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Immigrant Health – Bioethics in Community Health

Immigrant Health

(Incorporating Undocumented Patients website archive, 2011-21)

What is Immigrant Health?

Immigrant health (or migrant health) encompasses research, practice, and policy concerning the health and wellbeing of non-citizens, immigrant households, and immigrant communities, with attention to health inequities related to migration or immigration status. Immigrant health also encompasses the health and wellbeing of refugees, displaced persons, and asylum seekers.

Sources of immigrant health inequities include unequal access to health care and health-related programs due to legal exclusions based on immigration status. Increased risk of occupational injury due to physically demanding or unsafe working conditions and health risks produced by overcrowded or unsafe housing are other sources of health inequities for immigrants. Immigration-related policies and political speech become sources of health inequities when they obstruct immigrants’ ability to seek and use health-related programs or put a community at increased risk of harassment and threats to safety.

Community health centers have broad mandates, supported through funding from the federal Health Resources and Services Administration (HRSA), to serve patients facing barriers to health care. Community health practitioners frequently serve immigrants who face barriers that include lack of insurance, transportation, childcare, and workplace protections such as sick days, in addition to language, literacy, and cultural barriers. Hospitals that participate in Medicare are required under the federal Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) to provide medical screening to all patients presenting in the emergency department and, if there is a need for emergency medical treatment, to treat the patient until stable. Hospital care for uninsured patients, including immigrants, may be reimbursed through application to a state’s Emergency Medicaid program.


Ethical Challenges in Immigrant Health

Ethical challenges concerning how to provide medically appropriate health care arise in the care of undocumented immigrants, who are excluded from federally funded health insurance programs because they lack or no longer have authorization to be present in the country where they are living. Undocumented immigrants have limited access to state or other public insurance programs. Ethical challenges also arise when an undocumented immigrant (or other uninsured or underinsured patient) needs non-emergency specialty medical treatment or diagnostics beyond the scope of a community health center and not covered by a state’s Emergency Medicaid program. These challenges are especially likely to arise in metropolitan areas, where most undocumented immigrants live and work.

Ethical challenges in immigrant health, and in community health broadly, frequently reflect gaps in health care financing. Individual practitioners can rarely fill these gaps on their own. Resources for practitioners seeking to secure and coordinate needed care for immigrant patients include medical social workers, medical legal partnership attorneys with expert knowledge of immigration law, and local community-based organizations serving immigrant communities. Crucial skills for practitioners in immigrant health include learning how to effectively collaborate across organizations and how to provide language services and culturally sensitive care.


Hastings Center: Research on Immigrant Health

The Hastings Center has conducted research on ethical challenges in immigrant health since 2011. Selected projects and publications are summarized below.

Undocumented Patients: Human Rights, Access to Health Care & the Ethics of the Safety Net (2011-13)

Funded by: Overbrook Foundation Domestic Human Rights Program

This foundational project explored ethical, legal, and policymaking challenges in access to health care for undocumented immigrants and their families in the United States. The project produced a special report, issue briefs, and other publications, plus a public database of key literature on this topic.

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Undocumented Patients:
Undocumented Immigrants & Access to Health Care

Read the Executive Summary

Berlinger, Nancy, and Michael K. Gusmano. “Undocumented Patients: Undocumented Immigrants & Access to Health Care.” Executive Summary. The Undocumented Patients Project. The Hastings Center, March 2013.

Values Engineering:
The Ethics of Design in Community Health Centers

Read the Article

Boltin, Benjamin, and Nancy Berlinger. “Values Engineering: The Ethics of Design in Community Health Centers.” Hastings Center Report 41, no. 1 (2011): 27–28. https://doi.org/10.1002/j.1552-146X.2011.tb00096.x.

The Ethics of Advocacy for Undocumented Patients

Read the Article

Berlinger, Nancy, and Rajeev Raghavan. “The Ethics of Advocacy for Undocumented Patients.” Hastings Center Report 43, no. 1 (2013): 14–17. https://doi.org/10.1002/hast.126.

Health Economics Policy and Law Cover

Revisiting “The Clinic”:
Ethical and Policy Challenges in U.S. Community Health Centers

Read the Article

Berlinger, Nancy, Michael K. Gusmano, and Eva Turbiner. “Revisiting ‘The Clinic’: Ethical and Policy Challenges in U.S. Community Health Centers.” Health Economics, Policy, and Law 9, no. 4 (October 2014): 425–34. https://doi.org/10.1017/S1744133114000140.

Issue Briefs: Undocumented Immigrants in the United States

Undocumented Immigrants and Healthcare Access in New York City (2014-15)

Funded by: The Robert Sterling Clerk Foundation

This public health convening of the New York Immigration Coalition and the Undocumented Patients Project of The Hastings Center explored opportunities for the City of New York to close gaps in health care access for undocumented, uninsured city residents ineligible for state-funded Medicaid, with attention to values questions: how could a program be fair, equitable, and locally sustainable? The convening produced policy recommendations to the Office of the Mayor of New York City. The principal recommendation of this report – for a direct access program offering health care plus care coordination – informed a pilot that was developed into NYC Care, a program that provides low-cost or free health care and other services to more than 50,000 New Yorkers.

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Undocumented Immigrants and Access to Health Care in New York City:
Identifying Fair, Effective, and Sustainable Local Policy Solutions

Read the Report

Berlinger, Nancy, Claudia Calhoon, Michael K. Gusmano, and Jackie Vimo. “Undocumented Immigrants and Access to Health Care in New York City: Identifying Fair, Effective, and Sustainable Local Policy Solutions.” New York Immigration Coalition & The Hastings Center, April 2015.

