What Health Care Reform Means for Immigrants: Comparing the Affordable Care Act and Massachusetts Health Reforms

Immigrant-blind care: How immigrants experience the "inclusive" health system as they access care

A growing body of scholarship examines the varying impact of legal status and race on accessing healthcare. However, a notable gap persists in comprehending the supplementary mechanisms that hinder immigrants' pathway to seek care. Drawing on ethnographic observations in various clinical settings and in-depth interviews with 28 healthcare professionals and 12 documented Haitian immigrants in a city in Upstate New York, between 2019 and 2021, I demonstrate the tension between the conceptualization and implementation of inclusive care practices by healthcare providers. I argue that the mere expansion and adoption of inclusive discourse among providers do not inherently ensure equity and the removal of barriers to healthcare access. This work contributes to the social study of medicine and race and ethnic studies by introducing the innovative concept of "immigrant-blind." Through this concept, the research sheds light on how providers' conceptualization of inclusivity proclaims medical encounters to be devoid of stratifications and rationalizes their practices which mask the profound impact of immigration status and immigration on immigrant health. Furthermore, these practices reinforce existing divisions within care settings and medical encounters, where immigration laws and enforcement practices operate and further exacerbate stratifications. By examining providers' uninformed implementation of culturally competent care practices, the findings reveal that providers stigmatize and essentialize immigrants during medical encounters. This highlights the imperative for a more nuanced and informed approach to healthcare provision, where genuine inclusivity is upheld, and barriers to access are dismantled to foster equitable and dignified healthcare experiences for all.

Occupational health within the bounds of primary care: Factors shaping the health of Latina/o immigrant workers in federally qualified health centers

BACKGROUND

Many workers seek care for work-related medical conditions in primary care settings. Additionally, occupational medicine training is not consistently addressed in primary care professional training. These patterns raise concerns about the health outcomes of low-wage Latina/o immigrant workers who make use of primary care settings to obtain care for work-related injuries and illnesses. The objective of this qualitative study was to investigate how primary care clinicians assessed and addressed the role of occupational exposures on the health and well-being of Latina/o immigrant workers.

METHODS

We conducted semistructured in-depth interviews with 17 primary care clinicians (physicians, resident physicians, and nurse practitioners) employed in an urban federally qualified health center (FQHC) with two sites located in Orange County, CA.

RESULTS

Using a constructivist grounded theory approach, we determined that primary care clinicians had a general understanding that employment influenced the health and well-being of their Latina/o immigrant patients. Clinicians delivered care to Latina/o immigrant workers who feared reporting their injury to their employer and to Latina/o immigrants whose workers' compensation claim was terminated before making a full recovery. Clinicians were responsive to patients' work-related concerns and leveraged the resources available within the FQHC. Although some clinicians offered suggestions to improve occupational health in the FQHC, a few clinicians raised concerns about the feasibility of additional health screenings and clinic-based interventions, and pointed to the importance of interventions outside of the healthcare system.

CONCLUSION

This study underscores the complexities of addressing occupational health concerns in urban FQHCs.

Double Consciousness in the 21st Century: Du Boisian Theory and the Problem of Racialized Legal Status

In W.E.B. Du Bois’ Souls of Black Folk, he argued that the problem of the 20th century in the United States was the problem of the color line. Given that de facto and explicit racial discrimination persist, anti-immigrant rhetoric is intensifying, and legal status has become more salient, we argue Du Boisian theory remains relevant for understanding social and political cleavages in the 21st century United States. The intersection of race, ethnicity, and legal status or “racialized legal status” represents a new variation of Du Bois’ “color line,” due to how these statuses generate cumulative disadvantages and exclusion for citizens and immigrants of color, particularly the undocumented. We begin with a review of Du Bois’ double consciousness theory, highlighting the marginalization of African Americans. Next, we apply double consciousness to the 21st century U.S. context to empirically demonstrate parallels between 20th century African Americans and the marginalization faced today by people of color. We close with a discussion about how double consciousness enhances our understanding of citizenship and has also generated agency for people of color fighting for socio-political inclusion in the contemporary United States.

