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Stretching the Safety Net to Serve Undocumented Immigrants: Community Responses to Health Needs
Issue Brief No. 104
A small but increasing proportion of immigrants to the United States is
undocumented. Because most undocumented immigrants lack health insurance, they
primarily rely on safety net providers for care. Communities with more developed
safety nets and historically large numbers of immigrants appear more adept at
caring for both legal and undocumented immigrants, according to Center for Studying
Health System Changes (HSC) 2005 site visits to 12 nationally representative
communities. Communities with less experience caring for immigrant populations
and less-developed safety nets face challenges caring for this population, but
many are taking steps to improve their ability to meet immigrant needs. As the
number of immigrants in the U.S. grows, the need to develop community health
care capacity for immigrants will intensify.
Undocumented Immigrants and Health Care Coverage
hile immigration into the United States has decreased since peaking in 2000,1 immigration levels remain high. Recent reports indicate that an increasing proportion of immigrants lack health insurance,2 and more newly arrived immigrants are undocumented, in part because of a decline in visas granted after the 2001 terrorist attacks.3, 4 Though precise estimates are difficult, more than 10 million undocumented immigrants live in the United States, almost one third (29%) of the foreign-born population.5
Latinos represent the majority of the undocumented group. Nearly two-thirds are concentrated in eight states, including five states with HSC site-visit communities (see Data Source)California, New York, Florida, New Jersey and Arizonabut growth has been rapid in other areas as well.6
Immigrants in general are significantly more likely to be uninsured than native citizens, and while immigrants are as likely to work, a disproportionate number work in low-wage jobs that do not offer health coverage.7 Immigrants also have lower rates of public coverage. Federal law generally prohibits legal immigrants from enrolling in Medicaid and the State Childrens Health Insurance Program (SCHIP) for the first five years they reside in the United States. Undocumented immigrants generally are ineligible for Medicaid or SCHIP regardless of their length of residency in the United States.
However, all immigrants are eligible for emergency Medicaid, which covers treatment for a medical emergency, regardless of their status. Also, hospital emergency departments generally must screen and stabilize all people with an emergency medical condition under the federal Emergency Medical Treatment and Labor Act.
During HSCs 2005 site visits, researchers examined health care services available to undocumented immigrants. Obtaining specific information about undocumented immigrants was difficult because health care providers reported not attempting to distinguish patients by documentation status. HSC particularly focused on the roles of safety net providersthe group of hospitals, community health centers or free clinics, and, in some cases, local health departmentsthat provide the bulk of care to low-income, uninsured people. As part of their mission, safety net providers are generally open to seeing all patients and often rely heavily on public funding. Despite not differentiating patients by legal status, many respondents recognized the unique circumstances of illegal immigrant patients, shedding light on how providers and communities are responding to the issues presented by this group, as well as those of the larger immigrant population.
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A Spectrum of Community Need, Readiness and Responses
he perceived size of the undocumented immigrant populations and the subsequent demand on local heath care systems varied across the 12 HSC communities. At one end of the spectrum are Orange County, Miami, Phoenix and northern New Jerseycommunities with long immigrant histories and larger numbers of undocumented residents. At the other end are such communities as Syracuse and Lansing that have limited numbers of undocumented immigrants, mostly seasonal migrant workers, who place little demand on health care services. In between fall the other HSC communitiesBoston, Cleveland, Seattle, Greenville, Indianapolis and Little Rockthe latter three experiencing more recent growth in their Latino populations, including undocumented immigrants. A number of factors influence communities responses to undocumented immigrants health care needs, including:
Safety Net Capacity
n general, a community with a well-developed safety net is more prepared to serve undocumented immigrantspatients who are uninsured, have limited English proficiency and face many barriers to integrating into American society, including the fear of deportation. A well-developed safety net may include a relatively extensive network of public or private hospitals and community health centers that tries to respond to charity care needs. For example, Boston, Seattle, Indianapolis and Cleveland have public hospitals and a relatively robust number of community health centers, including organizations that focus on Latinos and other immigrant groups. Communities with well-developed safety nets may be more adept at serving undocumented immigrants than communities with less extensive safety nets, because they are used to dealing with populations that need more help and often have extra support services in place to help these persons.
