The COVID-19 pandemic provided multiple challenges for the healthcare community. One result has been the greater awareness of health disparities for specific populations living in the United States. Addressing personal biases and structural barriers to health has been a growing focus for healthcare organizations and communities. Despite these concerted efforts, at least one population living in the United States-undocumented immigrants (UI)-continues to encounter barriers to health as a direct result of exclusive public policies and limited community resources.
The Labor Council for Latin American Advancement (2020) estimates that more than 11 million UIs live in the United States, which is about 3% of the population. Undocumented immigrants are foreign-born people living in this country without authorization. They may have entered illegally or had lawful residency status which later expired (Artiga & Diaz, 2019). What is commonly misunderstood is whether UIs contribute to tax revenue, prompting the argument that UIs should not benefit from public aid and community resources (Rahman, 2021). In actuality, UIs paid $27.2 billion in taxes in 2017 alone, and close to 80% of UIs in the United States worked in 2021 (Rahman, 2021). Although UIs live, work, and pay taxes, many public and health policies restrict UIs' access to community and healthcare resources, contributing to health disparities and a decline in health over time (Kerani & Kwakwa, 2018). Individuals from Mexico and Central America are the fastest-growing foreign-born population in the United States; therefore, much of the research completed for this article is specific to Hispanic and Latino populations (Hammig et al., 2019). However, the implications discussed that speak to the nurse's role in health advocacy for the UI can apply to any ethnic population living in the United States. The Christian nurse, guided by biblical principles and the American Nurses Association's Code of Ethics for Nurses (ANA, 2015), should take the initiative to advocate for the UI's healthcare needs by supporting and promoting more inclusive institutional and government policies for the UI.
DEFINING THE PROBLEM
The Affordable Care Act (ACA) enacted in 2010 sought to make healthcare affordable and accessible for all U.S. citizens. A key motivator for its creation was the lack of affordable health insurance options to many people in lower-income households. What the ACA achieved simultaneously was the further restriction of healthcare access to UIs, as they were exempt from any public aid provisions available through the ACA (Artiga & Diaz, 2019). This has left healthcare access options for nonemergent needs to state legislation and private insurance. Some states have allowed for the provision of Medicaid funding for treatment of certain chronic health conditions, whereas others have restricted healthcare access still further (Philbin et al., 2018). If a particular state's policies do not provide public aid resources, a UI's employer may offer a private insurance option (Ingram, 2020). However, most UIs remain uninsured due to limited affordable insurance options and restrictions to eligibility (Artiga & Diaz, 2019).
Health policies are not the only policies that contribute to barriers of health. Restrictive immigration policies can encourage a culture of xenophobia within communities (Morey, 2018). Although immigration policies continue to be heavily debated across party lines, both Democrat and Republican political parties have proposed policies that have contributed to continued health disparities for the UI. Bipartisan support of policy reform is needed to address barriers of health for the UI. However, before nurses can advocate for this change, they should first understand the causes and types of disparities present for the population living in their community.
Social Determinants of Health
One way to recognize a population with health disparities is to collect data that compare a population's social determinants of health (SDOH) with the regional, state, and/or national rates. The SDOH is a globally acknowledged tool for identifying health disparities by evaluating a population's risk for poor health and livelihood in five categories: health and healthcare, economics, social/community, neighborhood/built environment, and education (Office of Disease Prevention and Health Promotion, 2020). Hospitals and community-based programs should identify barriers that individuals and populations encounter to aid in developing effective action plans to reduce these barriers (Lathrop, 2021). The following sections discuss barriers to health for the UI within the noted SDOH categories. Unfortunately, the UI encounters multifactorial barriers to health and wellness across all SDOH categories. The following sections discuss examples of these health gaps but are not an exhaustive list of disparities that can exist for the UI.