The legal violence of care: Navigating the US health care system while undocumented and illegible

Medical sociologists widely conceptualize illegality as a social determinant of health, implicating immigration law but not health care law in immigrant health disparities. Contributing to an emerging literature on legal violence in the context of health care, I explore how the Harris Health System in Houston, Texas legally affects low-income undocumented migrants' lives as they seek care. Drawing on eleven months of ethnographic and interview research with migrants and volunteers at a community-based organization, I argue that the health care system legally exacerbates migrant vulnerability in particular ways. Clerical staff follow medical protocol to deny migrants care on the basis of legibility (i.e., a photo ID), not legality (i.e., legal status), resulting in two classifications of illegality - what I term legible and illegible illegality. The former keeps migrants visible to the state but offers potential care, and the latter legally relegates migrants to the exploitative conditions of informal home care and/or a protracted state of suffering where, for many, death is the only recourse. This research shows that without substantive health reform, health practitioners - physicians, social workers, clerical staff, and home care workers - play an (in)direct role in shaping and normalizing immigrant health disparities.

Undiagnosed diabetes among Hispanic and white adults with elevated haemoglobin A1c levels

AIMS

The aim of this study is to compare the frequency and correlates of undiagnosed diabetes between Hispanic and white American adults ages 20 and older with known diabetes or elevated HbA_1c .

METHODS

Using 2007 to 2012 National Health and Nutrition Survey data, 1792 white and Hispanic Americans age 20 and older with known diabetes or elevated HbA_1c (≥6.5%) were included in the analysis. Undiagnosed diabetes was defined as elevated HbA_1c more than or equal to 6.5% without prior diabetes diagnosis. Covariates included demographics, health care access, and survey language.

RESULTS

Hispanics were younger (54.92 vs 61.45 y, p < .001) and had a higher rate of undiagnosed diabetes (28.2% vs 18.0%, p < .001) than their white counterparts. For Hispanics, those with undiagnosed diabetes had higher mean HbA_1c than those with known diabetes (p = .03), but no significant difference was found between diagnosed and undiagnosed diabetes among whites. Covariates that decreased the odds of undiagnosed diabetes among Hispanic Americans included having a routine place to receive health care. For whites, covariates that decreased the odds of undiagnosed diabetes were a higher ratio of income to poverty level, having health insurance and having a routine place for health care.

CONCLUSION

The high proportion of unknown diabetes among Hispanic Americans suggests the need for a culturally competent health campaign to improve community diabetes awareness. Emphasizing the importance of having a routine place of health care for regular health check-ups and expanded community resources for diabetes early detection and prevention among this population could decrease the burden of diabetes.

The Plenary Power Meets the Police Power: Federalism at the Intersection of Health & Immigration

On January 8, 2019, shortly after his inauguration, California's Governor Gavin Newsom announced a proposal to provide health coverage to undocumented immigrants up to age 26. That same day, New York Mayor Bill de Blasio offered a $100 million plan to cover 600,000 uninsured New Yorkers, regardless of immigration status. These proposals from public officials on opposite sides of the continent stood in stark contrast to the Trump Administration's demand for a wall at the southern border, and its proposed public charge regulations that are expected to lead millions of lawfully present immigrants and their families to forego health insurance.

How has the Affordable Care Act changed outcomes in emergency general surgery?

INTRODUCTION

Lack of insurance coverage increases complications and mortality from surgical procedures. The 2014 Affordable Care Act (ACA) Open Enrollment (OE) insured more Americans, but it is unknown if this improved outcomes from emergency general surgery (EGS) procedures. This study seeks to determine how ACA OE coverage changes outcomes in EGS.

METHODS

This is a retrospective review using the Nationwide Inpatient Sample database from 2012 to 2014. Patients aged 18 to 64 years undergoing EGS procedures were identified by International Classification of Diseases, Ninth Revision, codes. Medicare patients were excluded. Patient demographics, hospital characteristics, and Charlson comorbidity index were obtained. Outcomes were measured by mortality, complications, and calculated costs. Univariate and difference-in-differences multivariate analyses were performed to determine the effect of the ACA OE on EGS outcomes.

RESULTS

A total of 304,110 EGS cases were identified. After Medicare patients were excluded, there were 275,425 cases. In 2014, Medicaid admissions increased 18.2% from 18,495 to 22,615 (p < 0.001) and self-pay admissions decreased 33% from 14,938 to 10,630 (p < 0.001). Mortality significantly increased for self-pay patients in 2014 from 0.81% to 1.22% (p < 0.001). Difference-in-differences analysis indicated that, after risk adjustment, the ACA OE was associated with a small reduction in mortality for insured patients (-0.12%, p = 0.034), increased complications (1.4%, p = 0.009), and increased wage-index adjusted mean costs (4.6%, p < 0.001). There was a significant increase in Medicare (+26.5%) and private (+12.2%, p < 0.001) insurance admissions in teaching hospitals, while nonteaching hospitals had fewer EGS admissions with a greater reduction in uninsured EGS admissions.

