As we have seen with the recent Ebola outbreak in West Africa, the overall health of a population is a key component in the emergence and spread of contagious disease. But sovereign boundaries and distinctions between citizens and non-citizens undermine public health in the United States.
State and local public health departments serve as the primary defense against the spread of contagious disease. But these public health agencies—already under-resourced because public funding is politically tenuous—must work within a system in which citizens and non-citizens are segregated with respect to access to health care. The result should be alarming.
Most local health departments provide critical services to all persons regardless of citizenship or immigration status, primarily in the form of immunizations, health screening, and treatment. Effective outreach to immigrant groups is often lacking, however. Furthermore, undocumented immigrants fear that their immigration status will be reported to government officials who have the power to deport them. They consider it strongly in their interest to avoid the public health radar screen.
Foreign nationals present in the United States, both legally and illegally, often lack access to basic preventive health care and other services. The major public benefits programs have always prevented some non-citizens from securing assistance, but in 1996 the Illegal Immigration Reform and Immigrant Responsibility Act drastically expanded federal welfare exclusions that made it all but impossible for most immigrants to obtain non-emergency medical care. Lawful permanent residents living in the United States must wait at least five years before they are eligible for federally funded benefits, although some states provide benefits earlier. Lawfully present temporary immigrants—for example, those with tourist, student, or employment visas—are also generally not eligible for means-tested public benefits. Undocumented immigrants are excluded from all federal programs except the Women, Infants and Children Nutrition Program (WIC), the National School Lunch Program, and Head Start.
In recent years, a number of states have strictly limited access to government benefits at the same time that legislatures have cut funding for public health departments. While undocumented immigrants can access emergency medical care regardless of status, in most states they are excluded from safety-net programs. Notably, California state legislators have proposed a bill to extend Medicaid to undocumented immigrants.
Access to safety net benefits, then, depends upon immigration status. So too does access to preventative care. Private health care effectively excludes the vast majority of foreign nationals present in the United States. Under the Affordable Care Act, undocumented immigrants may not purchase private health insurance through state exchanges, even if they have the ability to pay for it with their own money. But many if not most of those legally present cannot do so either, including the “Dreamers”—children brought to the United States by undocumented parents. Even the 650,000 non-citizens granted “deferred action for childhood arrivals” under President Obama’s plan may not participate in the ACA exchanges and are not eligible for Medicaid.
Other foreign nationals who are legally present in the United States also face severe restrictions for the purchase of health insurance. Most temporary visa holders, like undocumented migrants, are not eligible to participate. Lawful permanent residents are subject to the ACA’s individual mandate and tax penalty, but many of those who cannot afford to purchase even a subsidized insurance plan remain ineligible for Medicaid or must wait five years for eligibility. In addition, employment-based health insurance remains a significant feature of private coverage, and most temporary visa holders are ineligible to work.
One bright spot in this picture is the allocation of federal dollars to Federally Qualified Health Centers (FQHCs) and Migrant Health Centers. Both are non-profit entities funded by the Health Resources and Service Administration. The centers offer primary care regardless of immigration status, insurance status, or ability to pay. As of 2010, there were 1,214 FQHCs and 159 federally funded migrant health centers. Not every state or region has one—and those that do offer only basic services, are often over-crowded, and suffer from limited staffing and medical supplies.
Dangerous contagious disease that is both difficult to diagnose and that requires lengthy treatment presents most starkly the deficiencies in U.S. immigration law that actively undermine public health. One such example is drug-resistant tuberculosis. The CDC considers drug-resistant tuberculosis to be a “serious threat” for the United States. Tuberculosis in all its forms is higher in the foreign-born population. Among the U.S.-born population, the greatest disparity in TB rates is between blacks and whites; the rate among blacks is nearly six times as high. The poor, especially those without access to basic medical care, are the weakest link in the U.S. chain of defense.
Public health concerns are most pressing for two classes of non-citizens: migrant agricultural workers and persons in immigration detention. Both present unique challenges for communicable disease control.
Migrant agriculture workers often pass through the jurisdictions of multiple local health agencies, making continuity of health treatment extremely difficult. State and local governments are responsible for population-based health services, including surveillance and treatment of tuberculosis. The nation’s primary public health authority is divided among 2,684 state, local, and tribal health departments. As is true for U.S. citizens, public health authority fragmentation makes it difficult to screen for and treat disease in a mobile population. Weaknesses in the U.S. public health system affect concern citizens and non-citizens equally.
The existing temporary agriculture worker visa program is widely criticized as costly and too slow for employers. But the leading proposals to reform it do not provide for health screening of foreign nationals prior to arrival. Pre-screening temporary agriculture workers for serious contagious disease could lessen a public health threat, although it would do nothing to prevent the spread of disease by temporary workers who acquire disease within the United States. It is this common mobility—agriculture workers moving from field to field and state to state, often following seasonal harvests over a period of months—that thwarts any effort to employ the most basic public health control measures.
Basic healthcare for immigration detainees is also a serious problem, unevenly addressed, as illustrated by the fact that the incidence of HIV and tuberculosis are higher in U.S. than in the general population.
All detainees brought into an ICE detention facility are routinely checked for tuberculosis as a mandatory component of their general intake medical screening. Each year, ICE confronts approximately 150 to 200 cases of active or suspected tuberculosis nationwide. No uniform system exists to inform state and local TB programs when a person under detention by ICE who has TB or suspected TB is released or repatriated. Non-citizens who fall through the cracks risk developing drug-resistant TB and spreading it to others.
Because standard data regarding the disposition and outcomes of TB patients in ICE custody are not collected (or are not publicly available), the magnitude of this problem is unknown. In addition, the majority of detainees are housed in local jails and state prisons, each of which has its own TB screening policies and relationships with TB control programs. Detainees are transferred frequently between facilities, and certain facilities might not transfer medical records containing TB treatment information.
Providing preventive and routine health care to non-citizens should be a priority. In the present political climate, however, we are unlikely to see much progress, even with the knowledge we have of serious public health consequences for failure to act.
Polly J. Price is a Professor of Law at Emory University School of Law where she is affiliated with the Emory Antibiotic Resistance Center.
 See Diana L. Schneider and Mark N. Lobato, Tuberculosis Control Among People in U.S. Immigration and Customs Enforcement Custody, American Journal of Preventive Medicine 2007;33(1); Alison Siskin, CRS Report for Congress, Healthcare for Non-Citizens in Immigration Detention (2008).
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