Let's imagine that someday we have a Congress and president willing (once more) to enact federal legislation that expands access to health care. That could happen as early as 2021. But what policies will result in the best coverage, for the least money, for the most people? Who will get left out? These are critical questions, and the debates among politicians, activists, and public-health professionals right now will determine which eventual proposals will have a chance of becoming law.
Medha Makhlouf, a professor at Penn State University's Dickinson School of Law, argues in a new article that many of the best ideas around expanding access to health care overlook a critical population: immigrants. In "Health Justice for Immigrants," published last month in the University of Pennsylvania Journal of Law & Public Affairs, Makhlouf makes two points. First, that the Affordable Care Act, the last major piece of legislation intended to increase health access, largely left out 23 million non-citizens; and, second, that "excluding immigrants from some of the key benefits of the ACA actually increased the disparity in access to health care between U.S. citizens and immigrants."
As Makhlouf demonstrates, immigrants were already excluded from many public-health benefits, and it's telling that the ACA solidified rather than eroded that exclusion.
Excluding immigrants from health care is bad for immigrants, but it also threatens public health more generally. Makhlouf describes the case of Elena (a pseudonym), a poultry worker in Iowa without employer-provided health care, who "came to the United States from Guatemala with her husband and young children to escape gang violence." Elena becomes sick with tuberculosis but can't afford the fee to see a doctor; she can't even afford to take a day off work. When she doesn't get treatment, though, that also puts her co-workers, friends, and family at risk.
The exclusion of vulnerable populations such as immigrants from social welfare programs is not exactly a new problem, but Makhlouf is concerned that even new, apparently progressive proposals might also exclude immigrants.
"Health justice," Makhlouf notes, is an analytical framework that shifts the focus from the rights of individuals to the ways that "universal access to affordable health care protects collective as well as individual interests." But are immigrants, she asks, "included in that 'universe?'"
Makhlouf's paper goes through immigrants' legal eligibility for all federal health-care programs, and finds a decidedly mixed picture. Makhlouf also discusses the stigma and fear that keep immigrants from accessing even programs for which they qualify. This latter factor is particularly important, Makhlouf says via email, because it means that simply expanding access to programs like Medicare and Medicaid to more immigrants won't solve the problems.
"One of the weaknesses of a rights-based strategy is that the hyper-focus on rights can diminish attention to factors that enable people to exercise their rights," Makhlouf tells me. "For example, an immigration policy crackdown and anti-immigrant rhetoric at the highest levels of government can dissuade immigrants from accessing health care even if they have the right to subsidized coverage."
In other words, health justice requires immigration justice. All the fights for equity are linked.
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