The Health Costs of Delayed Action on Immigration Reform

This article was originally posted at RH Reality Check. 

President Obama announced last weekend that he would delay taking executive action on immigration until after the November elections, despite his earlier promise that he intended to do something by the end of the summer. It seemed to be a move to protect vulnerable Senate Democrats, but some criticized that reasoning, and many immigrant rights advocates were left feeling deeply betrayed.

“He made a promise to our communities,” Kimberly Inez McGuire, director of public affairs at the National Latina Institute for Reproductive Health (NLIRH), told RH Reality Check. “People wept with hope at the power of that promise, that some kind of relief was coming to the communities that are suffering. He’s now gone back on that promise.”

The promise didn’t contain policy specifics, but advocates hoped the president might grant relief from deportation to as many as five million of the nation’s estimated 11 million unauthorized immigrants. He might even allow some of them to get work permits and Social Security numbers, which hundreds of thousands of young “DREAMers” now have thanks to the 2012 Deferred Action for Childhood Arrivals (DACA) program. 

Breaking that promise by delaying action further has real, daily, human costs—in the 60 days or so until the election, an estimated 60,000 people could be deported, and millions more must continue to live in fear of deportation each day. 

But there is another human cost of delay, less dramatic than deportations but no less destructive to immigrant communities. That cost is the lack of access to affordable health care—both for unauthorized immigrants and for some who are in this country legally.

“Women are living today with undiagnosed cervical and breast cancer who can’t see a doctor because of their immigration status,” Inez McGuire said. “When I think about the Latinas we hear from, this is an urgent issue—they cannot wait another day to find out if that lump in their breast is cancer.” 

That’s the situation Lorena is in. She is the sole caretaker for her special-needs son who doesn’t qualify for Medicaid because he is undocumented, and she can’t afford to get a Pap smear or a mammogram because programs that covered her health-care needs have been cut. “I really want to see a doctor because when I touch my breast I can feel a sort of lump,” Lorena said. “I don’t know if it’s an abscess or something more serious. So I need to see a doctor but haven’t been able to.”

Reproductive health care is a particular concern, advocates say, because women are the backbone of immigrant communities but are less likely than other groups to get the health care they need. Immigrant women are disproportionately represented among poor women of reproductive age, but they are almost twice as likely as poor native-born U.S. women to lack health insurance. They have higher birthrates and, because they are disproportionately young and poor, have a higher risk for sexually transmitted infections. 

The Affordable Care Act was supposed to increase access to health care for lower-income people, and to give women access to no-cost contraception and other crucial preventive reproductive health care. But the widely acknowledged public health benefits of affordable reproductive health care, advocates say, are off-limits to immigrant women who can’t afford the care they need due to legal restrictions.

NLIRH was one of 181 human rights organizations to sign a letter just before Labor Day to President Obama, urging him to make sure immigrants get affordable health-care access when he takes administrative action. 

“We know this is a president who has fought for access to health coverage,” Natalie Camastra, policy analyst at NLIRH, told RH Reality Check. “But we’re very concerned that that is not being extended to immigrant women and families.”

There’s good reason to think Obama might leave health care by the wayside even when he finally does address immigration, advocates say. Shortly after the DACA program was implemented, the Obama administration banned DACA recipients from accessing affordable federal health coverage—Medicaid, the Children’s Health Insurance Program (CHIP), and the subsidies and exchanges under the Affordable Care Act (ACA). Everyone else who is granted deferred deportation has access to those programs, but the administration changed its policy to specifically exclude the young DREAMers who got DACA. 

DREAMers, named after the yet-to-pass DREAM Act that would provide a path to citizenship for undocumented people brought to the country as children, are mostly young people of reproductive age. To qualify for DACA’s two-year, renewable deportation deferral and work authorization, young people under 30 must have come to the United States before age 16, lived in the country for at least five years, be in or have graduated high school, and have no serious criminal records.

These young people, brought to this country through no fault of their own, turned to DACA for a temporary reprieve from both the fear of deportation and the burdens of being undocumented. But even though DACA recipients are considered “lawfully present” and have Social Security numbers, and even though they work and pay taxes that help fund federal health programs like Medicaid or the ACA, in most states their access to health care is no better than if they had no papers at all. Even in states like California, where DACA recipients are supposed to have access to the state’s low-income Medi-Cal program, many have been rejected due to confusion over eligibility. 

And since DACA may well end up being a blueprint for wider immigration reform, there’s a danger that these inequities could be made law for generations of immigrants to come.

