“Undocumented Dreamers” and the Health of the Dreamers

Loyola University Chicago Stritch School of Medicine’s recent announcement that it would accept applications from Dreamers – young undocumented immigrants eligible for Deferred Action on Childhood Arrivals (DACA) status – is an innovative and welcome response to the promise implicit in DACA. The idea that young people who had been brought to the U.S. as children should be freed from the threat of deportation, allowed to work legally, and encouraged to complete their education offers, in the form of public policy, a vision of an open future in which young people have options and are not constrained by their current legal and socio-economic status.  Through organizational policy, Loyola Stritch School of Medicine now offers eligible DACA beneficiaries a pathway to American professional life. This medical school has also offered our society a new way of thinking about today’s undocumented immigrants: as our future physicians.

Once they enroll in medical school, future “undocumented doctors” will be eligible to buy health insurance through Loyola, which requires all students to do so if they are not already insured, with the premium cost being part of the calculation used to determine aid packages.  However, Dreamers currently face the same barriers to access to health care and health insurance as do other undocumented immigrants. The Obama Administration’s announcement of the DACA program in June 2012 was followed, two months later, by the clarification that DACA beneficiaries would not be eligible for “public benefits,” including the Child Health Insurance Program (CHIP), Medicaid, and the insurance provisions of the Affordable Care Act (ACA).  It is difficult to reconcile the idea that young undocumented immigrants should be encouraged to be stakeholders in American society, through work, education, or military service, with the idea that they should be left out of the reform of the American health care system, including ACA initiatives that aim to promote insurance coverage among young adults  and among Hispanics, who constitute 80 percent of the undocumented population.

This built-in tension – between the future of the Dreamers and the health of the Dreamers – is the subject of a video, “Dreaming of Healthcare,” produced by the California Endowment, a health care philanthropy concerned about the problem of the residually uninsured, including those who are excluded from the insurance provisions of the ACA.  In the video, California Dreamers ask, “Health care for everyone? Does everyone include me?” When the ACA is fully implemented in 2014, young immigrants and their advocates will be watching for an answer to this question.

Nancy Berlinger and Michael Gusmano are research scholars at The Hastings Center and co-directors of the Undocumented Patients project

Commentary was originally published on the Bioethics Forum.

The Undocumented Unwell

Jonathan H. Marks, “The Undocumented Unwell,” Hastings Center Report 43, no. 1 (2013): 10–11. DOI: 10.1.002/hast.124

Abstract: Nell Toussaint is not well. In recent years, she has been diagnosed with uterine fibroids, uncontrolled hypertension, nephrotic syndrome, poorly controlled diabetes, hyperlipidemia, and a pulmonary embolism. She also suffers from decreased mobility, shortness of breath, and-perhaps not surprisingly, given her other ailments-anxiety. Toussaint is an indigent undocumented immigrant living in Canada who has been trying to secure medical coverage in the federal courts. In the process, she has sacrificed the medical confidentiality that most of us ordinarily enjoy.

Toussaint first came to Canada from Grenada as a visitor in 1999 and remained after the term of her visa expired. At first, she earned enough to sustain a living, but in 2006, her health began to deteriorate, and she was no longer able to work. Although she has received some medical care since then, it has been sporadic, on an emergency basis, and at great expense. When Toussaint applied for medical health coverage under Canada’s Interim Medical Health Program, which covers the cost of emergency medical care for legally admitted indigents, her application was rejected. She challenged the decision in federal court on the grounds that her right to life and security of the person under the Canadian Charter had been violated and that the denial of coverage was discriminatory.

The Ethics of Advocacy for Undocumented Patients

Nancy Berlinger and Rajeev Raghavan, “The Ethics of Advocacy for Undocumented Patients,” Hastings Center Report 43, no. 1 (2013): 14–17. DOI: 10.1.002/hast.126

Abstract: Approximately 11.2 million undocumented immigrants have settled in the United States. Providing health care to these residents is an everyday concern for the clinicians and health care organizations who serve them. Uncertain how to proceed in the face of severe financial constraints, clinicians may improvise remedies–a strategy that allows our society to avoid confronting the clinical and organizational implications of public policy gaps. There is no simple solution-no quick fix-that will work across organizations (in particular, hospitals with emergency departments) in states with different concentrations of undocumented immigrants, varying public and private resources for safety-net health care, and differing approaches to law and policy concerning the rights of immigrants. However, every hospital can help its clinicians by addressing access to health care for undocumented immigrants as an ethical issue. We offer some recommendations for doing this in a structured, fair, and transparent way. We also describe the problems that may result when clinicians are forced to grapple with this issue on their own.

