Health Reform for All – What About the Rest of Them?

Hewett Chiu | NYU College of Arts and Sciences 2014, Wagner Graduate School of Public Service 2015

Hewett Chiu is currently in the joint-degree B.S./M.P.A. program, studying Neural Science and pre-medicine in CAS and Health Policy, Management & Finance at NYU Wagner. He is the President & CEO of the healthcare not-for-profit Academy of Medical & Public Health Services (AMPHS); the Executive Director of the federal Medical Reserve Corps Unit 2178 under the Office of the U.S. Surgeon General; and President & Principal Consultant at the strategic healthcare and business management consulting firm Chiu Consulting Group.

Implementing Health Reform for Undocumented Immigrants

With the Patient Protection and Affordable Care Act of 2010 (“ACA”) passing Supreme Court scrutiny and declared constitutional in June 2012, all U.S. citizens and “lawfully present” aliens as described by the ACA will be required to purchase health insurance. While this will help the many current Americans who are left without adequate health insurance and aims to patch up the traditional “donut-hole” left by the current healthcare system for the underinsured, the ACA is not the ultimate solution to addressing our healthcare needs. There are still certain individuals who are not covered, or to whom the ACA does not apply. Chief among these groups are undocumented immigrants. While the recent deferred action initiative opens doors for illegal immigrants to continue residing in the country, the influential and groundbreaking ACA does the opposite – barring these groups from partaking in the law’s new enactments, effectively preventing them from accessing affordable health insurance.

At the heart of the ACA is the individual mandate – the provision which aims to bring affordable health insurance options to every American. The mandate requires each American citizen to be enrolled in a health insurance plan, or face a tax penalty which would be collected by the Internal Revenue Service[1]. To help facilitate this, the act calls for the creation of state-based “health insurance benefit exchanges”.  These exchanges serve as an open marketplace for individuals to search for and enroll in a plan that fits their needs. For insurance carriers, the exchanges provide a competitive vehicle to promote their products to specific segments of their market. To help guide individuals through the web of health insurance intricacies and help facilitate searching for and enrolling in the best fitting plan, the law also calls for the designation of “navigators”. Navigators will be specific predetermined and screened community organizations, government agencies, or private entities (such as brokerage firms) who will go through a certification process to walk individuals through the exchanges.[2]

While it is evident that our federal government is taking significant strides towards bringing healthcare to every American with the exchanges, undocumented immigrants still face the same problem with health access as they always have.  The legislation does not allow undocumented immigrants to partake in the exchanges or any other part of the law, and thus, there really is no reform in healthcare for this population.  This being the case, what can we do to better serve these immigrants, and ultimately, improve the dynamics of our healthcare system?


It is true that there are still some options for an individual who needs medical attention but is not documented.  For example, the Emergency Medical Treatment and Active Labor Act (“EMTALA”), passed in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (“COBRA”), stipulates that all federally recognized hospitals and healthcare centers must, at a minimum, provide a full screening by a qualified healthcare professional, stabilize the patient’s condition, and make transportation arrangements for the patient to another facility if the current facility cannot admit the patient as necessary.  Hospitals not abiding by EMTALA risk losing their federal funding, which may account for a great portion of their overall annual operating budgets.[3]

Besides EMTALA, immigrants can also receive full Medicaid eligibility without having all their paperwork finalized under the Permanently Residing Under Color of Law (“PRUCOL”) eligibility criteria.  PRUCOL is not a citizenship category, it is merely a classification of eligibility for specific immigrants who may not be properly documented, but are residing under the knowledge or acquiescence of the federal government and the government has no plans of deportation for the individual.  Having been tried in court on a federal level, PRUCOL was effectively banished by the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996,[4] placing severe limits on state and local governments as to what welfare opportunities undocumented immigrants are eligible for.  Having been challenged by the states, many state and local governments now define PRUCOL eligibility for those who reside within their jurisdiction.  Once an immigrant is considered PRUCOL, he/she will receive all benefits as any other citizen covered under Medicaid.

For someone who does not fit the criteria for PRUCOL, there are still options to receive a wide range of care.  Local governments are charged with providing a safety net health system for those who cannot afford the price of healthcare, but really need it.  Many of these safety net systems are openly blind to documentation, and vow to treat and admit any patient who walks through its doors regardless of immigration status or financial situation.  In addition, many private and not-for-profit hospitals are also blind to documentation and seek to treat the uninsured and underprivileged.  These hospitals factor in uncompensated care into their budgets each year, knowing that they will not be reimbursed for a certain amount of care that they will provide during the year. To help alleviate these charity care expenses, many of these hospitals receiving federal funding as a disproportionate share hospital (“DSH”) to help adjust for the greater portion of uncompensated care they provide.


