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?*

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.

Where are they from? 56% Mexican 22% Other Latin American Countries 13% Asian 6% Canadian and EuropeanHow 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.

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

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

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

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

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

*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

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

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

*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

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

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*

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

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.

“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

  Berk ML, Schur CL, Chavez LR, Frankel M. Health care use among undocumented

Latino immigrants. Health Aff (Millwood). 2000 Jul-Aug;19(4):51-64. Bitterman RA.Explaining the EMTALA paradox.Ann Emerg Med. 2002 Nov;40(5):470-

5. Capps R. The dispersal of immigrants in the 1990s. 2002 Nov. Available at:

www.urban.org . Accessed November 8, 2007. Childress MT. Estimating Kentucky’s illegal immigrant population. Foresight. 2006

Nov;47 Cogrove J. Medicaid: states reported that citizenship documentation requirement

resulted in enrollment declines for eligible citizens and posed administrative burdens. 2007 June, Available at www.gao.gov . Accessed November 17, 2007.

Derose KP, Escarce JJ, Lurie N. Immigrants and health care: sources of vulnerability. Health Aff (Millwood). 2007 Sep-Oct;26(5):1258-68.

Diaz-Perez Mde J, Farley T, Cabanis CM. A program to improve access to health care among Mexican immigrants in rural Colorado. J Rural Health. 2004 Summer;20(3):258-64.

DuBard CA, Massing MW. Trends in emergency Medicaid expenditures for recent and undocumented immigrants. JAMA. 2007 Mar 14;297(10):1085-92. Erratum in: JAMA. 2007 Apr 25;297(16):1774.

Dwyer J. Illegal immigrants, health care, and social responsibility. Hastings Cent Rep. 2004 Jan-Feb;34(1):34-41.

Fong T. Hospitals get some back. CMS finally issues rules for doling out $1 billion for care of illegal immigrants. Mod Healthc. 2005 May 16;35(20):10. No abstract available.

Goldman DP, Smith JP, Sood N.Immigrants and the cost of medical care. Health Aff (Millwood). 2006 Nov-Dec;25(6):1700-11.

Goldman DP, Smith JP, Sood N.Legal status and health insurance among immigrants. Health Aff (Millwood). 2005 Nov-Dec;24(6):1640-53.

Jones JW, McCullough LB, Richman BW. My brother's keeper: uncompensated care for illegal immigrants. J Vasc Surg. 2006 Sep;44(3):679-82.

Kirchhoff LV. American trypanosomiasis (Chagas' disease) a tropical disease now in the United States. N Engl J Med. 1993 Aug 26;329(9):639-44.

Kullgren JT. Restrictions on undocumented immigrants' access to health services: the public health implications of welfare reform. Am J Public Health. 2003 Oct;93(10):1630-3.

Levinson D. Self declaration of US citizenship for Medicaid. 2005 July. Available at: www.oig.hhs.gov. Accessed: November 16, 2007.

Lubell J. Proof or consequences. Law to curb illegal immigrants' Medicaid coverage may sting U.S. citizens seeking medical treatment without documentation. Mod Healthc. 2006 Jul 3-10;36(27):6-7, 16, 1.

McKeon E. Treating illegal immigrants: the ANA aims to protect nurses against potential criminal penalties. Am J Nurs. 2006 Jun;106(6):31.

Passel JS. The Pew Hispanic Center, The size and characteristics of the unauthorized migrant population in the U.S., 2006 March 7, Available at: www.pewhispanic.org, accessed on November 16, 2007

Passel JS. The Pew Hispanic Center, Unauthorized migrants: numbers and characteristics. 2005 June 14, Available at: www.pewhispanic.org, accessed on November 16, 2007

Prentice JC, Pebley AR, Sastry N. Immigration status and health insurance coverage: who gains? Who loses? Am J Public Health. 2005 Jan;95(1):109-16.

Quill BE, Aday LA, Hacker CS, Reagan JK. Policy incongruence and public health professionals' dissonance: the case of immigrants and welfare policy.J Immigr Health. 1999 Jan;1(1):9-18.

Rivers PA, Fausto P, Barriers to health care access for Latino immigrants in the USA.International Journal of Social Economics. 2006 March:33(3):207-220.

Smith LS. Health of America's newcomers. J Community Health Nurs. 2001 Spring;18(1):53-68.

Sullivan MM, Rehm R.Mental health of undocumented Mexican immigrants: a review of the literature.ANS Adv Nurs Sci. 2005 Jul-Sep;28(3):240-51. Review.

Urrutia-Rojas X, Marshall K, Trevino E, Lurie SG, Minguia-Bayona G. Disparities in access to health care and health status between documented and undocumented Mexican immigrants in north Texas. Hispanic Health Care International. 2006 Spring;4(1):5-14.