The emergency department is an important source of health care for immigrants and refugees/asylum seekers.1,2
Since the passing of the Emergency Medical Treatment and Labor Act (EMTALA), the ED has functioned as the health care safety net for immigrants, especially undocumented immigrants.3 As immigration and immigration status greatly affect behavioral choices surrounding health care, emergency physicians must observe unique considerations when caring and advocating for this population.
In 2020, there were 22.1 million non-citizens in the United States.4 This included refugees/asylum seekers (individuals forced to flee due to persecution, war, or violence); visa holders (individuals with visas based on employment, family status, trafficking victim status [T visa], and crime victim/witness status [U visas]); and undocumented individuals.5About four in 10 non-citizens were undocumented immigrants, making up approximately 3 percent of the U.S. population.4
Risk Factors/Clinical Outcomes
Immigration and immigration status are important social and structural determinants of health.6 Undocumented individuals are more likely to live below the federal poverty level, have poor English proficiency, and have not completed high school.2 Non-citizens are also significantly more likely than citizens to be uninsured and less likely to have a primary care physician or health care access in general.4,7,8
After the Affordable Care Act (ACA), one in five immigrants remains uninsured.9 Contributing barriers to insurance enrollment include fear, confusion about eligibility policies, difficulty navigating the enrollment process, language and literacy challenges, and the exclusion of undocumented immigrants from federal insurance options and the ACA marketplace.4 Despite the fact that the majority of undocumented immigrants are employed, they remain uninsured due to the lack of financial resources to purchase private insurance or are employed in jobs that do not provide insurance.1
These social and structural determinants of health perpetuate health and health care inequities among immigrant populations. For example, the stress of living as an immigrant has been associated with adverse outcomes, including low birth weights and increased risk for mental health conditions such as depression and anxiety.11 Undocumented Latino persons with HIV infection entered care with more advanced disease compared to documented persons, in the setting of reduced access to medical care and preventative health.12 In 40 of the 50 U.S. states, scheduled dialysis is withheld from undocumented immigrants with end-stage renal disease, leaving emergency-only dialysis as the only option for many. Compared with emergency-only dialysis, scheduled dialysis was associated with reduced mortality, health care utilization, and health care costs.13
Bedside Awareness
EMTALA allows for all patients, regardless of factors such as immigration or insurance status, to be evaluated in the ED.11 However, undocumented immigrants note significant barriers in presenting to the ED largely due to fear of discovery and deportation. Approximately half stated that this fear caused them to delay coming to the ED (with a median delay of two to three days).1,14 Given EM’s crucial role in caring for immigrant populations, it is important that emergency physicians ensure patients feel safe in the ED and address any fears in accessing care. Patients need to feel that EM providers are concerned with their health and safety regardless of immigration status or cultural differences.
As emergency physicians, we can help mediate fear and health inequities for immigrants at the bedside by:
- Not making assumptions on who is or is not an immigrant
- Not asking directly about patient immigration status (to not increase fear and mistrust)
- If immigration status comes up, reassuring patients that this confidential, HIPAA-protected information will not be shared or reported
- Asking if the patient or anyone in their family/community would be interested in further immigration resources (e.g., medical-legal partnerships)
- Identifying language barriers and using professional interpreters
- Recognizing that immigrants are vulnerable to exploitation, including labor and sex trafficking, and maintain a high degree of suspicion
Key Actions
As emergency physicians, we can address these social/structural determinants of health by:
- Educating individuals in health care and policymakers about the social and structural determinants of health and inequities impacting immigrant populations
- Avoiding documenting patient immigration status in the medical chart in order to reduce stigmatization, discrimination, and unintentional exposure15; if necessary, using general terms like “immigration-related stressors”
- Supporting and developing medical-legal partnerships and accessible social resources (e.g., housing, food, health insurance, immigration relief) for all patients regardless of immigration status2
- Developing an ED workflow for immigration enforcement situations in your clinical environment (e.g., identifying a response team with individuals knowledgeable in warrants and subpoenas to ensure immigrants’ medical-legal rights and protections are enforced)11
This article is part of an EMRA Social EM Committee initiative to disseminate information about social EM topics encountered in the emergency department. More information can be found in the EMRA MobilEM app’s Patient Conversation Toolkit, available for download via iTunes and Google Play.
