Chutes and Ladders: Comprehensive Immigration Reform and Health Care Access for Undocumented Workers – Elizabeth Cartwright
Idaho State University
Immigration problems and issues of access to health care are both manifestations of an increasingly crowded world with dwindling natural resources. Given the desperation and violence that exist in so many places around the globe, immigration from poorer countries will continue—“legal” or not[i]. Health care, as a resource, will proportionally take up more and more of our national budgets and will be more and more out of reach for those who need it most. The short-term view is that those who are sick/poor are a financial drain and it’s a profit-driven system, so exclude. A long-term view could have a very different answer. What is needed for the long-term health, creativity and societal viability of the U.S. is an inclusive approach that maximizes human potential regardless of social and legal status.
For the last ten years I’ve worked with many immigrants from Mexico who now live here in Southeast Idaho[ii]. They come to Idaho for a better life. They have settled down in small agricultural communities, and they have worked hard in the fields, packing plants and small businesses of this region. They are now getting college educations for themselves and for their families. Some have become naturalized citizens; some are still moving through that incredibly slow process. They go back to Mexico to visit, less often now than in the past, but they still go. Most now say that Idaho is “home”—snow and all.
Initially, many of these individuals arrived here sin papeles. Undocumented workers have access to emergency medical care and to some stopgap services that are often provided by organizations that have a strong humanitarian credo of volunteering their time and skills to help others. Unfortunately, unless these medical services are integrated into the larger comprehensive medical system, and unless these individuals have a “medical home” complete with their medical charts, then they are receiving sporadic care without proper follow-up, mostly on a too-late basis. Working to include these services into existing community health clinics and the larger public health system (whatever that may be in the future) is essential. So is effectively channeling the goodwill and skills of medical practitioners who want to volunteer their expertise.
Indeed, this is the same problem facing many places in the world where NGOs provide emergency and/or short-term medical services and then leave when the “medical mission” is completed—whether that is in two weeks or two years. Short-term medical relief is important, but long-term, locally managed care should be the goal.
By working their way through the immigration maze, many immigrants will eventually obtain legal permanent residency and then naturalization. Comprehensive and humane immigration reform is needed to facilitate this process–that goes (almost) without saying.
Unfortunately, legal status just lets you play the game in the United States where social class is a key variable in morbidity and mortality (Navarro, 2009)[iii].
As newly authorized U.S. residents occupying the lowest rung of the socio-economic scale, these individuals find themselves on a difficult playing field. As soon as they start to work their way up the ladder, as soon as they put that first down-payment on a house, get a child into college, get a job with health care benefits, they become quintessentially vulnerable to losing everything. That is, if they or someone in their family gets sick or injured.
Medical insurance, even the pretty good plan offered by my university, only covers about 80% of the bill. As a friend recently said to me, “twenty percent of a really lot, is still a lot.” One premature infant will come out of the hospital with a bill that is easily $200,000. Twenty percent of $200,000 is $40,000. Even a bill for ten or fifteen thousand dollars will push a family living on low wages into medical bankruptcy. The hospital and the practitioners will go after all assets that can be liquefied to pay the outstanding bill. I’m told that when you file for medical bankruptcy in Idaho; you can keep a car, a roof over your head, a landline phone, the tools you need to work and two guns. It is Idaho, after all.
Our current medical system punishes our citizenry for being less than rich. Very few of us are immune to the risk of the dizzying downward spiral of health problems/financial problems/more health problems/more financial problems. New immigrants to this country are some of the most vulnerable; they are poor and they are in a socially devalued position with respect to the larger society.[iv] Financial destitution sets families back months and years as they try to juggle myriad competing demands on their small paychecks. The majority of the Latino families that I work with are moving family members through the complicated and expensive immigration gauntlet. Bankruptcy, for whatever reason, will totally derail this process. It’s like Chutes and Ladders; one medical misstep and you’re back to square one, or worse.
Still, more immigrants come to the U.S. and other rich countries every day, and most come to stay. As societies of plenty, we can choose how to respond to this situation. Immigration reform and health care reform need to be seen as part of the same problem. They should not be about blaming the victim for being sick or illegal. Rather, they should be about a realistic assessment of the costs of exclusion from society, from health care, from being fully participative members of a world community. Exclusion comes at a high price. Given the scope of the problems that we’ve put in motion for the future, we’re going to need all the brainpower and social buy-in that we can get. Creating large numbers of disillusioned and disenfranchised individuals who are excluded from fully participating in life will make matters even more complicated.
[i] Bowden, Charles Some of the Dead Are Still Breathing: Living in the Future, Harcourt Press, 2009.
[iii] Navarro, Vincente “What We Mean By Social Determinants of Health”, International Journal of Health Services, Vol 39(3) 423-441, 2009.
[iv] Quesada, James— “Latino Migrant Health in Troubled Times: Dealing with Structural Vulnerability, Xenophobia and Politics” American Anthropological Association, Nov. 20, 2008. see Quesada’s discussion of “structural vulnerability” a term coined by Daniel Hernandez Rosete and used in this context to highlight the devalued social position of Latino immigrants that results in lower life expectancies and more ill-health.
Elizabeth Cartwright, PhD, RN is Associate Professor of Anthropology and Director of the Hispanic Health Projects at Idaho State University and Adjunct Senior Lecturer School of Psychology, Psychiatry, and Psychological Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia. She is a medical anthropologist who has worked with Latinos in Mexico and in the Western United States. She is the author of Espacios de Enfermedad y Sanación: Los Amuzgos de Oaxaca, Entre la Sierra Sur y los Campos Agrícolas de Sonora (El Colegio de Sonora Press, 2003) and, with Pascale Allotey, the edited volume Women’s Health: New Frontiers in Advocacy & Social Justice Research (Haworth Medical Press, 2007).
Cartwright, Elizabeth. 2010. Chutes and Ladders: Comprehensive Immigration Reform and Health Care Access for Undocumented Workers. AccessDenied: A Conversation on Un/authorized Im/migration and Health. Accessed (date) at https://accessdeniedblog.wordpress.com/2010/01/21/chutes-and-ladders-comprehensive-immigration-reform-and-health-care-access-for-undocumented-workers-elizabeth-cartwright/