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Perhaps the first note on immigrant health is not about the health of the foreign-born but rather their indispensable role in the health of all Americans.  While the foreign-born make up 13% of the population, they represent 27% of physicians and surgeons and over 50% of biotech medical scientists in the states leading this industry (this according to the Immigrant Learning Center PEI).  The healthcare workforce reliance on immigrants is dramatic as noted by Jewish Vocational Services Director Jerry Rubin: "I think the health care system in Boston would collapse without immigrants." Still, we have undue barriers restricting the relicensing of foreign skilled workers to reenter the healthcare industry.
Examining the larger issues at the intersection of new Americans and health produces a plethora of subjects worthy of doctoral dissertations in the next decades. For 30 years, scholars have pursued the observation that Hispanic immigrants are healthier than their first-generation children or second-generation grandchildren. Despite Hispanic immigrants having lower levels of education and income and less access to health care than non-Hispanic Whites, on average they have the same or better health, coined the "Hispanic Paradox". As Latinos assimilate and adopt the attitudes, values, customs, beliefs and behaviors of U.S. culture, such as our diets and lifestyles, these health benefits are abated. As Mendoza (2009) (1) writes the impact of environment (poverty), behavior and genetics, as well as access to quality health care, are critical aspects of what must be addressed as the nation seeks improved overall health.

Social workers might take particular note of the impact of acculturative stress. While difficult to measure, some small studies like D'Anna-Hernandez's (2015) (2) indicate the increase of depressive symptoms during pregnancy is directly attributable to acculturative stress.  Recognizing that this maternal-fetal programming can have lifetime implications in health, it is cause for examination of policies and services that create barriers.
Immigrants remain among the most vulnerable and underserved populations leading to acute and chronic conditions. Delivery of services is key and community navigator programs are one approach proving highly effective in addressing the multiple barriers immigrants face. Shommu et al. (2016) (3) identified 29 studies that reinforce the positive outcomes resulting from culturally-sensitive navigator intervention programs. In this approach, navigators train members from immigrant and ethnic minority communities to help their peers navigate the health care system and connect with services to prevent and manage disease.

Immigration policy is a major public health concern. In the U.S., an individual's status impacts their access to health care and consequently, their short- and long-term health. Thus, policies which lead subpopulations into more integration, reducing fear and fostering trust, not only save lives but improves our physical, mental, and social well-being at a societal-level. Policy currently determines eligibility thus impacting the type and amount of health care and preventive services received. This impacts health care systems as well as registration, paperwork, alternative payers, and restrictive practices including turning away patients in need, widely interpreted as discriminatory. Alternative systems must be sustained and funded recognizing they often face excess demand and poor alignment of need and practice. Of particular concern is that immigrants in various stages of integration, especially with a Permanent Residence Under Color of Law (PRUCOL) status or without documents, face fear of deportation, stigma, lack of human and financial capital and thus go without needed services. While the preponderance of evidence is that benefits are not a magnet, immigrants face all the above issues and thus go without needed services (Hacker, Anies, Folb, & Zallman, 2015) (4). It is not surprising in this context that the American College of Obstetricians and Gynecologists supports providing all women living in the U.S., regardless of status, with basic health care as essential to improving the nation's health (5).
A provider view of this complex provision of services was studied by Suphachaimat, Kantamaturapoj, Putthasri, and Prakongsai (2015) (6). Congruent findings from 37 studies indicate that immigrant ignorance of the system is a primary barrier (the U.S. has a complex self-advocacy system that also confuses the native born), but institutions and providers face conflicting laws and professional norms. The right to health care is a serious concern. Institutional capacity is repeatedly noted as another realm of consideration with limited resources to address the cultural and linguistic needs of patients. Health care management that provides adequate care and is accompanied by appropriate laws and structures are needed.
The breadth of issues that might be noted, let alone addressed, is beyond this commentary but two notable recent articles warrant attention.  Marrow and Joseph (2015) (7) examine those who are "Excluded and Frozen Out." They provide an insightful study of the capacity of local government (esp. San Francisco and Massachusetts) to compensate temporarily for the limitations of the Affordable Care Act (ACA) that exclude adult unauthorized immigrants.  Sommers (2015) (8) in last month's New England Journal of Medicine did a notable assessment of the barriers to coverage in the U.S. with the current iteration of the ACA. He examines the 30 million uninsured who are impacted by the 20 states that did not expand Medicaid and particularly those 3-4 million in the Medicaid gap qualifying for neither state nor federal programs. While nearly half those uninsured qualify and most qualify for subsidized insurance, there remain 5-6 million immigrants who are 'unqualified.'  The proposed single payer system that failed to pass in Vermont would have closed many of the cracks, but in the end, a national plan is needed that must indeed cover all the residents of the United States.
Health care costs are surging and now represent 17.5% of the U.S. Gross National Product. Foreign-born staff are essential, representing more than twice their percentage as the health care workforce and at the same time, foreign-born who are new and in uncertain status are left without a pathway into status or a pathway into health care and preventive services.  Immigrants' needs have to enter these conversations-our nation's health depends on it.

