Chat with us, powered by LiveChat Discussion Instructions: · Read the four articles below | Coms Paper
+1(978)310-4246 credencewriters@gmail.com
  
Discussion

Instructions:

· Read the four articles below.

· Should undocumented immigrants be included or excluded from national proposals for health insurance?

· Why?

· Also discuss your stance on national insurance plans in general.

· Justify your position by referring to course readings, videos, or other relevant sources.

Remember that views differ on this contentious issue—don’t be afraid to present and defend your position. You may need to reference the chapters in the book on health insurance and economics.

Your initial post should be at least 400 words.

Please be sure to validate your opinions and ideas with citations and references in APA format.

The four Discussion Resources are below.

· Bustamante, A. V., Chen, J., McKenna, R. M., & Ortega, A. N. (2018). Health care access and utilization among US immigrants before and after the affordable care act. Journal of Immigrant and Minority Health. https://doi.org/10.1007/s10903-018-0741-6

· Galarneau, C. (2011). Still missing: Undocumented immigrants in health care reform. Journal of Health Care for the Poor and Underserved, 22(2), 422-428. https://repository.wellesley.edu/cgi/viewcontent.cgi?article=1096&context=scholarship

· National Academies of Sciences, Engineering, and Medicine. (2015). Health status and access to care. In The integration of immigrants into American society (pp. 377-411). Washington, DC: The National Academies Press. https://doi.org/10.17226/21746

· Sidhu, S. S. MD., & Song, S. J., MD, MPH, PhD. (2019, October 1). Growing up with an undocumented parent in America: Psychosocial adversity in domestically residing immigrant children. Journal of the American Academy of Child & Adolescent Psychiatry, 58(10), 933-935. DOI: https://doi.org/10.1016/j.jaac.2019.05.032

Journal of Health Care for the Poor and Underserved 22 (2011): 422–428.

CommentaryCommentary

Still missing:
Undocumented Immigrants in

Health Care reform
Charlene Galarneau, PhD

Abstract: The health care reform signed by President Obama in March 2010 mirrors the
Clinton reform proposal of 1993 in that both excluded undocumented immigrants from
federal insurance coverage. In both cases substantive discussion of their possible inclu-
sion was stifled by political timidity. This paper begins with a brief descriptive overview
of undocumented immigrants in the U.S. and their health care and insurance coverage. It
highlights the most common moral, economic, and public health arguments made for and
against the inclusion of undocumented immigrants in the 2010 health care reform. The paper
then asserts that undocumented immigrants are part of the U.S. health care community and
urges health care workers to become more active participants in this policy arena.

Key words: Immigrants, health care reform, social justice, insurance coverage.

In September 1993, then President Clinton addressed a joint session of Congress and the public in a televised speech about his proposed “universal” health care
plan—“universal” except for the 3.2 million undocumented immigrants it excluded.
The potential consequences of the plan included higher health care costs for these
immigrants as well as reduced access to care related to the dismantling of key safety
net programs that served them.1

In September 2009, President Obama similarly spoke to Congress and the public
about his health care reform proposal, a proposal that would also exclude, among
others, undocumented immigrants. It was in response to his emphatic statement that
“. . . the reforms I’m proposing would not apply to those who are here illegally,” that a
U.S. Representative shouted his now-infamous, “You lie!” interjection.2[p.1] Indeed, the
Patient Protection and Affordability Care Act signed months later by President Obama
does not cover the now near 11 million undocumented immigrants in the U.S.

Also in the fall of 2009, high-profile media attention was given to the fates of the
several dozen undocumented patients whose kidney dialysis was to end with a unit
closure at Atlanta’s Grady Memorial Hospital.3 Although the debate over health care
reform was full-blown when this story appeared, the place of undocumented immigrants
in health care reform never truly played a central role in it.

Charlene Galarneau is an Assistant Professor at Wellesley College. Please address correspondence
to her at the Women’s and Gender Studies Department, Wellesley College, 106 Central Street, Wellesley,
MA 02481; (781) 283-2598; [email protected]

423Galarneau

This omission was hardly an oversight. Senator Max Baucus, chair of the Senate
Finance Committee, ensured the relative silence of politicians when he warned, “We’re
not going to cover undocumented workers, because that’s too politically explosive.”4[p.17]
When pressed on this, he reiterated, “That’s very politically charged. And I don’t want
to take on something that’s going to sidetrack us.”4[p.31]

That said, some groups attempted to bring public and elected officials’ attention to
the consequences of the proposed reform bills for undocumented immigrants. Primarily
religious, Latino/a groups, and health/health care organizations argued for the inclu-
sion of these immigrants, while anti-immigration groups posed vocal opposition to
any potential benefits for them. This paper begins with a brief descriptive overview of
undocumented immigrants in the U.S. and their health care and insurance coverage. It
highlights the most common moral, economic, and public health arguments made for
and against the inclusion of undocumented immigrants in the 2010 health care reform.
The paper then asserts that undocumented immigrants are part of the U.S. health care
community and urges health care workers to become more active participants in this
policy arena.

Demographic Characteristics of Undocumented Immigrants
in the U.S., Including Health Care and Insurance Coverage

Imprecision and inaccuracies abound in the discourse and in the data about immigrants
in the U.S., so it should be noted that the focus here is on undocumented immigrants:
foreign-born people who reside in the U.S. but are not legally-recognized residents.
These people are sometimes also referred to as unauthorized immigrants, illegal aliens,
illegal immigrants, or people without authorized presence.

In January 2010, the U.S. Department of Homeland Security estimated that there
were 10.8 million undocumented immigrants in the U.S. as of January 2009.5 Pew His-
panic Center research based on 2008 Census data shows that these immigrants make
up 4% of the U.S. population and 5.4% of the workforce. Most are Hispanic (76%),
59% are from Mexico, and two-thirds (68%) reside in eight states: California, Texas,
New York, Florida, New Jersey, Arizona, Georgia, and Illinois. Nearly half (47%) of
undocumented immigrant households comprise an adult couple with children. Seven of
every 10 children of undocumented immigrants are U.S. citizens by birth. The median
annual household income of undocumented immigrants in 2007 was $36,000, notably
lower than the $50,000 of U.S.-born residents.6

Many undocumented immigrants who receive health care services receive them
from safety-net providers: community and migrant health centers, public health clin-
ics, hospital emergency departments, and out-patient clinics as well as some private
providers. The numbers of immigrants served by each type of provider are unknown
but the data do show that the common assumption that undocumented immigrants lack
all health insurance is an overly simplistic view. The Migration Policy Institute reports
that in 2007, 59% of undocumented adults had no health insurance, (four times the
rate of U.S.-born adults) and 55% of the children of undocumented immigrants were
uninsured. Yet, 31% of undocumented immigrants were covered by employer-based
insurance, despite the fact that undocumented immigrants tend to work for smaller

424 Still missing in 2010: undocumented immigrants in health care reform

employers and are less likely to be offered health insurance benefits. Perhaps surprisingly,
3% of undocumented immigrants are covered by privately purchased insurance.7

Although undocumented immigrants are ineligible for regular Medicaid services
or the Children’s Health Insurance Program, the emergency Medicaid program pays
hospitals for some services dispensed in emergency departments. National estimates
of the number of undocumented immigrants currently served by emergency Medicaid
are unknown.7

The Patient Protection and Affordable Care Act offers no federal health care benefits
to undocumented immigrants. These 11 million people are excluded from the man-
date to have health care insurance and are ineligible for the Act’s expanded Medicaid
eligibility provisions. Undocumented immigrants are barred from purchasing private
insurance through the new insurance exchanges—even at their own expense (which an
earlier House bill had allowed), and they are ineligible for federal subsidies of insurance
premiums.8 Regardless of what its name might suggest, the Act neither protects these
patients nor makes their care more affordable.