Health Reform and Access for Undocumented Patients: Pressure on the Safety-Net

Buy a bag of lettuce, and I guarantee you that the hands of at least one undocumented worker helped get it to your table. Unfortunately, rigorous identification requirements and changes to federal Disproportionate Share funding for safety-net providers will make access to medical care for that undocumented worker more difficult after implementation of the Patient Protection and Affordable Care Act (PPACA) than it is today.

Every public-sector physician I know supports the PPACA—at least as an improvement over what we have now. It will provide insurance coverage and access to care for approximately 30 million of the current 56 million Americans who currently do not have the “ticket of admission” to health care services.{{1}} We know that the PPACA is not a free lunch, however. The 26 million who continue not to have insurance will find access even more difficult; undocumented patients may find it almost impossible.

Currently, undocumented persons and other indigent, uninsured people are able to access health care services via safety-net providers such as Federally Qualified Health Centers and public hospitals that are largely funded by federal block grants supporting sliding-scale payment programs. After implementation of the PPACA, however, a significant portion of these grant monies will be redirected to finance an expanded Medicaid program and the new health insurance exchanges. Safety-net providers will receive the same level of federal funding only if they see a high volume of newly-covered individuals whose insurance plans will pay for their visits. These clinics and hospitals will simply not be able to afford to provide the same amount of care to those who do not have insurance coverage. Undocumented persons are not eligible for coverage via the PPACA. Even if we wanted to care for everyone—insured and uninsured, documented and undocumented alike—we are not going to be able to. There will simply not be enough primary care clinicians available to do so.

Workforce issues in both public and private sectors are real. We’re busy and stressed now: our schedules are full and our ability to document everything on new electronic medical record systems and provide case management within the “medical home” model has already pushed us to capacity. Plus, most public clinics are not exactly flush with support staff and other resources, and our patients have an array of education, transportation, language and cultural barriers to compliance. While it is true that the PPACA includes some money for FQHC overhead expansion, operations are another matter. Safety-net clinics will undoubtedly be expected to provide care to the “Medicaid half” of the 30 million patients with new coverage (the other half will be covered through the health insurance exchanges), and we are going to be overwhelmed. Further, in addition to the fiscal argument made by public clinic administrators to see as many of these newly-covered patients as possible—and therefore fewer block grant/sliding–scale patients—there is the legal and ethical argument of using a scarce resource (primary care clinicians) in support of the new legislation. If the intent of the PPACA is to provide care for those now entitled to it, are we not, as a nation, obligated to deliver that care to the newly-covered first? And if physician resources are scarce, shouldn’t they go to uninsured citizens and legal residents second? Illegal, undocumented persons will be a very, very distant third.

On the other hand, we all want to eat those healthy bags of lettuce—and we want our patients to eat them too. We need those undocumented workers to get that lettuce to our tables; and the truth is that there are not enough of them now.{{2}} Undocumented workers and their families come to the U.S. to escape poverty and to accept jobs that Americans do not want. They contribute directly to the economy, they pay taxes, and they raise their children here. The healthcare community’s obligation to them may not be straightforward, but it is real.

In California, counties’ and healthcare organizations’ early response to this dilemma has been mixed. We see the problem, but we don’t know what to do about it. Local solutions will most likely be slow and incomplete. The Salinas Valley—self-proclaimed Salad Bowl of the World, home of John Steinbeck, and more recently home to several thousand undocumented indigenous Mexican immigrants from the state of Oaxaca who speak little, if any, Spanish—is struggling to meet medical care demands and remain fiscally solvent. Monterey County’s attempt to develop an early demonstration project in advance of the PPACA has ground almost to a halt over fear of the unanticipated financial consequences of such a project in a small region.

