Where Every Man Is An Island:
A Comment on Immigrant Health Care

By Phyllis Griffin Epps

One of the greatest challenges faced by state and local urban governments is the delivery of health care to uninsured populations. Medicaid, for example, is an effort by the federal government to help states subsidize the cost of treating persons who lack private insurance. With the passage of welfare reform measures in 1996, however, eligibility for Medicaid was tightened to exclude recent immigrants. Five years later, the effects of such legislation on these challenges holds striking implications for the delivery of health care to immigrants and, indirectly, citizens alike. Recent developments in Texas illustrate the complexity associated with a large immigrant population and health needs that cannot be ignored.

In July, John Cornyn, the Attorney General for the State of Texas, issued an opinion that would effectively stop the Harris County Hospital District (HCHD) from providing free or discounted non-emergency health care to residents without regard to their immigration or legal status. The opinion is based on one interpretation of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), which purported to restrict the availability of public welfare services. According to the Attorney General, PRWORA preempts state and local laws charging the HCHD to serve indigent residents in need of medical services. The opinion has prompted legal debate and otherwise generated a great deal of controvery and consternation. Above the possible interpretations of PRWORA looms a question of particular importance: how can an area possessed of a large immigrant population, an typically overburdened health care system, and a collective sense of human dignity arrange the availability of medical care to fellow humans in need?

Texas, as with California, New York, and Florida, enjoys a large immigrant population relative to other states. In Houston, persons who are foreign-born immigrants comprised 18% of the population in 1999. According to the Kaiser Commission on Medicaid and the Uninsured, immigrants to Houston originate primarily from Mexico, Vietnam, and El Salvador. Where branches of government have acted to curtail the flow of non-citizens into the United States, such efforts have met with limited success. Consistent with a long American tradition, immigrants exist in large numbers and as a n important source of human capital in the local and national economy. And, like all humans, they get sick.

Immigrants, and particularly non-documented immigrants, are less likely to have the resources necessary to meet the high cost of medical care. With immigrants and non-immigrants alike, the inability to pay for medical care is associated with a tendency to delay seeking care. The wheezing worsens. An infection spreads. When the person can no longer avoid medical help, more serious intervention is required. Treatment administered later in the progression of disease or injury is more likely to require more time and expense. Thus, the greater the number of people who lack affordable access to medical care, the greater the number of persons who are likely to present as sicker patients requiring costly emergency services. The cost of treatment must be absorbed by the providers or passed on to other patients, both with insurance and without, through higher prices.

At the time of this writing, emergency care remains available to those who require it without regard to their legal status. Perhaps the availability is rooted in a shared sense of humanity or civility. Perhaps the prospect of denying emergency medical aid to persons without the proper papers for whatever reasons contradicts deep-seated social or moral values. Whatever the reasons, the financial realities attendant to a commitment to providing emergency care without regard to legal status seem inextricable from an interest in avoiding the cost of emergency medical services if opportunities exist to provide effective care more cheaply. Regardless of whether the network of health care delivery is predominately public or private in structure, the costs to the public are real and threaten what systems exist to administer care to those who legally reside in the area.

At issue in the Attorney Generalís opinion is an area of health care delivery with meaningful repercussions for the financial wherewithal of systems dedicated to the administration of medical care to indigent citizens unlucky enough to lack insurance in this country. Access to affordable medical care is not a problem unique to immigrants to the United States. The health care system in this country is arguably as famous for its expense as for its contributions to the world in technologies and technique. Persons living in the United States are less likely to have access to affordable medical services than are citizens of most industrialized countries. Texas is a leader among states in the numbers of citizens without insurance. With its high numbers of uninsured adults and children, Houston contributes its share to the state profile. In light of the Attorney Generalís opinion, those who would improve upon the delivery system of indigent medical care should consider Houston at the forefront of the problem, if not the solution. As always, their actions will have repercussions on citizens and immigrants alike.