Communities experiencing rapid growth in both legal and illegal Latino immigrants have responded by developing new service capacity. In Little Rock, religiously affiliated free clinics have been a longstanding source of care for Latino immigrants. More recently, because of increasing numbers of Latino patients, Childrens Hospital is planning a family clinic targeted at Latinos in conjunction with the Little Rock Community Health Center. In Indianapolis, Wishard Hospital opened the Pecar Health Center, where the majority of patients are Spanish-speaking and providers are bilingual. And some safety net providers in Greenville have expanded in the region between Greenville and Spartanburg, which has experienced significant population growth, including undocumented immigrants. Other community programs for uninsured persons are for the most part inclusive of undocumented immigrants. For example, the Wishard Health Advantage program in Indianapolis and the Ingham Health Plan in Lansing, both managed care programs for low-income, uninsured persons, require only that a person be a county resident and meet certain income guidelines. On the other hand, Medwell Access, a physician charity care program in Greenville, does not treat non-citizens.
Many safety net providers reported increased demand for services from uninsured patients. As part of this group, undocumented immigrants can typically access primary care through safety net providers, but providers report more difficulty referring undocumented immigrants for specialty care. In several communities, waiting times to see specialists in safety net hospitals have reportedly increased, with waiting times the longest for the uninsured. Other problem areas mentioned include the provision of chronic care treatment, mental health care and obtaining affordable prescription drugs, because program rules often impede services for undocumented patients. For example, most drug manufacturer patient assistance programs require citizenship or legal immigrant status.
|1.||Passel, Jeffrey S., and Roberto Suro, Rise, Peak and Decline: Trends
in U.S. Immigration 1992-2004, Pew Hispanic Center (Sept. 27, 2005).
|2.|| Employee Benefit Research Institute (EBRI), The Impact of Immigration
on Health Insurance Coverage in the United States (June 2005).
|3.||Passel and Suro (Sept. 27, 2005).|
|4.||Recent analysis determined that while the number of non-citizens has been increasing, immigrants are not the primary factor contributing to increases in the nations uninsured rates. Holahan, John and Allison Cook, Are Immigrants Responsible for Most of the Growth of the Uninsured? Kaiser Commission on Medicaid and the Uninsured (October 2005).|
|5.||Passel, Jeffrey S., Unauthorized Migrants: Numbers and Characteristics: Background Briefing Prepared for Task Force on Immigration and Americas Future, Pew Hispanic Center (June 14, 2005).|
|6.||Passel (June 14, 2005).|
|7.||Health Coverage for Immigrants Fact Sheet, Kaiser Commission on Medicaid and the Uninsured (November 2004).|
|8.||Ku, Leighton, and Timothy Waidmann, How Race/Ethnicity, Immigration Status and Language Affect Health Insurance Coverage, Access to Care and Quality of Care Among the Low-Income Population, Kaiser Commission on Medicaid and the Uninsured (August 2003).|
|9.||Fremstad, Shawn, and Laura Cox, Covering New Americans: A Review of Federal and State Policies Related to Immigrants Eligibility and Access to Publicly Funded Health Insurance, Kaiser Commission on Medicaid and the Uninsured (November 2004).|
|10.||Otto, M. Alexander, Program will cover health care for impoverished kids, Tacoma News Tribune (Dec. 11, 2005).|
|11.||Centers for Medicare and Medicaid Services Fact Sheet, Emergency Health Services for Undocumented Aliens: Section 1011 of the Medicare Modernization Act (May 9, 2005).|
Every two years, HSC researchers visit 12 nationally representative metropolitan communities to track changes in local health care markets. The 12 communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. In 2005, HSC researchers interviewed health care providers and an array of observers in government and community agencies to explore how communities serve undocumented immigrant populations, including: the major sources of care for undocumented immigrants, the main challenges in meeting their health care needs, and community-wide initiatives that may be underway.
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