Running head: IMMIGRANT DISPARITIES IN HEALTH CARE 1

Immigrant Disparities in Health Care: A Matter of Public Health and Human Rights

Lack of insurance can lead to poorer health, less access to health care and premature

death. Immigrant groups in the United States are among the demographic groups with the

largest percentage of uninsured individuals (Kullgren, 2003). Due to the increased

restrictions on current immigration public policy, the number of undocumented immigrants—

those least like to have access to health insurance—will most likely greatly increase (Derose,

Bahney, Lurie & Escarce, 2009). Apart from the uninsured, many United States immigrants

cannot receive adequate health care due to linguistic and cultural differences. The purpose of

this paper is to provide a brief overview of the current differences in health care access and

quality between undocumented immigrants in the United States and United States citizens.

Additionally, the purpose of this paper is to further explore the possible benefits and

detriments of extending healthcare to undocumented immigrants.

Health care access of undocumented immigrants proves to be a multidimensional

issue of interest under the broader academic area of women’s health, addressing multiple

rationales. A brief overview of the rationales is as follows: the scientific and medical

rationale of this subject includes but is not limited to matters and concerns of public health, as

well as increasing numbers of immigrant populations. Healthcare reforms are currently at the

center of United States politics, and the economic recession has further exacerbated measures

to extend health care coverage. However, although economic rationale has become a central

focus of health care debates, it is essential to consider the financial implications of limiting

health care access to emergency services. Limited health care access may in fact reduce the

cost-effectiveness of public resources. Quality of and access to health care for undocumented

immigrants also contain social and cultural considerations that warrant examination. Namely,

linguistic and cultural differences and misunderstandings create inferior health care

experiences for many undocumented immigrants. Finally, the issue of health care for
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undocumented immigrants contains an international rationale that is reflected in the term of

the topic itself: immigration involves an intricate relationship between host country and

country of origin.

One of the founding principles of United States ideology is the idea of a nation of

immigrants: political as well as popular discourse reflects the principle that all citizens of the

United States possess some degree of ancestral ties to immigration. It is an embrace of one’s

immigrant history, but a failure to identify with the experience of current immigrants. It is

estimated that in the United States, approximately 36 million people, or 12% of the total

population, are foreign born, which is a 57% increase from 1990 to 2000 (Derose, et al.,

2009). Approximately 300,000 to 500,000 undocumented immigrants enter the United States

each year (Kullgren, 2003). Of the estimated 10.3 million undocumented immigrants in the

United States, 8.4 million are Latino, with 5.9 million from Mexico and 2.5 million from other

countries in Latin America (Ortega, Hai, Perez, Rizzo, Carter-Pokras & Wallace, 2007).

Considering the origins of the United States are interwoven with immigration, it is significant

that availability and quality of healthcare for undocumented immigrants continues to remain

problematic, illustrated by policy measures such as the Responsibility and Work Opportunity

Reconciliation Act of 1996 and the Border Fence Act of 2006.

The Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 “. .

. greatly restricts the provision of many federal, state and local publicly funded services to

undocumented immigrants” (Kullgren, 2003). Although the intention of the Act was to

reduce illegal immigration, the restrictions on health care for undocumented immigrants have

increased problems for health care providers and have threatened the public health of the

community without displaying a notable effect on illegal immigration (2003). The Border

Fence Act of October 2006 and the deliberation of immigration reform by the 110th Congress
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illustrate the recently intensified political focus on undocumented immigration. One

recurrent issue in the immigration debate is the use of public services, including health care.

People in support of restrictive policies have argued that immigrants “. . . overuse services,

placing an unreasonable burden on the public” (Ortega, et al., 2007). However, these claims

are not necessarily verified with evidential support.

The medical rationale behind immigrant health care proves extensive. Undocumented

immigrants bear a disproportionate burden of undiagnosed illnesses, such as communicable

diseases like HIV and tuberculosis, and often times lack basic preventive care and

immunizations (Kullgren, 2003). Improved access to and quality of health care would

encourage early detection of preventable diseases, as well as help prevent the spread of

communicable diseases: ultimately it is a question of public health. Early detection could

create a more cost-effective system, since treating conditions early on could eliminate the

need for “costly services that have progressed to emergency status” (2003). Additionally, by

refusing to make health care treatment universally available, the United States health care

system conflicts with the ethical dimensions of health care practice. By either prohibiting or

preventing health care access, the heath care system is contradicting the ethical obligations of

clinicians.

