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New ANA policy brief: Aiming to help nurses better understand ramifications of immigrants’ lack of access to healthcare services

Many years later, Frances Downs, PhD, RN, can still recall the toddler who was brought to the county hospital’s emergency department (ED) in full cardiac and respiratory arrest. He could not be revived.

“A young life was ended,” says Downs, a Florida Nurses Association member and delegate to the American Nurses Association’s (ANA) 2010 House of Delegates (HOD). The toddler’s parents, who were undocumented immigrants from Haiti, feared being deported. So instead of seeking care when he first became ill, they waited.

Because of that experience and the firm belief that nurses must provide care to all people—no matter matter their background or the circumstances into which they were born—Downs voiced her support this summer for an HOD resolution focusing on healthcare access for immigrants. The resolution, which nurse delegates from around the country ultimately approved, reaffirms ANA’s long-held position supporting health care for all, and calls for ANA to educate nurses about the wide-ranging social, economic, and political ramifications of undocumented immigrants’ lack of access to healthcare services.

As a crucial step toward achieving that educational goal, ANA recently released a policy brief, Nursing Beyond Borders: Access to Health Care for Documented and Undocumented Immigrants Living in the United States (available at

On the front burner

The HOD resolution initially was crafted by the New York State Nurses Association (NYSNA). The state association’s board, members, and staff were increasingly concerned that access to health care for certain segments of the U.S. population wasn’t being addressed in healthcare reform (the Affordable Care Act of 2010) or was being restricted by other legislative measures, according to NYSNA Chief Executive Officer Tina Gerardi, MS, RN, CAE.

In the new ANA policy brief, author Tim Godfrey, S.J., MSN, RN, presents statistics that demonstrate a healthcare void. Using a range of research sources, he notes that an estimated 11.1 million undocumented immigrants live in the United States, with Latinos the overwhelming majority. In 2007, 59% of undocumented adults had no health insurance—twice the rate of documented immigrants and four times the rate of native-born citizens. Two years later, the rate of both documented and undocumented immigrants without insurance increased to 2.5 times that of native-born citizens.
Godfrey points out in the brief that most immigrants are younger and healthier initially, but their health deteriorates over time due to lack of
ongoing preventive and primary care and sometimes due to lack of insurance. That can have a huge impact on immigrants and their families, public health, overall health­care costs, and, because of their roles in all healthcare settings, nurses.

“Immigration is a hot political issue,” Gerardi acknowledges. “But what we’re talking about [in the HOD resolution] is a healthcare issue. We believe health care is a basic right, and as nurses, we advocate for what’s right for our patients.”

Downs contends nurses shouldn’t back away from issues that may be difficult or controversial. “It’s our role and responsibility to society to be involved and tackle complex issues,” Downs says. “In nursing, we’re proud to say that we are the most trusted profession. What would happen to that trust if we didn’t support health care for everyone—if we provided care only for someone who was born in the ‘right’ country or in the ‘right’ circumstances? If we believe in core ethical concepts, such as beneficence, fidelity, and privacy, we must support health care for everyone. It’s a human rights issue.”

Current ANA Board Member Karen Ballard, MA, RN, FAAN, who was NYSNA president when the resolution was introduced, adds, “As professionals, we need to be able to provide appropriate care and identify resources for primary and preventive services, so people won’t have to access the healthcare system when they are the sickest and healthcare costs are the highest.” The policy brief states, “Contrary to common belief or political rhetoric, giving this population access to insurance is an evidence-based way to actually reduce healthcare costs.”

It’s also important for nurses to understand how denying healthcare access to one subsection of the population can negatively affect the rest of the population, and to recognize the demands being placed on the country’s public healthcare infrastructure, which has been seriously underfunded for decades, Ballard adds.

The policy brief includes a range of statistics that places immigrant health within the bigger picture of health care and society. It’s an important document that will help nurses, who come in contact with immigrants through their practice, better grasp the difficulties this population faces, according to Godfrey.

The meaning behind the numbers

The policy brief notes a persistent belief that undocumented immigrants pose a burden to the country’s health system and are only a drain on the greater economy. Yet one study cited in the brief found that between 1999 and 2006, publicly funded healthcare expenditures for documented and undocumented immigrants were consistently lower than expenditures for adult U.S. citizens.

And although documented and undocumented immigrants are more likely than U.S. citizens to have their healthcare visits classified as “uncompensated care”, they’re less likely than U.S. citizens to use EDs, according to resources cited in the policy brief. Specifically, in 2007 about 20% of adult U.S. citizens reported visiting an ED, whereas only 13% of adult non-U.S. citizen immigrants did so.

Godfrey states that many documented immigrants also face healthcare access issues. In many states, low-income, documented immigrants must wait 5 years to become eligible for government programs, such as Medicaid and the Children’s Health Insurance Program. Furthermore, the Personal Responsibility and Work Opportunity Act of 1996 states that undocumented immigrants remain ineligible indefinitely, and the Affordable Care Act does little to improve their access to care. The fact that families may be blended—undocumented parents with children who were born in the United States—adds to the complexity of the issue.

Looking at a different angle, the policy brief includes 2009 statistics that show more than 93% of undocumented male immigrants and 58% of female immigrants contribute to the labor force, although generally in low-paying jobs that offer no health insurance. Other cited research reveals that undocumented immigrants generate tax revenues through sales and payroll taxes and file federal and state tax returns.

Also from the labor perspective, immigrants tend to work in high-risk occupations, such as roofing and construction, and in poor working conditions. For example, the brief cites an article in which health professionals reported migrant farm workers face job loss, pay cuts, and deportation if they miss work or object to unhealthy working conditions.

And then there are the hazards associated with urban work roles, such as day laborers and grounds­keepers, Godfrey says. “I saw a young man spraying pesticide who had no gloves or face mask on,” he says. “I told him his employer had to provide him with protective gear.” But Godfrey doubted that the young man, like farm workers, would complain about health-threatening work practices.

Nurses and the policy brief additionally reflect on the impact on public health if immigrants can’t access preventive care.

The brief highlights growing evidence that parasitic and bacterial infections plague the poorest populations in the United States, which includes undocumented and documented workers.

“When people aren’t immunized or treated for different diseases, that puts all of us at risk,” Godfrey says. “Just look at the recent pertussis outbreak.”

And then there is the cost issue. Preventive care costs less than acute and emergency care, nurses say.

For Downs, this issue brings up her memory of the toddler who died in her ED. “It would have cost pennies on the dollar if that baby had been seen early on,” she says. “More importantly, his life would have been saved.”

Susan Trossman is a senior reporter for ANA.

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