Even with EMTALA, PRUCOL, and DSH funding, not involving undocumented immigrants in the current healthcare system would be detrimental to the system as a whole.  The ACA calls for a significant reduction in DSH funding in favor of Medicaid expansion[5].  However, reducing this funding can contain costs only if those who seek to participate in the healthcare system can enroll in Medicaid.  Undocumented immigrants are not given this option aside from receiving state Emergency Medicaid under certain circumstances.  This translates to immigrants continuing to visit emergency rooms for medical care, even for non-emergency related matters.

Because our healthcare system already opened the doors for EMTALA, PRUCOL, and uncompensated care, immigrants who have no place to go for regular health care will visit emergency rooms and continue crowding the emergency department for health needs, where they know they will be seen.  However, from a social perspective, doing so would mean they are taking up the space of someone else who would really need the attention and care of the emergency department potentially more than they would.

From a clinical perspective, this usually means that these patients let diseases and conditions manifest to such a state that they can not bear it anymore.  This usually means a higher cost of treatment with worse rates of outcomes than if they had seek preventative care and services (another improvement called for in the ACA which they do not have access to) at the onset of the symptoms presenting.

From an economic perspective, they will be visiting one of the most resource-intensive departments of a hospital for care that they can seek faster and outside for a lower price.  The emergency department continually needs to be stocked appropriately for a full range of conditions to be treated, which raises the cost of the maintaining that facility.  If these immigrants were able to seek care like any other American, they can easily visit a local clinic as soon as they are ill or injured, which translates to lower medical costs, faster medical attention, better outcomes, and lower stress and frustration.  In addition, immigrants typically represent a lower socioeconomic status (“SES”) than other Americans.  If this is the case and they will still continue to visit the very health centers that our system has to pay for without letting them partake in the system, we still continue to bear much of the burden of cost for their care in the end.


Given a choice of whether or not to have good health, anyone would presumably choose to be healthy. However, in real life, it is not so simple.  There are certain factors which may predispose an individual to negative health conditions, and immigrants are especially prone to these limiting factors.

One particular factor is an individual’s socioeconomic status, which considers the income, occupation, and education of that individual.  These three elements interact and are dependent on each other to determine a person’s health status. For example, an individual’s lower education may lead to a less lucrative occupation, which in turn leads to lower income.  With lower income, that individual is less likely to have adequate health coverage and certainly fewer resources to pay for medical care when needed.  This leads to individuals who cut back on their healthcare costs, which in turn produces patient noncompliance to filling and taking their medications on time, deciding to undergo certain necessary procedures, or even seeking timely healthcare.

Occupation also plays several roles in determining one’s health status.  A person’s occupation may provide health insurance for their employees and their families, and thus may lead to better health outcomes.  In addition, the amount of stress experienced by a worker also contributes to overall health.  Continuous stressful jobs or jobs that do not produce enough income for a family may lead to toxic stress which can eventually contribute to permanent organ failure.  Immigrants are more likely to work in blue collar, physically demanding jobs and thus, would experience higher levels of toxic stress daily, coupled with the fact that many of these blue collar jobs do not offer health insurance to their laborers.

Many of these limiting factors stem from the lack of proper higher education for immigrants.  Without advanced education, it is more difficult for individuals to acquire a secure, well-paying job with excellent benefits.  In addition, a lower education also means lower understanding or comprehension of certain concepts and principles, and thus immigrants with lower education are less likely to understand diseases, what they can do, and proper management of their health conditions.  This in turn further contributes to patient noncompliance and an overall costlier healthcare system when providers must spend time educating patients and translating instructions into the immigrant’s native language.


To address the different factors affecting the health status of undocumented immigrants, three priorities should be considered:

Improve health literacy among immigrant populations.  Health literacy is a central contributing factor to many health concerns and can account for a good number of immigrants not seeking timely care.  Being able to understand different diseases, treatments, and methods of caring for various conditions may greatly impact the quality of life of someone living with a certain disease.  Raising awareness of the prevalence for specific diseases and the need for regular and periodic health screenings is an excellent prevention tool for those who do not know whether they have a certain condition.

