Federal immigration legislation in 1996 outlined that all immigrants to the United States are required to pass a "public charge" test and have a U.S. sponsor or sponsors willing to pledge their income to support them (refugees, asylees, and amnestied illegal immigrants are exempted). The public charge test is to be administered at the American consular offices and an evaluation is to be done to determine whether or not the immigrant applicant is likely to become a public charge, and if so, deny the visa. Such criteria used in making the public charge determination includes 1) the sponsor having an annual income of at least 125% of the federally designated poverty level 2) the resources and skills of the applicant, and 3) any special conditions (such as age or infirmity) that might affect the applicant's need for support.
Despite the public charge test and the stated goal to have the immigrant's sponsor, and not the U.S. government, support the needs of the immigrants brought to this country legally, the US government has served as a significant source of support for immigrants in this country. Once the immigrants pass the public charge test, they are eligible to receive numerous forms of welfare, which are not considered under the public charge test, such as food stamps, pre-natal care, nutrition programs, housing assistance, energy assistance, job training programs, child care services, free or reduced school lunch, public shelters, health clinics, Medicaid, and some cash assistance welfare programs.
The 1996 Welfare Reform Bill outlined the following eligibility provisions:
1) Legal immigrants are barred from all federal means-tested public benefits for five years after entering the country and barred from Social Supplemental Income (SSI) and food stamps until citizenship. However, benefits available to immigrants include school lunch and breakfast programs, immunizations, emergency medical services, disaster relief, and others programs that are necessary to protect life and safety as identified by the attorney general, regardless of immigration status.
2) Illegal immigrants are barred from federal public benefits including: grants, contracts, loans, professional licenses, retirement, welfare, health, disability, public or assisted housing, post secondary education, food assistance, and unemployment benefits. States are barred from providing state or locally funded benefits to illegal immigrants unless a state law is enacted granting such authority.
Although the many provisions in both the 1996 Immigration Reform legislation and the 1996 Welfare Reform legislation seek to help immigrants, studies find that the immigrants that are admitted legally are much poorer than the general population of the United States. Presently, 18% of immigrant households are below the poverty line, compared to 11% of non-immigrant households in the U.S. Legal Immigrants are 11% of the U.S. population, yet are 20% of the poor population. Further, immigrant households make up 21% of the welfare rolls, compared to 14% of non-immigrant households on welfare. The highest use rates for immigrants are in New York (30%), California (28%), Massachusetts (25%) and Texas (25%). In 2002, state governments spent an estimated $11 billion to $22 billion to provide welfare to immigrants, as 3.5 million immigrants were enrolled in Medicaid and an additional 3.7 million were enrolled in Medicare.
The number of legal immigrants on public assistance is only half the story. The Federal Emergency Medical Treatment and Active Labor Act of 1986 mandates that hospitals must treat and stabilize anyone who seeks emergency care, regardless of income, insurance, or immigration status. Given this law, many use emergency room care as their only point of access for health services or primary care provider, despite the much higher costs associated with emergency room visits, as compared to health clinic or general doctors' office visits. In 1993, the utilization rate of hospitals and clinics by illegal immigrants (29%) was more than twice the rate of the overall US population (11%). Between 1992 and 2001 visits to U.S. hospital emergency departments increased by 20%, while emergency departments shrank by 15%.
Hospitals are taking the brunt of the unfunded mandate to serve everyone. More importantly, they are incurring the costs associated with healthcare for illegal immigrants and the uninsured, as are full paying citizens or those with insurance. In some hospitals, as much as two-thirds of the total operating costs are for uncompensated care for illegal immigrants. This situation has led to a crisis in the healthcare industry. In 2000, 289 emergency rooms in California reported operating at loss. Those losses totaled $325 million in 2000 and $390 million in 2001. In 2002, Pennsylvania and New Jersey hospitals gave almost $2 billion in free emergency and short-term care to uninsured patients, a large share of whom officials believe are illegal immigrants. Chicago's Alivio Medical Center provides one million dollars a year in uncompensated care and estimate that more than half of its 20,000 annual patients are illegal.
Given this situation, several states, including Minnesota, have called on the federal government to shift the financial burden away from local hospitals. In 2002, a National Association of Counties survey revealed that 67% of counties cited an increase in legal and illegal immigration as a cause of the rise in uncompensated health care expenses and that the newly arrived immigrants are the predominant users of uncompensated health care. Some states even sued the federal government in the 1990's seeking reimbursement for the cost associated with handling the influx of illegal immigrants, but the cases were dismissed.
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Uninsured Healthcare
America's Immigration policies have been targeted as playing a significant role in the country's health care crisis, where more than 41 million Americans lack basic health insurance. One out of every four uninsured people in the U.S, approximately 10 million people, is an immigrant. North Carolina has 1.3 million residents with no health insurance. This is reflected in that the median household income for legal immigrant households is 13% lower than that of U.S. born households, and median households income of illegal immigrants is 23% lower.
