The Undocumented Elderly: Coverage Gaps and Low Health Care Use

Abstract

Near-elderly and elderly undocumented immigrants constitute a growing subpopulation in the U.S. with potentially high rates of preventable chronic conditions, but limited access to insurance coverage and low use of care. Associated impacts on health outcomes, safety-net resources, and health care costs are potentially significant. More research is needed to better understand the prevalence of avoidable conditions and the barriers to seeking care among the undocumented elderly.

Since 1990, the undocumented immigrant population has risen steadily; as of 2015, there were 11 million undocumented immigrants in the United States.¹ Nearly 60% of these immigrants have lived in the U.S. for at least 10 years, and over a third live at or above 200% of the federal poverty level.² Though they represent an increasingly large subset of the population, undocumented immigrants are often unaccounted for by the health care system. Overall, they are far less likely to be insured than U.S. citizens: between 40% and 61% of undocumented immigrants are uninsured,^2,3 compared with only 10% of citizens.³ Undocumented immigrants are also more likely to face barriers in accessing care and to report lower use of health care services than citizens,³ despite the fact that they experience higher prevalence of preventable chronic conditions such as hypertension.⁴

While health and health care issues among the undocumented population as a whole have been relatively well-established, problems unique to the aging undocumented remain largely unexplored, and the associated literature is limited. To the best of our knowledge, this article represents the first effort to highlight the importance of studying this particular immigrant subpopulation. Accordingly, we describe the health, resource, and cost implications of being elderly and undocumented in the U.S. First, coverage availability and health care use among the broader undocumented population are discussed using the available literature. We then call attention to the anticipated needs of a burgeoning aging population with limited access to public benefits. Finally, we make policy recommendations.

Insurance Eligibility and Coverage for Undocumented Adults in the U.S.

Undocumented adults—those who lack legal status in the U.S.—continue to be ineligible for Medicaid, which provides coverage for low-income individuals⁵ (as they were prior to passage of the 1996 Personal Responsibility and Work Opportunity Reconciliation Act, widely known as welfare reform), and do not qualify for Medicare, which provides coverage for individuals 65 and older.⁶ They have similarly fallen through the cracks of the 2010 Affordable Care Act (ACA). Although the ACA sought to improve care access and quality on a large scale through its 10 essential benefits, including provision of free preventive care and prescription drug coverage, these benefits did not extend to the undocumented. The ACA maintained long-standing restrictions on federal funding to insure undocumented immigrants.⁷ As a result, federally funded coverage for undocumented adults is limited to Emergency Medicaid, which covers treatment for acute medical emergencies that cause major impairment or dysfunction.⁸ Emergency Medicaid provides coverage for an authorized 12-month period, after which beneficiaries must go through a daunting recertification process if more care is required.⁹ In addition, the scope of care provided through Emergency Medicaid varies by state.¹⁰ A second, but limited, safety net is available through the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA), which requires emergency departments at hospitals participating in the Medicare program to provide treatment for any patient, regardless of their immigration status.¹⁰ Private insurance is unlikely, as undocumented immigrants tend to work in sectors in which employer-based coverage rates are low.¹¹

Health Care Use among Undocumented Adults: Barriers, Costs, and Consequences

Undocumented immigrants use health care services across the spectrum—including emergent, non-emergent, and preventive services—less often than U.S. citizens and legal immigrants.¹² When seeking care, undocumented immigrants rely on safety-net providers (typically public hospitals and community clinics that deliver care to substantial shares of uninsured, vulnerable, and Medicaid populations regardless of their ability to pay¹³), particularly for low-cost or free preventive services.^14,15 Those who have aged out of the workforce might be particularly reliant on safety-net providers due to financial constraints; elderly immigrants (65 and older) are more likely than their U.S.-born counterparts to live in low-income families and to have no source of income.¹⁶ Low use may be exacerbated by stigma, fear of deportation, or linguistic barriers; more than half of the elderly immigrants in the U.S. are limited-English proficient.¹⁶ Undocumented immigrants face barriers to care at all turns, via restrictions at the policy level, and fear, stigma, and resource constraints at the individual level. Perhaps as a result of low use, they are more likely to have unmet health care needs. Because they are less likely to seek timely care due to a variety of barriers, rates of hospital admission for preventable conditions are higher among undocumented immigrants.¹²

Low use runs counter to the belief that this population places an undue burden on public resources. Non-income tax contributions by undocumented immigrants (including sales and property taxes) far surpass costs incurred by any government benefits they access.^17,18 Furthermore, a recent study found that these tax contributions likely serve to keep the Medicare Trust Fund, which finances Medicare health services for the elderly and disabled and for which the undocumented are ineligible, afloat.¹⁸ However, it is important to note that the current emphasis on emergent treatment via coverage provided by Emergency Medicaid or EMTALA, rather than an emphasis on prevention and control of avoidable conditions, is a costly approach to health care provision for undocumented immigrants. Emergency Medicaid expenditures among undocumented immigrants have been linked to preventable conditions, including complications associated with chronic diseases.¹⁹ Caring for undocumented patients may also be disincentivized, as services provided are often not covered by public or private insurance and may go uncompensated. This can extend even to certain emergent services such as dialysis, for which inpatient, but not outpatient, treatment is covered by Emergency Medicaid, leading to inconsistent, lower-quality care.²⁰

Aging Undocumented U.S. Immigrants: Individual and Health System Implications of a Growing, High-Need Population

More specifically, a pressing priority emerges from the growing health care needs of near-elderly (55-64) and elderly (65 and older) undocumented immigrants. Over the coming decade, many undocumented individuals in the U.S. will be near-elderly or elderly; together, these groups will constitute nearly 25% of the total undocumented population.² An older population generally has greater, higher-cost health care needs, particularly related to management of chronic conditions. Sixty percent of the elderly struggle with two or more chronic conditions, including hypertension, heart disease, diabetes, and cancer.²¹ If diagnosed late or unmanaged, these conditions can necessitate costly care and lead to compromised quality of life and increased risk of mortality. Uninsured status has been linked with lower health care use (including lower use of preventive services), greater health care burden, and related high costs; these negative impacts are exacerbated by the increasing risk of health problems that accompanies increasing age. Consequently, insurance coverage is a key component of access to timely screening and prevention services, as well as adequate treatment.