Meanwhile, the number of undocumented workers and their families, like the bags of lettuce they produce, is slowly growing. We could, of course, stop eating lettuce and take all undocumented persons back to the border. Short of that, however, we are going to have to make some kind of conscious decision about what to do for them when they need care. It’s up to us.

[[1]]Congressional Budget Office. Updated estimates for the insurance coverage provisions of the Affordable Care Act. http://www.cbo.gov/publication/43076.  Published March 2012. Accessed November 30, 2012.[[1]]

[[2]]Chebium R, Kelly E. Gannett Washington Bureau, Gannett News Service. Salinas Valley hit by farm worker shortage plaguing rest of U.S. http://www.agweb.com/article/salinas_valley_california_hit_by_farm_worker_shortage_plaguing_rest_of_u.s._LN. Published December 7, 2012. Accessed December 17, 2012.[[2]]

The Intersection of Medical Education and Healthcare Access for Undocumented Immigrants

The personal statement I wrote twenty years ago to gain entrance into medical school read, “Accompanying my grandmother for medical appointments showed me firsthand unsettling inequities in our health care system.  Medicaid patients visited crowded clinics, endured long waiting periods, and experienced a lack of medical continuity as her physicians changed from week to week.  While I am aware that medical care for the poor presents complex problems with no facile answers, I am eager to explore such issues and become part of the solution.”  Things haven’t changed so much for the poor in this country, and undocumented immigrants have been completely left out of the healthcare access equation.  However, those of us involved in the parallel healthcare system of caring for undocumented immigrants know that the issue of access for this population must be addressed.

Full disclosure: from a moral, ethical, logical and practical point of view, I think everyone, regardless of socio-economic and immigration status should have access to good, respectful care.  I’m in good company.  The Ethics Manual of the American College of Physicians (ACP) counsels us that “The interests of the patients should always be promoted regardless of financial arrangements, the health care setting or patient characteristics.”{{1}}  Moreover, the ACP’s position’s paper on National Immigration Policy and Access to Health Care states that “Access to health care should not be restricted based on immigration status, and people should not be prevented from paying out-of-pocket for health insurance coverage.”{{2}}  The Institute of Medicine has outlined six essential components of health care: Safety, Effectiveness, Timeliness, Efficiency, Patient Centeredness and Equity.  If the present state of our health care system faces many challenges, the system in place for our country’s most vulnerable inhabitants is failing.

Residents in the primary care specialties as well as in the medical and surgical subspecialties have historically been at the forefront for caring for the un- and under-insured, and are part of the loosely meshed safety net that exists for this population. At Stamford Hospital where I run the internal medicine residency program, the residents’ educational experience in ambulatory medicine is held in a Federally Qualified Health Center (FQHC).  We estimate that about 35% of our patients are undocumented immigrants.  It is not known nationally what percentage of patients cared for by medical residents are undocumented patients, but it seems reasonable to assume that it is not an insignificant number, given the role of medical education in caring for the underserved.  If residents are caring for undocumented immigrants in significant numbers, then that care must be of concern for those bodies governing medical education.

We have a special obligation to the next generation of physicians.  How are we helping them to maintain the same level of idealism under the circumstances of caring for complicated patients who present late in the course of their disease because of concern over their immigration status?  Are our residents being trained adequately in cultural competency so that they can practice authentic patient centered care?  Are they given enough time to see patients who speak several different languages and pose unique cultural considerations as it relates to their medical care?  We need to help our trainees cope with feelings of impotence that arise when needed resources aren’t available.  For example, when patients are not well enough to go home but not sick enough to remain in the hospital, they often need to be transferred to a skilled nursing facility.  However, the resources residents need to effectively facilitate the transition are often unavailable.  Similarly, patients suffering from alcoholism may not be eligible for post-hospital rehabilitation and are readmitted again and again with relapse from their disease.  Do our trainees believe us when we tell them that we practice the same standard of care for all of our patients?   We have immense responsibility to our learners to help them frame what they are feeling and to help them transform those feelings of impotence into action.  Besides the ethical and moral implications, there are the practical considerations.  It costs hundreds of thousands of dollars for readmissions and to keep patients in the hospital because there is no where else for them to go.

