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04/21/2014

HealthCare & Immigration: A Summary to Accompany BioethxChat Twitter Event (4/21/14)

I recently did a TwitterChat sponsored by BioethxChat on the relationship of healthcare and immigration through a bioethical lens. Here is the transcript of that chat.

This was a great event and I hope self-explanatory. But Twitter’s 140 character limitation means things are expressed in such a condensed way that they might not always be clear. So, I provide the following summary as related to the four topics discussed.

Topic One asked about the Duty of Healthcare Providers to Treat all Patients without regard to Immigration Status – It’s hard to imagine a health-care provider discriminating on the basis of immigration status per se. However, immigration status is often relevant to a patient being uninsured and unable to secure resources that a citizen might have available. So, in some ways, an immigrant is simply another uninsured patient. However, because of their truncated eligibility, e.g., even a patient who has legal permanent resident status is not eligible for Medicaid until he or she is present in the US for five years. problems can arise for immigrant patients that do not arise for citizens. For instance, if the patient is uninsured and needs a stay at a long-term care facility after an acute hospitalization, the citizen can often get Medicaid to pay for the long-term care stay while an immigrant could be stuck in the hospital with no possibility of discharge to a more appropriate level of care. This raises the question of who is hurt when public policy restricts eligibility to access insurance based on immigration status.

Topic One also asked Is It Ethical to Prevent Undocumented Immigrants from Accessing the Insurance Exchanges? and whether this is just. Again, there is a very real way in which attitudes toward the lack of insurance among the undocumented resemble unhelpful biases toward the lack of insurance among citizens. That is, insurance is seen as something that benefits the covered individual only and therefore, is a privilege that one is not entitled to. If you don’t have it, you don’t have it.

1. The problem is that as a society we also hold and have codifed directly opposite premises. We believe in emergency care for all so that we don’t have people literally dying in the streets. We have enshrined this belief in the law that goes by the acronym EMTALA. So, the US ends up treating the uninsured in the ER in a costly way. Through widespread insurance, the US can work to prevent illness and deliver care more efficiently (We also then don’t end up with the problem of not being able to discharge patient to a more appropriate level of care that we noted above). And, by making the uninsured wait until their illness is an emergency, it potentially means that communicable disease will have spread. So, insuring uninsured members of our community makes good sense for the community. While some such as the ACP have argued that allowing the unsubsidized purchase on the exchanges is a good, I would argue that access to the new system of premium subsidies is entailed by the same reasoning. That is, the subsidies enable immigrants of low income to pay what they are able toward the insurance plan. This is far better than simply providing charity care through the ER. (I developed this position in a paper a couple of years ago Mark G. Kuczewski (2011) Who is My Neighbor? A Communitarian Analysis of Access to Health Care for Immigrants. Theoretical Medicine and Bioethics 32(4): 327-36.)

2. Medicare – While the considerations I’ve noted can equally apply to any mode of insurance including Medicare, that program has a symbolic place in the minds of many Americans as a program for elderly persons who paid into it for many years. As a result, it may be politically impossible to open this up to immigrants who arrived late in life and didn’t pay into this system. Considerations of expediency might mean that it would be easier to insure any immigrants who arrived as senior citizens through other channels.

Topic Two asked about whether Undocumented Immigrants (presumably young people called DREAMers) should be able to attend graduate medical and health science programs and what unique barriers might confront them.
Many of you might know that I have worked at the Loyola University Chicago Stritch School of Medicine to welcome DREAMers of DACA status to apply to our school and not consign them to some ill-fitting category such as considering them as international students (a category at most medical schools for which there is no institutional financial aid.

DACA status (the Deferred Action for Childhood Arrival program of the US Citizenship and Immigration Service) enables DREAMers who meet certain qualifications to receive two-year renewable deferrals of any action on their immigration status. They also receive a work permit and can apply for a social security number. This means that many state medical licensing boards (and presumably boards in other health professions) can license these individuals to practice. As such, it would be a terrible waste of talent to deny qualified individuals who meet admissions standards access to the health care professions. DREAMers of DACA status potentially can provide us a new source of bi-cultural, often bi-lingual talent to serve our increasingly diverse society.

Financial aid remains the single biggest barrier to utilizing this pool of talent. They are ineligible for any federal aid including federally-guaranteed student loans. Thus, alternative sources of financial aid must be sought (In Illinois, we worked to create a loan program tied to service to the underserved of our state for these students). (See also Mark G. Kuczewski, Linda Brubaker (2013) Medical Education as Mission: Why One Medical School Chose to Accept Dreamers, Hastings Center Report 2013;43(6): 21-24.

Topic Three asked If Medical Repatriation Can Ever be Ethical? There’s been a number of good articles written on this topic in recent years including one in the NEJM (Michael J. Young, Lisa Soleymani Lehmann, Undocumented Injustice? Medical Repatriation and the Ends of Health Care, NEJM, 2014; 370: 669-673. )

I made an argument a couple of years ago that I believe is correct. Namely, forced medical repatriation is always wrong. (Mark G. Kuczewski, Can Medical Repatriation Be Ethical? Establishing Best Practices. American Journal of Bioethics 2012;12(9): 1-5) If our hospitals engage in that practice, it will cause the immigrant community to avoid the hospital with all the negative consequences we know follow. That is, they won’t present until the illness has progressed and is harder and costlier to treat. Persons with infectious illnesses will continue to spread them rather than seek treatment. And, in general, it will undermine the caring ethos of our institutions. Some have argued to me that this should entail no medical repatriation period. However, I believe there are circumstances under which repatriation is actually the moral thing to do.

In some cases, a return to a prior community is in the patient’s best interests. US citizens sometimes return to other states when they are sick and need to be near family. Similarly, immigrants who come to the US for work but become unable to work owing to illness or injury may find that they would prefer to be near familial support systems that are in their country of birth. Furthermore, dying patients may also wish to be near their loved ones. So, I believe that with certain ethical safeguards, i.e., we seek the informed consent of the patient or appropriate surrogate decision maker and the repatriation can be seen to be in the patient’s best interests on some reasonable interpretation of those interests, repatriation can be ethical.
Finally, I was asked how Immigration Policy as it relates to healthcare can relate to concepts such as human rights and social justice. I see the health care question as a subspecies of the larger question of social justice (I am far more comfortable with social justice language but I think it can be translated to human rights thinking.). Social justice is about treating people as if they have worth (dignity) and so treating them fairly. This means enabling them to participate fully in the life of the community. Healthcare provides a condition for full participation.

The immigration debate has failed to see the issue in perspective. We are an increasingly globalized world with rather free trade. Capital, i.e., investment and profit, flows more easily across borders than ever before. But, we have not allowed labor to flow with similar ease. This can create untenable and unlivable situations for many people and cause them to cross borders without authorization.

The United States is an aging society with a workforce that has needed supplementation both from many workers at the lower level of the workforce and those with very high education and skills. We have been more responsive at the high end of the spectrum although even there one could say that many more workers are needed. In a sense, our immigration laws are like a broken traffic light that is stuck on stop. In the end, we usually thank those who after a time, cautiously proceed through the broken light.

Once people have lived in a community and contributed to it, they also gain a kind of equity interest in that community and are entitled to full participation. This is the need for immigration reform. Of course, as we have seen, there is a kind of regressive thinking that does not simply infect the immigration debate but the health insurance debate as well. That thinking sees the US as having a finite set of goods and that allowing access to them, e.g., health care, diminishes the pool for others who are more deserving. This kind of thinking fails to see that we can use access to promote the contributions of all to the common good of our communities and our society.

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