The Committee would like to thank Alan Waxman, MD, MPH, and Raymond Cox, MD, MBA, for their assistance in the development of this document.
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Undocumented immigrants are less likely than other residents of the United States to have health insurance. Their access to publicly funded health programs has become increasingly limited since the passage of welfare reform in 1996 and varies from state to state. This is reflected in less preventive health care, including prenatal care, and poorer health outcomes, including those associated with childbirth. The U.S.-born children of undocumented immigrant women are U.S. citizens, and the nation's public health is enhanced by assuring that all who reside in the United States, including undocumented immigrants, have access to quality health care.
Scope of the Problem
The United States has been called a nation of immigrants. Approximately 11% of the U.S. population, more than 30 million people, were born outside the United States (1). Two thirds of these immigrant residents are not U.S. citizens (1). Approximately 29% of these immigrant residents are undocumented (i.e. they either entered the country illegally or have expired visas) (2, 3). Over the past 30 years, the proportion of recent immigrants in the United States without documentation has increased almost 10-fold (4). A majority of undocumented immigrants (57%) come from Mexico, and almost one quarter (24%) are from elsewhere in Latin America. The remainder come from Asia (9%), Europe and Canada (6%), or Africa and other locales (4%) (2, 3).
The undocumented immigrant population is spread throughout the United States, with about one half concentrated in California, Texas, Florida, and New York (2). Thirty five percent of undocumented immigrants are women and 15% are children. Because children born in the United States are granted citizenship by the 14th amendment to the U.S. Constitution, many children living in families headed by undocumented immigrants are U.S. citizens (3, 5).
Undocumented immigrants frequently remain in the United States for many years. A survey by the Kaiser Family Foundation of undocumented Latinos in Fresno County and Los Angeles County, found that 60% and 65%, respectively, of adult undocumented Latinos have resided in the United States for more than 5 years (6). Most undocumented immigrants live in poverty and have low rates of health insurance coverage (5, 7, 8). Prenatal care coverage may be an exception. A recent study examining prenatal coverage among undocumented Hispanic women who gave birth in three U.S. cities, found that 79–99% had some coverage, mostly from public sources (9).
Immigrants do not appear to use an excess of health care resources. In Los Angeles County, undocumented immigrants comprise 12% of the population, but the cost of their medical care represents only 6% of medical expenditures in the county (4). In a 1998 study, immigrants (documented and undocumented) used 55% fewer dollars than their U.S.-born counterparts on medical care and prescription drugs (10). Undocumented Latino immigrants are less likely to visit a physician in an outpatient setting than the general U.S. population, although their rate of childbirth-related hospitalization is significantly higher (5).
Health Status of Undocumented Immigrant Women
Studies in several areas of the country have found that undocumented immigrant women begin prenatal care later and have fewer prenatal visits compared with the general population (9, 11). Use of prenatal care varies, however, with the availability of publicly funded prenatal programs (9). Looking at maternal outcomes, a Colorado study found significantly lower rates of primary cesarean deliveries and increased rates of operative vaginal deliveries and vaginal birth after cesarean in undocumented women when compared with the general state population (11). Birth complications were more common among the undocumented women, including meconium staining, excessive bleeding, precipitous labor, malpresentation, cord prolapse, and fetal distress. Neonatal morbidity, including fetal alcohol syndrome, respiratory distress syndrome and seizures, also was more common (11). Few studies of perinatal morbidity distinguish undocumented from legal immigrant women.
Some investigators have found that Hispanic immigrants have lower rates of prematurity and low birth weight infants than the general U.S. population (11–13). These outcomes have been attributed to a "healthy migrant effect" resulting from a bias toward younger and healthier individuals coming to the United States. This tendency toward better birth outcomes particularly in Latina immigrants appears to last only one generation.
Some evidence indicates that immigrants have less access to preventive services. For example, although the incidence and mortality from cervical cancer is on the decline among women born in the United States, it is actually increasing among immigrant women (14, 15). A 1998 survey showed that U.S. and foreign-born Latinas were less likely than whites to have had a recent mammogram and more likely to have never had a mammogram or Pap test (16). A retrospective study of patients with cervical cancer in Chicago found recent immigrant status to be a risk factor for never having had a Pap test (17). Lack of health insurance was the strongest predictor of no recent mammogram, clinical breast examination, or Pap test (16).
Health Programs and Undocumented Immigrants
Although some health care services are available to uninsured immigrants, the complexity of accessing care in the face of ever-changing and conflicting laws, coupled with a fear of harassment by immigration officials, inhibit many legal and undocumented immigrants from seeking care. The Personal Responsibility and Work Opportunity Reconciliation Act, popularly known as the 1996 Welfare Reform Act, widened the gap in health insurance coverage between low-income U.S. citizens and immigrants (18). The Act eliminated Medicaid and other federal health program eligibility for indigent undocumented immigrants, and restricted eligibility for legal immigrants, allowing exceptions for emergency medical conditions, immunization, and treatment for symptoms of communicable diseases.
