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A Promise Yet to Be Fulfilled

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The Affordable Care Act aims to move the nation toward universal coverage. But Fielding School experts point out that for some immigrants, basic, quality health care is no closer to becoming a reality.

The Patient Protection and Affordable Care Act (ACA) will extend insurance coverage to an estimated 25 million more people in the United States by 2016, according to the Congressional Budget Office. But for many U.S. immigrants, the ACA’s promise of improving access to health care is not being fulfilled.

Fielding School faculty experts point out that the two major provisions that expand coverage under the federal health care law – the ability to purchase subsidized plans through federal and state-run health insurance exchanges, and the expansion of Medicaid eligibility in participating states – are unavailable to many immigrants. This exclusion, they note, could have the effect of reducing access for a group that already faces challenges to receiving quality health care, beyond the issue of insurance coverage.

“Our estimates project no change in insurance coverage for undocumented immigrants – they have access problems now, and the ACA will do nothing to improve that.” 
—Steven Wallace

Under the ACA, immigrants lawfully residing in the United States are prohibited from obtaining federally subsidized insurance through Medicaid if they have been in the country less than five years, even if they are income-eligible. The ACA also explicitly excludes the approximately 11 million undocumented immigrants living in the United States, both from buying insurance through the exchanges (subsidized or otherwise) and from obtaining coverage under the Medicaid expansion. “Our estimates project no change in insurance coverage for undocumented immigrants – they have access problems now, and the ACA will do nothing to improve that,” says Dr. Steven Wallace, professor and chair of the Fielding School’s Department of Community Health Sciences and lead author of an analysis prepared by the Fielding School-based UCLA Center for Health Policy Research (of which Wallace is associate director) on the ACA’s impact on coverage for immigrants. Nationally, the Wallace-led report estimated, three-fifths of nonelderly adults who are undocumented immigrants are uninsured.

infographic about undocumented uninsured

Wallace’s report, which used data from the center’s California Health Interview Survey (CHIS), noted that 2.2 million undocumented immigrants live in California. His group found that while undocumented immigrants represent 7 percent of Californians, they make up almost a quarter of the state’s total uninsured population. Nearly half of California’s undocumented immigrants have lived in the United States for more than 10 years, the study reported.

Dr. Arturo Vargas Bustamante, assistant professor in the Department of Health Policy and Management at the Fielding School, sees other potential perils for undocumented immigrants. The ACA’s employer mandate – the requirement that all businesses with more than 50 employees provide coverage or pay a penalty – could deter smaller employers from offering insurance if it’s cheaper for them to simply pay the fee and send their employees to the exchanges. For the small percentage of undocumented workers who receive job-based insurance but are ineligible to purchase plans through the exchanges, this could mean the end of coverage. Enforcement of the mandate has been delayed until 2016.

“For many immigrants who have been living in the country legally but for fewer than five years, the continued exclusion from Medicaid coverage means greater vulnerability.” 
—Arturo Vargas Bustamante

 “For many immigrants who have been living in the country legally but for fewer than five years, the continued exclusion from Medicaid coverage means greater vulnerability,” says Vargas Bustamante, who helped to develop Mexico’s health care reform law more than a decade ago as a member of the administration of then-President Vicente Fox. In his research, Vargas Bustamante has found that U.S. immigrants who had been in the country fewer than five years were hit disproportionately hard during the 2007-2009 Great Recession because of exclusion from federal programs that cushion the impact of economic hits to low-income and unemployed populations, such as Medicaid, unemployment insurance and supplemental nutrition assistance programs. Immigrants have been ineligible for federally financed Medicaid in their first five years in the U.S. since the passage of federal welfare reform in 1996, although some states, including California, provide Medicaid coverage to recently documented immigrants using only state funds. California is also providing Medicaid eligibility to Deferred Action for Childhood Arrivals recipients (those brought to the U.S. without authorization as children) who are similarly not eligible for federal funding.

infographic about undocumented parents

The fear of deportation and/or losing the ability to achieve legal status represents another access barrier for undocumented immigrants – and in some cases for their lawfully residing family members.

Wallace notes that three-fourths of undocumented immigrants live in a household with at least one citizen. Nearly one in six California children has at least one undocumented parent, with more than 80 percent of those children being U.S. citizens. “In these mixed-status families, there can be a logical reluctance to walk into a county welfare office without papers and say ‘I want to sign my child up for health insurance,’ even though they are eligible and the government has tried to assure people that the information required by the programs is used only to determine eligibility,” Wallace says. Sometimes the mere presence of an undocumented relative in the household of an otherwise eligible family can be a deterrent to applying for benefits, Wallace adds, for fear of putting that relative at risk.

In a 2010 analysis using CHIS data, a research team headed by Vargas Bustamante reported that undocumented immigrants from Mexico are 27 percent less likely to have visited a doctor in the previous year and 35 percent less likely to have a usual source of care (a place one typically goes to when sick, other than an emergency department) than documented Mexican immigrants. “The recently approved Patient Protection and Affordable Care Act will not reduce these disparities unless undocumented immigrants are granted some form of legal status,” Vargas Bustamante and colleagues wrote.

