By Rayden Llano
While unprecedented levels of immigration around the world underscore the growing importance of immigrant health issues, immigrants continue to face substantial challenges in accessing care that often negatively impact their health. The degree to which immigrants experience barriers in access to care hinges on the structure and organization of their host country’s healthcare system. Given the fundamental differences between the American and British healthcare systems, this paper assesses the nature and extent to which immigrants face barriers to healthcare in the US and the UK as well as the degree to which each country’s health system structure allows for improvements in immigrant healthcare provision. A comprehensive analysis showed that barriers to insurance coverage in the US are substantial and vary significantly across states as a result of the “bewildering complex” of insurance schemes. This feature of the US system makes it difficult to implement reforms uniformly at the national level. Meanwhile, there are fewer access barriers in Britain for immigrants entitled to free care under the National Health Service as a result of its more centralized universal structure that is free at the point of service. While few free clinics and safety nets exist in Britain for illegal immigrants not entitled to free NHS care and although these restrictions appear to be increasing, the British healthcare system is in principle better positioned and structured to reduce immigrants’ barriers to care if it is able to find the political will to implement much needed immigrant health reforms.
While immigrants shoulder a disproportionate burden in accessing healthcare, the political will necessary to adequately address the access barriers faced by immigrants is often lacking. As the levels of immigration to countries like the US and the UK continue to increase exponentially, however, immigrant health issues are becoming increasingly difficult to ignore. During the 1990s, between 11 million and 14 million immigrants entered the US, and current projections suggest that almost one in five Americans will be a foreign-born immigrant by 2050.1,2 Similarly in Britain, immigration accounted for over half the population increase between 1991 and 2001, and the Office for National Statistics projects that immigration will account for 45 percent of population growth between 2008 and 2033.3
Against this backdrop, it is crucial to understand the nature of the barriers to care faced by immigrants and comparatively assessing them across countries can highlight feasible approaches to reform. To this end, this paper assesses the nature and extent to which immigrants face barriers to healthcare in the US and the UK as well as the degree to which each country’s health system structure allows for improvements in immigrant healthcare provision.
[box]Immigrant Status and Eligibility for Healthcare Coverage in the US [/box]
Immigrants with the means to pay for commercial insurance are free to do so in the US regardless of their immigration status. In 2003, 32 percent of immigrants living in the US for less than six years and 41 percent of those living in the US for over six years had employer-sponsored health insurance.4 However, the eligibility of low-income immigrants for public coverage depends on immigration status and has fluctuated over the years and across states. On the whole, between 58 and 65 percent of noncitizens lacked health insurance in 2003 versus 28 percent of native US citizens.4
Before 1996, low-income legal immigrants qualified for Medicaid coverage on the same basis as other eligible low-income American citizens. But the passage of the Personal Responsibility and Work Opportunity and Reconciliation Act in 1996 (PRWORA) greatly restricted immigrants’ access to Medicaid as well as many other public benefits.5 In effect, legal immigrants arriving in the US after August 22, 1996, became ineligible for Medicaid and SCHIP during the first five years of their US residency, though in 2009, the Children’s Health Insurance Program Reauthorization Act gave states the option to provide federally-funded Medicaid and SCHIP coverage to legal immigrant children and pregnant women regardless of their length of US residency.6 In stark contrast, undocumented and certain “lawfully present” immigrants remain ineligible for these benefits regardless of their length of residency in the US while at the other end of the spectrum refugees are immediately eligible for Medicaid coverage in all states on the same basis as American citizens.4 Nevertheless, all of the aforementioned immigrant groups are eligible for Emergency Medicaid if they meet the necessary financial and categorical requirements.7