Healthcare: Limited Insurance and Treatment Options
Limited healthcare access for the UI has several contributing factors, some of which will be discussed in later sections. However, it is impossible to discuss UIs' health disparities without first reflecting on the lack of preventative interventions arising from their limited or lack of health insurance. On average, UIs are healthier than U.S. citizens when they first arrive in this country (Kerani & Kwakwa, 2018). However, studies reveal that UIs' health degrades over time and is strongly correlated to how long they've lived in the United States (Kerani & Kwakwa, 2018). One contributing factor to the UI's degradation of health has been linked to their limited access to health insurance and preventative healthcare resources (Ingram, 2020). Access to affordable health insurance options and the provision of free community health clinics can mitigate these risks substantially, which affirms that healthcare access can improve wellness and reduce illness for the UI (Wyrick et al., 2017). Nevertheless, even if employers offer some level of insurance to the UI employee, UIs often avoid insurance due to cost or a fear that applying for it might increase the risk of deportation for themselves or family members (Rahman, 2021).
Economic: Limits to Public Aid
Undocumented immigrants are more likely to work seasonal and labor-intensive jobs when compared with citizens and other immigrant groups (De Trinidad Young & Pebley, 2017). Additionally, these individuals typically have lower incomes that make private insurance infeasible (Artiga & Diaz, 2019). (See sidebar) Also, UIs are ineligible for public aid established by the ACA, which can delay seeking medical care (Wyrick et al., 2017). These delays may result in emergency situations requiring more expensive medical treatment as well as the development of chronic conditions (Doshi et al., 2020). These chronic conditions also result in increased medical bills and a worsening state of health over time (Wyrick et al., 2017).
Education: Limitation to College Education
Access to a college education may seem the least likely to contribute to health disparities. However, Healthy People 2030 (n.d.) identified that individuals with access to higher education tend to be healthier. Undocumented immigrants face barriers with higher education because they cannot receive federally funded education benefits (Morey, 2018). This reality impacts career options, economic stability, and a stable living/working environment (Lopez-Sanders, 2017).
Social/Community: Chronic Stressors from Fear of Deportation
A key social determinant that impacts UIs is the chronic stress from fear of deportation (Green, 2019). This stress leads to the UI's general distrust of government workers that can lead to disengagement with the community and a decline in physical and mental well-being over time (Doshi et al., 2020). This reality increased after 2017 when the U.S. Immigration and Customs Enforcement Agency (ICE) received greater jurisdiction under the Office of Homeland Security (Morey, 2018). During fiscal year 2017, ICE performed twice as many noncriminal arrests of UIs compared with the previous year (Kerani & Kwakwa, 2018). Long-term stress related to deportation can negatively impact cognitive development in children and the overall health of adolescents and adults (Green, 2019). Health conditions in adults that may arise from chronic stress include hypertension, migraines, diabetes, heart disease, anxiety, and depression. Qualitative studies demonstrate a correlation between the UI's fear of deportation and delaying medical treatment due to the belief that healthcare workers might report them (Doshi et al., 2020). Furthermore, government policy infrastructure that actively discourages UIs' access to community and social services can lead to unavailability of resources within the healthcare community that can further exacerbate existing disparities (Philbin et al., 2018).
Environment: Unstable Work Environments
Undocumented immigrants are more likely to work in unstable work environments: physical labor jobs, seasonal positions, and other essential jobs (Langellier, 2020). This fact increases the possibility of work-related injury, but as previously stated, lower income makes it unlikely UIs will have health insurance (Ingram, 2020). Undocumented immigrants rarely receive paid sick leave, so are unlikely to take a sick day when needed (De Trinidad Young & Pebley, 2017). In certain states, UIs have more access to healthcare screening options. However, across the board, the UI encounters barriers to healthcare access and community resources due to restrictive state-level healthcare and immigration policies (Philbin et al., 2018). Many UIs are unable to afford time off work, so they delay seeking medical assistance for conditions until it is an emergency (Rahman, 2021). This cycle of avoidance of time off work for an injury or health condition leads to an overall worsened state of long-term health and adds further barriers to employment (De Trinidad Young & Pebley, 2017).
BARRIERS WITHIN THE HEALTHCARE SYSTEM
Language and Cultural Barriers
When a UI decides to seek medical attention, barriers within the health system also can negatively impact health outcomes. Regarding language, the National Standards for Culturally and Linguistically Appropriate Services provide standards for offering language interpreters to those with limited English (Think Cultural Health, n.d.). These standards of interpreter use can mitigate language barriers for the non-English speaker. However, even when interpreters are used appropriately, language and cultural differences can make it difficult for UIs to trust healthcare providers, resulting in perceived or actual lower quality health (Doshi et al., 2020). Language and cultural differences are two examples of institutional barriers encountered by UIs within the healthcare system that result in their failure to seek out healthcare resources when needed (Hammig et al., 2019).