  1. Mendoza, F. (2009). Health disparities and children in immigrant families: A research agenda. Pediatrics, 124(3), 187-195.
  2. D'Anna-Hernandez, K. L. (2015). Acculturative stress negatively impacts maternal depressive symptoms in Mexican-American women during pregnancy. Journal of Affective Disorders, 176, 35-42.
  3. Shommu, N. S., Ahmed, S., Rumana, N., Barron, G. R. S., McBrien, K. A., & Turin, T. C. (2016). What is the scope of improving immigrant and ethnic minority healthcare using community navigators: A systematic scoping review. International Journal for Equity in Health, 15(6).
  4. Hacker, K., Anies, M., Folb, B. L., & Zallman, L. (2015). Barriers to health care for undocumented immigrants: A literature review. Risk Management and Healthcare Policy, 8, 175-183.
  5. Committee on Health Care for Undeserved Women. (2015). Committee opinion no. 627: Health care for unauthorized immigrants. Obstetrics & Gynecology, 125(3), 755-759.
  6. Suphanchaimat, R., Kantamaturapoj K, Putthasri, W., & Prakongsai, P. (2015). Challenges in the provision of healthcare services for migrants: A systematic review through providers' lens. BMC Health Services Research, 15 (390).
  7. Marrow, H. B., & Joseph, T. D. (2015). Excluded and frozen out: Unauthorized immigrants' (non)access to care after US health care reform. Journal of Ethnic and Migration Studies, 41(14), 2253-2273.
  8. Sommers, B. D. (2015). Health care reform's unfinished work: Remaining barriers to coverage and access. The New England Journal of Medicine 373(25), 2395-2397.

Westy Egmont, Director
BCSSW, Immigrant Integration Lab

Health Law Advocates (HLA) is a public interest law firm based in Boston, Massachusetts, that provides pro bono legal services to low-income individuals experiencing difficulty accessing or paying for healthcare. In 2010, when 40,000 low-income immigrants were barred from Massachusetts state-funded health insurance, HLA filed a class action lawsuit, Finch v. Connector Authority that ultimately resulted in the Massachusetts Supreme Judicial Court overturning the Commonwealth's decision to bar these immigrants from health insurance. Since this historic victory, HLA has continued to work on behalf of immigrants in three ways. First, HLA provides direct legal services to individuals facing issues of denial of coverage, debt or other legal barriers to healthcare as a result of their immigration status. Secondly, HLA provides training and education on issues involving immigration and healthcare to both immigrants and advocates. Finally, HLA engages in policy advocacy to make large-scale change based on the issues faced by their clients.
While HLA has always served clients regardless of immigration status, Andrew Cohen, Staff Attorney and Project Director of HLA's Immigrant Health Care Access Initiative says "this is an area where people want more information than they have," referring to the complexity of the current healthcare and immigration policies and the way the two are intertwined. Namely, Cohen states that much of the work HLA is doing is helping clients understand how their immigration status affects their access to healthcare. For example, an undocumented person may not necessarily be "undocumented" for purposes of public benefits- a fact that is sometimes unclear to both immigrants and healthcare providers.