The possible public health benefits of increased health care access have been

addressed and analyzed in the following study. Researchers Nandi, Loue and Galea

conducted a qualitative, commentary review of peer-reviewed public health literature

concerning the health status and health care access among undocumented immigrant

populations in the United States. The authors chose articles that included empirical data in

order to examine if there may be plausible health and financial benefits from extending health

care access to immigrant populations. The authors also employed examples from infectious
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and chronic disease epidemiology to strengthen their argument. For example, they examined

recent increases in HIV/AIDS prevalence among Mexican migrants, increased morbidity of

pregnant mothers due to untreated STIs, and a recent epidemic of drug-resistant tuberculosis

in a California high school to assess the possible public health benefits. Also, they examined

studies of immigrants with chronic diseases (such as end-stage renal disease) that seek out

treatment in the emergency room to evaluate the financial implications of lack of health care

access. The authors aimed to reposition the health care debate focus, choosing to focus on

overall benefit rather than the exclusionary tendencies of the debate. The authors found that

research suggests excluding large populations from sufficient medical coverage has a

negative bearing on both the uninsured and the general population. With their study, the

authors are addressing the public health dangers in continuing to examine health care reforms

in terms of citizens and noncitizens (2009). They also briefly addressed the health economics

perspective of extending coverage to undocumented immigrants. This was further examined

in a study of health care disparities in the populations most affected by lack of health care

access: undocumented Mexicans and other Latinos (Ortega, Fang, Perez, Rizzo, Carter-

Pokras, Wallace & Gelberg, 2007).

In their investigation, Ortega, et al. confronted a relatively common perception

regarding immigrants and public services: the opinion that immigrants overuse such services.

The authors point to a notable contradiction in this discourse: although use of resources

remains a key point of public immigration debate, there is a lack of well-designed research

regarding undocumented immigrants’ use of public resources. The authors performed

multivariate analyses of the 2003 California Health Interview Survey (CHIS). The CHIS is a

random telephone survey of 42,044 participants taken from every county in California. The

authors found that undocumented individuals demonstrate less healthcare use than U.S. born-

citizens. Undocumented immigrants lack insurance more than any other demographic group,
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report lower satisfaction with the health care they have received, and have the lowest mean

number of physician visits in 2003 (2007). Although the study could have benefited greatly

with examination of more than one year’s worth of data, the authors’ findings emphasize an

important distinction between debate and evidence: although use of public resources remains

central to proponents of immigrant healthcare restrictions, evidence does not necessarily

support this claim.

However, it is dangerous to view the issue of immigrant health care disparities strictly

in political and economic terms. The issue must be looked at in terms of the universal human

right to one’s health. For women, limited or lack of access to health care affects every aspect

of their overall health: from prenatal care to preventable diseases, from nutrition to infection.

Even when medical coverage is granted for women, it is often limited and inadequate. For

example, “labor and delivery costs for undocumented immigrant women are covered under

the federal and state emergency Medicaid program, but most states do not cover prenatal

care, and there is no coverage for family planning” (Okie, 2007). Essentially, women are

being denied equal access to health care, a foundational principle of the feminist rationale.

Furthermore, undocumented immigrant women often remain unaware of the possible

available health coverage for their children who are born in the United States and therefore

United States citizens. This threatens not only the health of their children and public policy in

general, but also limits immigrant women’s ability to perform their roles as mothers to the

best possible degree.

Authors Rhee, Belmonte and Weiner explore the discrepancies in immigrant families

with children eligible for health care in their qualitative study that included eighteen

interviews of families—eight families with insured children and ten without. The authors

posited their study as a response to the lack of research regarding the “experiential factors”
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that influence a family’s enrollment—or lack thereof—in government sponsored programs.

All of the children in the families interviewed were eligible for some sort of health care, but

some families chose not to enroll their children in government sponsored programs. Several

reasons contributed to their decision. The common factors included misperceptions about

how health insurance functions in the United States, confusion about health options stemming

from employment, mistrust of the government and fear of being detected by the government.

Among the families that had enrolled in government sponsored programs, one common factor

was the assistance from a sponsor, family member, or friend in the United States to help them

with the application process. The findings in the study point to the importance of social

networking in navigating the health care system. What’s more, the findings “. . . suggest that

state officials should direct policy efforts toward educating sponsors and immigrant

communities” (2009). In this instance, the government is providing health care programs;

however, without assistance in exploring these options, the aid proves deficient in its

effectiveness.

The previous study introduces a more recent trend in research regarding healthcare for

immigrants: analysis of the quality of service, rather than an exclusive focus on quantity.

Another study performed a qualitative examination of previous literature on the immigrant

healthcare experience (Derose, et al., 2009). They reviewed empirical evidence and studies as

early as 1996 to identify trends among immigrant populations, focusing on studies that took

into account potential access to healthcare, realized access, quality of healthcare and cost. In

terms of quality of healthcare services, the authors’ review of literature indicates that foreign

born people tend to be “less satisfied, report lower ratings of care, and are more likely to feel

discrimination in health care.” (Derose, et al., 2009). Additionally, they highlight the negative

effect lack of language-concordant providers has on quality of services. Several studies

found that even if the subjects had health insurance, there was still a reduced use of
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healthcare for noncitizens and people with a lack of English proficiency. These results not

only provide suggestions for future public policy, but also point to the deficiency in literature

regarding quality of service.