CONCLUSIONS

The ACA OE created a significant reduction in uninsured EGS admissions but did not reduce EGS mortality. Mortality decreased in insured patients but increased in uninsured patients, indicating that the ACA OE primarily insured lower-risk patients. The ACA OE did increase cost and complications in insured admissions. Teaching hospitals saw the majority of the increase in Medicaid and private insurance EGS admissions. A national registry would improve future study of insurance policy on EGS outcomes.

LEVEL OF EVIDENCE

Economic analysis, level IV.

Towards universal health coverage: including undocumented migrants

As countries throughout the world move towards universal health coverage, the obligation to realise the right to health for undocumented migrants has often been overlooked. With unprecedented millions on the move - including refugees, asylum seekers, internally displaced persons, and returnees - undocumented migrants represent a uniquely vulnerable subgroup, experiencing particular barriers to health related to their background as well as insecure living and working conditions. Their legal status under national law often restricts access to, and affordability of, healthcare services. While striving to ensure health for all, national governments face challenging priority setting dilemmas in deciding: who to include, which services to provide, and how to cover out-of-pocket expenses. Building on comparative experiences in Norway, Thailand and the United States - which reflect varied approaches to achieving universal health coverage - we assess whether these national approaches provide rights-based access to affordable essential healthcare services for undocumented migrants. To meet the shared Sustainable Development Goal on universal health coverage, the right to health must be realised for all persons - including undocumented migrants. To ensure universal health coverage in accordance with the right to health, governments must evaluate laws, regulations, policies and practices to evaluate: whether undocumented migrants are included, to which services they have access, and if these services are affordable. Achieving universal health coverage for everyone will require rights-based support for undocumented migrants.

Cautious Citizenship: The Deterring Effect of Immigration Issue Salience on Health Care Use and Bureaucratic Interactions among Latino US Citizens

Research shows that health care use among Latino immigrants is adversely affected by restrictive immigration policy. A core concern is that immigrants shy away from sharing personal information in response to policies that expand bureaucratic monitoring of citizenship status across service-providing organizations. This investigation addresses the concern that immigration politics also negatively influences health care utilization among Latino US citizens. One implication is that health insurance expansions may not reduce health care inequities among Latinos due to concern about exposure to immigration law enforcement authorities. Using data from the 2015 Latino National Health and Immigration Survey, we examine the extent to which the politics of immigration deters individuals from going to health care providers and service-providing institutions. Results indicate that Latino US citizens are less likely to make an appointment to see a health care provider when the issue of immigration is mentioned. Additionally, Latino US citizens who know someone who has been deported are more inclined to perceive that information shared with health care providers is not secure. We discuss how cautious citizenship, or risk-avoidance behaviors toward public institutions in order to avoid scrutiny of citizenship status, informs debates about reducing health care inequities.

Closing Kynect and Restructuring Medicaid Threaten Kentucky's Health and Economy

Following passage of the Patient Protection and Affordable Care Act (ACA) in the United States, the Kentucky Health Benefit Exchange, Kynect, began operating in Kentucky in October 2013. Kentucky expanded Medicaid eligibility in January 2014. Together, Kynect and Medicaid expansion provided access to affordable health care coverage to hundreds of thousands of individuals in Kentucky. However, following the Kentucky gubernatorial election in 2015, the newly inaugurated governor moved to dismantle Kynect and restructure the Medicaid expansion, jeopardizing public health gains and the state economy. As the first state to announce both the closure and restructuring of a state health insurance marketplace and Medicaid expansion, Kentucky may serve as a test case for the rest of the nation for reversal of ACA-related health policies. This article describes Kynect and the Kentucky Medicaid expansion and examines the potential short-term and long-term impacts that may occur following changes in state health policy. Furthermore, this article will offer potential strategies to ameliorate the expected negative impacts of disruption of both Kynect and the Medicaid expansion, such as the creation of a new state insurance marketplace under a new governor, the implementation of a private option, and increasing the state minimum wage for workers.