Being overwhelmed by the lack of appropriate resources to care for these patients can engender physician burn-out and anger.  I have overheard physicians offering solutions to astronomical medical bills that get generated by uninsured patients by asserting “shouldn’t we just invest in a plane ticket for their return trip home?”  Such statements occur in the presence of medical students and residents, which is problematic because it borders on unprofessional behavior.  However, it’s easy to understand how these statements are made.  It is tempting to want the problem to just “go away.” As physicians who took oaths to care for the sick and to live up to the highest standards of moral behavior, it’s hard to look someone in the eye and say, “I can’t deliver best practices in medicine to you.”  How are we affected by caring for patients without access to necessary resources knowing that our actions are witnessed by our trainees?

The Affordable Care Act did not make provisions for undocumented immigrants, but we will continue to care for them, because it is the right thing to do.  Immigrants play an important role in our society, and they are not going to leave.  If home represented educational and work opportunities as well as good health care access, they would still be in their native countries.  They came to this country for the same reasons that our predecessors in this country came: to make a better life for their families and to escape unbearable poverty and violence.

Below is a three part approach for helping medical students, residents and the rest of us solve the inequities and disparities that exist in our system.

1. It is important to acknowledge the emotions of feeling overwhelmed and that the obstacles for caring for the uninsured and underinsured seem insurmountable

2. Identifying the resources that are available and standardizing those resources across the board is critical.  Coming to terms with the concept that we can’t do everything for everyone can be soul soothing.

3. We need to begin to consider what our collective responsibility is to the global picture of health care delivery to the most vulnerable people in our society and to take steps toward that aim.

There is no question that the work is complicated and that no “facile solutions” exist.  However, more can be done to ensure that professionals interested in universal healthcare access work together in collaborative and productive fashion rather than trying to cope with the real stresses of caring for a vulnerable population, and attempting to develop ad hoc solutions, on our own.

To quote the Ethics Manual of the ACP once again, “By history, tradition, and professional oath, physicians have a moral obligation to provide care for ill persons.  Although this obligation is collective, each individual physician is obliged to do his or her fair share to ensure that all ill persons receive appropriate treatment.”  The intersection of medical education and healthcare access for undocumented immigrants warrants closer inspection by those who frame healthcare policy – we owe it to the next generation of physicians who must never lose the special moral imperative to care for all, and especially for our most vulnerable patients.

[[1]]1. American College of Physicians. Ethics Manual, Sixth Edition.  Ann Intern Med 2012; 156: 73-104.[[1]]

[[2]]2. American College of Physicians. National Immigration Policy and Access to Health Care. Philadelphia: American College of Physicians; 2011: Policy Paper. (Available from American College of Physicians, 190 N. Independence Mall West,Philadelphia,PA19106.)[[2]]

Access to Health Care for Undocumented Immigrants as a Family Health Issue

The 2012 presidential election campaign is the latest reminder of how difficult it is to reach bipartisan consensus about health care policy in the U.S. In contrast, both parties offer rhetorical support to improving child health and providing children with access to health care.

The reality, of course, is more complex. Despite the importance of the Child Health Insurance Program (CHIP) and Medicaid for child health, President George W. Bush vetoed efforts to reauthorize and expand CHIP, but he also doubled the number of Federally Qualified Health Care Centers, which increased access to care for poor families and children. More recently, a number of Republican governors have threatened to refuse federal money to expand their Medicaid plans under the Affordable Care Act (ACA).{{1}} Disagreements about how best to achieve the goal of improving child health are likely to continue, but there is clear bipartisan support for the goal of healthy families and children. Our failure to provide access to undocumented patients, however, undermines this broadly held goal.

According the Pew Research Center, about 37% of adult undocumented immigrants have children who are U.S.citizens. As of 2009, there were at least 4 million children of undocumented immigrants who were born in the U.S.{{2}} Under the 14th Amendment to the U.S. Constitution children born in the U.S. are citizens. As citizens, they may be eligible for Medicaid, CHIP and other government health programs, but research suggests that these children are much more likely than other U.S. born children to be uninsured and more likely to go without needed care.