References
- Rodriguez RM, Torres JR, Sun J, et al. Declared impact of the US President’s statements and campaign statements on Latino populations’ perceptions of safety and emergency care access. PLoS ONE. 14(10): e0222837. https://doi.org/10.1371/journal.pone.0222837. Accessed September 15, 2022.
- Samra S, Taira BR, Pinheiro E, et al. Undocumented Patients in the Emergency Department: Challenges and Opportunities. West J Emerg Med. 2019;20(5):791-798. doi:10.5811/westjem.2019.7.41489. Accessed July 30, 2022.
- Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; clarifying policies related to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions. Final rule. Fed Regist. 2003;68(174):53222-53264.
- Health Coverage of Immigrants. Kaiser Family Foundation. Published April 06, 2022. Accessed May 18, 2022. https://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-of-immigrants/.
- Overview of Types of Immigration Status. Center for Public Policy Studies. Published April 01,2013. Accessed September 01, 2022. https://www.sji.gov/wp/wp-content/uploads/Immigration-Status-4-1-13.pdf.
- Castañeda H, Holmes SM, Madrigal DS, et al. Immigration as a Social Determinant of Health. Annual Review of Public Health. 2015; 36:1, 375-392. https://doi.org/10.1146/annurev-publhealth-032013-182419. Accessed August 30, 2022.
- Derose KP, Bahney BW, Lurie N, et al. Review: Immigrants and Health Care Access, Quality, and Cost. Medical Care Research and Review. 2009;66(4):355-408. doi:10.1177/1077558708330425
- Tarraf, W, Vega W, González HM. Emergency Department Services Use Among Immigrant and Non-immigrant Groups in the United States. J Immigrant Minority Health, 2014; 16, 595–606. https://doi.org/10.1007/s10903-013-9802-z.
- Li Y, Toseef MU, Jensen GA, et al. Gains in insurance coverage following the affordable care act and change in preventive services use among non-elderly US immigrants. Preventive Medicine. 2021; 148.https://doi.org/10.1016/j.ypmed.2021.106546.
- Sommers BD. Stuck between health and immigration reform--care for undocumented immigrants. N Engl J Med. 2013;369(7):593-595. doi:10.1056/NEJMp1306636
- Saadi A, Sanchez Molina U, Franco-Vasquez A, et al. Assessment of Perspectives on Health Care System Efforts to Mitigate Perceived Risks Among Immigrants in the United States: A Qualitative Study. JAMA Netw Open. 2020;3(4):e203028. doi:10.1001/jamanetworkopen.2020.3028
- Poon KK, Dang BN, Davila JA, et al. Treatment Outcomes in Undocumented Hispanic Immigrants with HIV Infection. PLoS ONE. 2013; 8(3): e60022. https://doi.org/10.1371/journal.pone.0060022
- Nguyen OK, Vazquez MA, Charles L, et al. Association of Scheduled vs Emergency-Only Dialysis With Health Outcomes and Costs in Undocumented Immigrants With End-stage Renal Disease. JAMA Intern Med.2019;179(2):175–183. doi:10.1001/jamainternmed.2018.5866
- Maldonado CZ, Rodriguez RM, Torres JR, Flores YS, Lovato LM. Fear of discovery among Latino immigrants presenting to the emergency department. Acad Emerg Med. 2013;20(2):155-161. doi:10.1111/acem.12079
- Kim G, Molina US, Saadi A. Should Immigration Status Information Be Included in a Patient’s Health Record? AMA Journal of Ethics. 2019;21(1):8–16. doi.org/10.1001/amajethics.2019.8.