arguments for exclusion

Typically, the opponents of including undocumented immigrants in health care reform
were groups who oppose current U.S. immigration policy and who were, and are, work-
ing to reduce significantly the number of immigrants in the U.S. Two vocal examples,
quite prominent in the national media, are the Federation for American Immigration
Reform (FAIR) and the Center for Immigration Studies (CIS). Their discussions of
health care reform were characteristically woven into broader concerns about immigra-
tion. In a CIS-sponsored panel presentation, CIS Director of Research, Steve Camarota
asked, “. . . [C]an we have health-care reform without immigration reform?” He replied,
“. . . the answer is almost certainly no.”9[p.5]

Economic and political arguments dominate the American citizen-only perspectives.
The leading economic argument asserts that the health care of undocumented immi-
grants is a financial burden on U.S. taxpayers.10 Excluding undocumented immigrants
would save American taxpayer dollars, says FAIR, whereas including them would
increase state and federal deficits.10 Furthermore, CIS asserts that including undocu-
mented immigrants would enlarge the government’s role in health care (apparently
problematically).11 Some exclusionists have targeted the health care costs of pregnant
undocumented immigrant women who birth in the U.S., calling these U.S. citizen new-
borns “anchor babies,” for the supposed security and opportunity citizenship brings,
not only to the babies, but to their families.12

The central political reason given for exclusion is the claim that the inclusion of
undocumented immigrants in health care reform would encourage more immigration
to the U.S. Referring to both House and Senate health care reform bills, CIS Fellow
James Edwards maintains that “. . . the legislation amounts to a reward for illegal aliens
and another power boost to the magnet that draws illegal aliens.”13[p.1]

FAIR has raised concerns about health care quality and access if undocumented
immigrants are cared for: “Greater utilization by illegal aliens could impact health care

425Galarneau

quality for all Americans, resulting in longer waits at the doctor’s office and reduced
access to services.”14[p.1]

Edwards also poses a moral question: “Shouldn’t immigrants be expected to abide
by our American core principles like individual responsibility? Is it too much to ask of
those who live here, even illegally, that they act responsibly in this one area and obtain
health coverage, rather than risk imposing a burden on society?”15[p.1]

Finally, Edwards claims that health care is not a priority for undocumented immi-
grants: “Many could (and do) find some form of affordable health insurance today
if they were willing to buy it. But many would apparently rather spend their money
on other things, including remittances of amounts about equal to the premiums of
low-cost insurance policies of health savings accounts.”15[p.1] He adds, “. . . pretty much
every medical screening and routine service is available to anyone, including illegal
aliens, at no or nominal cost almost anywhere in America. Seeking out such medical
attention rests with the person who needs it, and again, this seems a lower priority to
illegal aliens.”15[p.1]*

arguments for Inclusion

The majority of those arguing for the inclusion of undocumented immigrants in health
care reform fall into three groups: Christian organizations, most notably the U.S. Con-
ference of Catholic Bishops (USCCB); Latino/a groups including National Council
of La Raza and the Congressional Hispanic Caucus, and organizations of health care
professionals, such as the American College of Obstetricians and Gynecologists. Moral,
economic, and public health arguments dominate their perspectives.

The moral arguments for inclusion are typically straightforward: undocumented
immigrants are human beings with health care needs and a right to health care. As
the USCCB put it, “In the Catholic tradition, health care is a basic human right not a
privilege. It is a fundamental issue of human life and dignity.”16[p.1] They add, “All people
need and should have access to comprehensive, quality health care that they can afford,
and it should not depend on their stage in life, where or whether they or their parents
work, how much they earn, where they live, or where they were born.”16[p.1] Similarly
Bioethicist Ruth Faden has argued that entering the U.S. without permission does not
justify withholding one’s human rights, including access to health care.17

Economic arguments for inclusion recognize undocumented immigrants as monetary
contributors to society through their labor, tax payments, and market participation.
The Center for American Progress disputes the notion that undocumented people are
“free riders” noting that “. . . workers without valid social security numbers contribute
$7 billion in Social Security tax revenues and roughly $1.5 billion in Medicare taxes
annually, yet elderly immigrants rarely qualify for Medicare or long-term care services

* The statement that “pretty much every medical screening and routine service is available to anyone,
including illegal aliens, at no or nominal cost almost anywhere in America” is a fine example of the
misinformation found in the health care reform debate.

426 Still missing in 2010: undocumented immigrants in health care reform

provided through Medicaid.”18[p.8] These workers contribute financially to these public
benefits despite being ineligible to receive them.

In a somewhat more philosophical economic argument, the National Immigration
Law Center notes that American free market principles are violated when people are
prohibited from purchasing private health insurance.8

Some inclusionists take a more pragmatic economic perspective: If undocumented
immigrants can’t buy insurance, they will continue to rely on safety net providers
including emergency care, and everyone pays for this care.19 Additionally, insuring
the undocumented would enlarge the insured pool with relatively young and healthy
people, spreading the risks and costs for all.8

The central public health argument for including undocumented immigrants rests
on the reality that any individual’s health depends in part on the health of others. As
one county health director plainly put it, “. . . to have a healthy community, we can’t
have subset of people who don’t have access to health care.”20[p.3] Another observer
noted, undocumented people “can’t afford to practice social distancing.”21[p.11] In other
words, undocumented workers may continue to work when sick absent paid sick
days and job security. President Obama recognized this social nature of health when
he suggested that undocumented children may need insurance coverage “because if
you’ve got children who may be here illegally but are still in playgrounds or at schools,
and potentially are passing on illnesses and communicable diseases, that aren’t getting
vaccinated, that I think is a situation where you may have to make an exception [to
excluding them under the reform].”22[p.1]

Still missing

Despite the many arguments made by these organizations on both sides of the issue,
elected officials paid little substantive attention to them. As Senator Baucus illustrated,
officials feared that addressing undocumented immigrants would “sidetrack” their
reform work. “Sidetrack” perhaps, because to debate the issue would require explicitly
addressing the tough fundamental questions posed by a commentator back during the
1990s reform dabate: who are “we” as a health care community? Who are community
members and what rights and responsibilities do “we” have?1 Instead the recent Con-
gressional debate largely ignored such questions and maintained the status quo.

The nearly 11 million undocumented immigrants are, I assert, members of this
country’s health care community even if they aren’t legally-recognized as citizens. No
one argues that undocumented immigrants do not contribute to this country or that
they do not benefit from it, though there is certainly disagreement about how much
of each they do, and whether they should at all. Their simple presence, not to mention
their multi-faceted social integration— occupational, economic, educational, religious,
and health-related—makes them health care community members in fact and thus
entitles them to care like other community members. To the extent that health care
is a social and relational good, then all residents belong to the country’s health care
community and have rights and responsibilities associated with it.23

I suggest that in any just health care system—regardless on one’s definition of
justice—the burden rests with those who would exclude some of us from health care

427Galarneau

coverage to demonstrate convincingly why that exclusion would be just rather than
simply politically or economically advantageous. The current legislation does not justify
its exclusion. It never had to, and that suggests a role for health care practitioners.

Health care practitioners have unique relationships with undocumented immi-
grants, and rare insights into their lives. Some practitioners and professional societies
have spoken about the need to include undocumented immigrants in reform efforts,
countering the dominant political voices that assume the health care of undocumented
immigrants is a burden or even that the mention of it, would divert the reform discus-
sion.24,25 Determinations about who belongs in our health care community and who
ought to receive care are ultimately moral decisions about which health care practitio-
ners have relevant knowledge and experience. Stronger health care voices are needed to
help ensure that the exclusion of undocumented immigrants is not assumed by elected
officials the next time health care reform is debated.

acknowledgments

An earlier version of this paper was given at the Eastern Sociological Society Annual
Meeting, Boston, MA, March 20, 2010.

notes
1. Galarneau CA. Missing persons: undocumented immigrants. Dissent. 1994 Spring.