Welfare reform also made undocumented immigrants ineligible for many similar benefits previously provided by state and local governments unless new state legislation was enacted (19). A number of states have passed legislation to continue use of state funds to provide care, especially prenatal care, to undocumented immigrants based on residence and financial need (9, 20). A number of federally funded public health programs are still available to undocumented immigrants, including those administered under Title V of the Social Security Act (Maternal and Child Health Services Block Grant) and Title X of the Public Health Service Act (Family Planning). In addition, Federally Qualified Health Centers, Healthcare for the Homeless, and Migrant Health Clinics provide comprehensive primary care, including prenatal care, without regard to income, insurance, or immigration status.
State grantees in the National Breast and Cervical Cancer Early Detection Program may elect to offer screening without regard to immigration status. If cancer or premalignant conditions are diagnosed via this program, however, undocumented patients may not receive care through its companion law, the Breast and Cervical Cancer Prevention and Treatment Act (21). The Act allows Medicaid eligibility for those who receive diagnoses through the program; as stated earlier, undocumented immigrants cannot receive Medicaid benefits.
The State Children's Health Insurance Program, which provides health coverage for children in families with incomes too high for Medicaid but too low to afford private coverage, contains similar restrictions on care for immigrant children. In 2002, the Centers for Medicare and Medicaid Services permitted states to use the State Children's Health Insurance Program funds to provide coverage for fetuses. Some states have used this option as a way to finance coverage for legal and undocumented pregnant women. This can be done because, although the pregnant woman is ineligible, her child will be a U.S. citizen and qualifies for the program. However, conferring eligibility on the fetus, rather than the pregnant woman herself, may lead to the exclusion of essential perinatal services, including postpartum care.
Undocumented immigrants, who meet Medicaid financial and categorical eligibility requirements but are not eligible for Medicaid because of their immigration status, can receive Emergency Medicaid to cover emergency care, including labor and delivery (18). In addition, federal law requires provision of emergency care to any individual regardless of insurance or ability to pay, citizenship, or immigration status (22). Under the Emergency Medical Treatment and Active Labor Act, passed in 1986, hospital emergency departments must provide an appropriate medical screening examination to any patient who comes to an emergency department requesting examination or treatment for a medical condition. If the emergency department determines that the patient is experiencing an emergency medical condition, the hospital must provide treatment until the patient is stabilized (23). The Emergency Medical Treatment and Active Labor Act was enacted to ensure that indigent and uninsured patients receive necessary emergency medical care, and the law specifically addresses emergency medical conditions for pregnant women.
A pregnant woman in true labor who seeks care may not be transferred to another facility if there is not adequate time to effect a safe transfer and if the transfer would pose a threat to the health or safety of the mother or the fetus.
The Emergency Medical Treatment and Active Labor Act requires hospitals to provide necessary treatment, but does not require the federal government to reimburse hospitals for the cost of this care. Funding was addressed for the first time when Congress passed Section 1011 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Pub. L. 108-173), which provides $250 million each year for fiscal years 2005–2008 to reimburse hospitals, physicians, and ambulance companies for emergency care provided to undocumented immigrants under the Emergency Medical Treatment and Active Labor Act (22). Health care providers can send payment requests until March 30, 2009, when the program's fiscal year ends. Funds will remain available until expended or otherwise revised. Updated information can be found at: http://www.cms.hhs.gov/undocAliens/.
The American College of Obstetricians and Gynecologists supports a basic health care package for all women. The College has long promoted the elimination of the disparities in health status and health care access among women and includes recent and undocumented immigrants in its advocacy efforts. Immigrant women living within our borders should have the same access to basic preventive health care as U.S. citizens without regard to their country of origin or documentation of their status. The College can help to achieve this by promoting universal access to health insurance for all individuals in the United States and eliminating barriers to existing federal programs, such as Medicaid (24). Health professionals can play a pivotal role in improving access to needed health care for undocumented immigrants by:
- Helping the larger society understand the importance of universal health care access
- Being advocates for the goal of securing quality, affordable coverage for every woman with active support of proposed local, state, and national legislation
- Continuing to support the safety net system and provision of care in the community and office setting for the uninsured
- Providing a comfortable office atmosphere with trans-lators and materials available in languages appropriate for the patient population
- Becoming informed and involved in the American College of Obstetricians and Gynecologists' government relations outreach activities. (For more information go to: http://www.acog.org/About_ACOG/ACOG_Departments/Government_Relations_and_Outreach.aspx.)
- Gold RB. Immigrants and Medicaid after welfare reform. Guttmacher Rep Public Policy 2003;6(2):6–9.
- Pew Hispanic Center. Unauthorized migrants: numbers and characteristics. Washington, DC: PHC; 2005. Available at: http://pewhispanic.org/files/reports/46.pdf. Retrieved January 31, 2008.
