 47 states allowing self declaration of citizenship. Basically involved checking a box declaring citizenship and signing the dotted line. • 27 of the 47 states were not following up benefit applications to ensure the veracity of the information on their forms • The Deficit Reduction Act passed despite a report by the Inspector General of Health and Human services which fell short of recommending this requirement • This provision affected more than 50 million recipients of Medicaid • In 2007 a GAO report “examined how the requirement has affected individual’s access to Medicaid benefits and assessed the administrative and fiscal effects of implementing the requirements” • 22 of the 44 states with available data reported declines in Medicaid enrollment directly due to the new requirement with a majority of the delays and losses affecting eligible US citizens 12 states reported no change and 10 reported effect unknown

10. Legislation: 1994 California state proposition 187 • *Denied publicly funded health care as well as other social services and education to unauthorized migrants • Additionally, the proposition would have required hospitals and clinics to not only report patients suspected of being unauthorized migrants to authorities, but to deny care in non-emergency situations; placing health care providers in a terrible ethical and legal dilemma and casting them in a role for which they were neither trained nor hired…. That of immigration enforcement. • Proposition 187 passed with 59% voter approval • It was later reviewed by a federal district judge who determined that it was not in accord with federal law and was therefore never implemented

11. Legislation: Emergency Medical Treatment and Active Labor Act • Passed in 1985 • This legislation provides access to the US health care system to any person regardless of citizenship status, or ability to pay • Requires hospitals to provide care to anyone who enters with an emergency and is often referred to in the literature as an “unfunded government mandate” because it makes no provision for reimbursing hospitals for the delivery of care to those lacking the ability to pay. • Refusing to provide care leads to punitive fines, additional civil liability and the loss of participation in Medicare and Medicaid

12. Fiscal Impacts • In 2006 Goldman et al did a study to estimate the taxpayer burden of providing care to unauthorized migrants, aged 18-64, nationally • Results: • Unauthorized migrants represent 3.2% of the population

13. Fiscal Impacts: Goldman's Results • *Amount of health care consumed nationally • *% of total health care consumption • *Share of the health care cost covered by public funds • $ amount of hc costs paid for by public funds • % of public funds consumed • *$ amount spent per US household to provide publicly funded health care • UMs Total –UMs • $6.5 b 422.5 b • 1.5% 98.5% • 17% 21% • $1.1 b $88.7 • 1.24% 98.76% • $11 $843

14. Fiscal Impacts • Conclusion: “Although there are many legitimate issues surrounding the provision of health care to the undocumented, higher taxpayer burden is not one of them. • Addressing the question of uncompensated care provided by hospitals Jones et al find that, “the 11million illegal migrants distributed around the country represent too small of a sample of uninsured indigents to statistically affect the larger problem the individual states confront in caring for all the patients who can’t pay their medical bills because they are uninsured. • Important to note that while on a national level the financial burden unauthorized migrants place on the health care system is relatively small local impacts can be profound. Hospitals near borders and in cities with particularly large populations of unauthorized migrants can be deeply impacted by the amount of uncompensated care that they are mandated to provide under EMTALA

15. Effects of the US Health Care System on Unauthorized Migrants • Barriers to accessing care • Poverty rates among unauthorized migrants are twice that of native born citizens or 27% • 65% lack health insurance: the medical literature confirms that people who lack health insurance experience poorer health outcomes • Low educational levels, limited English proficiency, crowded living conditions as well as poor diets and nutrition are prominent characteristics of this population • Lack of familiarity with the system*

16. Effects of the US Health Care System on Unauthorized Migrants • Barriers to health care access • Fear • Fears of being deported are common and often lead to delays in seeking health care ---- can be detrimental to the health of the patient, because what was once a very treatable medical condition may transform into a true medical emergency. Also from a public health standpoint it is important to diagnose and treat contagious diseases as early as possible in order to prevent possible outbreaks and limit their spread in the general population

17. Effects of the US Health Care System on Unauthorized Migrants • Barriers to health care access • Geographic location • Generally states with well established unauthorized migrant populations have more social services available and stronger support networks in place. While in states with less established populations access to culturally sensitive care and trained interpreters is difficult to find These barriers all contribute to a unique risk profile within the unauthorized migrant population. Sullivan found in her research that feelings of fear, vulnerability, guilt, marginalization and restricted mobility are common.

18. Hippocrates • “Sometimes give your services for nothing … and if there be an opportunity of serving one who is a stranger in financial straits, give full assistance to all such. Where there is love of man there is also love for the art.” Hippocrates

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