Rhea Acharya

11/14/22

Honors 230B

Healthcare Disparities among the Unauthorized Immigrant Population and their Utilization of

Safety-Net Hospitals and Clinics

Seven percent of the American population is comprised of undocumented immigrants, yet

these individuals are rarely included in progressive legislature. Laws surrounding non-citizen

residents have ranged from building additional walls to physically keep out this population or

separating families through increased deportation. Our federal government has consistently

passed laws that tell these individuals that they are unwanted and have no home in America,

while hypocritically preaching about the American Dream. Even today, the narrative surrounding

undocumented immigrants is ignorant and alienating, and this mentality extends to our

healthcare system. Systemic health disparities mainly target people of color and are further

amplified by a lack of immigration status and financial instability. Without access or trust in for-

profit federalized institutions, undocumented immigrants have solely relied on safety-net

hospitals and community clinics to receive emergency medical care. Unfortunately, with recent

healthcare reforms, the accessibility of these facilities has paradoxically decreased for those

without legal immigration status. This begs the question: are safety net hospitals effectively

catering to these marginalized individuals’ needs?

To answer this question, it is vital to contextualize the health disparities prevalent within

the undocumented immigrant community. Individuals without legal status have a higher

likelihood of being diagnosed with mental health disorders than their legal counterparts. The
constant paranoia of ICE showing up to their door and the real possibility of separation from

their family is enough to induce depression, anxiety disorders, and suicidal thoughts. When this

mentality is present in children, it can stunt developmental growth and lead to adverse behavioral

changes (Fuentes). Additionally, the physical toll of the blue-collar work available to

undocumented immigrants can lead to increased occurrences of fatal injuries and infections.

During COVID-19, all legal residents were given weekly stipends to replace their salaries but

undocumented immigrants were given no federal aid. They were forced to work during a global

pandemic because it was their only option to provide for their families. Consequently, the

mortality rate of the Hispanic and Black populations skyrocketed to no fault of their own. The

healthcare system was ill-prepared for the influx of patient hospitalizations from low-income,

undocumented communities. Accessibility issues such as limited transportation, hospital short-

staffing, and a lack of resources hit undocumented individuals the hardest (Health Coverage).

They did not have the money to spend on medical treatment due to their ineligibility for

insurance and the shortage of ventilators meant only some of the COVID-19 patients would

receive life-saving care. The pandemic merely increased the existing deficiencies in healthcare

that fuel disparities between populations of privilege and those without.

Due to a lack of access to affordable medical care at most healthcare facilities, safety net

hospitals are the primary providers for undocumented immigrants. Safety net hospitals are

usually located in lower-income neighborhoods to serve underrepresented populations in

healthcare (Comparing). Patients without the financial capability to pay for their treatments are

not expected to reimburse the hospital regardless of their background. Since most undocumented

immigrants live under the poverty line, this policy allows them to receive care without

compromising their financial conditions. Even with financial accessibility, the threat of
deportation and ICE prevents most of the community from routine preventative care (Fuentes).

Undocumented immigrants only utilize safety-net hospitals in emergency situations to minimize

contact with government facilities. As a result, Washington health administrators recently

created an Apple Health (Medicaid) category that extends to all pregnant individuals and

children under 18 regardless of immigration status. The program was formed to incentivize

routine check-ups and preventative care for the most vulnerable patients in the undocumented

community. Although it was difficult to find quantitative data regarding program usage by

individuals without documentation, I stumbled on an anonymous story about a Hispanic mother

and her children who could not afford medical treatment and had to go to Mexico for healthcare

(Helping People). Once the new Apple Health addendum was created, however, she was able to

receive financial support for her family and full coverage of preventative medicine including

dentistry and primary care. This story outlines how the program is successfully targeting the lack

of access to insurance for many undocumented immigrants and it is a step in the right direction.

Nevertheless, it only includes a portion of the unauthorized community and should be extended

to all individuals. Additionally, the program needs to address the lack of trust between this

population and healthcare providers. In the FAQs of the Apple Health website, one of the

questions was “will the information on my application be shared with immigration enforcement

officials” (HealthCare). The fear of deportation is so engrained in undocumented immigrants

that they’re willing to sacrifice quality healthcare to avoid discussing their legal status for

insurance. This Apple Health extension program was successful on a smaller scale but must be

further improved through increased inclusion and a stronger focus on building trust with

marginalized individuals.
 In recent years, the federal government has focused on decreasing health disparities

through policy changes but undocumented immigrants are repeatedly left out of progressive

action. The Biden administration created a COVID-19 Health Equity Task Force that invested

$150 million into expanding access to treatment and vaccinations for underrepresented

communities (Biden). Although undocumented immigrants are included in this population, they

weren’t the target population for this initiative. Additionally, after the implementation of DACA