Proponents of excluding undocumented immigrants from the health insurance exchanges have argued that they contribute to high costs and emergency department crowding. But a Fielding School team found that in California, undocumented immigrants see doctors and visit ERs significantly less often than U.S.-born citizens and documented immigrants. “Most people who go to the emergency room have insurance and are not worried about providing documents. The undocumented who end up in the emergency room have often delayed getting any care until they are critically sick,” says Dr. Nadereh Pourat, the study’s lead author and director of research for the UCLA Center for Health Policy Research, as well as professor of health policy and management at the Fielding School.

The findings of Pourat’s team, based on CHIS data and published in a 2014 issue of the journal Health Affairs, suggest that including undocumented immigrants in ACA provisions would not overburden emergency departments and health providers. At the same time, the study presents evidence that undocumented immigrants seek fewer outpatient services, particularly preventive care – potentially leading to more advanced disease and higher public expenditures. “Not only are they not using expensive services that you would hope could be avoided, but they are not using the services that you want people to receive,” Pourat says.

“The great majority of undocumented persons in California are adults who contribute greatly to California’s economy. It makes economic and ethical sense to make sure they have affordable health coverage options.”
—Nadereh Pourat

As important as health insurance coverage is to determining whether immigrants receive appropriate health services, it is not the only factor. In Pourat’s studies she has examined access barriers that lead to a lower level of cancer screening and other preventive services among many immigrant groups. She has concluded that even among the insured, being in the country for a shorter period of time is associated with more difficulties navigating the health care system, resulting in a lower use of important services.

“We often talk about health literacy,” says Wallace. “Usually, that means whether patients understand how to use their prescriptions or follow instructions for managing their chronic conditions. But another kind of health literacy is whether you understand what your insurance covers, when you should be getting well visits, and how to make an appointment when you need to see a new doctor.”

Wallace adds that getting in the door isn’t enough; access to quality health care often requires being able to connect with a provider, both linguistically and culturally. In Los Angeles County alone, approximately 100 languages are spoken. Particularly for smaller immigrant groups, the difficulty in finding a provider who speaks the same language and understands the culture is often an access barrier, even among the insured.

Dr. Ninez Ponce, professor of health policy and management at the Fielding School and director of the school’s Center for Global and Immigrant Health, says that for California’s immigrant population, access to linguistic services has improved in the last decade as Medicaid and commercial plans have begun addressing the language needs of their patients through the use of live interpreters, language hotlines, and efforts to diversify the health care workforce. Ponce believes CHIS, which since its inception in 2001 has gone to great lengths to measure health status and access to care through outreach in multiple languages to accurately capture the state’s diverse population, has helped to promote the changes. Among other things, CHIS provided data that assisted the California Pan-Ethnic Health Network in sponsoring the 2003 Health Care Language Assistance Act, a first-of-its-kind state law holding health plans accountable for the provision of language services. Ponce, who has been the survey’s principal investigator since 2012, participated in the initial planning process when CHIS was being developed by the late Dr. E. Richard Brown, founding director of the UCLA Center for Health Policy Research.

A health economist, Ponce describes her focus as unconventional: Rather than studying health care spending in terms of dollars, she assesses what she considers to be transaction costs – including the cost of communicating with a physician when there are language barriers. “It’s important to understand these costs not just for the average consumer, but for those who are left behind by eligibility, cultural and linguistic barriers,” Ponce says. “If access to care and the quality of that care are compromised just because you can’t communicate with your doctor, that should be fixable. You shouldn’t need your 13-year-old to go with you to an exam to translate.”

Ponce, whose family moved to the United States from the Philippines when she was a child, says the many Fielding School students who come from other countries provide constant fuel for her efforts to improve immigrants’ access to quality care.

“If access to care and the quality of that care are compromised just because you can’t communicate with your doctor, that should be fixable. You shouldn’t need your 13-year-old to go with you to an exam to translate.”
—Ninez Ponce

“As a professor I am inspired by my students’ life stories,” Ponce says. “So many of them have a family member whose care was compromised because of language or cultural barriers. I’ve met students from dozens of countries, and on a daily basis they remind me that this work isn’t just academic, but can change lives.”

Unfortunately, she adds, in times of scarce resources the threshold for receiving benefits tends to be raised and immigrants – particularly those who are undocumented – are often among the first groups excluded. Ponce argues that anti-immigrant sentiment can be harmful to both immigrants and society as a whole. “Not long ago there was a strong movement for English-only policies,” she says. “Of course immigrants want to learn English, but it can take 10-15 years to become proficient. In that time, if you and your doctor have trouble communicating about something like cancer screening, a tumor can develop and that is going to be costly not only to the patient, but also to the system.”

Indeed, Wallace notes, beyond the humanitarian reasons, providing health insurance to undocumented immigrants makes economic sense: As a population that on average tends be younger, healthier and less likely to use health care, they could contribute to lower premiums by improving the risk-sharing in state insurance pools. Expanding coverage to all immigrants could also reduce the burden of uncompensated care, another cost borne by society.

“The great majority of undocumented persons in California are adults who contribute greatly to California’s economy by working in physically demanding service, agriculture and construction jobs,” says Pourat. “It makes economic and ethical sense to make sure they have affordable health coverage options so they can stay healthy.”