In response to the decline in Medicaid coverage of immigrants precipitated by PRWORA, many states increased public coverage of these groups through other means, though these efforts vary greatly by state. By 2004, 23 states used state funds to extend coverage to some or all immigrants who became ineligible for federally-funded Medicaid and SCHIP.4 California and New York, for instance, provide the same or very similar services as Medicaid or SCHIP to all qualified immigrants, including “lawfully present” immigrants known as PRUCOLs.4 Some states, such as Arkansas and Michigan, do not offer state-funded coverage for immigrants, but they do provide SCHIP-funded prenatal care to pregnant women regardless of immigration status.4 Meanwhile, other states, including Arizona, Colorado, and Georgia, have passed legislation making it even harder for immigrants to attain coverage.8 Naturally, states’ varied responses to the 1996 welfare reform law have resulted in great differences in public coverage of low-income immigrant groups. In fact, foreign-born children in Florida, Illinois, and Texas were 7 times more likely to lack health insurance than children in New York.7
In an attempt to increase rates of insurance coverage among legal immigrants, the 2010 Patient Protection and Affordable Care Act (PPCA) will provide eligible legal immigrants with premium credits to purchase health insurance plans through the state-based health insurance exchanges beginning in 2014.9 Unfortunately, the PPCA does not remove the 5-year residency requirement to qualify for Medicaid and SCHIP, thereby perpetuating the perplexing variation of coverage eligibility across states. Moreover, the new health law also prohibits undocumented immigrants from even purchasing private insurance through the health insurance exchanges, further contributing to the already substantial barriers faced by immigrants in obtaining health insurance coverage.9
[box]Coverage and Access to Care in the US[/box]
While health insurance coverage is not equivalent to access, many research studies suggest that health insurance is a “major determinant to access to health care for immigrants”.10,11,12 Insurance coverage promotes financial access to care, connects immigrants with a regular source of care, and facilitates use of services.13 Given that immigrants are much less likely to be insured than native US citizens, it follows then that they are much less likely to have a regular source of care, doctor visits, and preventive health services.4 In a nationally representative sample, Ku & Sheetal (2001) found that 37.4 percent of noncitizen adults (below 200% FPL) did not have a usual source of care in 1997 as compared to 19 percent of native citizens.12 These rates are even higher among undocumented immigrants. A study of undocumented migrants in Texas and California found that rates of no doctor visits in a year range from a low of 50 percent in Fresno to a high of 73 percent in Los Angeles.14 Consistent with these findings, annual per capita expenses for healthcare were 86 percent lower for uninsured immigrant children than for their uninsured US-born counterparts.15
Even immigrants with Medicaid or state-funded public insurance are often “medically disenfranchised.” In New Jersey, for instance, few specialists are willing to see Medicaid patients because Medicaid fees for physicians are about half the national rate; this, in turn, makes it extremely difficult for immigrants with Medicaid to access subspecialty care.16 Moreover, many state-funded insurance coverage schemes, such as Washington State’s Basic Health Program, are often “significantly more limited than Medicaid or SCHIP” and have rules that can limit access, such as premiums and cost-sharing that many low-income immigrants cannot afford to pay.4
Nevertheless, varying levels of access are still possible even for uninsured immigrants through community clinics and federally qualified health centers (FQHCs). In fact, community clinics and hospital outpatient departments are “the most common source of ambulatory care for immigrants”; 38.5 percent of noncitizens report them as their usual source of care.12 FQHCs, in particular, offer many underserved immigrants a vast array of health services, including general medicine and preventive dentistry, ob-gyn, diagnostic laboratory services, family planning, and chronic disease and case management.16 According to the Kaiser Family Foundation, in 2007, 257 of the 1,057 federally-funded FQHCs in the US were located in four states with some of the highest concentrations of immigrants (Florida, New York, Texas, and California).17 Despite their existence, however, many immigrants still face barriers in accessing them, such as lack of knowledge of these services, which will be discussed later.
