Undocumented, Uninsured, Unafraid

Undocumented, Uninsured, Unafraid

In the fight for healthcare for all, single-payer and immigrant rights activists face serious obstacles, but also the opportunity to demonstrate the benefits of true universalism.

A ten-year-old girl with cerebral palsy is detained by immigration authorities in her hospital room following surgery. Farm workers on their way to the doctor spot the green-and-white vans of the border patrol and cancel their urgently needed medical appointments. Legal immigrants drop their Medicaid coverage so they do not expose undocumented family members to detection. As these incidents reported by CBS News in January 2018 show, the Trump administration’s immigration rhetoric and crackdown is damaging to the health of immigrants and their families.

The 11 million undocumented immigrants in the United States already have the lowest rates of healthcare utilization and the highest uninsurance rate of any group in the country. Unauthorized immigrants are excluded from Medicare and regular Medicaid coverage, and are banned from participating in the Affordable Care Act (ACA). Some states have limited programs for undocumented children and pregnant women, but mostly, undocumented immigrants must rely on emergency rooms, join the massive waiting lists of free or sliding-scale clinics, or skip needed care altogether. Immigrants’ ability to access healthcare has deteriorated even further due to the increased threat of deportation under the Trump regime, which leaves people afraid to seek medical services.

Yet the exclusion of immigrants from the U.S. healthcare system has also been fiercely contested. For decades, activists and providers have worked to provide care to immigrants and migrants, while immigrants themselves have long made the case for healthcare for all. And today, the exclusion of the undocumented from the ACA has led to a new convergence of the immigrant-rights and single-payer movements. Advocates for access regardless of citizenship status argue that immigrants’ health affects the entire population; that millions of unauthorized residents pay taxes for Medicare, Medicaid, and other health programs; and, simply, that healthcare is a universally recognized human right.

These are especially challenging arguments to make in the United States today, a country that still does not recognize a right to healthcare for its citizens, much less for immigrants. Both our healthcare and immigration systems are broken, and have proved stubbornly immune to policy solutions. But an immigrant health-rights movement that advocated for universal healthcare for all, regardless of immigration status, could do much to make both systems more just.

Newcomers to this country, and people connected to immigrant communities, were among the leaders in early movements for social insurance, including healthcare, in the late nineteenth and early twentieth centuries. Nurse and reformer Lillian Wald, a descendant of German-Jewish immigrants, co-founded the Henry Street Settlement in 1895 to provide health services in New York’s immigrant neighborhoods. Wald went beyond the provision of healthcare, however, in connecting immigrants’ health problems to their social conditions, especially poor housing and unsafe workplaces. She wrote that immigrants, “strugglers on a foreign soil,” were “the most helpless of our population and the most exploited.” Wald would also later become one of the most prominent supporters of the progressive-era campaign for state-sponsored health insurance, which began in 1915. Other activists in immigrant and labor circles would join this campaign. For instance, Jewish immigrant garment workers Rose Schneiderman and Pauline Newman, who famously attacked dangerous conditions in factory sweatshops and insisted on women immigrant workers’ right to organize, were also outspoken advocates for comprehensive health coverage that would include sick pay and medical and hospital care. Yet these state-level health insurance proposals had powerful foes in business interests and local medical societies, and by 1920, the campaign became the first (but obviously not the last) major attempt at healthcare reform in the United States to face defeat.

Immigrant groups have also focused on health and medical issues as ways to strengthen their own communities. In the nineteenth and early twentieth centuries, for example, they created mutual-aid societies and built ethnic and religious hospitals to serve immigrant neighborhoods. Unions of immigrant garment workers in the East and miners in the West built clinics and hospitals to address a variety of their members’ health problems, from tuberculosis to black lung disease.

But at the same time, health concerns have also been wielded against immigrants. Since the mid-nineteenth century, nativists have argued—without evidence—that immigrants bring disease epidemics. Medical inspections at the border, ranging from the famous Ellis Island eye exam to the spraying of Mexican bracero (guest) workers with poisonous pesticides, sent the message that immigrants posed a potential threat to the health of the nation. Nativist scaremongering continues today, as seen during the Ebola outbreak several years back. “We must immediately stop all air traffic,” Donald Trump ominously tweeted in September 2014, “coming from the Ebola infected areas of Africa—before it is too late.”

Just as pervasive as the notion of an immigrant threat to public health has been the idea that newcomers will become dependent on government services. Immigrants who appear likely to become a “public charge” can be denied admission, and those who use welfare services after admission can lose eligibility for legal residency. During the Great Depression, public-charge accusations underpinned the massive repatriation campaigns in which over a million U.S. residents of Mexican descent were forced out of the country. Authorities in 1930s Los Angeles were so insistent that Mexicans and Mexican Americans who used health services should leave that they actually stationed officials in hospital waiting rooms to detain patients for repatriation.