The study also highlights the social and cultural rationale behind the issue of

healthcare disparities for undocumented immigrants. Additionally, it addresses degree to

which cultural misunderstanding and mistreatment can influence an individual’s quality of

health care. Another study highlights the influence of language and culture on perceived

quality of service, as well as the experiential disparities among undocumented and

documented Latinos. Rodríguez, et al. (2009) use cross-sectional data from the 2007 Pew

Hispanic Center/Robert Wood Johnson Foundation Hispanic Healthcare Survey. They

interviewed and analyzed the responses of the 3,847 eligible participants. In their analysis,

they found undocumented Latinos reported their “inability to pay, racial/ethnic background,

and English proficiency are the main reasons for receiving poor quality of health care”

(Rodríguez, 2009). Essentially, this study found undocumented Latinos are least satisfied

with the quality of health care received. The study’s findings highlight the importance of

respect for cultural beliefs and preferences in creating effective patient-physician

relationships, and the noticeable lack of such cultural relativism in the health care system

today.

The limits of this paper are notable. Given the broad category of immigration and the

complicated nature of the healthcare system, it proves very difficult to conduct narrowed,

concise research and analysis. Undoubtedly, the heterogeneity within the population of

United States immigrants limits the accuracy of the research. Furthermore, studies focusing

specifically on the experience of immigrant women proved difficult to find: although most

studies mentioned the effects immigrant healthcare disparities have on women, exclusive
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focus is rarely given to undocumented female immigrants. Such limited available research

regarding the specifically female immigrant experience has hindered a thorough examination

of the issue of immigrant access to health care under the more focused category of women’s

health. However, inferences can be drawn from the general findings regarding healthcare

disparities.

As the above studies illustrate, the issue of health care disparities for undocumented

immigrants is not only a public health concern and misuse of public funding services, but a

denial of the universal right to one’s health. Not only is respect for this right given limited

access in health care, but its effectiveness continues to be exacerbated by lack of awareness

and respect of cultural differences and linguistic barriers within the practice. Inherent

contradictions exist within the current health care system when services are treated as

commodities and when capital goods are placed above human life. The contradictions and

limitations of the health care system today, as well as gaps in current research cannot

continue to be suppressed in a nation of immigrants. In terms of future research, more effort

should be made to examine immigrants as smaller demographic groups, rather than

examining the entire immigrant population as a whole. By addressing United States

immigrants as one large group despite the numerous differences in nation of origin,

socioeconomic status, citizenship status and legal status proves detrimental to obtaining

accurate research and also hinders reforms in policy. Furthermore, the health care system

should establish more language services, enhance awareness of and respect for cultural

differences, and implement more social networking resources. In the current health care

reform debates, serious considerations should be given to improved coverage of immigrants

—both documented and undocumented. Although this is certainly a controversial issue, and

debates on immigration tend to focus almost exclusively on issues of national security, the

United States government should consider the possible implications on overall public health
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with the increasingly prevalent uninsured populations. Furthermore, with discourses on

universal health coverage, the United States government should sincerely contemplate what it

wishes to include under the umbrella term “universal.”

References

Derose, K., Bahney, B., Lurie, N., & Escarce, J. (2009). Immigrants and health care access,

quality and cost. Medical Care Research and Review, 66(4), 355-372.

Kullgren, J. (2003). Restrictions on Undocumented Immigrants' Access to Health Services:

The Public Health Implications of Welfare Reform. American Journal of Public

Health, 93(10), 1630-1633. Retrieved from Academic Search Premier database.

Nandi, A., Loue, S., & Galea, S. (2009). Expanding the universe of universal coverage: The

population health argument for increasing coverage for immigrants. Journal of

Immigrant and Minority Health, 11, 433-436. doi: 10.1007/s10903-009-9267-2.

Okie, S. (2007). Immigrants and health care—at the intersection of two broken systems. The

New England Journal of Medicine, 357(6), 525-529.

Ortega, A., Hai, F., Perez, V., Rizzo, J., Carter-Pokras, O., Wallace, S. (2007). Health care

access, use of services, and experiences among undocumented Mexicans and other

Latinos. Archives of Internal Medicine, 167(21), 2354-2360. Retrieved from

Academic Search Premier database.

Rhee, Y., Belmonte, F. & Weiner, S. (2008). An urban school based comparative study of

experiences and perceptions differentiating public health insurance eligible immigrant

families with and without coverage for their children. Journal of Immigrant and

Minority Health, 11, 222-228. doi: 10.1007/s10903-008-9132-8.

Rodríguez, M., Vargas Bustamante, A. & Ang, A (2009). Perceived quality of care, receipt of

preventive care, and usual source of health care among undocumented and other

Latinos. Journal of General Internal Medicine, 24(3): 508-513. doi: 10.1007/s11606-

009-1098-2.