The National Immigration Law Center (NILC) is doing similar work on a national level. NILC dedicates itself to defending and advancing the rights and opportunities of immigrants and their families, including the opportunity to obtain affordable healthcare. The advocacy of NILC specifically focuses on making sure that immigrants are included in healthcare expansion and reform, and currently have access to the healthcare safety net.

Young, M. J., & Lehmann, L. S. (2014)
The New England Journal of Medicine, 370, pp. 669-673
Each year, there is a growing number of undocumented immigrants that experience involuntary medical repatriation. Medical repatriation is the transfer of undocumented patients from hospitals in the U.S. to medical facilities in their country of origin. Often, these facilities lack the necessary resources to adequately care for medically fragile patients, which can lead to devastating outcomes for the patients after they are transferred out of the U.S. Further, incidents of involuntary repatriation often go unreported and are done with little to no oversight, which is just one of the many ethical concerns associated with this practice that the authors explore in this article. In addition to the ethical issues, the authors take a critical look at the policies currently in place that affect undocumented immigrants' accessibility to health care and their limited protections under such policies. The majority of the approximately 11 million undocumented immigrants who reside in the U.S. are unlikely to have health insurance, thus placing them at risk for involuntary medical repatriation to their country of origin.
Castaneda, H., & Melo, M. A. (2014)
American Behavioral Scientist, 58(14), pp. 1891-1909
Currently, there are approximately 2.3 million mixed-status families living in the U.S. Depending on the immigration status of the family member within a mixed-status family, it is likely that each member has a varying degree of accessibility to health services and benefits. This article examines the negative impact, both direct and indirect, that the Affordable Care Act has had on mixed-status families, particularly looking at the disparity that exists with regards to the accessibility to health care services between those with differing immigration statuses in the same household. Utilizing qualitative ethnographic methods to measure the accessibility and quality of health care services within mixed-status families living in the Lower Rio Grande Valley in southern Texas, the authors conducted 55 semi structured interviews with mixed-status families and 43 interviews with health care providers, case workers, and public health officials in order to gather their data. The study shows how the various U.S. policies surrounding immigrant health care reform have created an atmosphere of fear that prevents many undocumented immigrants from applying for health care benefits, which has led to unsafe practices such as buying needed, but unregulated medication through illegal channels and having potentially life threatening conditions left untreated. 
Avila, R. M., & Bramlett, M. D. (2013)
Maternal and Child Health Journal, 17, pp. 415-423
The purpose of this study is to examine Hispanic/non-Hispanic White health disparities and assess the extent to which disparities can be explained by immigrant status and household primary language. Using data from the 2007 National Survey of Children's Health (NSCH), the authors calculated disparities for various health indicators between Hispanic and non-Hispanic White children, and used logistic regression to adjust them for socio-economic and demographic characteristics, primary language spoken in the household, and the child's immigrant status. The results showed that English-speaking and non-immigrant Hispanic children are more similar to non-Hispanic White children than are Hispanic children in non-English speaking households or immigrant children. Hispanic/non-Hispanic White health disparities among children are largely driven by that portion of the Hispanic population that is either newly-arrived to this country or does not speak primarily English in the household.
Brisset, C., Leanza, Y., & Laforest, K. (2013)
Patient Education and Counseling, 91, pp. 131-140
In an effort to identify relational issues involved in working with interpreters in healthcare settings and to make recommendations for future research, the authors of this study used a meta-ethnographic analysis to conduct a systematic literature search in French and English. The results of their analysis identified three themes: (1) Interpreters' roles: Interpreters fill a wide variety of roles. Based on Habermas' concepts, these roles vary between agent of the Lifeworld and agent of the System. This diversity and oscillation are sources of both tension and relational opportunities; (2) Difficulties: The difficulties encountered by practitioners, interpreters and patients are related to issues of trust, control, and power. There is a clear need for balance between the three, and institutional recognition of interpreters' roles is crucial; (3) Communication characteristics: Non-literal translation appears to be a prerequisite for effective and accurate communication. The authors concluded that the health care (and scientific) community must pay more attention to the complex nature of interpreted interactions. Researchers need to investigate how relational issues in interpreted interactions affect patient care and health.