It’s notable that the victims of the 1930s repatriation were targeted based on their national origin, not their immigration status. In that campaign, immigrants, legal residents, and citizens alike were all defined as “Mexicans.” For the first half of the twentieth century, newcomers to the United States were frequently denied health and welfare services based on their race, national origin, residency, or other factors, but rarely their immigration status. In fact, sociologist Cybelle Fox has shown that most U.S. health and welfare services were not restricted based on citizenship status until the 1970s. In a recent article in the Journal of American History, Fox demonstrates that explicit exclusion of the undocumented from federal welfare programs began during the Nixon administration, when citizenship requirements were added to both Medicare and Medicaid. Government officials were reacting to both the rise in unauthorized immigration (an unintentional result of the 1965 Immigration and Nationality Act) and the growing number of welfare recipients—even though these two phenomena were not connected. Despite a lack of evidence that welfare benefits ever served as an incentive for immigration, officials argued that citizenship requirements for health and welfare programs would deter undesirable aliens. This backlash was also clearly about race: the new immigration, both legal and illegal, was overwhelmingly Latino and Asian, groups that were viewed as less “assimilable” than white Europeans. Fox quotes a California newspaper article from 1970 that complained, “California has been known as a land of milk and honey. Its reputation is well known in Mexico, where to wetbacks . . . the word is out: ‘Go to California, where welfare workers hand out free food, free money, and free medical-dental care just for the asking.”

Anti-welfare met anti-immigration backlash even more starkly in the 1990s, when the Clinton welfare reform imposed a five-year waiting period on legal immigrants’ eligibility for Medicare and Medicaid. And the ACA, signed into law in 2010, explicitly banned undocumented immigrants from purchasing even unsubsidized healthcare plans.

As a result of this history, immigrants today are frequently excluded from the healthcare system. In 2016 some 40 percent of non-elderly undocumented adults—and 23 percent of children—were uninsured, according to the Kaiser Family Foundation. Although legal immigrants are eligible for Affordable Care Act coverage, the five-year waiting period for Medicare and Medicaid, and their fear of exposing undocumented faculty members, has led to one out of six legal immigrants being uninsured.

Donald Trump also seeks to broaden the definition of “public charge” to include legal immigrants who have accessed any kind of public benefit, possibly including ACA insurance. At the same time, however, immigrants, activists, and healthcare providers have also pushed back.

Until recently, explicit demands for a right to healthcare for undocumented immigrants were rarely heard. Mid-twentieth-century civil rights organizations, such as the Texas-based American G.I. Forum, battled healthcare discrimination against Mexican Americans, both citizens and immigrants, but focused their arguments on equality by race and national origin. These groups avoided taking positions that would imply support for unauthorized immigrants. The United Farm Workers of America (UFW) was important in focusing national attention on farmworker health issues, such as pesticide poisoning, and opened medical clinics for its immigrant and non-immigrant members throughout the West and Southwest. But the UFW leadership also engaged in attacks on undocumented workers, blaming them for lowering agricultural wages. That began to change by the mid-1970s, when UFW activists started to challenge the union’s anti-immigrant stance, and the Arizona Farmworkers Union established health clinics that openly assisted undocumented workers.

The turning point that led to a convergence between healthcare rights and undocumented rights did not come until two decades later. In 1994, California voters passed the anti-immigrant Proposition 187, which among other measures ended non-emergency medical care for the undocumented and required hospitals and clinics to report any undocumented immigrants seeking care. The passage of Proposition 187 led to the largest immigrant-rights protests in U.S. history to that date. Many argue that today’s strong immigrant rights movement can be traced to this moment in California history. But it was also the first time the exclusion of the undocumented from healthcare became a major issue for immigrant rights activists.

Because of the law’s clearly negative potential effect on healthcare access, physicians and other medical practitioners took a leading role in opposition. The California Medical Association and the American Medical Association argued that Proposition 187 would endanger public health because immigrant patients would be afraid to self-report infectious conditions, and that the provider-reporting requirement would violate the confidentiality of the doctor-patient relationship. Although Proposition 187 was eventually struck down by the courts, subsequent anti-immigration laws in Arizona and Alabama would also target immigrant access to healthcare. The California battle was not the first time, and certainly would not be the last, that medical practitioners resisted policies that would force them to report patients to immigration authorities. The Prop 187 battle was a dramatic turning point in U.S. immigration politics, giving rise to both a virulent anti-immigrant backlash and a powerful movement in support of the undocumented.

It was the game-changing protests of 2006 that signaled an era in which both immigrant rights and civil rights organizations openly support the undocumented, and led to immigrant activists “coming out of the shadows” by openly declaring their undocumented status. The movement erupted in reaction to the proposed Sensenbrenner Bill in Congress that would have, among other things, criminalized providing medical assistance to undocumented immigrants. In March 2006, 200,000 protesters filled the streets of Chicago, and on May 1’s “Day without Immigrants” an estimated 1.5 million people participated in demonstrations in over fifty U.S. cities. The bill was defeated, but so was the Dream Act, which would have created a path to citizenship for millions.