Available at: http://www.dissentmagazine.org/article/?article=2361.
2. Gerhart A. The congressman who cried “Lie.” Washington, DC: Washington Post,

Sept 10, 2009. Available at: http://www.washingtonpost.com/wp-dyn/content/article/
2009/09/09/AR2009090903585.html.

3. Sack K. Hospital falters as refuge for illegal immigrants. New York, NY: New York
Times, Nov 21, 2009. Available at: http://www.nytimes.com/2009/11/21/health/policy/
21grady.html.

4. Kaiser Family Foundation. Health care reform newsmaker series: Sen. Max Baucus.
Washington, DC: The Kaiser Family Foundation, 2009 May 21. Available at: http://
www.kff.org/healthreform/upload/052109_Baucus_newsmakers_transcript.pdf.

5. Hoefer M, Rytina N, Baker BC. Estimates of the unauthorized population residing in
the United States: January 2009. Washington, DC: Office of Immigration Statistics,
Policy Directorate, U.S. Department of Homeland Security, January 2010. Available
at: http://www.dhs.gov/xlibrary/assets/statistics/publications/ois_ill_pe_2009.pdf.

6. Passel JS, Cohn D. A portrait of unauthorized immigrants in the United States. Wash-
ington, DC: Pew Hispanic Center, 2009 Apr. Available at: http://pewhispanic.org/
files/reports/107.pdf.

7 Capps R, Rosenblum MR, Fix M. Immigrants and health care reform: what’s really
at stake? Washington, DC: Migration Policy Institute, 2009. Available at: http://www
.migrationpolicy.org/pubs/healthcare-Oct09.pdf.

8. National Immigration Law Center. Why excluding people from the health care
exchange is impractical and harmful to all of us. Washington, DC: National Immi-
gration Law Center, Sept 2009. Available at: http://www.nilc.org/immspbs/health/
exchange-imms-2009-09-14.pdf.

9. Camarota SA, Rector R, Krikorian M, et al. The elephant in the room: panel on
immigration’s impact on health care reform. Washington, DC: Center for Immigration

428 Still missing in 2010: undocumented immigrants in health care reform

Studies, 2009 Aug. Available at: http://cis.org/Transcript/HealthCare-Immigration-
Panel.

10. Ruark E, Martin J. The sinking lifeboat: uncontrolled immigration and the U.S.
health care system in 2009. Washington, DC: Federation for American Immigration
Reform, 2009 Sept. Available at: http://www.fairus.org/site/DocServer/healthcare_09
.pdf?docID=3521.

11. Edwards JR. Memorandum: immigration-related provisions of senate and house health
reform bills. Washington, DC: Center for Immigration Studies, 2009 Dec. Available
at: http://www.cis.org/articles/2009/healthcare-12-01-09.pdf.

12. Conservative Coulter Fan. Anchor Babies: part of the immigration-related lexicon.
Fresno, CA: Free Republic, 2010 Oct 27. Available at: http://www.freerepublic.com/
focus/news/2615734/posts.

13. Edwards JR. Immigration’s zero-sum impact on health care. Washington, DC: Cen-
ter for Immigration Studies, 2010 Feb 10. Available at: http://www.cis.org/edwards/
zero-sum-healthcare.

14. Stein D. Opposing view: don’t let them buy policies. Mclean, VA: USA Today. 2009
Nov 12. Available at: http://www.calhospital.org/public/opposing-view-don-t-let-them-
buy-policies.

15. Edwards JR. Washington Post’s take on illegal’s in health reform. Washington, DC:
Center for Immigration Studies, 2009 Dec 27. Available at: http://cis.org/edwards/
illegalsexchange.

16. United States Conference of Catholic Bishops. Health care reform: questions and
answers. Washington, DC: United States Conference of Catholic Bishops, 2009. Avail-
able at: http://usccb.org/healthcare/faqs.shtml.

17. Faden R. Denying care to illegal immigrants raises ethical concerns. Washington,
DC: Kaiser Health News, 2009 Dec 31. Available at: http://www.kaiserhealthnews
.org/Columns/2009/December/123109Faden.aspx.

18. King ML. Immigrants in the U.S. health care system: five myths that misinform
the American public. Washington, DC: Center for American Progress, 2007 Jun 7.
Available at: http://www.americanprogress.org/issues/2007/06/pdf/immigrant_health_
report.pdf.

19. United States Conference of Catholic Bishops. Letter to the United States Senate.
Washington, DC: United States Conference of Catholic Bishops, 2009 Dec 22. Avail-
able at: http://usccb.org/healthcare/letter-to-senate-20091222.pdf.

20. Jordan M. Illegal immigration enters the health–care debate. New York, NY: The Wall
Street Journal, 2009 Aug 15. Available at: http://online.wsj.com/article/SB1250272
61061432585.html.

21. Mastroianni AC. Slipping through the net: social vulnerability in pandemic planning.
Hastings Center Report. 2009 Sept–Oct;39(5):11–12.

22. CBS News. Obama: no health care for illegal immigrants. New York, NY: CBS News,
2009 Jul 21. Available at: http://www.cbsnews.com/8301-503544_ 162-5178652-503544
.html.

23. Galarneau CA. Health care as a community good: many dimensions, many communi-
ties, many views of justice. Hastings Center Report. 2002 Sept–Oct;32(5):33–40.

24. Cohen MH. Commentary: undocumented women: pushed from poverty and conflict,
pulled into unjust disparity. J Public Health Policy. 2009, 30(4): 423–6.

25. American College of Obstetricians and Gynecologists. ACOG committee opinion No.
425: health care for undocumented immigrants. Obstet Gynecol. 2009 Jan;113(1):
251–4.

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

Vol.:(0123456789)1 3

Journal of Immigrant and Minority Health (2019) 21:211–218
https://doi.org/10.1007/s10903-018-0741-6

O R I G I N A L PA P E R

Health Care Access and Utilization Among U.S. Immigrants Before
and After the Affordable Care Act

Arturo Vargas Bustamante1 · Jie Chen2 · Ryan M. McKenna3 · Alexander N. Ortega4

Published online: 9 April 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
We examine changes in health insurance coverage and access to and utilization of health care before and after the national
implementation of the Patient Protection and Affordable Care Act (ACA) among the U.S. adult immigrant population. Data
from the 2011–2016 National Health Interview Survey are used to compare adult respondents in 2011–2013 (before the ACA
implementation) and 2014–2016 (after the ACA implementation). Multivariable logistic regression analyses are used to
compare changes over time. This study shows that the ACA has closed the coverage gap that previously existed between U.S.
citizens and non-citizen immigrants. We find that naturalized citizens, non-citizens with more than 5 years of U.S. residency,
and non-citizens with 5 years or less of U.S. residency reduced their probability of being uninsured by 5.81, 9.13, and 8.23%,
respectively, in the first 3 years of the ACA. Improvements in other measures of access and utilization were also observed.

Keywords Affordable Care Act · ACA  · Immigrants · Access to care · Health care reform · Health insurance

Introduction

Early evidence from the Patient Protection and Affordable
Care Act (ACA) shows that uninsured rates have declined
from 16.6 to 10.4% between 2013 and 2016 [1, 2]. Vari-
ous studies have linked the different ACA provisions with
short-term improvements in access to care, prescription drug
utilization, health outcomes, and health care disparities by
race and ethnicity [3–6]. Studies have also documented that
changes in health insurance coverage are strongly associ-
ated with improved health care access and primary care uti-
lization [7–10]. As a result of the 2016 election, both the
executive and legislative branches have promised to repeal
and replace the ACA, and the Senate has promoted legisla-
tion to repeal the individual health insurance mandate. To
that end, it is important to understand what impact the ACA
has had on vulnerable populations, as they are likely to be
disproportionally affected by changes to the law.

