Elsevier

The Lancet

Volume 393, Issue 10186, 25–31 May 2019, Pages 2168-2174
The Lancet

Health Policy
Challenges for immigrant health in the USA—the road to crisis

https://doi.org/10.1016/S0140-6736(19)30035-2Get rights and content

Summary

The USA is home to more immigrants than any other country—about 46 million, just less than a fifth of the world's immigrants. Immigrant health and access to health care in the USA varies widely by ethnicity, citizenship, and legal status. In recent decades, several policy and regulatory changes have worsened health-care quality and access for immigrant populations. These changes include restrictions on access to public health insurance programmes, rhetoric discouraging the use of social services, aggressive immigration enforcement activities, intimidation within health-care settings, decreased caps on the number of admitted refugees, and rescission of protections from deportation. A receding of ethical norms has created an environment favourable for moral and public health crises, as evident in the separation of children from their parents at the southern US border. Given the polarising immigration rhetoric at the national level, individual states rather than the country as a whole might be better positioned to address the barriers to improved health and health care for immigrants in the USA.

Section snippets

Immigration-related demographic changes

Worldwide, more than 250 million people live outside their country of birth, which represents a 49% increase in global immigration since the turn of the century.10 The USA is home to 46·6 million immigrants—a population greater than in any other country and representing nearly a fifth of all immigrants worldwide.11 Despite having the largest absolute number of immigrants, foreign-born residents constitute only 14% of the US population,11 a relatively modest proportion compared with in other

Health care use and barriers faced by immigrants

Overall, immigrants in the USA are younger, healthier, and use fewer health resources than native-born residents.18 They also have lower overall health expenditures and contribute more to the economy in taxes than they use in public benefits.19 But immigrants continue to face substantial barriers to medical care, which vary greatly according to legal status, and are particularly pronounced for those who are of low-income or undocumented status.20

Non-citizens are much more likely to be medically

Health-care outcomes for US-born co-ethnic residents and mixed immigration status households

Many non-citizen residents live in mixed immigration status households comprised of citizens, legal immigrants, and undocumented immigrants.21 One in four children in the USA lives in an immigrant household, with at least one non-citizen parent; more than 80% of these children are themselves US citizens.22 The negative health effects of anti-immigrant rhetoric and policy can affect both legal and undocumented immigrants, as well as native-born co-ethnics. Ideologies that use racialising

Restricting access to health coverage

Before 1996, legal immigrants in the USA qualified for Medicaid in the same way as low-income American citizens. But in the same year, former President Clinton signed into law the Personal Responsibility and Work Opportunity Reconciliation Act, commonly known as the Welfare Reform, which abruptly restricted immigrants' access to public health insurance and other public benefits. Legal immigrants were no longer eligible for Medicaid or CHIP for 5 years after moving to the USA (undocumented

An atmosphere of fear and anxiety: law enforcement meets health care

Law enforcement now has a prominent role in the health system, and can sometimes create an atmosphere of fear and anxiety for legal and undocumented immigrants, as well as native-born co-ethnics. Evidence suggests that aggressive immigration law enforcement can lead to a so-called chilling effect for legal immigrants and US-born children of immigrants, who are then less likely to seek care than when faced with less aggressive actions.36

Soon after his inauguration in 2017, President Trump signed

Current policy considerations and growing uncertainty for the future

Several current policy efforts have created uncertainty about health and health-care access for both legal and undocumented immigrants. The US Department of Homeland Security in 2018 announced that it is considering extensive changes to the public charge rule.9 Currently, individuals labelled as public charges—defined as being primarily dependent on the government for more than half of one's income—can be denied entry into the USA, or prohibited from transitioning from temporary visa status to

State-based reforms to improve immigrant health care

Substantial heterogeneity exists in state-level immigration policies across the USA, with disparate consequences for immigrant health and health-care access.56 Some states have taken steps to improve the health of immigrants, especially undocumented immigrants who face the greatest barriers to accessing health care. California, for example, recently passed a bill to extend Medicaid benefits to all low-income individuals, regardless of age or immigration status. The state has already used

Conclusions

Practitioners and policy makers should focus on lessening further damage in the current political environment. The US National Association of Community Health Centers, for example, has published guides on caring for immigrant patients and on how to discuss recent policy proposals, like the public charge rule, with affected individuals. The US National Immigration Law Center offers toolkits to help both patients and providers understand their rights in the rapidly changing policy environment.

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