Immigrant activism, including on the issue of healthcare, continued into the years of the Obama presidency. The exclusion of the undocumented from the benefits of the ACA reflected Obama’s bifurcated strategy on immigration, which offered concessions to both pro- and anti-immigrant forces. This was especially evident when the administration announced that young immigrants protected under the new DACA program would not be eligible for Obamacare, Medicare, or Medicaid. In a letter to the president, the National Hispanic Leadership Agenda, currently a coalition of forty-five Latino rights organizations, objected that excluding DACA recipients from coverage would lead to “human suffering and diminished health. . . . Despite the tremendous benefits of the Affordable Care Act, Latinos remain the most uninsured racial/ethnic group, in part due to immigrant restrictions on eligibility for health care programs.” It also noted that these restrictions “take a disproportionate toll on the health and opportunity of Latino immigrants.”

The convergence of major healthcare reform with greater national attention to the undocumented also meant that mainstream groups and Democrats that supported Obamacare have had to grapple with the immigrant exclusions. This included provider organizations like the American Nurses Association, whose House of Delegates passed a resolution in 2010 that “immigrants, whether documented or not, should have access to quality health care, including the opportunity to purchase insurance.” It was also an issue during the 2016 presidential primary campaign, when Hillary Clinton came out in favor of allowing undocumented immigrants to buy Obamacare coverage, but without federal subsidies. Meanwhile, the single-payer plan released by Senator Bernie Sanders in the heat of the primary campaign “would cover everyone, including aspiring Americans,” his senior policy advisor told Politico in January 2016.

The Obamacare exclusions have also led to a surge of immigrant health activism at the state level, especially in states that already provide some coverage to the undocumented. Both New York and California enacted legislation to allow low-income DACA recipients to enroll in their Medicaid programs, getting around federal regulations by using state funds only. Also in California, home to one quarter of the undocumented immigrants in the United States, a campaign by immigrants and allies led to passage of a bill in 2015 extending the full benefits of its Medicaid program (Medi-Cal) to undocumented children. And today, there is a strong push in the California Assembly to include undocumented adults in Medi-Cal, and to allow undocumented people to purchase insurance in the state Obamacare exchanges. David Zingale, Senior Vice President of the California Endowment, praised the shift in California’s approach to immigrant health coverage in the Huffington Post in January: “Now we are witness to California’s divisive past of immigrant scapegoating and exclusion replaced with a vision of health for all. Today, California’s single-payer enthusiasts and skeptics alike agree on the value of universal coverage.”

This is indeed a major shift in single-payer activism. Earlier single-payer proposals in California excluded undocumented immigrants or imposed a waiting period, but the most recent iteration (currently shelved) included them. On the national level, Bernie Sanders’s Medicare-for-All Act in the Senate proposes single-payer coverage for “Every individual who is a resident of the United States”; the House version would cover “all United States residents.” Because both versions leave the task of defining “resident” to the Secretary of Health and Human Services, they may stop short of entirely eliminating immigration status as a potential criterion for eligibility. However, the thrust of both seems to be in the direction of truly universal coverage, which has not gone unnoticed by the right-wing media: “Illegal Immigrants Will Receive Free Health Care Under Bernie’s Single Payer Bill,” noted a headline from the Daily Caller last fall.

In the fight to really put the “all” into “healthcare for all,” single-payer and immigrant rights activists face serious obstacles, but also the opportunity to embrace and explain the benefits of true universalism. Abundant research on immigrant health exists, and needs to be further publicized. For example, advocates can emphasize that one of the reasons that immigrants, both documented and undocumented, have the lowest rates of healthcare utilization of any group is because they tend to be healthier than Americans (for a variety of reasons including age, diet, and family support); so, including them in coverage will not be inordinately expensive and could even bring down overall costs. Accusations that immigrants come here to get “free healthcare” can be refuted by discussing the Medicare, Medicaid, and ACA exclusions, and referring to the numerous studies showing that medical services are almost never an incentive to immigration. Arguments about burdens on taxpayers need to be refocused on the high cost of uninsured people’s (including immigrants’) dependence on emergency rooms, which ends up being shifted into higher hospital and insurance costs for everyone.

The American public also needs to hear more about the negative effect of Trump’s immigration crackdown on the health of not just undocumented people, but also on their legal immigrant and citizen family members. We need to hear more about the positive effect programs that extend coverage to all can have on public health and government expenditures. Beyond the practical and public health considerations lie ethics, equity, and human rights: providers’ ethical obligation to care for those in need, the reality that immigrant exclusion disproportionately hurts working people of color, and the very definition of human rights as something that should extend beyond borders. Since the United States does not yet recognize the human right to healthcare beyond emergency care, this is a fight not just for immigrants, but for everyone.

Beatrix Hoffman is professor of history at Northern Illinois University and author of Health Care for Some: Rights and Rationing in the United States since 1930 (University of Chicago Press, 2012). She is working on a history of immigrants’ rights to healthcare.