Under the ACA, U.S.-born individuals, naturalized citi-
zens, and legally authorized immigrants have similar enti-
tlements. U.S.-born and naturalized citizens are entitled to
receive Medicaid coverage up to 138% of the federal pov-
erty level (FPL) in states that implemented the expansion.
Those with incomes between 100 and 400% of the FPL are
eligible to receive subsidies in the private health insurance
exchanges (HIE).

* Arturo Vargas Bustamante
[email protected]

Jie Chen
[email protected]

Ryan M. McKenna
[email protected]

Alexander N. Ortega
[email protected]

1 Department of Health Policy & Management, UCLA
Fielding School of Public Health, 650 Charles E. Young
Drive South Room 31-299C, Box 951772, Los Angeles,
CA 90095, USA

2 Department of Health Services Administration, University
of Maryland, College Park, 3310A School of Public Health
Building, College Park, MD 20742-2611, USA

3 Department of Health Management and Policy, Dornsife
School of Public Health, Drexel University, Nesbitt Hall,
Room 357, 3215 Market Street, Philadelphia, PA 19104,
USA

4 Department of Health Management and Policy, Dornsife
School of Public Health, Drexel University, 3215 Market St
Nesbitt Hall, Room 335, Philadelphia, PA 19104, USA

212 Journal of Immigrant and Minority Health (2019) 21:211–218

1 3

Non-citizen lawfully present immigrants (e.g., “green
card” holders and other visa categories) face a 5-year wait-
ing period to enroll in Medicaid. Some states have chosen
to eliminate the 5-year wait through state financed coverage
to adults, pregnant women, and children or for those who
need specific health services [11]. Individuals with incomes
below 100% of the FPL who are ineligible for Medicaid
based on immigration status are entitled to purchase cover-
age from the HIE and receive subsidies.

All other non-citizen lawfully present immigrants are
entitled to purchase health insurance coverage in the HIE
and receive subsidies in the same terms as U.S.-born and
naturalized citizens [12]. Uninsured U.S.-born, naturalized
citizens, and non-citizen lawfully present immigrants with
incomes above 400% of the FPL are eligible to purchase
health insurance coverage without subsidies in the HIE [11].
Undocumented immigrants are excluded from all of the
ACA’s provisions [13, 14]. While undocumented immigrants
are represented in our study, information about documenta-
tion status is unavailable in the National Health Interview
Survey (NHIS).

To our knowledge, this is one of the first studies to ana-
lyze access to and utilization of health care specifically
among U.S. immigrants before and after the national imple-
mentation of the ACA using a nationally representative sur-
vey. We also explore how the main predictors associated
with access to and utilization of health care changed after
the implementation of the ACA.

Conceptual Framework

The conceptual framework for this study is the behavioral
model of health services utilization developed by Aday and
Andersen and Andersen [15, 16]. This model postulates that
health care access and utilization are determined by pre-
disposing, enabling and need factors. Our analyses use this
framework to guide model specification and variable selec-
tion. The predisposing factors in our models include charac-
teristics such as age, gender, race and ethnicity, marital sta-
tus, education, and language. Enabling factors include health
insurance coverage, income, employment status and region
of residence. Need factors are captured by self-reported
health status and poverty status [17–19].

In this study, we hypothesize that health insurance cov-
erage would increase among immigrants, due to the ACA
health insurance mandate and related programs. The ACA
made health insurance more affordable for lawfully stayed
immigrants through the Medicaid expansion and the avail-
able subsidies at the state and federal health insurance
exchanges [6]. At the same time, lacking health insurance
became costly due to the penalties associated with the health
insurance mandate.

In the case of access to and utilization of health care,
we hypothesize that they improved or remained unchanged
after the ACA was implemented. Previous research shows
that immigrants are self-selected, which partly explains the
existence of a “healthy immigrant” effect on health care
access and utilization [20–22]. We hypothesize that the
healthy immigrant effect can partly explain reduced health
care utilization among immigrants, particularly in the early
years of U.S. residence. As immigrants acculturate, age and
become more familiar with the U.S. health system, differ-
ences between the U.S.-born  population and immigrants
should decrease. Immigrants who have been in the U.S. for
a long period will have similar health care access and uti-
lization patterns of the U.S.-born population, as previous
research has concluded [23, 24].

Methods

Data

This study uses a repeated cross sectional design that pools
data from the 2011–2016 National Health Interview Sur-
vey (NHIS), a nationally representative survey of the civil-
ian, non-institutionalized U.S. population [25]. This survey
reports information on a broad range of health care topics
and socioeconomic and demographic characteristics of sur-
vey respondents. Our total sample size is 113,439 adults
18–64 years of age. The weighted sample size corresponds
to 48,839,629 adults nationwide.

Insurance Coverage and Access to and Utilization
of Care

Survey questions used as outcome variables are the share of
immigrants who reported health insurance coverage, if they
experienced any delay when trying to access health care, if
they forgone treatment due to cost, if they have used emer-
gency department services, and if they reported a physician
visit (Fig. 1; Table 1).

Before and After Comparison

We created variables of survey years as main explanatory
variables to compare insurance coverage and access to and
utilization of health care measures before and after the
implementation of the ACA in 2014. In accordance with
our pooled cross-sectional design, variable years for 2011,
2012, and 2013 correspond to the period before the national
implementation of the ACA. The variable years for 2014,
2015 and 2016 correspond to the years after the implemen-
tation of the ACA. This empirical framework has been used
previously in studies that have investigated differences in

213Journal of Immigrant and Minority Health (2019) 21:211–218

1 3

insurance coverage and access to and utilization of health
care before and after the implementation of the ACA [3, 26].

Citizenship and Time of U.S. Residence

We constructed three mutually exclusive dichotomous
measures of citizenship and time of U.S. residence based
on immigrant eligibility rules under the Affordable Care
Act: U.S.-born citizen, naturalized U.S. citizen, non-citizen
immigrant with 5 years or less of U.S. residence (≤ 5 years),
and non-citizen immigrant with more than 5 years residence
(> 5 years), which coincide with the 5 year waiting period
that non-citizen lawfully present immigrants (e.g. “green
card” holders and other visa categories) need to observe
before they become eligible for Medicaid in states that have
expanded this program. Besides the 5-year waiting period
for Medicaid coverage, non-citizen lawfully present immi-
grants are eligible to access Medicaid and the HIE in equal
terms as U.S.-born or naturalized citizens.

The ACA does not make any distinctions between
U.S.-born and naturalized citizens in terms of eligibility
or responsibilities. Thus, these populations are analyzed
as single categories. Consequently, U.S.-born citizens
(N = 90,513), naturalized U.S. citizens (N = 10,691), non-
citizen immigrants with 5 years or less of U.S. residence
(N = 2,391), and non-citizen immigrants with more than
5 years residence (N = 9844) are the groups of focus in our
study. Undocumented immigrants are represented in our
study under the non-citizen immigrant categories. Our study,
however, does not distinguish between lawful non-citizen
immigrants and undocumented immigrants since NHIS lacks
an identifier for documentation status.

Other Covariates

Our study included additional co-variables that have been
identified in prior studies to affect insurance coverage and
health care access and utilization, including socioeconomic
and demographic variables [19, 23]. The selection of co-
variables in our models is consistent with our conceptual
framework, and they include sex, marital status, race and
ethnicity, age, education, income, self-reported health status,
Spanish interview, and region of residence.

Statistical Analyses

Initial analyses provided summary statistics for each out-
come measure and showed how insurance coverage and
access to and utilization of health care changed from 2011
to 2016 (Fig. 1). Multivariable logistic regression analyses
were used to compare the change in insurance rates and
access to and utilization of care before (reference category)
and after the national implementation of the ACA. After
we performed the goodness of fit test for our models (i.e.
svylogitfof), we ran separate regression analyses for the
outcome measures including all co-variables in each model
(Table 1).

