President Obama has said repeatedly that healthcare reform is one of his top priorities. Prominent democrats, including Hillary Clinton, have long called for providing universal access to healthcare coverage and it is likely that Congress will debate how best to accomplish this in the coming months. As the US recession persists, the imperative for healthcare reform grows. According to the Bureau of Labor Statistics, the unemployment rate reached a sixteen-year high in December of 2008 . In that month, there were more than eleven million unemployed in the US, an increase of more than three and-a-half million since the start of the recession 1 year earlier. As firms falter and fail, workers lose their jobs, and along with them, their health insurance. This will likely increase the number of uninsured in the US. Concurrently, as tax revenues fall, governments at all levels are likely to scale back on social and other salutary resources at a time when they are needed most. This trend, along with the ongoing retirement of the baby-boomers, portends an increasing burden on our healthcare system in the years to come. Therefore, furthering the debate about healthcare reform is now even more important than ever.
All of the healthcare reform plans proposed during the presidential campaign, although distinct in their means, had one end in common—to reduce the number of uninsured. Taking this one step further, recent Democratic candidates, including Hillary Clinton and Barack Obama, proposed accessible health care coverage for all. A productive discourse about how to achieve universal coverage should start with defining the target population. The most frequently cited estimate provided by the different campaigns, including the Obama campaign , was that were are approximately 45 million uninsured Americans lacking health insurance. This number is derived from the Current Population Survey (CPS), a monthly survey conducted by the US Census Bureau that is representative of the US civilian non-institutionalized population . The sampling frame for the survey includes all individuals who indicate that the US is their usual place of residence, including citizens, foreign-born lawful permanent residents, temporary immigrants, humanitarian immigrants, and undocumented immigrants. Consequently, the frequently cited 45 million uninsured Americans is actually an estimate for the number of uninsured individuals living in America, not the number of uninsured citizens. Therefore, healthcare reform proposals aimed at providing universal coverage by reducing the reported 45 million Americans without it have misspecified the universe of the uninsured. This is an important distinction that needs to enter the debate on healthcare reform.
Most explanations for the substantial proportion of individuals lacking health insurance in the US take a health economics perspective and center around pricing issues. While these considerations are certainly important, one barrier that is rarely mentioned in the discourse is legal status. Although the CPS does not specifically ask about the legal status of its respondents, estimates suggest that approximately 10 of the 45 million uninsured individuals living in the US are foreign-born non-citizens , many of whom are likely undocumented immigrants. Few plans aimed at facilitating universal coverage, including the one delineated by President Obama during his campaign, make any mention of increasing access for non-citizens who are legally restricted from coverage; this includes legal immigrants who have been in the US for less than 5 years and are denied Medicaid and State Children’s Health Insurance Program (SCHIP) coverage, as well as undocumented immigrants. As far as we know, only one proposal, the recent Call to Action Health Reform 2009 plan by Senator Max Baucus , attempts to reduce the 10 million uninsured foreign-born non-citizens living in the US by eliminating the five-year waiting period before legal residents are eligible for Medicaid and SCHIP. Although some would argue that universal coverage implies access for citizens only, we suggest that coverage for all members of our society, including citizens, legal residents, and undocumented immigrants, is important and should be considered.
Given the privatized employer-centric nature of the US healthcare system, along with a dismal history of extending coverage to even the most vulnerable of groups (e.g., President Bush’s veto of SCHIP in 2007), few arguments have been made for extending healthcare to immigrant groups. Those that have commonly take a human rights approach . While we believe that health, and specifically access to healthcare, is a human right, this belief is not universally held and has failed to gain political traction. After all, it was only a few months ago that John McCain categorized access to healthcare as a responsibility rather than a right . Recognizing the limitations of this perspective, we conducted a critical review of the peer-reviewed, public health literature covering topics related to the health status and access to health services among immigrant populations in the US. Based on the results of this review, and specifically examples from infectious and chronic disease epidemiology, we argue that access to health services is at the intersection of the health of uninsured immigrants and the general population and that extending access to healthcare to all residents of the US, including undocumented immigrants, is beneficial from a population health perspective.