In addition to poverty, this situation shows that the immigrant population is largely unable to secure employer provided healthcare and that uninsured workers also have many family members who are subsequently uninsured. Among full-time wage earners, 51% of illegal and visa status workers had employer provided health insurance, while 76% of naturalized citizens did and 81% of the U.S. born residents had insurance.
The situation of uninsured immigrants (legal and illegal) continues to grow. Immigrants who arrived between 1994 and 1998 and their children accounted for 59% (2.7 million) of the growth in the size of the uninsured population since 1993. The problem also extends farther back. More than a third (37%) of immigrants who entered in the 1980's have still not acquired health insurance, and more than a quarter (27%) of immigrants who entered in the 1970's remain uninsured. When the 3.5 million immigrants receiving insurance through publicly funded Medicaid programs are factored in, almost half of immigrants (legal and illegal) have either no insurance or have it provided to them at taxpayers' expense.
The cost for the uninsured is staggering. In 2001, public funds made up for up to 85% of the $34 - $38 billion shortfall in unreimbursed expenses incurred by the uninsured. In 2005, the cost for the uninsured in North Carolina was $1.4 billion. In 2005, the North Carolina Division of Medical Assistance, the State's Medicaid Manager, reported that North Carolina illegal immigrants cost the state $52.8 million in Medicaid payments, up from $25.8 million in 2000. The Kenan Institute at UNC-Chapel Hill estimated the state's 2004 cost for health services provided to all Hispanics, legal and illegal, at $299 million. Most of the North Carolina Medicaid payments for illegal immigrants were mostly for the delivery costs for pregnant women, but also paid for ambulances, diagnostic imaging, and other emergency care. Charlotte and Mecklenburg County hospitals, as well as most all North Carolina hospitals, do measure the cost of treating the uninsured, but not for illegal immigrants as a separate group, as health care providers and hospitals do not ask immigration status of patients.
Anchor Babies
As noted above, a significant amount of medical expenses for illegal immigrants are for the delivery cost for pregnant women. Current U.S. fertility indicators show that foreign-born Hispanics have 112.3 live births per 1,000 women, while the US born non Hispanic is at 59.9 births per 1,000 women. In 2005, the Mecklenburg County Health Department reported that one in every five births was to a Hispanic.
In 1994, there were 74,987 births to illegal immigrants in California at a cost of $215 million. Those births consisted of 35% of all the Medi-Cal (California's Medicare System) births. Illegal immigrants comprised 760,000 of the Medi-Cal beneficiaries in 2003, up from 470,000 in 2002. In 2003, 70% of the 2,300 babies born at San Joaquin General Hospital maternity ward were to illegal immigrants. In 2004, it is estimated that 300,000 babies of illegal immigrants were born in the United States.
The high birth rate of illegal immigrants not only has cost implications, but demographic and social implications for America. The term "Anchor Baby" is used by some to refer to babies born in the United States that immediately become U.S. citizens under the 14th Amendment, yet whose parents are illegal. The baby is viewed to be the anchor the families can use to get Welfare and Medicaid benefits and later, when the babies are adults, they can use U.S. family immigration laws to help the parents gain citizenship.
The growing concern over the number of "Anchor Babies" has caused many to reflect on the 14th amendment and how it relates to immigration policy. Many argue it is being misinterpreted as it was ratified in 1868 to protect the civil rights of native-born black Americans, who had recently been freed from slavery and whose rights were being denied. However, in the last two years, the US Supreme Court reinforced that citizenship status is determined by being born on American soil, when they ruled that a Taliban fighter born in Louisiana and raised by his Saudi parents in Saudi Arabia was due full rights of citizenship and could not be held as a non-combatant and denied due process by the Bush Administration.
The U.S. is not unique in this issue of "Anchor Babies" and citizenship by birthright. The Irish Supreme Court ruled that immigrant parents could be deported even if they have an Irish child. On June 11, 2004, Irish voters supported a national referendum to end birthright citizenship for any child regardless of the parents' residence status, due in large part to women from outside the European Union, such as Nigeria, who were having babies and claiming political asylum. In the 1980's, Great Britain and Australia both changed their citizenship laws for similar reasons. The country of Switzerland does not automatically grant citizenship for those children born in the country.
At least two members of Congress have tried in the past year to address the "Anchor Baby" situation and re-evaluate citizenship by birth through changes to the 14th Amendment, but their proposals died in Committee.
Public Health Issues
The concerns for poverty and medical costs generated by illegal and legal immigrants are only part of the concern by healthcare professionals when it comes to illegal immigration.
The fact that millions of visitors and thousands of illegal immigrants come from countries with endemic health problems and less developed health care systems raises special concerns for the healthcare professionals in Charlotte and across the country.
