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Community Safety Nets Stretching to Catch Immigrant Patients

Minimal Federal Help Leaves Communities to Care for Uninsured, Undocumented Immigrants

News Release
Feb. 28, 2006

Alwyn Cassil (202) 264-3484 or

WASHINGTON, DC—With the federal government opting to provide little health care aid to legal and illegal immigrants alike, communities across the country are stretching already-strained safety nets to care for more immigrant patients, according to a study released today by the Center for Studying Health System Change (HSC).

"Because they are essentially shut out of public coverage, many recently arrived immigrants who work in low-wage jobs without health insurance must rely on local safety net providers for care," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation. "And safety net providers generally get no dedicated or additional funding to care for growing numbers of immigrant patients."

Federal law generally prohibits legal immigrants from enrolling in Medicaid and the State Children’s 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.

The study’s findings are detailed in a new HSC Issue Brief—Stretching the Safety Net to Serve Undocumented Immigrants: Community Responses to Health Needs—is available here. The study is based on HSC’s 2005 site visits to 12 nationally representative communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y.

"There was a fair amount of variation across the 12 sites-communities with more developed safety nets and historically large numbers of immigrants appeared more adept at caring for both legal and undocumented immigrants," said HSC Health Research Analyst Andrea B. Staiti, coauthor of the study with HSC consulting researchers Robert E. Hurley of Virginia Commonwealth University and Aaron Katz of the University of Washington.

At one end of the spectrum are Orange County, Miami, Phoenix and northern New Jersey—communities 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.

Nationally, other research has shown that immigration into the United States has decreased since peaking in 2000, but immigration levels remain high. Recent reports indicate that an increasing proportion of immigrants lack health insurance, and more newly arrived immigrants are undocumented, in part because of a decline in the number of visas granted after the 2001 terrorist attacks.

Though precise estimates are difficult, an estimated 10 million-plus undocumented immigrants live in the United States, almost one third (29%) of the foreign-born population. Latinos represent the majority of the undocumented group. Nearly two-thirds are concentrated in eight states, including five states with HSC site visit communities—California, New York, Florida, New Jersey and Arizona—but growth has been rapid in other areas as well.

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. The HSC study found that a number of factors influence communities’ responses to undocumented immigrants’ health care needs, including:

Safety net capacity. In general, a community with a well-developed safety net is more prepared to serve undocumented immigrants-patients 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 try 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.

Language/cultural diversity of community. Regardless of their insurance or legal status, immigrants often face language and cultural barriers in accessing health care. Communities with more immigrants are a step ahead in bridging language gaps and providing culturally sensitive care than communities with less experience. In Phoenix, Orange County, Miami and northern New Jersey, safety net providers are often bilingual, and multilingual signage is common in hospitals and clinics.

Financial resources. In most communities, there is little resistance to allowing publicly financed providers to care for undocumented persons, but most communities have not provided or received additional funds to support providers serving this population. Care is usually financed through general sources, including disproportionate share hospital payments, grants to federally qualified health centers, cross-subsidization through cost shifting by hospitals and in physician practices, and in some cases, emergency Medicaid coverage.

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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by The Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.


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