A Medical Provider’s Perspective on Treating Undocumented U.S. Immigrants

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Liz Willetts

Liz Willetts, PA-C, MEM, practices medicine at a Hispanic community health center operated by Brigham & Women’s Hospital in Boston. She also works with an international team of writers for the International Institute for Sustainable Development, traveling and reporting on United Nations’ and other global environment and development policy negotiations. Liz has worked with many marginalized populations, including inner city youth, urban homeless, migrant workers, and refugees in the US, as well as rural populations in Peru, Chile and Guatemala. She graduated the University of Pennsylvania in 2002.

As I was writing this article I received a message from a medical friend in the Midwest regarding one of her patients:

“Liz, I need a consult. I’m treating a 13-year-old boy from Mexico with type 2 diabetes, and his hemoglobin A1c is 11.9% (normal is <6.5%) despite taking Metformin (the first line diabetes treatment). He needs insulin. The family can’t afford it (300-400$/month). No social security number so he can’t apply for assistance. Do you know of any resources or have suggestions of where I could start looking?”

 (For reference, an A1c of 11.9 is a marker of severe diabetes, more than likely to lead to complications of eye, kidney, heart and nerve function.)

Access to health care for undocumented immigrants is, whether you are for it or against it, a popular news topic. However, in parallel with this, and largely unnoticed, is the challenge health care providers face, either treating or navigating care for this population in the clinical environment.

Let’s step back for a second.

Between 1990 and 2007 the number of undocumented immigrants in the U.S. rose from 3.5 to 12.2 million, and now hovers at 11.3 million people.

There are several ways we can look at the scale of this number. For one, it is a community significantly larger than the native population of many European countries. It is roughly equal to the population of Greece (10.8) and Belgium (11.3), a little larger than that of Sweden (9.9) and Serbia (7.1), twice as many as Ireland (4.6) and Norway (5.1), and about one quarter the size of the population of Spain (46.4). The US population is ~324 million, making undocumented immigrants equal to about 3% of our total population.

Approximately 78% of these undocumented immigrants are from Latin countries, and about 12% are from India and China.

This un-ignorable volume of people at the macro level has not gone unnoticed at local levels.

We health care providers confront this population directly when they have colds, bleeds, accidents and births and deaths. We see their sadness, struggles and pain.

Dani Kaplan, PA-C, treating a pediatric patient.

Dani Kaplan, PA-C, treating a pediatric patient.

It is a unique patient sub-population, presenting with the added challenges of language barriers, lack of vaccinations, poor health literacy, and minimal access to preventative and non-acute care. Many can’t obtain condoms, medications, or even basic hygiene (water and sanitation). This population faces unique and elevated stressors, including separation from family, financial insecurity, physically strenuous labor conditions, and genuine fear of deportation. They bring no health records, and may be geographically untraceable by the time labs have resulted.

So, how do we provide competent health care for this complicated population?

Political preferences aside, how do we address the large scale chronic and transmissible diseases this population hosts right now inside our borders?

Some U.S. residents may brush off these questions, assuming that migrant workers are only temporary inhabitants of the U.S. and not worth the effort or expense. Yet data shows the duration of temporary residence is increasing. According to the Pew Research Center, 62% of undocumented immigrants have been in the U.S. for at least a decade.

The magnitude of this population is impressive as is their hidden longevity within our borders. These facts raise a number of practical questions for public health practitioners:

How do we assess, monitor and treat these patients if they are outside the structures of our health care system until a critical care moment? How do we address infections that may spread to and within our documented population? What do we providers do and say when someone needs long term treatment for serious life-long chronic disease? Finally, how do we communicate and build trusting patient relationships with a population that does not speak fluent English?

For a patient off-the-grid, like our 13-year-old boy above, how do we ensure uninterrupted access to diabetic medication, multi-organ monitoring, and, at a very simple level, prevent him from becoming disabled, such as by vision loss? Basically, at what point do we accept that we medical providers divert from the U.S. “standard of medical care” when treating undocumented immigrants?

Undocumented immigrants lining up for health care at a volunteer mobile free clinic on a farm in south Georgia, 2015.

Let’s look closer at how these challenges present clinically, which means understanding regional and employment differences of undocumented communities.

In New England, for instance, community clinics are heavily populated by Caribbean, largely Dominican and Central American patients. This population frequently shuffles in and out of their tropical origins, if not multiple times a year, than for months long stretches at a time. Undeniably, this population increases the prevalence of mosquito-borne disease in this region. For example, symptoms of the Zika virus, a fast-spreading mosquito-borne disease that causes birth defects, are commonly seen at the Hispanic community clinic where I work in Boston. For context, the U.S. Center for Disease Control (CDC) says “if trends continue 1 in 4 Puerto Ricans may become infected with Zika,” leading me to conclude that this ratio must be at least similar for other low land areas of the Caribbean. We have not seen a case of Zika-related birth defects at our clinic, but if and when we do it won’t be surprising. The combination of significant travel to high-risk areas and minimal education on the virus is a recipe for increasing disease prevalence.

measles vaccine

Clearly, there is a role here for medical providers interacting with undocumented Caribbean patients to contribute to preventing infectious disease while also guarding against an epidemic in our documented population.