Improving Immigrant Access to Health Care in New York City

Read the Report

Barrios-Paoli, Lilliam. “Improving Immigrant Access to Health Care in New York City: A Report from the Mayor’s Task Force on Immigrant Health Care Access,” 2015.

Creating Systems of Safety for Immigrant Health (2018)

Funded by: Open Society Foundations Public Health Program

This public health convening reflected accelerating threats and harms to the health of immigrants and their families, including policies intended to curtail use of federally funded health-related programs by applicants for green cards (lawful permanent residents). The convening produced a working paper to identify realistic system-level responses for hospitals, clinics, and public health systems and continues to inform thinking concerning how to structurally support practitioners in immigrant health.

Related publications (2016-21)

The Illness Experience of Undocumented Immigrants With End-stage Renal Disease

Read the Article

Cervantes, Lilia, Stacy Fischer, Nancy Berlinger, Maria Zabalaga, Claudia Camacho, Stuart Linas, and Debora Ortega. “The Illness Experience of Undocumented Immigrants With End-Stage Renal Disease.” JAMA Internal Medicine 177, no. 4 (April 1, 2017): 529–35. https://doi.org/10.1001/jamainternmed.2016.8865.

Knowledge is Key for Safety-Net Providers

Read the Article

Berlinger, Nancy, Laura Guidry-Grimes, and Adira Hulkower. “Knowledge Is Key for Safety-Net Providers.” Health Progress, August 2017.

The Trump Administration’s Assault on Health and Social Programs:
Potential Consequences for Older Hispanics

Read the Article

Angel, Jacqueline L., and Nancy Berlinger. “The Trump Administration’s Assault on Health and Social Programs: Potential Consequences for Older Hispanics.” Journal of Aging & Social Policy 30, no. 3–4 (June 2018): 300–315. https://doi.org/10.1080/08959420.2018.1462678.

AMA Journal of Ethics

Is It Ethical to Bend the Rules for Undocumented and Other Immigrant Patients?

Read the Article

Berlinger, Nancy. “Is It Ethical to Bend the Rules for Undocumented and Other Immigrant Patients?” AMA Journal of Ethics 21, no. 1 (January 1, 2019): 100–105. https://doi.org/10.1001/amajethics.2019.100.

American Society of Law, Medicine & Ethics

“Getting Creative”:
From Workarounds to Sustainable Solutions for Immigrant Health Care

Read the Article

Berlinger, Nancy. “‘Getting Creative’: From Workarounds to Sustainable Solutions for Immigrant Health Care.” The Journal of Law, Medicine & Ethics 47 (2019): 409–11. https://doi.org/10.1177/1073110519876173.

Moving the Needle: How Hospital-Based Research
Expanded Medicaid Coverage for Undocumented Immigrants in Colorado

Read the Article

Cervantes, Lilia, and Nancy Berlinger. “Moving the Needle: How Hospital-Based Research Expanded Medicaid Coverage for Undocumented Immigrants in Colorado.” Health Progress, April 2020.

Journal of Palliative Medicine

Hospice Access and Scope of Services for Undocumented Immigrants: A Clinician Survey

Read the Article

Gray, Nathan A., Nathan A. Boucher, Lilia Cervantes, Nancy Berlinger, Sophia K. Smith, and Kimberly S. Johnson. “Hospice Access and Scope of Services for Undocumented Immigrants: A Clinician Survey.” Journal of Palliative Medicine 24, no. 8 (August 2021): 1167–73. https://doi.org/10.1089/jpm.2020.0547.

AMA Journal of Ethics

Resources for Teaching and Learning About
Immigrant Health Care in Health Professions Education

Read the Article

Berlinger, Nancy, and Rachel L. Zacharias. “Resources for Teaching and Learning About Immigrant Health Care in Health Professions Education.” AMA Journal of Ethics 21, no. 1 (January 2019): E50-57.

Responding to Low-Wage Migrant Workers’ Health During Covid-19 (2020-21)

Funded by: World Health Organization Health Ethics and Governance Unit, World Health Organization (WHO) 

This rapid-response collaboration with the University of Augsburg and investigators in the US and South Africa aimed to help practitioners, advocates, and researchers in low- and middle-income countries (LMIC) to identify promising practices and policy ideas concerning migrant health that were preserved in unindexed (“grey”) literature, such as newsletters and social media posts from community-based organizations in addition to working papers from academic sources.  The project produced a normative framework and practical toolkit for distribution via the WHO’s Public Health Emergency Preparedness and Response Ethics Network (PHEPREN).

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Responding to Low-Wage Migrant Workers’ Health During COVID-19: A Normative Framework and Practical Toolkit for Using “Grey Literature” as a Source of Promising Practices and Policy Ideas

Read the Report

N Berlinger, L Eckenwiler, V Wild, B Wills, “Responding to Low-Wage Migrant Workers’ Health During COVID-19: A Normative Framework and Practical Toolkit for Using ‘Grey Literature’ as a Source of Promising Practices and Policy Ideas,” Resource prepared for Public Health Emergency Preparedness and Response Ethics Network (PHEPREN) and the Ethics and Governance Unit, World Health Organization (WHO, March 31, 2021

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Covid-19 Update: Essential Resources on Immigrant Health

Read the Update

Berlinger, Nancy, and Benjamin Wills. “Covid-19 Update: Essential Resources on Immigrant Health.” The Hastings Center (blog).

Bioethics in Community Health