Research on the effects of insurance status of parents on access to care and the health of children is clear. Children of parents without health insurance coverage are less likely to have health insurance coverage and less likely to access needed care. Parents who go without health care are more likely to be in poor health and less able to provide care for their children.{{3}} Regardless of immigration status, children of uninsured parents are more likely to go without necessary health services than are children of parents with health insurance.{{4}} Not surprisingly, this problem is even more acute among children of immigrants. U.S. born children of immigrant parents are twice as likely to go without insurance and access to routine medical care than are U.S. born children of U.S. born parents.{{5}}

It is hard or impossible to separate the health and welfare of children from that of their parents. And yet, our health policy does that when citizen children have undocumented parents. U.S. born children of undocumented immigrant parents are eligible for Medicaid and the Child Health Insurance Program, but their parents may not enroll their children in these programs. Some of this may be due to fears that attempting to access these services for their children will result in deportation.{{6}} Even if they do not fear immediate deportation, immigrant parents may fear that applying for public health insurance will make it impossible for them to obtain citizenship or legal status at a later date.{{7}}

Beyond insurance, the extent to which parents have access to a “usual source of care” can influence the adequacy of care that children receive. Children of parents who do not have a usual source of care are more likely to go without needed care than children with parents that do have a usual source of care. This holds true even among children who have a usual source of health care for themselves.{{8}}

The debate about whether to use public funds to provide health care to undocumented immigrants generates strong reactions. Many people argue that it is inappropriate to use public funds to provide health care to undocumented patients when so many American citizens are uninsured and go without access to needed care. While reasonable people can disagree about the merits of these arguments, the existence of “mixed status” families in which at least one parent is undocumented and at least one child is a U.S. citizen complicates this discussion. When we contemplate the arguments for and against using public funds to provide health care to undocumented adults, we must consider the implications for their families. If we believe that justice requires offering all children an equal opportunity to live a healthy productive life, it is more difficult to justify denying care to their parents.

[[1]]1. Michael Cooper, “Many Governors Are Still Unsure About Medicaid Expansion,” New York Times, July 2012: A17.[[1]]

[[2]]2. Jeffrey Passel and Paul Taylor, “Unauthorized Immigrants and Their U.S.-Born Children,” Pew Research Center, August 11, 2010. Accessed October 2, 2012 http://www.pewhispanic.org/2010/08/11/unauthorized-immigrants-and-their-us-born-children/.[[2]]

[[3]]3. Kinsey Alden Dinan and Jodie Briggs, “Making Parents Health Care a Priority,” National Center for Children in Poverty, April 2009. Accessed on October 2, 2012. http://www.nccp.org/publications/pub_874.html.[[3]]

[[4]]4. Jennifer E. DeVoe, Carrie J. Tillotson, and Lorraine S. Wallace, “Children’s Receipt of Health Care Services and Family Health Insurance Patterns,” Annals of Family Medicine 7, no. 5 (2009): 406-412.[[4]]

[[5]]5. Gilberto Granados, Jyoti Puvvula, Nancy Berman, and Patrick T. Dowling, “Health Care for Latino Children: Impact of Child and Parental Birthplace on Insurance Status and Access to Health Services,” AJPH 91, no. 11 (2001): 1806-1807.[[5]]

[[6]]6. Yoshikawa, H., & A Kalil, “The effects of parental undocumented status on the developmental contexts of young children in immigrant families,” Child Development Perspectives, 5 (2011): 291–297.[[6]]

[[7]]7. Kathleen M. Ziol-Guest and Ariel Kalil, “Health and Medical Care among the Children of Immigrants,” Child Development 83, no. 5 (2012): 1494–1500.[[7]]

[[8]]8. Jennifer E. DeVoe, Carrie J. Tillotson, Lorraine S. Wallace, Heather Angier, Matthew J. Carlson, and Rachel Gold, “Parent and Child Usual Source of Care and Children’s Receipt of Health Care Services,” Annals of Family Medicine 9, no. 6 (2011): 504-513.[[8]]