New Opportunities for Funding Dialysis-Dependent Undocumented Individuals

The cost of dialysis for the estimated 6500 dialysis-dependent undocumented individuals with kidney failure in the United States is high, the quality of dialysis care they receive is poor, and their treatment varies regionally. Some regions use state and matched federal funds to cover regularly scheduled dialysis treatments, while others provide treatment only in emergent life-threatening conditions. Nephrologists caring for patients who receive emergent dialysis are tasked with the difficult moral dilemma of determining "who gets dialysis that day." Without a path to citizenship and by exclusion from the federal marketplace exchanges, undocumented individuals have limited options for their treatment. A novel opportunity to provide scheduled dialysis for this population is through the purchase of insurance off the exchange. Plans purchased off the exchange must still abide by the 2014 provision of the Patient Protection and Affordable Care Act, which prohibits insurance companies from denying coverage based on a preexisting health condition. In 2015 and 2016, >100 patients previously receiving only emergent dialysis at the two largest safety-net hospital systems in Texas obtained off-the-exchange commercial health insurance plans. These undocumented patients now receive scheduled dialysis treatments, which has improved their care and quality of life, as well as decompressed the overburdened hospital systems. The long-term sustainability of this option is not known. Socially responsive and visionary policymakers allowing the move into this bold, new direction deserve special appreciation.

Access and utilization of healthcare services in Massachusetts, United States: a qualitative study of the perspectives and experiences of Brazilian-born immigrant women

Background

Understanding immigrants’ interactions with the United States (US) healthcare system will likely make it possible to meet their healthcare needs and improve their quality of life in the US. Although challenges to accessing and utilizing healthcare in the US have been identified, there is little information specific to Brazilian-born immigrants’ experiences. Brazilians comprise a fast-growing immigrant population group in the US. The purpose of this study was to explore Brazilian immigrant women’s perspectives and experiences with healthcare services in the US to gain insights into factors amenable to interventions that may contribute to disparities in access to and utilization of services.

Methods

Five focus groups were conducted from April to May in 2015 using a purposeful sampling of Brazilian-born immigrant women living in Massachusetts, US.

Results

Thirty-five women participated in this study. Although participants expressed their overall satisfaction with the US healthcare system, they noted several barriers to care, including sociocultural differences in delivery of care and communication barriers, including inconsistent quality of interpreting services.

Conclusions

This study provides new information on the experiences and challenges faced by Brazilian immigrant women in accessing and utilizing healthcare services in the US and points out opportunities for improving services and the overall health of this immigrant population. Addressing noted sociocultural differences and communication barriers including inconsistent quality of hospital’s interpreting services might enhance Brazilian-born immigrants’ experiences with the healthcare system.

Ethnoracial inequality and insurance coverage among Latino young adults

Previous research has demonstrated that Latino young adults are uninsured at higher rates relative to other ethnoracial groups. Recent implementation of the 2010 Affordable Care Act (ACA) has increased access to health insurance for young adults, in part by maintaining health coverage through their parents until age 26. This paper examines patterns of Latino young adults' insurance coverage during early ACA implementation by addressing three questions: 1) To what extent do Latino young adults remain uninsured relative to their peers of other ethnoracial groups? 2) How do young adults' family socioeconomic background, immigrant characteristics, college enrollment, and employment status mediate their coverage? And, 3) do patterns of insurance coverage differ for employer-provided coverage versus other sources of coverage (including parents’ health insurance)? Using a 2011 representative sample of U.S.-born and 1.5-generation immigrant young adults in California, we find that Latinos are more likely than other ethnoracial groups to remain uninsured. While they are as likely as similar peers to obtain employer-provided health insurance, they are less likely to possess insurance through other sources (including their parents). This study contributes to our understanding of the limits of the ACA in reducing disparities in insurance coverage for Latinos by highlighting the importance of family socioeconomic background, immigrant characteristics, college enrollment, and employment in shaping coverage among this age group.

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We examine ethnoracial disparities in Latino young adults' health insurance coverage.

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Latino young adults exhibit low rates of insurance coverage during early ACA implementation.

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Family SES, four-year college enrollment, and employment status predict coverage.

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Legal status, language use, and immigrant generation predict insurance coverage.

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In spite of low overall coverage, Latinos access coverage from employers similar to other groups.