“To say to someone, ‘You can live here and work here, but if you get sick you’re out of luck,’ is simply inconsistent with our nation’s values,” Inez McGuire said. “It’s an unjust double standard where the same people who are invited to contribute to our economy are locked out of our health-care system.”

Undocumented immigrants, and lawfully present DACA recipients under the status quo, don’t have many options when it comes to health care. They could get health care through their employer, but they often work in industries like agriculture or domestic work that rarely offer employer-sponsored health care. They can purchase insurance individually, but it will be wildly expensive because they lack access to the subsidies or exchanges in the Affordable Care Act. That leaves unauthorized immigrants mostly with “safety net” providers like community health centers, which constantly face funding cuts and which can be too few and far between in some rural areas. 

LGBT immigrants also face a double-bind when it comes to care, since they are already at higher risk of employment or relationship discrimination, so they are less likely to have employer-sponsored health insurance.

If nothing else, immigrants can rely on emergency room care—which many do, especially when it comes to giving birth. Any pregnant woman, in all 50 states, regardless of her immigration status, can get emergency Medicaid funding for labor and delivery in an emergency room. But if she wants prenatal care, which reduces the risk of complications and low birth weight, her level of care would depend heavily on the state she lives in. 

“In some cases, immigrant women have access to health care while pregnant, and the moment they give birth, that coverage goes away,” Inez McGuire said. “The way the policy is written just fails to account for the entirety of a woman’s health.”

Even if a low-income immigrant woman broke her ankle while pregnant, Inez McGuire said, emergency Medicaid funds might not pay for it because it doesn’t directly relate to the pregnancy.

Ever since the 1996 “welfare reform” law was passed, lawfully present immigrants—that includes people with green cards, refugees, and anyone granted deferred deportation except DACA recipients—have had to wait five years until they can access affordable health-care services such as Medicaid, which is one option for low-income women seeking prenatal care.

There are some exceptions to this “five-year bar,” but they are an inconsistent patchwork that varies state by state. A federal program started in 2002 under President Bush allows states to use federal dollars to provide prenatal care to low-income immigrant women, regardless of their immigration status or when they arrived. But only 15 states have chosen to take that option. And in an anti-choice twist, the program works by granting CHIP funding to the woman’s fetus. Advocates say that’s problematic because it creates fetal “personhood” language that undermines the woman’s autonomy and her right to an abortion if she needs one.

There is also coverage in about half the states for either low-income pregnant immigrant women, their children, or both, with some coverage dependent on the woman or child’s immigration status, and some not. 

“Asking an immigrant to navigate this system is difficult when it takes a policy expert to understand it,” Camastra said. “It’s so, so complicated.”

There are clear, if dubious, political reasons that immigrants have restricted access to health care. Many people think immigrants come across the border to obtain “free” services (forgetting that immigrants pay taxes too). During the recent child migrant crisis, DACA became a scapegoat, with conservative politicians like Sen. Ted Cruz (R-TX) calling for an end to the program because they feared it was luring these children to come to the United States. It almost certainly wasn’t; the migrant influx began before DACA was implemented, and most who arrived had never heard of it. But this kind of fearmongering is a steep obstacle, for both advocates and Obama, against convincing the public that immigrant health needs are worth meeting. 

Failing to meet those needs is “more than an injustice, more than an indignity—this is a denial of human rights, plain and simple,” Inez McGuire said. “Health care is a human right, and it shouldn’t depend on your immigration status, gender, or zip code.”

And meanwhile, the deportations will continue—along with the sometimes-nightmarish reproductive and sexual health crises that immigrants can face in detention centers. Pregnant women like Juana Villegas or Miriam Mendiola-Martinez are sometimes shackled during childbirth, and transgender people like Victoria Arellano often face especially appalling conditions—Arellano, who was HIV-positive, died after being taunted by guards and denied medical treatment. 

But advocates aren’t going to give up on fighting for health-care access. They’re still lobbying Congress, including the most vocally anti-immigration-reform members. They’ve thrown their support behind the HEAL Act—HR 4240, the Health Equity and Access under the Law for Immigrant Women and Families Act of 2014, sponsored by Rep. Michelle Lujan Grisham (D-NM)—which would remove the five-year waiting period for lawful immigrants to access affordable federal health care and remove the restrictions on DACA recipients.

And they’re going to keep putting pressure on the president to do everything he can absent action from Congress. 

“The community will not be sitting down, we will not be stepping back. We’re going to keep the pressure on as long as immigrant women and families continue to suffer,” Inez McGuire said. “There is no excuse for the president’s continued delay.”

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