Lack of Research Studies
In 2020, Latinos represented 18.7% of the U.S. population and the largest immigrant group (Jones et al., 2021). However, researchers find it difficult to capture data for the UI-the lack of representation in studies is due to UIs' fear of deportation and general mistrust of the healthcare system. Even inclusive studies can underrepresent UIs, as many avoid participation (Doran et al., 2018). Thus, healthcare workers have challenges in anticipating and meeting the needs of UIs. Lack of data also can lead to health disparities as limited evidence-based research exists about the root causes of their health disparities.
Bias of Healthcare Workers
The UI may manage to navigate through the previously discussed barriers to health. However, personal or implicit bias of healthcare staff is an additional barrier that impacts equitable provision of care (Morey, 2018). Doshi et al. (2020) cited studies that demonstrated how immigration policies influenced healthcare workers' personal biases, resulting in differential treatment for specific ethnic populations regardless of citizenship status. Furthermore, implicit biases tend to be present in the healthcare community at the same rate as those existing in the general population (Edgoose et al., 2019). If healthcare staff are unable or unwilling to identify their biases toward specific populations, the result can be harm to the patient through misdiagnosis, cultural misconceptions, and a breakdown in trust between providers and patients (Edgoose et al., 2019). Healthcare organizations can combat this by educating staff on multicultural communities and supporting inclusive community resources regardless of ethnicity or citizenship (Bryant-Moore et al., 2018).
A BIBLICAL BASIS FOR ADVOCACY
The Christian nurse should feel compelled to advocate for the removal of healthcare barriers for the UI as a reflection of God's concern for foreigners. In the Old Testament, God gave clear instruction to Israel about living in a manner that pleases him and serves as a witness to surrounding nations. A part of God's instruction to Israel included the need to care for the foreigner (Leviticus 25:35). God directed the Israelites to "treat the stranger who sojourns with you as the native among you, and you shall love him as yourself, for you were strangers in the land of Egypt" (Leviticus 19:34, ESV). This language anticipates Jesus' greatest commandment in the New Testament: "Love the Lord your God with all your heart and with all your soul and with all your strength and with all your mind, and your neighbor as yourself" (Luke 10:27, ESV). In Zechariah 7:9-10, God stated his expectation that his people show kindness and mercy to strangers in the land.
As Christians, we are people of God proclaiming the truth of the Gospel through word and deed in our communities. God calls us to love our neighbors and defend the needs of the oppressed (Proverbs 29:7). In the parable of the Good Samaritan, a neighbor is described as anyone who shows compassion to those they encounter who are in need (Luke 10:30-37). As nurses engage daily with patients and populations who have needs, the Christian nurse is, therefore, uniquely positioned to lead in advocating for and providing equitable healthcare to the UI.
A CONSTITUTIONAL REASON TO ADVOCATE FOR EQUITABLE HEALTHCARE
Public policy provides society a way to establish what is right and to correct what is wrong. Health policy can correct institutional and societal injustices while developing pathways of health for the poor and marginalized (Williams et al., 2018). Nevertheless, over the last several decades, government has struggled to enforce immigration policies. Arbitrary limits to the type of healthcare a UI can receive indirectly enforces immigration laws while creating ethical dilemmas for healthcare workers who wish to provide equitable care to patients.
