This is a policy memo by Soraya Ghebleh that addresses improving access to healthcare for undocumented immigrants living in Arizona.

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Policy Analysis Memo: Improving Accessto Healthcarefor
Undocumented ImmigrantsResiding in Arizona
Executive Summary
Access to care is an issue that has been necessary to address for those with
insurance or without insurance. A population that is vulnerable regardless of
insurance status, however, is individuals who are undocumented but live and work
in the United States. Under health care reform, these undocumented immigrants
would remain uncovered and unprotected.1 In many respects, they may become
more visible as those who previously did not have insurance gain coverage. While in
the short run it may appear as though providing undocumented immigrants with
basic services and preventative care may create a burden for the system, the long-
term ramifications of not providing these services will inevitably lead to larger and
more expensive healthcare problems.2 In 2010, Governor Jan Brewer of Arizona
signed one of the toughest bills in the nation on illegal immigration, marking an
extremely controversial shift in the politics of state law and immigration.3 Arizona
has long been a hotbed for immigration politics but not providing access to basic
healthcare services and preventing undocumented immigrants from seeking care
poses not only ethical problems but will in fact increase the cost burden of
healthcare in this country. Providing basic, preventative services could reduce the
emergency room burden and have the potential to reduce systemic costs.

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Problem Statement:
How can we provide access to healthcare for undocumented immigrants without
increasing the cost burden or change health-seeking behaviors among
undocumented immigrants in Arizona?
Background of Access to Healthcare for Undocumented Immigrants
Illegal immigration is a controversial issue for many individuals. Those living
in border states such as Texas, New Mexico, Arizona and California may have
stronger opinions on how to deal with immigration policies because the population
of undocumented immigrants is very high in these states. The passing of Senate Bill
1070 by Janet Brewer demonstrated the lengths state legislation was willing to go to
exert control over what was perceived to be a growing problem and threat to the
local stability of the community.4 The main controversies that surround
undocumented immigrants now are no different than many of the causes of anti-
immigrant sentiment in the past. Individuals in Arizona, under the strain of the
current economy, may view the existence of a large immigrant population as a
threat to their employment or future employment status. As the economy is
strained, individuals may be less inclined to support undocumented immigrants
receiving any form of social services, including access to healthcare.5
Access to healthcare is unique for an undocumented immigrant in that many
individuals who contribute much less to the American economy receive health
benefits but undocumented immigrants often have no access to healthcare and are
fearful. Many of these immigrants suffer disproportionate health consequences
solely due to their socioeconomic status and existing racial disparities but the strict

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and extreme nature of the current immigration policies now in place in Arizona
exacerbate this problem even more.6 Currently, the environment undocumented
immigrants need to navigate through to receive access to any type of basic care
involves decreased access to health care and social services and increased strict
enforcement stringent policies. In 2011, Arizona attempted to pass even more
specific legislation aimed at further reducing access to care but this measure did not
reach fruition. The ramifications, however, continue to challenge immigrant use of
healthcare in Arizona.6
Under health reform, there are further questions that need to be addressed.
Many undocumented immigrants who do not have access to regular care often
receive their only care in safety net settings. These settings include emergency
rooms, which are the most expensive care setting and often cause the highest
burden to the health system. Even with universal coverage being implemented as a
requirement, this coverage extends only to citizens. Undocumented immigrants will
still have access to the emergency rooms and will continue to utilize these services
at a much higher cost than if they received access to these services elsewhere.7
The main issue lies at the crux of the moral obligation held by the United
States to provide health care to all those who need it on one hand, and on the other
hand that those illegally in this country should not receive the social benefits paid
for by tax-payers and citizens.8 Under health care reform, the fate of the
undocumented immigrant will be left to the hands of state governments and it is
crucial in this moment to decide on how to move forward in addressing the
undocumented immigrant’s access to health care resources and services in Arizona.9

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Statement of the Policymaker’s Interest in the Issue
Senator Flake has been interested in broad immigration reform but now
maintains a strong stance where border control and security are concerned. Senator
Flake understand the dangerously high costs associated with providing the majority
of care in an emergency room setting and has supported obtaining federal funding
reimbursement for emergency health services to illegal aliens. Because Senator
Flake is interested in reducing these costs and improving issues associated with
immigrant populations, he is potentially the best politician for this proposal to be
seen by.10
Existing Programs addressing Health Care for Undocumented Immigrants
Various programs and policies have been implemented that have affected
immigrant access to healthcare. Medicaid provided coverage to poor legal
immigrants and their children and Medicare provided access if immigrants were
covered in the United States legally or if a spouse had covered employment for at
least ten years after the introduction of the programs.11 The Emergency Medical
Treatment and Active Labor Act of 1986 requires all hospitals to assess and stabilize
patients in the emergency room and this in turn provided presumptive Medicaid
coverage to every individual entering the emergency room, including
undocumented immigrants.11 The Personal Responsibility and Work Opportunity
Reconciliation Act in 1996 began to deny undocumented immigrants access to
Medicaid and food stamps and required documented immigrants to wait five years
for Medicaid. Under the Patient Protection and Affordable Care Act, undocumented
immigrants are largely excluded despite the overarching principle of reform being

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to provide coverage for nearly every American.11 Increased restrictions as well as
changes to Medicaid and SCHIP coverage have reduced the access to care and
increased expenditures on emergency room care for undocumented immigrants
place a burden that could potentially be reduced if care was supported and provided
in an alternative setting.11
Policy Recommendations
One policy option in the light of healthcare reform is to ensure that a robust
safety-net system exists in order that those excluded from health care reform, like
undocumented immigrants, will still have access to care. This should not, however,
be in the form of an emergency department setting. If increased funding and
support is given to free clinics to provide very basic services and preventative care
for undocumented immigrants in a safe setting that does not require immigrants to
produce documents, this could have the potential to reduce the cost burden by
reducing the number of undocumented immigrants who seek care in emergency
room settings.8 These services can be provided in much of the same way they were
previously provided to uninsured individuals.7
Another policy option is to ensure that women continue to retain their ability
to access certain services like childbirth and health screening and be covered under
Medicaid.8 This policy is not indicating that equal and identical services be provided
but that there remains a viable option to seek care without fear of penalty. Health
care centers should not be institutions that instill fear for individuals who are
already burdened with disease and should not be looked at as places to potentially
discover and punish undocumented immigrants.12

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Conclusions
Health reform and current trends in healthcare have been aimed at
accomplishing increased access, improved quality, and reduction in cost.13
Implementing policy that is aimed at reducing emergency room expenditures that
will be spent on undocumented immigrants can have the potential to accomplish all
three of these components. Because of the Emergency Medical Treatment Act,
undocumented immigrants will have access to healthcare services regardless of any
policy that is instituted unless this particular law is overturned. With this in mind, it
is prudent to consider that rather than continuing down a path that will singularly
provide access to health care in the emergency department, policymakers should
consider cheaper alternatives. Increased access in community health centers that
may not even include being seen by a physician but instead by a nurse or a
physician’s assistant could drastically reduce the emergency department burden
that gets shifted between the federal government and the state. The increasing
numbers of undocumented workers who contribute to the economy in the form of
consumption are not going to disappear and they will continue to require access to
medical care. Therefore, it is essential that we affect policy change that is in the best
interests of the financial burden of the nation but also policy that provides essential
health services to all individuals, regardless of their documentation or paperwork.
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