To improve the health literacy in any highly saturated immigrant community, grassroots outreach efforts need to be made consistently and aggressively.  Community organizations and boards built into the foundation of each immigrant community should consider implementing a weekly or biweekly seminar series that is free and open to the public, presented in the languages predominant in that community and lasting only one hour.  Each seminar can concentrate on a different disease or condition, with first explaining in simple vernacular the signs and symptoms and the common clinical manifestations of that disease, followed by the necessary follow up and common treatment methods available.  Each seminar should end with a “Take Action Now” segment, highlighting screenings or other services an individual should seek to help with that condition.  At the end of each seminar, the facilitators should make themselves available to answer any personal questions from community members, and should be ready to make proper referrals to community health centers as necessary. These seminars may run on a rotating schedule such that if a community member cannot make one on a certain day, another seminar on the same topic will be available in the near future.

Promote healthy behaviors in the daily lifestyles of residents.  With higher rates of uncontrolled health conditions within undocumented immigrant populations, a need arises to address not just treating the disease, but proper long-term management of the health condition such that the condition does not excessively worsen or the condition does not precipitate in an otherwise healthy individual.  This would require each individual to understand and practice healthy social behaviors and make positive, healthy lifestyle choices long-term.  However, the lower education rate within this population usually contributes to a more physically and/or mentally stressful occupation with a lower income; and habits such as healthy eating with fresh fruits and vegetables and exercising are not common or affordable.

Enacting this proactive intervention utilizes a multi-faceted grassroots and integrative approach.  From one perspective, local healthcare organizations may implement a regular free public hands-on workshop to coincide with the seminar series mentioned above.  This hands-on workshop would be a weekly hour of guided exercise, relaxation, and stress reduction techniques similar to classes found at a costly gym or health club.  Providing access to such services and at such a regular interval would ensure that community members have a long-term solution to maintaining an exercise regimen and reducing stress that may otherwise become toxic.

From another perspective, the local community boards should consider working with local not-for-profit food pantries who give out foods and vegetables to the underprivileged.  The community board can implement a nutrition program at such pantries to ensure that fresh produce are being used and distributed, and healthy methods and alternatives are being used to prepare meals.  In addition, the community board can co-host cooking demonstrations on-site at these food pantries, showing community members how simple and fun it is to cook healthy.

Finally, local organizations can also make substance abuse, smoking cessation, and alcohol dependency counseling programs free, open, and readily available to community members.  Each of these programs targets the leading social behaviors leading to many of the leading health disparities seen today, especially hypertension and cardiovascular diseases.  These programs should be available in the predominant languages in that community, and guided by facilitators and counselors from the same ethnic and cultural background as residents.  This ensures that there is a degree of understanding and trust between the resident and the counselor such that residents would not shy away from seeking assistance to cease unhealthy habits and behaviors.  These organizations should also engage in mass marketing and dissemination of information about these programs to reduce the stigma they currently face in society.

Develop an integrated network of culturally-oriented community health centers working together and coordinating medical care and health outreach efforts.  Because of certain language barriers and providers who do not understand cultural values within health centers, many undocumented immigrants feel unwelcome or afraid of seeking healthcare when they need it most, being frightened of having to explain their condition to a stranger.

It is therefore necessary to have culturally competent community health centers located within the core of immigrant communities staffed by professionals who hold the same values, speak the same language, and understand the same cultural practices of the immigrants they serve.  These community health centers should be a place where residents are not afraid to seek out healthcare. Local community boards can develop a process to guide community centers to become navigators for the new state health insurance benefit exchanges under the ACA.

In addition, these community centers should be able to work together and not compete against one another. The community boards can develop a community “Shared Health Record Database”, an Electronic Health Record system in line with Meaningful Use [6] criteria that spans the network of culturally-competent community health centers.  This allows each resident to be able to visit a community health center for follow up, specialty services not offered at another center, or just for a second opinion, and not have to worry about transferring prior medical records and duplication of efforts leading to excessive testing and a waste of resources.  Integrating efforts across such centers also allows for stronger and wider outreach and education efforts from the provider perspective, and a more solid system of care rooted in the community it serves.


While the current state of health reform effectively prevents undocumented immigrants from accessing the healthcare they need, there are still options for implementing health reform to meet the needs of this group.  From analyzing the dynamics of how undocumented immigrants affect the healthcare system that we all partake in, even if they are barred from participation themselves, we begin to see that neglecting undocumented immigrants may very well still drive our healthcare costs up and lead to higher rates of illnesses and diseases within our society.  Thus, by proactively developing an understanding of the backgrounds of these immigrants and the specific situations they face, we can truly begin to enact a healthcare reform model that can be implemented at the community level to improve the health and wellbeing of everyone in society.




  1. Great posts- a great point. A discussion not being had today…

  2. Anonymous · ·

    What an important and interesting insight into what we need to focus on moving forward!

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