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Published On Jun 10, 2016

Policy

Hidden Americans

Xóchitl Castañeda looks for the immigrants invisible to the U.S. health care system.

Sharp words are nothing surprising during any presidential election, but some of the unkindest this year have been directed at people who can’t easily respond. More than 11 million undocumented workers and their families have been put in the political spotlight, and while the legal status of these immigrants has been a hot issue, very little public attention has focused on where these immigrants fit into the complex U.S. health care system.

That is a problem, says Xóchitl Castañeda, because their needs are great and their access is limited. As the founder of the Health Initiative of the Americas (HIA), Castañeda aims to be a steady voice on this volatile topic. The HIA, based at the University of California, Berkeley’s School of Public Health, produces research and policy papers and works directly with health care organizations throughout the Americas to find better solutions for equitable and humane care. 

Q: Who are the undocumented?

A: Well, they are familiar faces. Nearly two-thirds have been in the country for more than 10 years. And they’re here to work. The men tend to work in physically demanding or hazardous occupations, such as agriculture, construction and meat packing, while the women tend to fill other high-demand, low-paying jobs, such as those in the service industry and domestic work. 

Back home, the majority of these workers come from urban areas, which is interesting, because many of them in the United States end up in agricultural jobs that they aren’t prepared for.

Q: And what are their health care needs?

A: Crossing the border, many face physical assault, rape and mental health trauma. After they arrive, their major health risks often come from work, as most are performing risky jobs nobody else will do. Farm work employs just 3% of the workforce nationally, but accounts for 13% of all workplace deaths and high injury rates as well as exposure to pesticides. They also suffer high rates of injury and death in construction and other occupations in the United States.

Later on come the problems of long-term poverty. After 10 years in the country, these immigrants are more likely to be obese than whites are. And about 13% of all immigrants from Mexico, documented or not, are diagnosed with diabetes, compared with just more than 7% of whites. Of those immigrants with diabetes, only 64% have health insurance. 

Q: How well does insurance work for the undocumented?

A: Not well. Even though they might have the means to pay for health insurance, they are not allowed to participate in the new Affordable Care Act exchanges. That means they don’t get the lower premiums, the tax credits and other benefits that are meant to help the working poor.

So, without insurance, some find the health centers and other public clinics in their communities that do not necessarily ask for papers and offer sliding scale fees. The rest of them access health care through more expensive private practice clinics. It’s a culture shock, because most of this population comes from Mexico, where there is universal health care.

Q: So many end up paying more for care?

A: Yes, in several ways. If they’re on somebody’s payroll, for instance, their paychecks are subject to taxes, which pay for Medicaid. But when it’s time to claim benefits, the system says, “No, no, you are undocumented.” 

Another big economic myth is that immigrants without medical insurance are more likely to use emergency services. Our studies show that among Mexican-born immigrants, just 11% use these services, compared with almost 20% of the white, U.S.-born population. 

There are a few federal health benefits for which undocumented immigrants qualify, but they generally cover only life-threatening situations. As we know, things like preventive care, care for chronic conditions, and rehabilitation after injuries are all more cost effective than treating the catastrophic illnesses that result from their absence. 

Q: Are there good political solutions?

A: There are a few promising reforms. One new policy in California allows undocumented children to access affordable primary health care through programs operated at the county level. And some advocates are proposing telemedicine programs, which are based in these workers’ home countries. Migrants could call doctors who speak their own language, and who could advise on some conditions. It’s a way for those governments to take more responsibility for these workers who contribute so much to both countries. But really, we’re looking at a whole range of solutions. The problem is too big to take anything off the table. 

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