Bridging the gap: How community health workers promote the health of immigrants
By Findley, S., & Matos, S.
Oxford University Press (2015)
Stress and changing lifestyle have made immigrants vulnerable to long-term diseases; immigrants in the United States are still challenged by a lack of access to effective health care. Under such circumstances, the role of community health workers is of great importance. Through a decade-long project evaluating healthcare programs in New York City, Bridging the gap investigates how community health workers successfully provide quality health care access to marginalized immigrant populations in the United States and beyond. Toward the end of the book, Findley and Matos also provide recommendations for optimizing community healthcare worker programs to bring the successful practices identified in their empirical research into larger social contexts.
Migration and health: A research methods handbook
By Schenker, M., Castaņa, X., & Rodriguez-Lainz, A.
University of Carifornia Press (2014)
"The study of migrant populations poses unique challenges owing to the mobility of these groups, which may be further complicated by cultural, educational, and linguistic diversity as well as the legal status of their members. These barriers limit the usefulness of both traditional survey sampling methods and routine public health surveillance systems. Since nearly 1 in 7 people in the world is a migrant, appropriate methodological approaches must be designed and implemented to capture health data from populations. This effort is particularly important because migrant populations, in comparison to other populations, typically suffer disparities related to limited access to health care, greater exposure to infectious diseases, more occupational injuries, and fewer positive outcomes for mental health and other health conditions." -Publisher website
Health care and immigration: Understanding the connections
By Fernández-Kelly, M. P., & Portes, A.
Routledge (2014)
As its title indicates, Health care and immigration: Understanding the connections aims to reveal the relationship between health care and immigration in the United States. Are the needs of the underserved immigrant populations effectively addressed by medical institutions? This book focuses on the challenges and arrangements of medical institutions serving immigrant populations. Emphasizing all levels of the health care network, from immigrants, health care institutions and legislation to the greater society, this book represents a useful resource for researchers, students and public health administrators alike.
Entitled to nothing: The struggle for immigrant health care in the age of welfare reform (nation of nations)
By Sun-Hee Park, L.
New York University Press (2011)
After interviewing nearly 200 government agencies, immigrant organizations, and safety net providers, Park provides accounts as to how immigrants in the United States have struggled over the 'public charge' doctrine of 'paying back' benefits that they are legally eligible for. Park shows evidence that states are targeting immigrants of color, as a way of not including immigrants in public programs. Through the careful tracking of media coverage and policies, along with multiple interviews, Park investigates how the politics of immigration, health care, and welfare are intertwined.

Silent travelers: Germs, genes, and the immigrant menace
By Kraut, A.
John Hopkins University Press (1995)
"Epidemics and immigrants have suffered a lethal association in the public mind, from the Irish in New York wrongly blamed for the cholera epidemic of 1832 and Chinese in San Francisco vilified for causing the bubonic plague in 1900, to Haitians in Miami stigmatized as AIDS carriers in the 1980s. Silent travelers vividly describes these and many other episodes of medicalized prejudice and analyzes their impact on public health policy and beyond. The book shows clearly how the equation of disease with outsiders and illness with genetic inferiority broadly affected not only immigration policy and health care but even the workplace and schools. The first synthesis of immigration history and the history of medicine, Silent travelers is also a deeply human story, enriched by the voices of immigrants themselves. Irish, Italian, Jewish, Latino, Chinese, and Cambodian newcomers among others grapple in these pages with the mysteries of modern medicine and American prejudice." -Publisher Website            
Follow Professor Egmont on Twitter @wegmont
EDITORS: W. Egmont, K. Kalliontzi, J. Margolis, K. Medeiros, J. Ozieblowski, C. Palleschi, A. Spalding, & Q. Zhang-Wu