I stared at the black, ulcerated foot before me and two thoughts ran through my mind: undocumented immigrant and minimal healthcare access.
“Why did you not come to the clinic earlier? You have diabetes, it’s dangerous to let this kind of wound fester.” Diabetes doesn’t play nice with foot wounds, and those that go untreated too often lead to gangrene and amputations.
“I know, Doctora. I stubbed my toe last month and I kept hoping it would go away, but it just didn’t. I got scared of how much it would cost and I also had to work.”
It was my first week as a nurse practitioner and my first hard lesson in what I now call healthcare on the back end, or more costly healthcare later in the disease process rather than earlier. On the front end, this would have been so much easier. Education on diabetic ulcers, a quick lesson in simple wound care, and perhaps an antibiotic. On the back end, however, it would cost him his foot.
For undocumented immigrants in the United States, far too much healthcare takes place on the back end. Due to the high risk of being uninsured and limited access to coverage, necessary care is often delayed. This underutilization of primary and preventive health services is further exacerbated by those forgoing medical care owing to a pervasive fear of being deported as a consequence of harsh deportation orders under the Trump administration. This leaves many undocumented immigrants exclusively dependent on emergency departments and the hospitals that are required to treat all patients under federal law regardless of immigration status. In spite of this, undocumented adults still visit emergency rooms at a lower rate than U.S.-born adults due to fear of incurring bills or of their citizenship status being exposed.
Anti-immigration rhetoric has perpetuated the idea that undocumented immigrants are here to take what is good (jobs, social services) and bring what is not (crime). Yet the truth is immigrants tend to work grueling physical jobs, increase the growth of local economies, and contribute to job creation. This is often while paying taxes towards services including Social Security and other safety net programs for which they are ineligible. Moreover, there has been no evidence to suggest that undocumented immigrant status is associated with higher crime rates. This makes sense considering anxiety over being deported if they are arrested, particularly in the current political climate.
In 2010, the Affordable Care Act (ACA) was a major step towards expanding healthcare coverage. Yet the ACA’s benefits were not extended to undocumented immigrants who were even disqualified from purchasing plans on the marketplace with their own money and who continue to be systemically excluded from social and safety net programs they often pay into.
COVID-19 is now highlighting how the disparity in undocumented immigrant healthcare affects more than the community it targets. Some hospitals are reporting being overwhelmed by the number of positive COVID-19 immigrants currently in their health systems. Additionally, many of these patients have not had regular access to primary care and are more likely to have uncontrolled chronic conditions, furthering their risk of developing costly complications from COVID-19 and further straining an already overburdened system.
The pandemic has also exposed the U.S. healthcare system’s failings in comparison to other countries. Ours is more expensive, more inefficient, and inequitable. The need for universal access to healthcare is increasingly obvious, yet the benefits of widespread access should not stop at immigration status. Our current system forces millions of people to seek expensive care from emergency departments later in the course of their diseases rather than before the late complications develop. This burdens already vulnerable groups of people and increases costs to the system as a whole, which further contributes to the cycle of inflating healthcare costs for everyone.
Most uninsured, U.S.-born adults cite hyperinflated healthcare costs as their primary reason for forgoing coverage. As this pandemic has painfully revealed, it is time for change. Yet with change we cannot buy into the rhetoric that if “they” have then “we” do not — it is an economic and ethical imperative that whatever changes are made to our current healthcare setup, whether universal healthcare or something else, that it be universal to all members of our society. The anti-immigration rhetoric breeds xenophobia and ignores the integral role undocumented immigrants play in bolstering the U.S. economy. This pandemic has torn apart the delicate fabric of our bloated health system and revealed that we are only as healthy as our sickest neighbors.
Jacqueline Naperola-Johnson, NP-C, is a family nurse practitioner in the process of earning a doctorate of nursing practice at Duke University. She has spent her career working with immigrant populations in Los Angeles and homebound and disabled patients in Detroit.