In regions with large agricultural states migrant farmworkers from Mexico and Central America are the significant undocumented population and present other challenging clinical scenarios. To begin with, agricultural work poses very high risks for fatal and non-fatal injuries yet health care benefits are not guaranteed (and usually not provided) for these employees. The CDC estimates that 5% of crop worker injuries result in permanent impairment and 50% of all workers suffer a musculoskeletal sprain or strain. During a volunteer mobile clinic of the South Georgia Farmworker Health Project, I evaluated a thin 18 year-old boy with a rotator cuff strain and spasms along his paraspinal muscles because his day-long job consisted of carrying 30lb buckets of tomatoes 100 meters and then lifting them onto one shoulder so they could be dumped into a truck. This is the kind of injury that takes about 8 weeks of rest to heal, and with prolonged overuse can lead to chronic ligament and tendon damage and herniated discs in the spine.

Fieldwork on a tomato farm.

Risk of disease transmission, such as HIV, have also been noted to be high in this population, particularly due to infrequent use of condoms with sex workers. A 2011 briefing by the National Center for Farmworker Health cites the prevalence of HIV potentially ranges from ~3 to 13%, according to the most recent assessment (1998).

The number of cases of musculoskeletal and infectious disease in this population is impressive. The U.S. government estimates the total population of migrant farmworkers (who are mostly men) ranges between 787,000 and 3 million, of which the CDC estimates 472,000 are youth. Of these, it is thought that 50-60% are non-resident workers. At a minimum, using percentages cited above, this means 20,000 permanent physical impairments, 197,000 sprains/strains, and 11,800 cases of HIV exist in this undocumented population.

These are the patients who come to emergency rooms when they can no longer walk or lift their arm, or when a secondary infection like pneumonia has overwhelmed a body immunosuppressed by HIV.

In some states that provide free care these medical problems can be addressed more easily or even directly in appropriate settings. Providers have access to the tools they need to diagnose, manage and treat conditions. In states without this type of health care, a medical provider’s job is much more difficult. Beyond emergency rooms, these patients cannot get, e.g., pain relief, anti-viral medicine, or follow up.

Not knowing how to ensure a patient is being taken care of makes me feel clinically inadequate.

Though “patchwork” is a word frequently used to describe the landscape of medical options for undocumented immigrants, there are a few reliable facilities providers can use as go-to medical resources.

For medical providers in states that do not provide free care it is useful to know about 340b organizations. These are registered health centers federally-funded to host reduced drug-pricing programs for any patient as long as those individuals are established patients at the center. These programs require drug manufacturers to provide outpatient drugs at significantly reduced prices. A searchable database of these organizations is available.

Federally Qualified Health Centers (FQHC), a type of community clinic, and Ryan White clinics for HIV/AIDS are two common 340b organizations. An FQHC is where my Midwestern friend’s 13-year-old patient was able to start titrated insulin treatment for his advanced diabetes. The Kaiser Family Foundation counted a total of 1,202 FQHCs in the U.S. in 2013.

Emergency Medicaid continues to be a viable short-term option for undocumented immigrants in most states since it mandates treatment for anyone with urgent medical conditions and/or labor and delivery.

For those working with migrant farmworker populations, the National Center for Farmworker Health offers a searchable database of federally funded farmworker health centers and some useful trainings and links for providers.

In general, the same health care eligibility restrictions exist for both adults and children in terms of residence. Though the “dreamer” generation, the 2 million undocumented immigrants brought to the U.S. as youth, were granted immunity from deportation in 2012 based on age under 30 years and other factors, this population is still classified as undocumented when it comes to health care. Some states, however, expand pediatric coverage for immigrants, either via Medicaid or Children’s Health Insurance Program (CHIP). The most recent comprehensive chart I could find describing these state differences is from 2004; see the Kaiser Family Foundation’s Table 2: State Coverage for Immigrants, 2004.

Most people, and this includes patients as well as health care practitioners, struggle to understand the health insurance system in the U.S. As a recent post in Health Affairs reports, the disconnect between federal and state rules makes things even more confusing, particularly for immigrants. It also makes things more confusing for me, a medical provider.

In 2016, we like to call ourselves a global society. But I question if we honestly know how to be health care providers in an impressively migrant world. We train in a system that does not acknowledge the frequent ethical decisions we face when it comes to standard of care for those who are off-the grid, including millions of undocumented immigrant patients.