Healthcare policy change and implementation

Definition and Description of the Issue
Health policy and immigration policy are interconnected, as attitudes towards immigrants—especially those who are undocumented—have impacted the substantive content of healthcare policies like the Affordable Care Act. Similarly, immigration policies have been influenced by real or imaginary threats immigrants may pose to public health or public health spending. Political and economic expediency guides both health and immigration policy, whereas frontline healthcare workers including nurses have a direct ethical and professional responsibility to patients regardless of immigration status. Effective public policy blends the ethic of duty to care with an honest evaluation of budgetary constraints and evidence-based practice. As much as possible, immigrant-related health policy ignores emotionally laden and fallacious rhetorical arguments.
Background
Since the nineteenth century, healthcare and immigration policy have been inextricably linked. New immigrants have been blamed for public health problems and for burdening the public health budget, and have also been labeled as being undeserving of health benefits (Mitchell, 2018). As a result, health policy in the United States has veered towards being anti-immigrant and exclusionary, culminating in a series of executive orders issued by President Trump that “fanned the flames of that anti-immigrant narrative, raising it into the country’s national consciousness,” (Center for Health Progress, 2018). The Affordable Care Act had only offered provisions for permanent residents, opening the healthcare insurance marketplace to green card holders and other documented immigrants—with strident provisions such as a mandatory five year residency period prior to eligibility (National Conference of State Legislatures, 2017). Therefore, even documented immigrants struggle to access essential services, and suffer from a wide range of mental and physical health problems as a result of denial of coverage. Undocumented immigrants are systematically excluded from accessing the healthcare insurance marketplace, but in some cases may be able to receive some emergency treatments, immunizations, and some disaster relief programs (National Conference of State Legislatures, 2014). The current state of immigrant health policy remains in flux, bogged down by inconsistencies among various states and rapidly changing rhetoric. The way forward is through a clarification of federal healthcare and immigration policy that aligns healthcare ethics with the principles of social justice.
Stakeholders
It would be a mistake to assume that the only stakeholders in the issue are undocumented immigrants. While the most vulnerable population, undocumented immigrants are also part of a broader social network. Therefore, American citizens and permanent residents are also primary stakeholders in immigrant healthcare policy. Immigrant healthcare policy also has a strong bearing on public health outcomes. Punitive immigration policies and irregular immigration policy enforcement leads to “profound mistrust of health services, avoiding health services, and sacrificing their health and the health of their family members,” (Rhodes, Mann, Siman, et al., 2014, p. 329). Fear of deportation also compounds mental health issues among immigrant communities—undocumented or not—with measurable increase in diagnosed cases of depression, anxiety, and post-traumatic stress disorder (Martinez, Wu, Sandfort, et al., 2015). Likewise, research shows that individuals living in states with “a more exclusionary immigration policy climate had higher rates of poor mental health days than participants in states with a less exclusionary policy climate,” (Hatzenbuehler, Prins, Flake, et al., 2017, p. 169). Both legal permanent residents and undocumented residents are underinsured; and about 28% of foreign-born residents in the United States are undocumented (Messias, McEwen & Clark, 2015). Undocumented immigrants and legal permanent residents can be considered primary stakeholders, but because healthcare policy ultimately affects all Americans, the stakeholder base should be expanded to include all taxpayers and all healthcare workers who daily meet with the struggle between the ethical duty to care and the financial barriers to providing care to individuals who need it.
Issue Statement
Immigration policy and health policy must converge to undermine the stranglehold insurers have on healthcare and allow for a single payer option that efficiently allocates funding for essential services. Anti-immigrant policy is not only unethical and impossible to align with healthcare ethics, but also impractical and ultimately, financially untenable. Boosting immigrant health promotes improved public health services for all.
Possible Methods of Addressing the Issue
Addressing the issue through policy change allows for an entrenchment of moral values that undergird the healthcare system. Furthermore, changes to immigrant health policy can spill over into other areas of concern including general immigration policy and economic policy. “When the system is amended to be inclusive, immigrants become contributors to the systems that they access,” (Kuczewski, 2017, p. 1). Healthier immigrants become more able and likely to contribute to their local and state economies. Similarly, opening healthcare options for new undocumented immigrants may reduce the rates of preventable mental and physical illnesses that drain local communities and the healthcare system in general. Healthcare policy should also be designed in ways that recognize the net value and gains that come from fostering trust: such as a greater willingness to receive vaccinations and preventative care. As it stands, immigrant adults and children are less likely to visit a doctor’s office whether or not they are insured and whether or not they are documented; the likelihood of visiting a doctor decreases as income decreases (Ku & Jewers, 2013).