The current U.S. healthcare system relies heavily on government funding from Medicare/Medicaid reimbursement, so the provisioning of equitable healthcare to the UI is unavoidably policy-driven (Lopez-Sanders, 2017). Immigration discussions are also policy-driven and have been heavily debated across party lines for the last several decades. The 19th century French economist Frederic Bastiat provided clarity to why healthcare professionals should prioritize improving healthcare access to UIs even when policy restricts equitable healthcare. Bastiat explained, "Life, liberty, and property do not exist because men have made laws. On the contrary, it was the fact that life, liberty, and property existed beforehand that caused men to make laws" (Bastiat, 1950, p. 5). Although the natural laws are protected by the U.S. Constitution, they are not rights limited to U.S. citizens. These natural laws are available to every human because all people possess intrinsic value as creatures bearing God's image (Genesis 1:26-27). Therefore, these rights should be protected for all people and populations regardless of citizenship. The treatment of illness and promotion of wellness is a humanitarian discussion that surpasses government policy when this principle is applied to the issue of healthcare access for the UI. The UI population is, like U.S. citizenry, living, working, and paying taxes, yet UIs' lack of citizenship acts as a barrier to their life, freedom, and livelihood.
THE NURSE AS PATIENT ADVOCATE
The ANA Code of Ethics for Nurses (2015) states that nurses practice "with compassion and respect for the inherent dignity, worth, unique attributes, and human rights of all individuals" (p. 1). Furthermore, Provision 8.3 asserts that nurses have an obligation to advocate for policies and practice changes that correct health disparities (ANA, 2015). The nursing profession is integral to healthcare institutions and is rooted in a history of compassionate, ethical treatment of the sick and suffering regardless of a patient's circumstance. Nurses are tasked with caring for the health and wellness of individuals, communities, and populations. Nursing educator Sheila Burke (2016) calls on nurses to wield influence for the improvement of healthcare systems through practice standards and shaping policies at local and national levels. As current federal legislation restricts equitable healthcare access to the UI, nurses and other healthcare professionals are positioned to advocate for institutional and government policy changes that can begin to reduce existing health disparities.
The UI encounters numerous barriers within the healthcare system. The nurse advocate is well suited to take an active role in promoting change as well as providing compassionate and equitable care, believes community health equity leader David Ansell (2020).
The Christian nurse should begin any work by praying and seeking God's direction. The risk of implicit bias can impact a nurse's ability to provide equitable care and further health disparities; a worthy practice is to ask God to identify any personal ways we might be inclined toward bias against the UI. Each of us can prayerfully seek whether God is calling us to work toward healthcare equity for the UIs living in our own communities as well as in the state or nation. Acting on God's desire for Christians to practice hospitality to the stranger (Romans 12:13) and care for the oppressed (Psalm 146:9), we can trust God will provide tangible answers to prayers for our care for the disenfranchised (Matthew 7:7-8).
Raising Institutional Awareness
Perhaps the most feasible intervention for nurses is at the institutional level. Raising awareness among healthcare workers can begin the process of correcting aspects of personal or implicit bias present in healthcare organizations (De Trinidad Young & Wallace, 2021) and is a step toward reversing poor patient outcomes of UIs (Joseph, 2018). Repairing healthcare-related disparities can improve a person's health outcome as well as the state of health for the general UI population (Joseph, 2018). Nurses can advocate for specific patient needs and participate on institutional committees that identify and work to reduce health disparities.
Adopting implicit bias and diversity training programs within hospital institutions and nursing schools can aid healthcare workers in identifying areas of bias (Bryant-Moore et al., 2018). Nurses at institutions who do not have these types of educational resources can act as agents of change by asking hospital leadership to make these resources available.
Local/State Health Policies
Partnering with community and advocacy groups at the local and state levels for policy change can be the most impactful work to reduce health disparities for the UI (Williams et al., 2018). Working with communities in research of health disparities and correctional action plans can fuel local and state policy changes while widening avenues of healthcare access for the UI (Doran et al., 2018). Many communities have privately run health clinics for individuals without insurance. These clinics rely on private grants and donation, so they are often underfunded. Volunteering as a healthcare worker with these clinics and committing to their financial support are tangible avenues to improve healthcare for the uninsured, including UIs.
Although immigration status is determined at the federal level, most healthcare access for UIs occurs at the state level (Philbin et al., 2018). Some states extend Medicaid coverage to children of UIs and pregnant women. Nurses can advocate for change by asking policy makers for more inclusive public aid policies. Become informed about state legislation related to healthcare bills; communicate with legislators and government leaders about existing health disparities for the UI. Sharing personal experiences as a nurse can go a long way in giving context for a call to action.