Among the growing elderly undocumented population, limited access to and subsequent low use of health care services, particularly preventive services, can result in high rates of morbidity and mortality due to avoidable or easily treatable chronic conditions.^14,22 Failure to provide near-elderly and elderly undocumented immigrants with insurance, particularly public coverage, will cause them to become an increasingly large proportion of the remaining uninsured population, placing undue burden and financial stress on safety-net providers. Lack of coverage will also lead to increased demand for health care services and stretch the already limited resources of the safety-net system, once it becomes easier for this population to access services. Lack of access to public insurance options may lead to increased reliance on emergency rooms for even such basic needs as prescription refills, resulting in higher rates of uncompensated care, overcrowding, and longer wait times for undocumented immigrants,^14,23 and by extension, for U.S. citizens as well. Finally, delayed care-seeking due to a variety of barriers will result in higher-cost care in the long run.^14,22,23 A recent study in North Carolina demonstrated that emergency treatment of chronic disease complications constituted one of three significant care gaps filled by Emergency Medicaid, and that the largest increases in the state’s Emergency Medicaid spending for undocumented immigrants occurred among the elderly.²⁴

Policy Recommendations

The current political climate and changes in immigration reform may serve to lower health care use even further and worsen already poor health outcomes, as undocumented immigrants may prefer to avoid care of any kind out of an acute fear of deportation.^23,25 Recent immigration enforcement raids have led to higher levels of toxic stress and poorer self-reported health among undocumented immigrants;²⁶ unfortunately, reluctance to seek care has also increased.²⁷ Those who are considered, or will soon be considered, near-elderly or elderly are particularly vulnerable to compromised health outcomes, poor quality of life, and increased risk of mortality. Expanding access to coverage options in a way that minimizes stigma and fear of deportation is a first step, and public insurance is likely the best way to facilitate such an expansion.

In the case of the near-elderly and elderly undocumented, one option at the federal level might be to expand the scope of services provided by Emergency Medicaid, perhaps to replicate the essential benefits under the ACA in order to target prevention and timely diagnosis of chronic conditions. An additional approach might be to streamline covered services provided across states. Currently, the scope of care provided through Emergency Medicaid is highly fragmented and at each state’s discretion. At the very least, treatment for complications of chronic conditions covered by Emergency Medicaid must meet best practices for care.

In the past, disproportionate share hospital (DSH) payments made by Medicaid have helped safety-net hospitals treating high volumes of low-income and uninsured patients to cover costs of uncompensated care.²⁸ However, DSH payment cuts originally proposed by the ACA continue to be a threat; though delayed through 2019, if implemented, these cuts would reduce payments by as much as $8 billion in 2021.²⁸ The reliance of undocumented immigrants on safety-net hospitals for care, coupled with a rapidly growing undocumented aging population with more critical, costly health needs, necessitates a reexamination of proposed cuts. At minimum, payment reductions should be scaled back for states with the largest undocumented populations.

At the state level, particularly for states with large undocumented populations, Medicaid waivers can potentially expand basic health coverage to include undocumented immigrants.²⁹ Using a Medicaid waiver, states can provide care to individuals who would otherwise be ineligible for Medicaid according to federal rules.³⁰ For example, a waiver-based initiative in California sought to allow undocumented adults to purchase health plans via the state’s insurance marketplace.³¹ Though ultimately unsuccessful, the program would have been the first of its kind to offer undocumented immigrants access to standard insurance plans without fear of their immigration status being shared with other government entities. However, it is important to note that even if such a waiver were implemented, undocumented immigrants are not eligible for federal subsidies and might therefore be discouraged from enrolling in standard plans because of inability to pay insurance premiums.³¹ As a result, the onus would be on states to provide premium subsidies for the undocumented. Given already stretched budgets, a better option in the short-term might be for states to apply for waivers to secure increased funding for safety-net providers; both Florida and Texas set a precedent in successfully applying for waivers to cover uncompensated care.²⁹ Such waivers could also help to offset significant DSH payment cuts. In addition, shifting focus from coverage for the undocumented to funding for uncompensated care might prove a more feasible approach at a time when immigration has become an extremely controversial topic.

Conclusion

Undocumented immigrants who are 55 and older are often hard-to-reach, and sometimes “invisible;”²⁵ data on health care use and cost impact for them are limited. Similarly, it is hard to know the exact burden placed on safety-net providers who care for the undocumented, particularly those who are near-elderly or elderly. Additional efforts are vital to try and fill significant knowledge gaps regarding health care needs and use among the aging undocumented, including the prevalence of avoidable chronic conditions and the practice implications and costs of caring for these individuals. In addition, barriers that are particularly strong among this population, including linguistic and financial barriers, as well as transportation constraints and isolation^25,32 and the ways in which these interact with use, must be better understood. Further research is necessary to make a case for practice or policy change on any scale for a growing, yet critically underserved and needy group.