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Treating Patients Afraid to Present

(from the October 2018 ACP Internist)

Undocumented patients pose a challenge to medical care, as they have trouble accessing and affording services. The current political environment is making it tougher for those who need help.

By Charlotte Huff

Effectively treating undocumented patients has always been difficult for physicians, given that lack of insurance and fear of deportation can delay diagnosis and hamper medical care, sometimes to a life-threatening degree. Some fear that the situation will worsen in an existing anti-immigration political climate.

Roughly 11 million undocumented individuals live in the United States, nearly three-fourths of whom were born in Mexico or in Central America, according to an analysis from the Migration Policy Institute, a Washington, D.C., nonprofit think tank. A 2017 report from the nonprofit Institute on Taxation and Economic Policy in Washington, D.C., estimated that undocumented immigrants contribute nearly $12 billion annually in a mix of state and local taxes, among them sales, property, and personal income. However, access to affordable health care has traditionally been limited.

The numbers of undocumented residents in the U.S. are likely to soon increase as people originally from Central America, Haiti, and Sudan lose their temporary protected status, according to a New England Journal of Medicine perspective piece published on May3, 2018. Meanwhile, people who are in the U.S. legally under the Deferred Action for Childhood Arrivals (DACA) program also remain vulnerable, potentially placing their jobs and health insurance at risk.

“There is not the most welcoming climate for immigrants right now,” said ACP President Ana María López, MD, MPH, FACP. Dr. López, who practiced in Arizona during that state's controversial SB 1070 “show me your papers” law, recalled how community health centers there reported a decline in patients because “people were afraid.” For instance, someone who is the sole breadwinner for his or her family may repeatedly postpone getting a medical problem checked out, fearful of heightening deportation risk, she said.

“Fear is a really powerful emotion,” said Dr. López, vice chair of medical oncology at Sidney Kimmel Cancer Center at Thomas Jefferson University in Philadelphia. “It's not only fear for themselves, but fear for their families.”

Gaps in care

In a 2011 position paper about national immigration policy, ACP leaders stressed the need for national policy changes to improve health care for immigrants, regardless of their legal status. “Access to health care should not be restricted based on immigration status, and people should not be prevented from paying out-of-pocket for health insurance coverage,” they wrote. They also cited the public health risks and costs incurred when individuals delay treatment or skip vaccinations and other basic care out of fear of prosecution.

Several recent studies have attempted to quantify gaps in care for undocumented patients, as well as the emotional strain on their treating clinicians. One recent study, looking at hospice access for undocumented immigrants, found that only two-thirds of the 179 responding agencies offered unrestricted enrollment. (The researchers noted that one limitation of the study, published in April 2017 in JAMA Internal Medicine, was that an additional 51 agencies responded to the rest of the survey, but not the questions about undocumented immigrants.)

In another study, published in the July 17, 2018, Annals of Internal Medicine, researchers interviewed 50 clinicians in Denver and Houston about the emotional impact of providing emergency-only dialysis to undocumented immigrants. They identified various drivers of burnout and moral distress, including emotional exhaustion from witnessing needless suffering, fears of jeopardizing patient trust, and frustrations with using costlier emergency services instead of routine dialysis.

The emotional impact on clinicians has been a worry for some time, but this study is the first effort to quantify its impact on professionalism, said nephrologist Ashwini Sehgal, MD, an ACP Member and professor of medicine at Case Western Reserve University in Cleveland, who wrote the accompanying editorial. Any hallmark of strain is worrisome, and more than one can exert a cumulative effect on clinicians, he said. “I think that takes it up to another order of magnitude in terms of how concerned we should be.”

Read the full article in ACP Internist.

ACP Internist provides news and information for internists about the practice of medicine and reports on the policies, products, and activities of ACP.

Back to the November 2018 issue of ACP IMpact