- Pew Hispanic Center. The size and characteristics of the unauthorized migrant population in the U.S. estimates based on the March 2005 Current Population Survey. Washington, DC; PHC; 2006. Available at: http://pewhispanic.org/files/reports/61.pdf. Retrieved January 31, 2008.
- Goldman DP, Smith JP, Sood N. Immigrants and the cost of medical care. Health Aff 2006;25:1700–11.
- Berk ML, Shur CL, Chavez LR, Frankel M. Health care use among undocumented Latino immigrants. Health Aff 2000; 19:51–64.
- Henry J. Kaiser Family Foundation. California's undocumented Latino immigrants: a report on access to health care services. Menlo Park (CA): KFF; 1999. Available at: http://www.kff.org/statepolicy/upload/California-s-Undocumented-Latino-Immigrants-A-Report-on-Access-to-Health-Care-Services-Report.pdf. Retrieved January 31, 2008.
- Prentice JC, Pebley AR, Sastry N. Immigration status and health insurance coverage: who gains? Who loses? Am J Public Health 2005;95:109–16.
- Goldman DP, Smith JP, Sood N. Legal status and health insurance among immigrants. Health Aff 2005;24:1640–53.
- Fuentes-Afflick E, Hessol NA, Bauer T, O'Sullivan MJ, Gomez-Lobo V, Holman S, et al. Use of prenatal care by Hispanic women after welfare reform. Obstet Gynecol 2006; 107:151–60.
- Mohanty SA, Woolhandler S, Himmelstein DU, Pati S, Carrasquillo O, Bor DH. Health care expenditures of immigrants in the United States: a nationally representative analysis. Am J Public Health 2005;95:1431–8.
- Reed MM, Westfall JM, Bublitz C, Battaglia C, Fickenscher A. Birth outcomes in Colorado's undocumented immigrant population. BMC Public Health 2005;5:100.
- Kelaher M, Jessop DJ. Differences in low-birthweight among documented and undocumented foreign-born and US-born Latinas. Soc Sci Med 2002;55:2171–5.
- Leslie JC, Diehl SJ, Galvin SL. A comparison of birth outcomes among US-born and non-US-born Hispanic women in North Carolina. Matern Child Health J 2006;10:33–8.
- Schleicher E. Immigrant women and cervical cancer prevention in the United States. Baltimore (MD): Women's and Children's Health Policy Center, Johns Hopkins Bloomberg School of Public Health; 2007. Available at: http://www.jhsph.edu/wchpc/publications/ImmigrantWomenCerCancerPrevUS.pdf. Retrieved July 28, 2008.
- Seeff LC, McKenna MT. Cervical cancer mortality among foreign-born women living in the United States, 1985 to 1996. Cancer Detect Prev 2003;27:203–8.
- Rodriguez MA, Ward LM, Perez-Stable EJ. Breast and cervical cancer screening: impact of health insurance status, ethnicity, and nativity of Latinas. Ann Fam Med 2005; 3:235–41.
- Behbakht K, Lynch A, Teal S, Degeest K, Massad S. Social and cultural barriers to Papanicolaou test screening in an urban population. Obstet Gynecol 2004;104:1355–61.
- Henry J. Kaiser Family Foundation. Key facts: Medicaid and SCHIP eligibility for immigrants. Kaiser Commission on Medicaid and the Uninsured. Washington, DC: KFF; 2006. Available at: http://www.kff.org/medicaid/upload/7492.pdf. Retrieved January 31, 2008.
- Kullgren JT. Restrictions on undocumented immigrants' access to health services: the public health implications of welfare reform. Am J Public Health 2003;93:1630–3.
- Henry J. Kaiser Family Foundation. Deficit Reduction Act of 2005: implications for Medicaid. Kaiser Commission on Medicaid and the Uninsured. Washington, DC: KFF; 2006. Available at: http://www.kff.org/medicaid/upload/7465.pdf. Retrieved January 31, 2008.
- Centers for Disease Control and Prevention. National breast and cervical cancer early detection program. Available at: http://www.cdc.gov/cancer/nbccedp. Retrieved July 28, 2008.
- Centers for Medicare and Medicaid Services. Emergency health services for undocumented aliens: Section 1011 of the Medicare Modernization Act. Baltimore (MD): CMS; 2005. Available at: http://www.cms.hhs.gov/apps/media/ press/release.asp?Counter=1452. Retrieved January 31, 2008.
- Kaiser Commission on Medicaid and the Uninsured. Covering new Americans: a review of federal and state policies related to immigrants' eligibility and access to publicly funded health insurance. Washington, DC: KCMU; 2004. Available at: http://www.kff.org/medicaid/upload/Covering- New-Americans-A-Review-of-Federal-and-State-Policies-Related-to-Immigrants-Eligibility-and-Access-to-Publicly-Funded-Health-Insurance-Report.pdf. Retrieved October 1, 2008.
- The Uninsured. ACOG Committee Opinion No. 416. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;112:731–4.