Undocumented and Uninsured
Health, and Immigration
Healthcare in the United States has largely been treated as a privilege reserved for citizens who could afford it; in most states, undocumented immigrants are unilaterally excluded. But individual exclusion has a collective cost.
More than a decade ago, Rep. Joe Wilson infamously interrupted President Obama’s healthcare speech: breaking all conventions, he shouted “you lie!” when the president denied that the ACA would extend to undocumented immigrants. Unfortunately—from both a moral and policy perspective—the President was telling the truth. So while over 20 million more Americans have received health insurance since the ACA’s implementation, 11 million undocumented immigrants remain categorically excluded.
Today, almost no one will argue that a person who arrives at an emergency room with treatable but life-threatening injuries should be turned away because they cannot pay or are uninsured. Indeed, Congress enacted legislation in 1986 to prohibit hospitals from doing just that. But while everyone must be treated, some are prohibited from buying the insurance that will render treatment affordable for them and the hospital.
There are no serious health care policy rationales for prohibiting undocumented immigrants from purchasing coverage. Without insurance, cost makes it nearly impossible to receive regular preventive care and the prospect of massive emergency room bills means even those in crisis wait until the last moment to seek care.
Excluding undocumented immigrants is also self-defeating from a basic insurance pooling perspective. Undocumented immigrants fit the demographic that insurers seek out: they are significantly younger and healthier than the U.S. citizen population and their contributions would help offset the costs of older, sicker citizens while avoiding the uncompensated ER trap.
More pointedly, the global pandemic has rendered it manifestly obvious that the exclusion of some from healthcare treatment jeopardizes the health of us all. More than 50 million people lost their jobs during this crisis and health insurance remains largely tethered to employment; meaning millions of Americans were forced to confront the possibility that treatment for a life-threatening disease could end in bankruptcy. To prevent that economic cataclysm and to ensure that people get tested and seek treatment once they become ill, Congress stepped in to guarantee health coverage for COVID related illness. Except, that is, for undocumented immigrants.
Political opposition to extending protection to the undocumented led to their categorical exclusion from the CARES Act. Not only does the exclusion belie the premise of the legislation—that the health of one of us is tied to the health of all of us—it also ignores the fact that many undocumented immigrants are essential workers who continue to put their lives on the line. Even in a pandemic when what is both right and smart are plain to see, divisive politics continues to trump good policy.
Congress stepped in to guarantee health coverage for COVID related illness. Except, that is, for undocumented immigrants.
The common-sense way to unlock this political box is to eliminate the root cause of the policy dispute by creating a path to citizenship for the undocumented population. Doing so will begin to address some of the glaring structural health inequities that have been revealed during this crisis.
Although no data is available for COVID infection and death rates among undocumented immigrants specifically, there is limited racial data that provides some insight into the scope of the inequities. Latinx people are contracting coronavirus at three times the rate of White people. Disproportionate exposure is the result of other inequities in our economy and society, but our healthcare system is also clearly failing those who do get sick: of Latinx people who died, more than a quarter were younger than 60. Only six percent of White people who died were that young.
Creating a way for undocumented immigrants to earn citizenship will eliminate the excruciating decision millions of mixed-status American families regularly must make: whether to seek care and face bankruptcy, or wait until it’s too late or until others have become sick—the very problem Congress sought to preempt for most Americans in the CARES Act. And it will lift the additional risk factor influencing whether undocumented immigrants seek critical medical assistance: deportation.
Although hospitals are purportedly considered sanctuary spaces and doctors cannot share information with immigration officials, well-founded distrust pervades. Two thirds of respondents to a Migrant Clinics Network survey said they had seen a reluctance among their patients to seek healthcare since the Trump Administration’s immigration crackdown.
This is not paranoia: in the first half of 2019 alone, enforcement officers spent an unprecedented 153,000 hours monitoring hospitals—an average of 69 trips a day.
Against this bleak backdrop, it is perhaps unsurprising that the psychological toll of lockdown poses an outsized threat for the undocumented, too. The social isolation required by the pandemic is a familiar loneliness for many: a retreat from social interaction is standard, not out of fear of illness, but of deportation. And when isolation isn’t a temporary measure but a way of life, the impacts are devastating. In a yet-to-be published study, an Arizona State University scholar found that, compared to immigrants with legal status, undocumented immigrants are 2.9 times more likely to report symptoms of depression, 8.5 times more likely to report symptoms of anxiety, and 5.9 times more likely to report symptoms of stress.
A path to citizenship would not only sidestep the political minefield of insuring the undocumented, it would deny opponents of universal health coverage a weapon they deploy to block systemic reforms. It would resolve the hypocrisy of an undocumented workforce that we rely on but will not care for. It would remove the cause of toxic stress and promise better health for generations of American citizens to come. And it would strengthen our public healthcare system and distribute costs more equitably. We have learned the hard way that public health does not exist with caveats. It is a lesson we must heed.