(Deferred Action for Childhood Arrivals), the narrative surrounding documentation seemed to

shift into a more positive light, giving immigrants the chance to become naturalized citizens

(Cohn). Yet they were still left out of the Affordable Care Act (ACA). Most of the reforms in the

ACA begin with the phrase “U.S. citizens and legal residents”. While other families under the

poverty line received federal aid for health insurance, families without documentation were left

with no financial assistance and forced to compete with the new standard for universal

healthcare. Since safety-net hospitals are only given a small amount of federal funding to

primarily support patients under Medicare/Medicaid, covering care for uninsured individuals

became more difficult. It was not financially sustainable for safety net hospitals to provide for

numerous uninsured patients which disproportionately affected the undocumented community

(Health Reform). On the institutional scale, the ACA health reforms were largely positive for

safety-net health providers in Medicaid expansion states. They received increased federal aid and

began partnering with federally qualified health centers (FQHCs) to broaden access to care.

Increased revenue allowed these facilities to “continue expanding outpatient capacity, invest in

strategies to improve care coordination, hire new staff, and develop better infrastructure to

monitor costs” (Comparing). Hospitals in non-expansion states, however, had worse operating

margins and struggled to cover uncompensated care costs. Hospital function was impaired by
financial instability and a lack of resources which further perpetuated the health disparities

among marginalized communities, especially those without documentation.

Reflecting on the contents of this paper, I don’t believe safety net hospitals are meeting

their mission of serving all marginalized communities. Recent legal and societal developments

have prioritized equitable healthcare for underrepresented communities from the context of race,

socioeconomic background, and disability, but do not acknowledge immigration status. The

Affordable Care Act, said to revolutionize healthcare from a progressive standpoint, specifically

excluded this community from receiving quality healthcare and amplified their healthcare

disparities (Summary). Coupled with a lack of access to insurance and a lack of trust in

government institutions, the healthcare system has been inadequate for undocumented

individuals. Although some post-ACA safety-net hospitals have improved their financial margins

to support uninsured individuals, many are unable to balance uncompensated care with hospital

finances. Furthermore, competing against for-profit health institutions sets non-profit hospitals at

a severe financial disadvantage. The gradual bankrupting of safety-net hospitals will merely

eliminate the only source of healthcare available to the undocumented population. Uninsured

individuals will experience a lower quality of care and pay larger sums for treatment at for-profit

institutions compared to safety-net facilities. Unfortunately, for-profit hospitals will always

prioritize the finances of the institution, not the needs of marginalized communities. Therefore,

changing the health provider landscape to primarily capitalistic facilities will further perpetuate,

not alleviate, inequitable access to medicine.

 Works Cited:

Biden Administration to Invest $150 Million to Expand Access to COVID-19 Treatments in Underserved

Communities, HHS.gov, 17 Mar. 2021, www.hhs.gov/about/news/2021/03/17/biden-

administration-to-invest-150-million-to-expand-access-to-covid-19-treatments-in-underserved-

communities.html.

Cohn, D'Vera. How U.S. immigration laws and rules have changed through history, Pew Research

Center, 30 Sept. 2015, www.pewresearch.org/fact-tank/2015/09/30/how-u-s-immigration-laws-

and-rules-have-changed-through-history/.

Comparing the Affordable Care Act’s Financial Impact on Safety-Net Hospitals in States That

Expanded Medicaid and Those That Did Not, The Commonwealth Fund, 21 Nov. 2017,

www.commonwealthfund.org/publications/issue-briefs/2017/nov/comparing-affordable-care-

acts-financial-impact-safety-net.

Fuentes, Liza. New Analyses on US Immigrant Health Care Access Underscore the Need to Eliminate

Discriminatory Policies, Guttmacher Institute, May 2022, www.guttmacher.org/report/new-

analyses-us-immigrant-health-care-access-underscore-need-eliminate-discriminatory.

Health care coverage in Washington State: Non-citizen eligibility, Washington Law Help, 16 June 2022,

www.washingtonlawhelp.org/resource/health-care-reform-immigrant-eligibility.

Health Coverage of Immigrants, KFF, 6 Apr. 2022, www.kff.org/racial-equity-and-health-policy/fact-

sheet/health-coverage-of-immigrants/.
Health Reform and Access for Undocumented Patients: Pressure on the Safety-Net, The Hastings

Center, 7 Dec. 2012, undocumented.thehastingscenter.org/commentary/health-reform-access-

pressure-safety-net/.

Helping people navigate their way to Washington Apple Health, Washington State Healthcare Authority,

www.hca.wa.gov/free-or-low-cost-health-care/i-need-medical-dental-or-vision-care/helping-

people-navigate-their-way-washington-apple-health.

Summary of the Affordable Care Act, KFF, 25 Apr. 2013,

www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/.