National Immigration Reform
The final area of nurse advocacy is at the federal level. Social and immigration policies can have a dramatic impact on the UI's health and wellness (De Trinidad Young & Wallace, 2021). Emergent care is the only provisioned form of healthcare access for the UI within the ACA, despite evidence that demonstrates this does not promote long-term health and wellness (Lopez-Sanders, 2017). Although immigration laws are made by the federal government, there is an opportunity to advocate for immigration policy changes as well as health policies. National advocacy can pursue policy change to correct ICE deportation methods. Redirecting immigration assistance programs back to nongovernment agencies would unburden the Department of Homeland Security from overseeing noncriminal immigration cases (Kerwin & Warren, 2020). The peaceful oversight of immigration by privatized agencies and Christian mission work could help reduce fear of deportation for noncriminal UIs and provide better access to avenues of citizenship. Nurses can present a unique perspective on the benefits of immigration policy reform by demonstrating the impact immigration policies have on health disparities for the UI.
CONCLUSION
Healthcare and social policies often restrict healthcare access to the UI, resulting in health disparities. Although UIs lack citizenship, many contribute positively to society in the work force and pay taxes, yet they are unable to benefit from affordable and accessible healthcare. This sacrificial contribution of work and income without participation in community benefits is an inequitable handling of resources to the detriment of the UI. The UI's health is suffering from structural interference that requires a regulatory change that will allow for equitable healthcare access. As Christians, our responsibility to love and care for the foreigner is affirmed through Jesus' command to love our neighbors as ourselves. We are called to move against the tide of social norms in pursuit of love for the oppressed and socially marginalized. The Christian nurse seeking to uphold the ANA Code of Ethics can defend and stand with UIs by advocating for health and immigration policy changes that improve these persons' health and well-being.
Sidebar. Undocumented Means Insecure
Seeing police officers induces in 37-year-old Maya* a feeling of suffocating anxiety. When the car she shared with several family members was "borrowed" by an acquaintance who refused to return it, she declined to contact the police: Their involvement might lead to the discovery that her residency in Washington is illegal.
Maya's U.S. work visa expired 2 years ago. She was recovering from pneumonia and couldn't get her visa renewed in time. Now she lives like a shadow, avoiding uniformed law enforcement personnel and government entities in fear that any interaction could mean deportation.
Without valid papers, Maya, a single mother, sends her three children to school, but avoids visits to the school herself. Two extended family members share a small, poorly maintained apartment with Maya and her children. They pool money to try to pay the rent on time and buy food.
Maya works at a cafe, earning minimum wage, without benefits. Few options are evident to Maya to improve her lifestyle. She completed basic education in her homeland, but her English is limited to speaking and rudimentary reading. This limits her job possibilities and also increases her self-consciousness.
Maya cannot apply for food stamps, public health insurance, housing assistance, or any federal benefits. She visits food banks in her neighborhood and in a church basement near work. Although helpful financially, the products are often high in carbohydrates, ultra-processed, and sometimes lacking dairy and produce.
During the COVID pandemic, a Christian free clinic offered COVID vaccines; that's where she found treatment for her asthma and a new diagnosis: hypertension. Stress has deeply strained her body as well as her emotions. She has had to add the cost of prescriptions to her meager income.
The volunteers at the church food bank and the free clinic are the few trusted supports Maya encounters. There, she doesn't feel looked down on for her secondhand clothes or broken English; the stigma of being an undocumented immigrant is lessened. Through these interactions, Maya ventured into a church where her language is spoken, and she feels a sense of community. She wonders if someone there might help her improve her English and tutor her children so they can hope for a more secure future.-Karen Schmidt, BA, RN, JCN Contributing Editor
Web Resources
* Good RX Healthhttps://www.goodrx.com/healthcare-access/patient-advocacy/healthcare-undocumente
* Immigration Advocates Networkhttps://www.immigrationadvocates.org/about/
* Informed Immigranthttps://www.informedimmigrant.com/resource-type/healthcare/
* Kaiser Family Foundationhttps://www.kff.org/racial-equity-and-health-policy/fact-sheet/health-coverage-o
* The Hastings Centerhttps://undocumented.thehastingscenter.org/
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