A comparison of means analyses compared the main
study outcome measures before and after the implementa-
tion of the ACA for all population categories. We summa-
rized the main outcomes of the data analyses using marginal
effects to ease interpretation of the main findings (Table 2;
Fig. 2). Marginal effects were first estimated using the val-
ues of year indicator for each individual. Then, the results
for each individual were averaged to estimate the mar-
ginal effect, as recommended by Karaca-Mandic [27]. The

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

before after

Fig. 1 Health insurance coverage and access to and utilization of care
by U.S. Immigration status before and after the ACA Implementa-
tion. Source 2011–2016 National Health Interview Survey. Notes:
“Before” corresponds to mean values for years 2011–2013, period
before the implementation of the ACA individual health insurance

mandate. “After” corresponds to mean values for years 2014–2016,
period after the implementation of the ACA individual health insur-
ance mandate. Vertical axis corresponds to percentage point changes.
Horizontal axis describes the study variables

214 Journal of Immigrant and Minority Health (2019) 21:211–218

1 3

statistical analyses included sampling weights to estimate
nationally representative results. We used Stata 13 and per-
form -svy- commands for all statistical analyses.

Results

Figure 1 shows mean differences in health insurance cov-
erage and access to care before (2011–2013) and after

Table 1 Health insurance
coverage and access to and
utilization of care by U.S.
immigration status before and
after the ACA Implementation
Source 2011–2016 National
Health Interview Survey

“Before” corresponds to mean values for years 2011–2013, period before the implementation of the ACA
individual health insurance mandate. “After” corresponds to mean values for years 2014–2016, period after
the implementation of the ACA individual health insurance mandate
a The weighted sample size corresponds to 48,839,629 adults

Uninsured Delayed care Forgo care ED use MD visit

OR p OR p OR p OR p OR p

Before ACA REF
After ACA 0.62 < 0.001 0.76 < 0.001 0.76 < 0.001 0.97 0.13 1.10 < 0.001
U.S. born REF
Nat U.S. citizen 2.25 < 0.001 0.99 0.94 0.99 0.90 0.63 < 0.001 0.60 < 0.001
Non-citizen (5<) 3.02 < 0.001 1.05 0.35 1.14 0.02 0.59 < 0.001 0.66 < 0.001
Non-citizen (5≥) 1.16 < 0.001 0.92 0.06 0.95 0.33 0.82 < 0.001 1.00 0.91
African-American 0.98 0.54 0.75 < 0.001 0.92 0.02 1.33 < 0.001 1.01 0.73
Latino 1.40 < 0.001 0.87 < 0.001 0.99 0.76 0.99 0.78 0.89 < 0.001
Other 0.93 0.14 0.72 < 0.001 0.80 < 0.001 0.88 0.01 0.87 < 0.001
Age
 25–34 1.98 < 0.001 1.85 < 0.001 1.92 < 0.001 1.02 0.66 0.78 < 0.001
 35–44 1.64 < 0.001 1.72 < 0.001 1.92 < 0.001 0.85 < 0.001 0.98 0.58
 45–54 1.47 < 0.001 1.92 < 0.001 2.01 < 0.001 0.74 < 0.001 1.19 < 0.001
 55–64 1.11 0.04 1.58 < 0.001 1.57 < 0.001 0.72 < 0.001 1.66 < 0.001

Female 0.71 < 0.001 1.17 < 0.001 1.12 < 0.001 1.31 < 0.001 1.53 < 0.001
Married 0.59 < 0.001 0.48 < 0.001 0.53 < 0.001 0.97 0.23 1.23 < 0.001
Federal poverty
 < 100 FPL REF REF REF REF REF
 100–200 1.11 < 0.001 1.27 0.00 1.14 < 0.001 0.80 < 0.001 0.97 0.20
 200> 0.34 < 0.001 0.54 0.00 0.40 < 0.001 0.59 < 0.001 1.32 < 0.001

Education
 <High school REF REF REF REF REF
 High school 0.95 < 0.001 1.09 0.03 1.07 0.12 0.86 < 0.001 1.09 < 0.001
 Some college 0.67 < 0.001 1.36 < 0.001 1.25 < 0.001 0.88 < 0.001 1.39 < 0.001
 College degree 0.48 < 0.001 1.22 < 0.001 1.02 0.62 0.74 < 0.001 1.44 < 0.001
 College> 0.21 < 0.001 0.95 0.39 0.71 < 0.001 0.66 < 0.001 1.76 < 0.001

Health status
 Excellent REF REF REF REF REF
 Very good 1.86 < 0.001 0.21 < 0.001 0.19 < 0.001 0.13 < 0.001 0.24 < 0.001
 Good 1.94 < 0.001 0.36 < 0.001 0.29 < 0.001 0.18 < 0.001 0.30 < 0.001
 Fair 2.11 < 0.001 0.54 < 0.001 0.50 < 0.001 0.27 < 0.001 0.36 < 0.001
 Poor 1.66 < 0.001 0.83 < 0.001 0.79 < 0.001 0.53 < 0.001 0.58 < 0.001
 Spanish response 1.38 < 0.001 1.04 0.46 0.83 0.01 0.60 < 0.001 0.76 < 0.001

Urban REF REF REF REF REF
Rural 1.26 0.09 0.65 0.02 0.65 0.02 0.68 0.06 1.11 0.38
U.S. region
 Northeast REF REF REF REF REF
 Midwest 1.30 < 0.001 1.32 < 0.001 1.26 < 0.001 0.97 0.38 0.85 < 0.001
 South 1.96 < 0.001 1.34 < 0.001 1.52 < 0.001 0.89 < 0.001 0.77 < 0.001
 West 1.54 < 0.001 1.51 < 0.001 1.51 < 0.001 0.82 < 0.001 0.72 < 0.001
 Na 113,439

215Journal of Immigrant and Minority Health (2019) 21:211–218

1 3

(2014–2016) the implementation of the ACA. Uninsured
rates across all categories declined after its implementation.
The drop of the mean uninsured rates was 5% points for
U.S.-born citizens, 6% points for naturalized U.S. citizens,
8% points for non-citizens with more than 5 years of U.S.
residence, and 9% points for non-citizens with 5 years or
less of U.S. residence.

Similar trends were observed for two of our outcome
measures. Individuals reporting that they delayed care
diminished by 3% points among U.S. born citizens, 4%
points for naturalized U.S. citizens, 3% points for non-
citizens with more than 5 years of U.S. residence, and 5%
points for non-citizens with 5 years or less of U.S. residence.
Approximately 2% of U.S.-born and naturalized citizens and
immigrants with more than 5 years of U.S. residence forwent
care after the ACA implementation, while the corresponding
figure for non-citizens with 5 years or less of U.S. residence
was 4%.

The before-after mean difference of adults reporting
emergency department (ED) utilization was relatively con-
stant for all categories, with the exception of non-citizen
adults with 5 years or less of U.S. residence, who had a 2%
increase after the implementation of the ACA. The share

of adults reporting at least one physician visit in the pre-
vious year increased 2% for U.S.-born individuals, 3% for
naturalized U.S. citizens, 4% for non-citizens with more
than 5 years of U.S. residence, and 2% for non-citizens with
5 years or less of U.S. residence.

Table 1 shows the results of the multivariable logistic
regressions that include socioeconomic and demographic
characteristics. After controlling for all co-variables, the
ACA implementation measure (after ACA) shows that
adults had lower odds of being uninsured (OR = 0.62,
p < 0.001), delaying (OR = 0.76, p < 0.001) and forgoing care
(OR = 0.76, p < 0.001) and had higher odds of reporting a
physician visit in the previous year (OR = 1.10, p < 0.001).