[box]Immigrant Status and Entitlement to NHS Care in Britain[/box]
Unlike the insurance-based coverage scheme in the US, the British National Health Service is a universal tax-based system that provides its beneficiaries with comprehensive health services that are largely free at the point of service.18 As is the case in the US, entitlement to NHS care is based on immigration status. Primary Care Trusts (PCTs) are tasked with determining whether the patient is ordinarily resident in the UK, and if not, whether he or she is eligible for NHS care under the Overseas Visitor Regulations.19 Among the immigrants entitled to full NHS treatment are those who have been “living legally in the UK for 12 months,” permanent residents, students in the UK for more than 6 months, individuals from countries with a reciprocal agreement, refugees, and asylum seekers.20
Asylum seekers, however, are eligible for full NHS treatment only if they have submitted an application to remain in the UK or have been detained by the immigration authorities.20 If their application for asylum is denied, their eligibility for full NHS care is rescinded. Nevertheless, in a written statement to the House of Commons on July 20, 2009, Parliamentary Under-Secretary of Health Ann Keen proposed that full NHS care should continue to be provided to failed asylum seekers “who are being supported by the UK Border Agency because they would otherwise be destitute, have children and/or because it is impossible to return home through no fault of their own”.21
With regards to undocumented immigrants, the term “illegal migrant” was previously not included in any of the official NHS documents.22 Prior to 2004, people who had been living in Britain for 12 months or who had come with “the intention of permanent residence” were exempt from charges for NHS care.22 These loosely regulated requirements combined with an absence of systematic internal checks on residential status made “healthcare largely accessible to undocumented migrants”.22 However, revisions to NHS regulations in April 2004 required proof of legal residence status in the UK and levied charges for “overseas visitors,” which greatly curtailed access for undocumented immigrants and will be discussed in the next section.
Currently, those ineligible for full NHS care, including the estimated 400,000 illegal immigrants in the UK, are still provided with emergency care as in the US in addition to treatment of sexually transmitted infections (except HIV), treatment of illnesses that threaten public health (e.g. tuberculosis, malaria, meningitis), family planning, and compulsory psychiatric treatment.20 It is worth noting, however, that illegal immigrants may still have access to GP services (albeit inconsistent at best) given that GPs do not believe it is their role to “police” the healthcare system.23
[box]NHS Entitlement and Access to Care[/box]
In an interview with a GP working in London, Dr. Katy Haynes said, “Legal immigrants should not face barriers in accessing care as the rules are now clear, but in practice, this is not always the case.”24 A free clinic in East London run by a humanitarian aid organization called Médecins du Monde UK found that over 40 percent of their immigrant patients were unable to access care to which they were entitled.25 According to the clinic, which provides temporary healthcare to migrants, their patients had been living in the UK for an average of three years before coming to the clinic to see a doctor or get help accessing NHS care to which they are entitled.25
Moreover, even though the 230,000 refugees living in the UK are entitled to full NHS care free of charge, some studies suggest that GPs are “confused” about this. In Islington, a study found that 38 percent of refugees had problems registering with a GP.26 In addition, even though a 1995 Home Study found that 70 percent of refugees had been living in their current home for over a year, many refugees are often added to a GP’s list on a temporary rather than permanent basis.26 Temporary status, in turn, means that they remain on the GP’s list for less than three months, which removes the GP’s incentive to offer patient screening checks, immunizations and cervical screening.22 However, it appears that such barriers in access to care for refugees and asylum seekers may vary by region given that most asylum seekers arriving in Glasgow received letters from the health board explaining how and where to register with a GP.27 In fact, at one site, they even had an “Asylum Support Nurse” who was employed specifically to help asylum seekers with the registration process, leading most patients to report “feeling welcomed and cared for”.27
Overall, compared to the US where alarming rates of legal immigrants do not even have a regular source of care, most studies on legal immigrants’ access to NHS resources point to significantly less insurmountable barriers to care. Legal immigrants in the UK mainly report difficulty in “getting timely appointments with their doctor,” accessing dental care, and seeing the same GP.27,28 Access to over-the-counter medication was also oftentimes cited as a barrier since prescription drugs are covered but not over-the-counter drugs. Some people in the UK perceive this as a “significant cost for families where young children often needed childhood cold and flu remedies”.27
However, there are greater barriers in accessing care for UK immigrants not entitled to full NHS care, such as undocumented migrants and failed asylum seekers. While they are in principle able to access care through the private health insurance market, most undocumented immigrants do not have the means to do so.22 Consequently, the main care to which they have access and to which they are entitled is emergency care. Prior to the 2004 regulations, it was fairly easy for undocumented migrants to “slip through the net” and get free NHS treatment. However, the new regulations have made access to primary care harder and essentially impossible for specialist care. While GPs are required to provide immediately necessary care, the ability of illegal immigrants to access non-urgent primary care “depends on the GP’s willingness to ask difficult and sensitive questions or require evidence of immigration status”.19,22
According to Dr. Katy Haynes,24 there are strict requirements to be met before people get registered for an NHS number, such as proving residency and providing home office documents:
“Our front desk staff have (reluctantly) become experts in this as the need to protect NHS resources for those entitled to them has become more urgent. Some GPs may be less stringent about this than we are but registrations all have to get through the Primary Care Trust Registration Department and will be bounced back if the correct documents have not been provided.”
