ACP: National immigration policy and health care

A guest column by the American College of Physicians, exclusive to

by John Tooker, MD, MBA, MACP

There are over 11 million undocumented immigrants in the United States — about 3.7% of the U.S. population — according to a 2011 report from the Pew Hispanic Center.

Although there are many reasons why immigrants elect to come to the U.S., the primary motivations for unauthorized entry are jobs (about 8 million are employed in the U.S. labor force), a better standard of living, and, increasingly, established networks of family and friends.

Access to public benefits, such as health care, is thought to be a secondary incentive for unauthorized immigration. Once in the U.S., some benefits, such as public schooling for children, are generally available and protected by Federal law, but at a substantial expense to the most heavily impacted states, such as California and Texas. In contrast, undocumented immigrants are generally ineligible for publicly funded health care regardless of their length of residence, precluding regular access to health care except for emergency care.

Last year, a record 400,000 undocumented immigrants were deported, a small fraction of the 11 million who either entered the country illegally or remained in the U.S. after their visas expired. Although the ailing U.S. economy has slowed the influx of unauthorized immigrants, those in the United States have not returned to their native countries in significant numbers, according to the Pew report. It appears very unlikely, either through deportation or voluntary emigration, that significant numbers of undocumented immigrants residing in this country will return to their countries of origin.

Matters of immigration are primarily subject to Federal law and the Congress has the complete authority to make Federal immigration law. However, current Federal law is inadequate to control unauthorized entry into the United States or to address the challenges posed by those already in this country, such as health care or public schooling for children of undocumented immigrants. For a variety of political reasons, the prospects for national immigration legislation in the near future are dim.

Frustrated by the absence of a national and comprehensive immigration policy, some states — such as Arizona, South Carolina, Georgia, Oklahoma, and Utah — have enacted laws unique to their states to curb illegal entry and to facilitate deportation, even though the states have limited authority to do so. For example, the Georgia General Assembly recently passed House Bill 87, the Illegal Immigration Reform and Enforcement Act of 2011 — modeled on Arizona’s immigration statute — intended to require local and state police to document legal residency and detain people they reasonably suspect are not legal residents.

Current legislation in the South Carolina legislature would make it illegal to transport immigrants anywhere within the state, including to hospitals. One South Carolina state legislator said, ”The bill is intended to make South Carolina a very hostile place for those who are in this country illegally.” Such punitive policies designed to limit access to health care for patients are a serious threat to immigrants and potentially to public health.

The state of Utah has taken a different approach. While wishing to curb unauthorized entry, Utah, a conservative state with a Republican governor and legislature, has taken a more humane and pragmatic approach to undocumented immigrants already in the state, recognizing that many are integrated into Utah society and deportation is not a realistic option.

Utah Governor Gary Herbert recently signed a package of immigration bills: an enforcement law, less restrictive than Arizona’s, and a guest-worker bill that provides that if you pay a fine, have no criminal record and are working, you can stay in Utah without fear of arrest and deportation. The Utah guest worker legislation is similar to the December 2010 legislation proposed by President Obama that passed the House but died in the Senate.

Responding to the challenge of health care access for immigrants, the American College of Physicians recently released a comprehensive position paper on immigration and health care at its recent annual meeting in San Diego. Designed to stimulate a national conversation on immigration and help provide health care for immigrants now in the U.S., the key recommendations are:


  • Access to health care for immigrants is a national issue and should be addressed with a national policy.
  • Access to health care should not be restricted based on immigration status, and people should not be prevented from paying out of-pocket for health insurance coverage.
  • U.S.-born children of parents who lack legal residency should have the same access to health coverage and government-subsidized health care as any other U.S. citizen.

Care delivery:

  • National immigration policy should recognize the public health risks associated with undocumented persons not receiving medical care because of concerns about criminal or civil prosecution or deportation.
  • The federal government should develop new and innovative strategies to support safety-net health care facilities that provide a disproportionate share of care for patients who are uninsured, covered by Medicaid, or indigent.

Eliminating discrimination in health care and professionalism:

  • Physicians and other health care professionals have an ethical and professional obligation to care for the sick. Immigration policy should not interfere with the ethical obligation to provide care for all.
  • Immigration policies should not foster discrimination against a class or category of patients in the provision of health care.

Immigration in general and unauthorized immigration in particular are polarizing issues in this country with strongly held positions on every side of the debate. We need a national dialog and a new and comprehensive national immigration policy and physician leadership when it comes to health care for immigrants. Your ideas leading to sound policy and solutions will be a welcome contribution to the conversation.

John Tooker is Associate Executive Vice President of the American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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