When compared to U.S.-born citizens, naturalized U.S.
citizens had higher odds of being uninsured (OR = 2.25,
p < 0.001) and lower odds of using the ED (OR = 0.63,
p < 0.001) and having a physician visit in the previous
year (OR = 0.60, p < 0.001). Non-citizens with more than
5 years of U.S. residency had higher odds of being uninsured
(OR = 3.02, p < 0.001) and of forgoing care (OR = 1.14,
p = 0.02) and lower odds of using the ED (OR = 0.59,
p < 0.001) and of having a physician visit in the previous
year (OR = 0.66, p < 0.001). Non-citizens with 5 years or
less of U.S. residency had higher odds of being uninsured
(OR = 1.16, p < 0.001) and lower odds of using the ED
(OR = 0.82, p < 0.001).

Socioeconomic and demographic characteristics show
that Latinos, adults ages 25–64  years of age, those from
households 100–200% of the FPL, those reporting poor,
fair, good and very good health status, those responding to
the questionnaire in Spanish, those living in rural areas, and
those living in the Midwest, the South and the West had
significantly higher odds of being uninsured compared to
the reference categories. Females, married individuals, and
those with a college degree or more had statistically signifi-
cant lower odds of being uninsured after the implementation
of the ACA compared to the reference categories.

Table 2 and Fig. 2 show the results of the multivariable
logistic regressions using marginal effects comparing indi-
viduals by citizenship/nativity status before and after the
implementation of the ACA. U.S.-born individuals were
4.47% less likely to be uninsured (p < 0.001), 2.44% less
likely to delay care (p < 0.001) and 1.81% less likely to

Table 2 Estimated marginal
effects of the ACA
implementation on health
insurance coverage and access
to and utilization of care by
U.S. immigration status Source
2011–2016 National Health
Interview Survey

Marginal effect shows percentage changes in 2014–2016 compared to the 2011–2014 period

Uninsured Delayed care Forgo care ED use MD visit

(%) p (%) p (%) p (%) p (%) p

US born − 4.47 < 0.001 − 2.44 < 0.001 − 1.81 < 0.001 − 0.50 0.135 0.02 < 0.001
Nat U.S. Citizen − 5.81 < 0.001 − 3.92 < 0.001 − 2.21 0.002 0.00 0.719 0.03 0.006
Non-Citizen (5<) − 9.13 < 0.001 − 4.53 0.003 − 3.23 0.027 − 0.01 0.732 0.01 0.637
Non-Citizen (5≥) − 8.23 < 0.001 − 2.86 0.110 − 1.77 0.013 0.01 0.389 0.04 0.004

-0.1

-0.09

-0.08

-0.07

-0.06

-0.05

-0.04

-0.03

-0.02

-0.01

0
US born Nat U.S. Citizen Non-Citizen (5<) Non-Citizen (5≥)

Fig. 2 Likelihood of Being Uninsured  by U.S. Immigration Status
After the ACA Implementation. Source 2011–2016 National Health
Interview Survey. Notes: Marginal effect shows percentage changes
in 2014–2016 compared to the 2011–2014 period. Vertical axis cor-
responds to percentage point changes. Horizontal axis describes the
U.S. immigrant categories

216 Journal of Immigrant and Minority Health (2019) 21:211–218

1 3

forego care (p < 0.001), after controlling for all co-variables
(not shown in the exhibit but available upon request). They
were 0.02% more likely to report a physician visit (p < 0.001)
in the previous year. U.S. naturalized citizens were 5.81%
less likely to be uninsured (p < 0.001), 3.92% less likely to
delay care (p < 0.001) and 2.21% less likely to forego care
(p < 0.001). They were 0.03% more likely to report a physi-
cian visit (p < 0.001) in the previous year.

Non-citizens with more than 5 years of U.S. residency
reported that they were 9.13% less likely to be uninsured
(p < 0.001). Non-citizens with 5 years or less of U.S. resi-
dency were 8.23% less likely to be uninsured (p < 0.001) and
0.04% more likely to report a physician visit (p < 0.004) in
the previous year. Utilization differences of the ED before
and after the implementation of the ACA were not statisti-
cally significant for all comparison categories.

Discussion and policy implications

After its approval in 2010, access to ACA-related health
insurance programs were restricted for some U.S. immi-
grants based on their time of U.S. residency and legal
authorization status [17, 18]. Our study shows that, in spite
of these restrictions, uninsured rates for U.S. immigrants
were reduced significantly. The coverage gap that previ-
ously divided non-citizen U.S. immigrants with naturalized
U.S. citizens and U.S.-born individuals was shortened in
the first 3 years of the national implementation of the ACA.
These findings are consistent with our hypothesis that health
insurance rates would increase among immigrants because
of increased health insurance affordability through the Med-
icaid expansion and the subsidies available at the state and
federal health insurance exchanges. At the same time, law-
fully present immigrants were incentivized to seek health
insurance coverage due to the penalties associated with the
ACA health insurance mandate. The penalties associated
with the mandate increased the cost of being uninsured.

Measures of access to health care also showed some
improvement. U.S.-born individuals and naturalized
U.S citizens were less likely to forgo or delay care than
immigrants with less than 5  years of residency. These
two populations were also slightly more likely to report
a physician visit in the previous year. These findings are
consistent with the hypothesis that access to and utiliza-
tion of health care among immigrants would improve or
remain unchanged after the ACA. Prior research that has
investigated the healthy immigrant effect partly explains
reduced health care access and utilization among immi-
grants due to immigrant self-selection [22, 24]. Recently
arrived immigrants are more likely to be healthy compared
to the average population. Over time, immigrants accul-
turate, learn how to navigate the U.S. health system and

their health status starts to resemble that of the average
population. Consequently, longer-stayed immigrants would
be more likely to seek care because they are perhaps in
greater need of using health care, and they have learned
how to use the health system. Increased access to and uti-
lization of health care among longer-stayed immigrants
supports this hypothesis.

Improvements in access to care, however, could have
potentially been better for non-citizens with more than a
5-year residency if it were possible to separate immigrants
by documentation status. As mentioned above, even though
undocumented immigrants were accounted in our analysis,
the lack of a documentation status identifier in NHIS did
not allow us to distinguish between lawfully present and
undocumented immigrants. Since approximately 85% of
undocumented immigrants in the U.S. would be accounted
for in this cohort, separating the analyses by documentation
status would have shown a larger improvement for eligible
immigrants who have lived in the U.S. for more than 5 years.

Non-citizens with less than 5  years of U.S. residency
reported fewer improvements in access to care, but their
overall insurance rate increased substantially. This change
could be due to the ACA eligibility among non-citizen law-
fully present immigrants, who are eligible for ACA benefits.
However, lower coverage levels compared to longer-stayed
immigrants could be due to both the 5-year waiting period
for Medicaid eligibility and the difference in socio-demo-
graphic characteristics. These findings are important consid-
ering that approximately 15% of undocumented immigrants
in the U.S. have less than 5 years of residency [28].

The lack of significant differences in delayed and forgone
care and in reporting a physician visit after the ACA imple-
mentation among non-citizen immigrants could be related
to the hypothesis of reduce demand for health care from
recently arrived immigrants due to the healthy immigrant
effect, as discussed above. Alternatively, it can be related to
the type of care that immigrants use and the supply of phy-
sicians in the areas where immigrants settle. Non-citizens
are likely to cluster in geographic areas with more physi-
cian shortages. These immigrants could rely more on non-
physicians (e.g. advanced practice clinicians) health services
to address their health needs.

A large share of non-citizen lawfully present immigrants
with 5 years or less of U.S. residency reside in states that
do not provide Medicaid coverage until immigrants have
fulfilled the 5-year waiting period. This population, however,
could have access to Medicaid if they lived in one of the
15 states (including Washington, DC) that use state funds
to provide this benefit for recent immigrants. Non-citizen
lawfully present immigrants with less than 5 years of U.S.
residency who lived in other states were eligible to pur-
chase coverage from the health insurance exchanges before
the 5-year Medicaid threshold. Importantly, ED utilization

217Journal of Immigrant and Minority Health (2019) 21:211–218

1 3

remained constant for all comparison categories before and
after the implementation of the ACA.

