Immigrants and Access to Care: Public Health Must Lead the Way in Changing the Nation’s Narrative

The United States has long held an ambivalent stance toward our nation’s Latino immigrant populations. Ignoring our history of colonization and perpetual dependence on low-paid immigrant labor, we charge immigrants with spreading infectious disease, stealing American jobs, and living off public resources. Public discourse on immigration conveys the sentiment that as a nation we are unmoved by the physical, emotional, and economic factors that drive Latino immigrants from their home countries, many of them rooted in US foreign policy. Historically, immigration policy has sought to deny immigrant access to health and human services, an expression of our core belief that immigrants must be self-reliant. This, despite evidence that as a group with high participation in the labor force they generate a surplus in the Medicare Trust Fund by paying in substantially more than they take out in social security benefits.¹ Recent state and federal policies magnify perceptions that immigrants seek to exploit the system while further diminishing their access to services.²

In the current issue of AJPH, Guadamuz et al. (p. 1397) illustrate the manifestation of these exclusionary policies in their examination of the medical treatment of cardiovascular disease (CVD) risk among Latino immigrants. The authors use data from the Hispanic Community Health Study of Latinos, a population-based cohort study in five US cities, to examine access to health care. Their analysis demonstrates that among foreign-born Latinos, documented and undocumented immigrants are less likely to receive treatment for high cholesterol, hypertension, and diabetes than are naturalized citizens. Health insurance coverage or having a regular medical provider mitigates, but does not erase, this increased risk. These findings are not surprising and provide further evidence of the relationship between access to care and health outcomes across US populations. Although insurance coverage is the cornerstone of any effort to address access to care, it would only begin to alleviate many immigrant health disparities. Access to care is rooted in social ecologies, and a contextual analysis is required to confront the complex issues facing documented and undocumented immigrants in addressing CVD risk.

Latino immigrants fill many essential and underappreciated roles in the US economy, such as agricultural workers, cleaning and maintenance workers, meat-packing workers, construction workers, and factory workers.^2,3 Employers of these low-wage workers quite often do not provide health insurance, and undocumented immigrants are further barred from the health coverage expansion under the Affordable Care Act.⁴ As the analysis of CVD risk treatment conducted by Guadamuz et al. makes clear, a foundational approach is needed to expand both public and private health insurance coverage to include all sectors of the population. However, even with access to health care, preventive management of CVD risk requires immigrants to negotiate a set of complex factors that may present greater hazards than does forgoing care.

Immigrant workers in general do not have paid sick leave. A day spent seeing a doctor is often a day of lost wages. Aware that they cannot afford to be sick, immigrant workers are likely to dismiss symptoms related to hypertension and high glucose levels even when those symptoms become unmanageable and debilitating. Fear of deportation is a constant threat for undocumented individuals and those with undocumented family members, which further affects decisions to seek assistance of any kind.⁴ Immigrants experience discrimination in every facet of their daily lives from employers, law enforcement agents, landlords, and service providers.⁵ On a fundamental level, immigrants are discouraged from participating in public life or interacting with the structural fabric of American society.

An immigrant may become aware of their CVD risk if they encounter a mobile health unit that provides screening and outreach services at family-centered or church-sponsored events that are considered safe havens for communities.⁶ Mobile units are designed to connect vulnerable populations to a primary health care home, the most common being a federally qualified health care center. As the backbone of the nation’s health care safety net for the uninsured, federally qualified health care centers provide primary care services on a sliding fee scale. However, applications for fee assistance can require extensive paperwork, leaving immigrants feeling vulnerable about their documentation status or that of their family members.^4,7 Furthermore, entry into this system often requires long waiting times for appointments or to be seen by a doctor.⁵ Hence, although immigrants may have access to screening, the care itself may still not be accessible. The quality of the care in terms of linguistic and cultural congruence is variable, which may result in an immigrant receiving a diagnosis of CVD risk but not purchasing medication or taking medication as prescribed. In the event that an immigrant does find his or her way into competent and compassionate care, the expectation of self-reliance is both external and internal to the immigrant community, making it difficult for individuals to prioritize the time and money for CVD treatment over family needs.⁴

Addressing disparities in the treatment of CVD risk for documented and undocumented immigrant Latinos in the United States requires a concerted and comprehensive effort. Reversing entrenched erroneous and negative attitudes toward immigrants will require not only policy change but also a transformation of the public and political narrative on immigration. Foremost, our country’s leaders must reject the temptation to scapegoat immigrants for economic downturns and other societal problems, a strategy that has proven effective in winning elections. Today, the COVID-19 pandemic is forcing our nation to confront the inequities of an economic system that pays unlivable wages to individuals performing essential services, both immigrant and US born. Our immediate, communal, and overwhelming need for these services provides an opportunity to consider how to redefine the value of different types of work.

The temporary closure of the US–Mexico border to nonessential travel on March 20, 2020, to control transmission of the COVID-19 virus underscores the harsh reality that on a daily basis we rely on labor from Latino countries. The H-2A temporary agricultural visa, touted as a solution to the shortage of farmworkers to harvest our nation’s food, brings Latinos into the country as cheap laborers, while ignoring and abusing their rights as independent workers.² The location of US factories in border communities in Mexico ensures access to low-cost labor, while avoiding the responsibility of supporting our workforce through livable wages and adequate benefits. Americans seek to avoid the lowest-paying and most physically demanding jobs, while enacting policies that allow us to sidestep paying for the long-term health implications of this work.

The COVID-19 crisis exposes the perils of a health care system that perpetuates health disparities across low-wage workers in the United States, and especially among foreign-born Latinos. The major role of immigrants, both documented and undocumented, in performing the essential services that allow our country to function, underscores the risk of health policies, as articulated by Guadamuz et al., that arbitrarily exclude some portion of the population as undeserving. The COVID-19 crisis provides an opportunity to change the national narrative on immigration, expand health care coverage to all immigrants, and address the economic, social, and structural barriers to connecting with health care services. Access to care is the foundation of a successful and functional society as well as a basic human right.