Goals and Options for Change
The goals for changing current immigration healthcare policy would be to increase the accessibility of all healthcare services, reducing mistrust and fear among the immigrant population and thereby improving health outcomes for all stakeholders. Furthermore, the goal would be to eliminate confusion and inconsistency in policy implementation as nurses would no longer be constrained by conflicts of interest or competing ethical systems. Healthcare workers should not be placed in a position of having to deny treatment to those who need it based on immigration status. From a public health perspective, the goal of policy change would also be to improve local, state, and federal health outcomes.
Options for change include the development of a robust public awareness, media relations, and public relations strategy. Public health marketing actively changes the tenor of the discourse on immigration and health policy, by altering the diction used to refer to new immigrants, ceasing to portray immigrants as being drains on the system, and avoiding the logical fallacies that too often influence public opinion. All Americans would benefit from improving immigrant health policy, a message that can be ensconced in healthcare literature and political dialogues with the goal of influencing young voters. Switching from an attitude of anti-immigrant fear towards one that embraces the long-term plan of boosting quality of life for all Americans, healthcare policy can reflect the underlying values of the Constitution and the ethics that guide healthcare.
Risks and Benefits of Change
Without a doubt, changes to immigrant healthcare policy entail tremendous political and financial risk. Basing policy change on empirical evidence and systematic evaluation methods would help reduce risk and maximize the benefits of the intended policy change. Short-term costs will be offset by long-term gains, including paving the way for undocumented immigrants to ease their financial burdens and contribute to the intellectual, cultural, and economic growth of the country. The policy changes may require a total re-evaluation of the American healthcare system.
Once implemented, the benefits of the change to immigrant health policy will evolve, unfolding over the course of the next several generations. The outcomes will take time to manifest, as it will take years for immigrant attitudes towards healthcare to change, and for the attitudes of the American public to transform to the degree that healthcare is no longer viewed as a privilege but as a right.
Evaluation Methodology
Immigrant health policy and corresponding healthcare programs can be evaluated using several methodologies including outcomes-based or impact models. Outcomes-based and impact models use both quantitative and qualitative methods to determine which interventions are working and why, and what specific changes would be warranted in order to better meet program goals. Needs assessments should initially guide policy development, while ongoing interviews with stakeholders, quantitative measures of healthcare service usage patterns, and financial analyses will also help provide the data set that can be used to evaluate the proposed policy changes.
Recommendations
Based on an analysis of the successes and failures of immigrant health policy, it is strongly recommended that all immigrants, including the undocumented, be encouraged to access preventative and essential services with the goal of improving public health outcomes for all Americans. It is recommended that healthcare workers advocate on behalf of disenfranchised patient populations like undocumented immigrants, and ensure that families and communities build on their collective social resources to promote attitudinal changes. Finally, it is recommended that immigrant healthcare rhetoric reflect Constitutional values and the ethics of care.


References
Center for Health Policy (2018). Immigration policy is health policy. https://centerforhealthprogress.org/blog/publications/immigration-policy-is-health-policy/
Hatzenbuehler, M.L., Prins, S.J., Flake, M., et al. (2017). Immigration policies and mental health morbidity among Latinos: A state-level analysis. Social Science & Medicine 174(2017): 169-178.
Ku, L. & Jewers, M. (2013). Health care for immigrant families. Migration Policy Institute. https://www.migrationpolicy.org/topics/health-welfare-benefits
Kuczewski, M.G. (2017). How medicine may save the life of US immigration policy. AMA Journal of Ethics. https://journalofethics.ama-assn.org/article/how-medicine-may-save-life-us-immigration-policy-clinical-and-educational-encounters-ethical-public/2017-03
Martinez, O., Wu, E., Sandfort, T., et al. (2015). Evaluating the impact of immigration policies on health status among undocumented immigrants. Journal of Immigrant and Minority Health 17(3): 947-970.
Messias, D.K.H., McEwen, M.M. & Clark, L. (2015). The impact and implications of undocumented immigration on individual and collective health in the United States. Nursing Outlook 63(1): 86-94.
Mitchell, R.L. (2018). How does immigration policy affect public health in the US? Texas A&M Today. May 3, 2018. https://today.tamu.edu/2018/05/03/how-does-immigration-policy-affect-public-health-in-the-us/
National Conference of State Legislatures (2014). Federal benefits available to unauthorized immigrants. http://www.ncsl.org/research/immigration/federal-benefits-to-unauthorized-immigrants.aspx
National Conference of State Legislatures (2017). Immigrant eligibility for health care programs in the United States. http://www.ncsl.org/research/immigration/immigrant-eligibility-for-health-care-programs-in-the-united-states.aspx
Rhodes, S.D., Mann, L., Siman, F.M., et al. (2015). The impact of local immigration enforcement policies on the health of immigrant Hispanics/Latinos in the United States. American Journal of Public Health 105(2): 329-337.