With the exception of Louisiana and Arkansas, Southern
states did not expand Medicaid as part of the ACA. In our
analyses, participants in Southern states had higher odds of
reporting lack of health insurance coverage and forgone care
after the ACA. A stratified analysis (not shown, but avail-
able upon request) among immigrants from the South versus
immigrants from other U.S. regions did not reveal broad
differences among immigrants. In Southern states, however,
non-citizen (5<) immigrants did not report any statistically
significant coverage changes after the ACA implementa-
tion, which contrast with the national results reported in
our findings. Since most differences in ACA-related poli-
cies occurred at the state level, future research with access
to state-level data should investigate how heterogeneity in
the ACA implementation across states could impact cov-
erage rates, access to …

Description

The United States prides itself on being a nation of immigrants, and the country has a long history of successfully absorbing people from across the globe. The integration of immigrants and their children contributes to our economic vitality and our vibrant and ever changing culture. We have offered opportunities to immigrants and their children to better themselves and to be fully incorporated into our society and in exchange immigrants have become Americans – embracing an American identity and citizenship, protecting our country through service in our military, fostering technological innovation, harvesting its crops, and enriching everything from the nation’s cuisine to its universities, music, and art. Today, the 41 million immigrants in the United States represent 13.1 percent of the U.S. population. The U.S.-born children of immigrants, the second generation, represent another 37.1 million people, or 12 percent of the population. Thus, together the first and second generations account for one out of four members of the U.S. population. Whether they are successfully integrating is therefore a pressing and important question. Are new immigrants and their children being well integrated into American society, within and across generations? Do current policies and practices facilitate their integration? How is American society being transformed by the millions of immigrants who have arrived in recent decades? To answer these questions, this new report from the National Academies of Sciences, Engineering, and Medicine summarizes what we know about how immigrants and their descendants are integrating into American society in a range of areas such as education, occupations, health, and language.

Book Details

TITLE

The Integration of Immigrants into American Society

AUTHORS

Engineering, and Medicine National Academies of Sciences,
Division of Behavioral and Social Sciences and Education,
Committee on Population,
and Panel on the Integration of Immigrants into American Society

EDITORS

Marisa Gerstein Pineau
and Mary C. Waters

PUBLISHER

National Academies Press

PRINT PUB DATE

2016-04-17

EBOOK PUB DATE

N/A

LANGUAGE

English

PRINT ISBN

9780309373982

EBOOK ISBN

9780309373999

PAGES

459

LC SUBJECT HEADING

Top of Form

United States–Emigration and immigration.

Bottom of Form

LC CALL NUMBER

Top of Form

JV6475 — .I49 2015eb

Bottom of Form

DEWEY DECIMAL NUMBER

Top of Form

305.9/069120973

Bottom of Form

BISAC SUBJECT HEADINGS

SOCIAL SCIENCE / Demography
SOCIAL SCIENCE / Minority Studies

DOCUMENT TYPE

book

Show less

CLINICAL PERSPECTIVES

Growing Up With an Undocumented Parent in America:
Psychosocial Adversity in Domestically Residing
Immigrant Children
Shawn S. Sidhu, MD, and Suzan J. Song, MD, MPH, PhD

E

Journal of t
Volume 58

nrique is a 6-year-old male child presenting for an
evaluation at the request of his school. Both he and
his undocumented mother appear tense and

worried. He was born in the United States after his parents
migrated from El Salvador due to safety concerns, and the
police arrested his father in a workplace raid 2 months prior to
this visit. Since then Enrique and his mother have been living
in cramped quarters without access to a washing machine.
Enrique’s mother has been looking for work and money is tight.
Despite being a United States citizen, Enrique does not have
access to health insurance, housing support, school program-
ming, or other services for which he qualifies. He did not attend
preschool, and as a first-year kindergarten student, he is now
struggling academically with English. Other students are
bullying him because of his speech and appearance. He and his
mother do not know where to turn, and the school is concerned
about developmental and learning disabilities. Enrique’s
mother states, “He has not been the same boy since his father got
arrested. Before he used to go outside and play with the
neighborhood kids, and he used to laugh a lot at home. Now he
mostly stays in his room, barely talks, and barely eats. I’m really
worried about him.” Enrique’s mother also relays that she
herself has been struggling to adjust to the loss of her spouse,
which has resulted in her having far less support. She has been
feeling depressed herself, and is worried about her ability to care
adequately for her children in her current predicament. On
examination, Enrique has his head down throughout most of
the interview, defers questions to his mother, and becomes
briefly tearful when talking about his father.

According to Pew Research Center, 6 to 7 million
children are residing in the United States with at least one
undocumented parent. The vast majority of these children
were born in the United States themselves, and a small
minority were born outside America. Even more note-
worthy is the longitudinal data that 7% to 9% of all
children born in the United States between 2003 and
2014 have at least one undocumented parent. Given the

he American Academy of Child & Adolescent Psychiatry
/ Number 10 / October 2019

numbers, it is highly likely that all child health care pro-
viders will encounter this population clinically. In this
Clinical Perspectives article, we start by reviewing general
and specific vulnerabilities in this population, and then
discuss how child and adolescent psychiatrists can effec-
tively help these children and their families. The majority
of data presented herein refers to the US-born children
of undocumented immigrants, but some may include
foreign-born children of undocumented immigrants
residing in America.

The children of undocumented parents in America are
at risk for several general vulnerabilities. Like the children of
many minority groups, they are more likely to suffer from
poverty than their peers.1,2 Poverty translates to cramped
living conditions,1,2 decreased access to washers and dryers,1

food insecurity and malnourishment,1,2 difficulties with
academic achievement and increased risk for learning
disabilities,1 behavioral issues,1 community violence,3

parental depression and stress,4 and a whole host of
adverse childhood experiences.

Yet, the children of undocumented parents are at risk
for a number of specific and unique vulnerabilities as well.
Unexpected parental arrest and deportation can cause
drastic transitions for these families, with little to no
notice. Parental arrest and deportation worsen the existing
problems of economic hardship, housing and food insta-
bility, loss of childcare, reluctance to go to agencies for
assistance, and difficulty obtaining basic needs.2,3 Care-
givers who remain after a parent is detained report diffi-
culties in emotional adjustment, their ability to support
their children financially, emotionally, and education-
ally.2,4,5 Remaining caregivers also report increased social
isolation, depression, and suicidal ideation following the
arrest of a spouse. These sudden and specific traumas also
increase the rates of posttraumatic stress disorder, depres-
sion, and anxiety in children born to undocumented
parents.2,5

www.jaacap.org 933

SIDHU AND SONG

Other vulnerabilities that are specific to this population
include eligibility for services, academic difficulties, and
acculturation stress. The fact that undocumented parents
are ineligible for services such as housing and health
insurance increase the risk that their children will not get
these services even if they qualify.1,2,6 For example, the
children of undocumented Mexican parents report lower
reading and mathematics skills, and lower rates of preschool
enrollment than other ethnic groups matched for poverty,
immigrant, and minority status.1 Finally, the children of
undocumented immigrants report acculturation stress in
the form of difficulty communicating with friends, negative
perceptions of their home country, a lack of supportive
school networks, and difficulty in their relationships with
their parents.3

Health care providers who work with the children of
undocumented immigrants must be aware of the afore-
mentioned vulnerabilities to provide holistic, comprehen-
sive, compassionate, and effective care. There are several
clinical considerations when working with this patient
population. First, child and adolescent psychiatrists may
inquire about immigration status, but should only do so in a
careful and thoughtful way, and only if the child and family
feel comfortable sharing this information. Providers can
explain their rationale in asking this information so that
additional referrals for services can be made for the family.
Forcing the issue could cause undocumented parents and
their children to become even more fearful and reluctant to
return. Child and adolescent psychiatrists should explain
that immigration status is protected information under the
Health Insurance Portability and Accountability Act
(HIPAA), and that child and adolescent psychiatrists do not
have any legal mandate to report this information. Many
child and adolescent psychiatrists who are experienced in this
work will not document immigration status, even if dis-
closed by the patient or family, for fear that this information
could be used against the family if subpoenaed by a court.