The increase in the illegal immigrant population has also brought rise to many contagious diseases that had been totally or nearly eradicated by the U.S. public health system. Because illegal immigrants do not undergo medical screenings, like those legally admitted, the incidents for infectious diseases are on the rise in the U.S. The issue is acute along the border states, where the incidence of tuberculosis in El Paso County, Texas is twice that of the U.S. rate, leprosy is readily evident along the border, and the pork tapeworm, which thrives in Latin America and Mexico, is showing up along the border. However, the increase in diseases is not limited to border states, as typhoid appeared in Silver Spring, Maryland in 1992. In Queens, New York, 81% of tuberculosis cases in 2001 were attributed to immigrants. Such diseases as river blindness, malaria, and guinea worm have all been brought to Northern Virginia by immigration patterns.
Schools and Immunizations
The concern for public health starts in the school system. Given that all schools must educate all children, regardless of immigration status, the focus of public health professionals is to ensure the school aged population has the necessary immunizations for school enrollment. Immunization requirements vary from State to State and country to country, but the State of North Carolina requires that all students have immunizations for diphtheria, tetanus, whooping cough, and vaccinations for oral polio, measles, rubella, mumps, haemophilus influenzae, and hepatitis B. The state law further requires that each child present adequate immunization records by the 30th day of attendance or the student will be excluded from school. Charlotte Mecklenburg Schools follow state law and require the NC Certification of Immunization before a student can be enrolled, however they do not track down the authenticity of the records if they are from other countries. They do however, evaluate the immunization documents to make sure the immunization timeframes match up with the date of birth timeframe of the child and use health insurance records, physician offices and parent records for verification. If they do have a concern for the immunization record or certificate, they follow the state law and provide a "notice of deficiency" and give 30 days for the parent to provide records to show compliance with the student immunization requirement.
Serving the Immigrant Population
The Charlotte-area hospitals and healthcare providers operate under the premise and policy that no one is turned away. The overall goals of the local healthcare community are to:
- promote a healthier community
- improve the quality of healthcare provided in the community
- stabilize the cost of healthcare borne by the state and local governments
The 585% rise in the Hispanic population in North Carolina between 1990 and 2004 and the statistic that 54% of Hispanic adults in North Carolina are uninsured, compared to 11% for non-Hispanic whites and 22% for African-Americans, has had a ripple effect in the healthcare community and strained the premise to turn no one away. In 2005, the Mecklenburg County Health Department provided care to 17,500 Hispanic patients, or 26% of their total patients. This is up from 17% of the Health Department patients in 2000.
In addition to the Health Department, Carolinas Healthcare System reported that 30% of all the patients seen in 2005 at the Carolinas Medical Center (CMC) clinics are Hispanic. The four Ambulatory Care Clinics realized a 20% growth in the number of Hispanic patients at CMC between 2002 and 2005. In 2005, Carolinas Healthcare System provided service during 61,000 visits by Spanish speaking patients in its Ambulatory care division, with 34,000 of those visits at the CMC NorthPark clinic. The NorthPark clinic alone realized a 41% increase in the number of Hispanic patients between 2002 and 2005.
Carolinas Healthcare System has determined that it takes 17.6% longer to care for a Spanish speaking patient than it does to care for an English speaking patient. This statistic has shown that compensating a bilingual staff member at CMC is nine times more cost effective than paying an internal interpreter and 30 times more cost effective than paying an outside agency interpreter. Given this situation, Carolinas Healthcare System actively recruits bilingual employees with culturally appropriate advertisements in the major local newspaper and area Hispanic newspapers. CMC has instituted a bilingual pay program that includes a per hour compensation incentive for time staff spend using their language skills. The hospital also offers a bilingual referral bonus to employees who refer a new bilingual hire that is placed in a high need area. This bilingual recruitment effort has paid off. Now, 33% of the employees at the CMC NorthPark clinic and 25% of the employees at CMC Myers Park clinic are bilingual.
The hospital system has responded to a service need by its patients to have services provided in Spanish. The hospital system now provides bilingual staff and interpreters on site in locations where greater than 5% of the population speaks Spanish. Carolinas Healthcare System also has interpreters or bilingual staff on call in the other areas with a smaller Spanish-speaking population. The hospital utilizes English and Spanish signage and offers telephone prompts in Spanish. They also provide information brochures and educational materials in Spanish. Spanish and bilingual books are given to children at their well child checks and prescription bottles are printed in Spanish. In 2005, CMC Outpatient Pharmacies filled 75,000 prescriptions in Spanish.
The hospital has been able to make the business or financial case to hire bilingual staff. The CMC clinics presently employ 11 interpreters at an annual cost of $440,000. The bilingual staff provides an additional 15,500 hours of interpretation at a cost of $23,000 above base pay. The Mecklenburg County Health Department employs six full time interpreters at an annual cost of $300,000 and utilized their bilingual staff at a cost of $25,000 above base pay for their bilingual skills.
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