There is unfortunately no practical way of quantitatively determining how much access to primary care illegal immigrants have since the NHS does not consistently check residential status for patients already in the system. However, specialist care is not provided without an NHS number, effectively curtailing any access by illegal immigrants.24
[box]Other Barriers in Accessing Care[/box]
Many immigrants in the US and Britain have limited English proficiency, which represents yet another significant obstacle in accessing care. This is because, in the absence of an interpreter, doctors’ ability to understand their patients’ needs is often compromised, resulting in decreased symptom reporting by patients, fewer referrals to needed specialist care, and prescription of inappropriate medications.28,29 For this reason, various studies have found that language problems are cited by Hispanic parents in the US as the “single greatest barrier to healthcare” for their children ahead of other barriers such as no medical insurance and difficulty paying medical bills.12,30
Recognizing the challenges faced by non-English speakers in accessing care, many states are trying to mitigate the problem through increased availability of interpreting and translation services. Minnesota, for instance, has made its state application for healthcare programs available in 10 languages in addition to English, and asks whether families would like to request an interpreter.4 These efforts are improving access to care for immigrants in the US, but much remains to be done. Studies still show that Spanish-speaking Hispanics were more likely than non-Hispanics to fail to complete the Medicaid application and miss deadlines for submitting necessary documents.4 In addition, 43 percent of Spanish-speaking Hispanics had communication problems with doctors versus 16 percent of whites, and non-English speakers had a harder time understanding doctor instructions.31
Immigrants in the UK face similar language barriers in accessing care. In fact, in London alone, over 300 languages are spoken, and only 14 percent of Bengalis, 29 percent of Gujeratis, 26 percent of Punjabis, and 41 percent of Chinese report a “survival level of competence in the use of English”.32 That said, asylum seekers living in Glasgow reported that the availability of interpreters “appeared to be well organized and fairly stable,” highlighting the potential of the British healthcare system to mitigate access problems associated with language barriers.27
In both countries, immigrants’ lack of knowledge of the health services available to them and unfamiliarity with the healthcare system also contribute to their poor patterns of access.30 In addition to illegal immigrants’ fear of immigration authorities, US immigrants in general are often “confused” by state and federal eligibility criteria, and parents often do not seek healthcare for their US-born children because they do not believe they qualify for services.33 Similarly, in Britain, immigrants entitled to free NHS care were largely unaware of health promotion and health screening programs.27 In fact, immigrants, especially South Asians, have significantly underused the two existing UK cancer screening programs for breast and cervical cancer.32 These trends are further supported by Randhawa & Owens’ (2004) findings that South Asians in Luton experienced access to appropriate cancer specialist services at a “relatively late stage of the illness” and that awareness of these services was “concerningly low”.34 Relative to the convoluted US healthcare system, however, Britain’s more centralized universal structure makes it easier to attempt to make immigrants more aware of the services available to them.
In retrospect, immigrants in both the US and the UK face disproportionate challenges in accessing care. Nevertheless, the “bewildering complex of service and insurance inequalities” that exist in the US makes it much more difficult to address the challenges faced by immigrants in accessing care as compared to Britain’s more centralized and coordinated healthcare system. 35 It is worth noting, however, that few free clinics and safety nets exist for illegal immigrants and failed asylum seekers not entitled to free NHS care in Britain, and these restrictions appear to be increasing “as the need to protect NHS resources for those entitled to them has become more urgent”.24 Consequently, while the British healthcare system is in principle better positioned and structured to reduce immigrants’ barriers to care, it remains to be seen how the US and the UK will continue to grapple with the health needs of their diverse immigrant populations against a backdrop of increasingly scarce healthcare resources.
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