The child and adolescent psychiatrists who provide
clinical care to this population are not doing so in a forensic
role with immigration authorities, and thus families can be
reassured that their information is as safe as possible.
Second, the knowledge of a family’s immigration status can
be incredibly helpful in treatment planning. Child and
adolescent psychiatrists can listen empathically and
normalize the experiences of the family, while providing
psychoeducation on migration stress and trauma. The ease
of efficient communication is critical to forming a thera-
peutic alliance with families, and bilingual mental health
providers and/or easy access to high-quality interpreter
services can help to facilitate communication with families.
Children should not translate for their parents, as this could

934 www.jaacap.org

cause undue stress and could violate confidentiality laws.
Undocumented families, especially those with US-born
children, may qualify for a number of services. US-born
children should be eligible for special school program-
ming where available, health care, and potentially even
housing. In such cases, child and adolescent psychiatrists
should advocate for the child directly and should avoid
situations in which children feel pressured to secure services
for their parents. These families may also require assistance
in the form of case management, transportation, and
language/translation services. Moreover, undocumented
families may benefit from connections to nonprofit grass-
roots organizations, immigrant law centers, and churches,
and being tied into their local immigrant communities.
Third, a family-centered, trauma-informed, and culturally
sensitive approach should be applied to the clinical care of
this population.7 The trauma experienced by the children
of undocumented parents is transgenerational and historical
in nature. Thus, a family-centered approach, which could
include components of family therapy, allows the entire
family unit to heal simultaneously while enhancing the
family’s ability communicate with one another and support
one another through difficult transitions. Similarly, trauma-
informed systems of care anticipate the potential for trauma
in patients and create clinical environments that are safe
and healing for patients and families who are suffering.
Trauma-informed systems of care include calm, patient,
and welcoming staff at the reception desk, a soothing “look
and feel” of clinical environments, and efforts to avoid
potential re-traumatization and/or triggering of patients.
Finally, many children of undocumented parents may have
experienced discrimination at school or in the community.
Thus, a culturally sensitive approach in which cultural
norms are understood and respected, rather than judged
and questioned, will likely enhance the quality of the
therapeutic relationship and effectiveness in patient
engagement. Fourth, it is a great advantage for clinics to be
located in areas with high concentrations of undocumented
immigrants. This can help to facilitate community re-
lationships between child and adolescent psychiatrists and
other local providers, stakeholders, and families. It also
improves trust in and visibility of mental health services.
Similarly, flyers can be placed in community mental health
center offices where there are high concentrations of un-
documented patients, informing them that they are safe to
receive care. Finally, physicians can play an effective role in
advocating for policies that promote the mental health and
wellness of children residing with undocumented parents in
America.8 Many undocumented parents and their children
may refrain from speaking out for fear of retaliation, and
therefore their voices may not be heard at a local and

Journal of the American Academy of Child & Adolescent Psychiatry
Volume 58 / Number 10 / October 2019

CLINICAL PERSPECTIVES

national level. This may especially be the case in areas
where immigration raids, arrests, detention, and deporta-
tion are more prevalent. The American Academy of Child
and Adolescent Psychiatry released policy statements
against immigration executive orders and the separation of
immigrant children from their families in 2017 and 2018,
respectively. We must continue joining with other medical
organizations in this advocacy effort to address the vul-
nerabilities discussed in this article.

Accepted May 28, 2019.

Dr. Sidhu is with University of New Mexico, Albuquerque. Dr. Song is with
George Washington University Medical Center, Washington, DC.

The contents of this article have not been presented by Dr. Sidhu or
Dr. Song to date, nor have they been published elsewhere. Both Dr. Sidhu
and Dr. Song have given multiple American Academy of Child and
Adolescent Psychiatry (AACAP) Annual Meeting presentations on special
immigrant populations, including immigrant youth fleeing torture and

Journal of the American Academy of Child & Adolescent Psychiatry
Volume 58 / Number 10 / October 2019

persecution as well as domestically residing immigrant youth. Both
Dr. Sidhu and Dr. Song have written multiple articles on this topic as well.

Disclosure: Dr. Sidhu has received grant funding from the 2018 AACAP
Advocacy and Collaboration Grant. He has received honoraria as the 2018
AACAP Hansen Review Course Co-Chair and from Tulane University
Department of Psychiatry Grand Rounds. He has received travel expenses
from the University of New Mexico Health Sciences Center and AACAP.
Dr. Song has served as consultant to the International Rescue Committee, the
Office of Refugee Resettlement, the United Nations High Commissioner for
Refugees, and the TriCity Health Center. She has received honoraria from the
Penn State Medical Center Department of Psychiatry Spring Symposium and
Grand Rounds and the Department of Behavioral Health of Virginia Grand
Rounds. She has received book royalties from Springer Nature. She has
received travel expenses from the George Washington Medical Center.

Correspondence to Shawn S. Sidhu, M.D, DFAACAP, FAPA, Division of Child
and Adolescent Psychiatry, Department of Psychiatry, University of New
Mexico, 2400 Tucker Avenue NE, MSC 095030, Albuquerque, NM 87131;
e-mail: [email protected]

0890-8567/$36.00/ª2019 American Academy of Child and Adolescent
Psychiatry

https://doi.org/10.1016/j.jaac.2019.05.032

REFERENCES

1. Yoshikawa H, Kalil A. The effects of parental undocumented status on the develop-

mental contexts of young children in immigrant families. Child Dev Perspect. 2011;5:
291-297.

2. Chaudry A, Capps R, Pedroza JM, Castaneda RM, Santos R, Scott MM. Facing our
future: children in the aftermath of immigration enforcement (research report). Wash-
ington, DC: National Council of La Raza; 2010. Available at: https://www.urban.org/
sites/default/files/publication/28331/412020-Facing-Our-Future.PDF. Accessed January
1, 2019.

3. Gulbas IE, Zayas LH, Yoon H, Szlyk H, Aguilar-Gaxiola S, Natera G. Deportation ex-
periences and depression among US citizen-children with undocumented Mexican parents.
Child Care Health Dev. 2015;42:220-230.

4. Child Trends DataBank indicators of child and youth well-being: parental depression
(research report). Bethesda, MD: Child Trends; 2014. Available at: https://www.
childtrends.org/wp-content/uploads/2014/08/54_Parental_Depression1-1.pdf. Accessed
January 14, 2019.

5. Henderson SW, Baily CDR. Parental deportation, families, and mental health. J Am Acad
Child Adolesc Psychiatry. 2013;52:451-453.

6. Ortega AN, Fang H, Perez V, et al. Health care access, use of services, and experiences
among undocumented Mexicans and other Latinos. Arch Intern Med. 2007;167:
2354-2360.

7. Kohrt B, Song SJ. Who benefits from psychosocial support interventions in humanitarian
settings? Lancet Glob Health. 2018;6:e354-e356.

8. Sidhu S. Impact of recent executive actions on minority youth and families. J Am Acad
Child Adolesc Psychiatry. 2017;56:805-807.

All statements expressed in this column are those of the authors and do not
reflect the opinions of the Journal of the American Academy of Child and
Adolescent Psychiatry. See the Instructions for Authors for information about
the preparation and submission of Clinical Perspectives.

www.jaacap.org 935

  • Growing Up With an Undocumented Parent in America: Psychosocial Adversity in Domestically Residing Immigrant Children
    • References
error: Content is protected !!