Challenges in Treating Undocumented Immigrants

In a 2016 report, the nonpartisan Pew Research Center estimated that the number of unauthorized immigrants in the United States—defined as those who entered the country without valid documentation or those who violated the terms of a lawful admission, such as staying past a visa expiration date—accounted for 11.1 million people in 2014, falling from a peak of 12.2 million in 2007 (2). One framework to analyze the effect of immigration laws and policies on health services is to identify those restricting access to any services, those granting minimum rights to services, and those granting more than minimum rights to services (3). Federal laws restrict unauthorized immigrants from coverage for routine health visits through federally funded programs, such as non-emergency Medicaid, the Children’s Health Insurance Program, or the Patient Protection and Affordable Care Act (4). However, unauthorized immigrants can receive emergency medical services without restriction and apply for Emergency Medicaid if they qualify for low-income status (5). Federal restrictions also apply to unauthorized pregnant women and children, including those known as “DREAMers” who qualify for the Obama administration’s Deferred Action for Childhood Arrivals program, although children born in the United States whose parents are unauthorized immigrants are eligible for the same types of coverage as other American citizens (6, 7). Despite their full exclusion, unauthorized immigrants contributed a net total of $3.5 billion to Medicare’s Hospital Insurance Trust Fund in 2011 through payroll or self-employment taxes, leading some analysts to raise questions about the ethics of excluding them (8).

Notwithstanding federal restrictions on routine health care, undocumented immigrants may have minimum or more than minimum rights to services based on their geographic location. States can use nonfederal funds to provide health coverage at community health centers and safety-net hospitals (9); 16 states and the District of Columbia provided such services as of 2011 (10). The state of New York implemented its Basic Health Program in 2016 to provide health insurance for preventive and primary care to adults with incomes up to 200% of the federal poverty level and may expand the program to cover unauthorized immigrant adults (11). Agencies may also enact specific guidelines. For example, the Chancellor of the New York City Department of Education reiterated in January 2017 that its staff would not proactively record the immigration status of any student or family member, but would protect such information if shared, under the city’s confidentiality policy (12). Hence, clinicians should provide emergency care to unauthorized immigrants as they would to others and follow local policies for practice guidance in nonemergency situations.

Despite the option of private insurance, most unauthorized immigrants are uninsured and opt for safety-net care (13). Unauthorized immigrants face unique barriers to care, such as a requirement to present documentation to receive services in some institutions, concerns about being reported to the authorities, inability to communicate fluently in the dominant languages of community clinics, and inexperience with navigating the health system (14). Research with this group is limited, since many institutional review boards have not adopted policies responding to the distinct needs of unauthorized immigrants as a vulnerable population (15). The few existing studies show that unauthorized immigrant children and adults experience higher rates of anxiety, depression, and posttraumatic stress disorder compared with authorized immigrants and citizens (16). Unauthorized immigrants are likely to face psychosocial stressors such as difficulty finding employment, workplace exploitation, limited freedom to return home (17), and lower rates of referral to government agencies for domestic violence (18) and child maltreatment (19). Consequently, adjustment and substance use disorders may be higher among unauthorized immigrants than among authorized immigrants and citizens (20).

Studies on utilization show mixed results. Compared with authorized immigrants and citizens, unauthorized Latinos have lower lifetime rates of inpatient and outpatient service utilization (21), but unauthorized Fuzhounese show higher rates of hospitalization, rehospitalization, and treatment discontinuation (22). These results dispel notions of unauthorized immigrants as a monolithic group. Clinicians may have difficulties arranging outpatient follow-up appointments because of patient stigma, difficulties with getting time off work, and preferences to pay in cash for diagnostic studies and medications, which can limit financial resources for future care (23). Despite the lack of systematic epidemiological research on mental disorders in this population (24), the studies cited above suggest that clinicians should screen broadly for mental disorders when unauthorized immigrants present for services.

Apart from societal and patient-level barriers to caring for unauthorized immigrants, clinician-level barriers may also exist. Culture and ethnicity can trigger powerful transference and countertransference reactions of overfriendliness, mistrust and hostility, or ambivalence (25). Clinicians may face individual biases, language barriers, cultural misunderstandings, and their own attempts to serve as “gatekeepers” of health and social services in treating immigrants and minorities (26). Cultural competence initiatives in medicine have encouraged clinicians to consider their reactions to patient identities as a way of reducing health disparities for disadvantaged groups (27). Too often, however, such initiatives treat culture as a single static variable rather than a dynamic interplay of interpersonal processes, or as a collection of patient traits that explain treatment nonadherence without understanding the conditions responsible for disparities (28, 29).

In response, cultural psychiatrists have recommended approaches that situate cross-cultural aspects of patient care within the social institutions and circumstances that structure health resources. Older models of transference and countertransference that attributed cultural differences to either patients or clinicians have yielded to analysis of the patient-clinician relationship at the intersection of social, political, and economic forces (30, 31). DSM-5 now includes a definition of culture as “systems of knowledge, concepts, rules, and practices that are learned and transmitted,” including within the patient-clinician relationship (32). The 16-item Cultural Formulation Interview (CFI) can help clinicians ask patients about their identities, relationships, and conceptions of illness and treatment (33). A CFI supplementary module also encourages clinicians to contemplate how such patient factors influence diagnostic assessment and treatment planning (34). Undocumented immigrants confront particular structural vulnerabilities of social stigma, inferior political status, and the economic disadvantages of frequently working in hazardous, humiliating conditions without access to basic provisions (35, 36). By engaging curiously with a patient’s narrative, allowing for the possibility of extreme affect, and processing countertransference, clinicians can cultivate a space for empathy with those whose life experiences and cultural backgrounds differ dramatically from theirs (37).