The Myth of the Burdensome Immigrants

Xenophobia and anti-immigrant sentiments situate South Asian and other immigrant communities as burdens on the health care system, missing the barriers, racism and classism they experience. To meet the needs of immigrant workers, these structural inequalities need to be addressed and considered in proposals for US health care reform.

Despite being one of the richest countries in the world and spending far more than other developed countries on health care, US residents experience consistently poor health status indicators, such as life expectancy, infant mortality rates, rates of chronic disease, etc. Poor health status in the US can be attributed, not surprisingly, to socio-economic burdens, which exacerbate inadequate access to health care. Those in the US who have insufficient or no health care access steadily continue to grow in number, reflecting these mounting socio-economic inequities. But there are additional factors that affect the health of these individuals, specifically among immigrant and minority communities in the US. Of particular interest to the reader, the South Asian immigrant community's experiences of the multiple burdens of classism, racism (including Islamophobia), and anti-immigrant sentiment, among others, have had adverse effects upon its health. So, the question arises, in the discussions of health care reform that are emerging now, how are South Asians configured into the analysis and the proposed solutions? While most traditional approaches to health care reform rely on studying the point of service delivery, we propose to take a step back, and look instead at the socio-economic and political context within which health services are being made available to South Asians, an approach advocated by Daniels, Kennedy, and Kawachi in their enlightening book Is Inequality Bad for our Health? In the process, we will examine the multiple systemic barriers that South Asian communities are confronted with as they interface with the US health care system. We do acknowledge the tremendous cultural and linguistic barriers that our community members also face at the point of health care delivery, but we propose to address these issues in a subsequent piece.

Let us first examine the US health care system itself more closely. Opening with much fanfare as well as scrutiny in 2007, SICKO, Michael Moore's much-anticipated documentary on the US health care system, has contributed to the heated debate about the broken health care system (the "unsystematic health care system" as Grace Budrys calls it in Our Unsystematic Health Care System) in this country and what should be done about it. In the 2008 presidential election, health care was deservedly regarded as one of the most important issues that merited consideration, and the film's impact has been by no means insignificant.

SICKO's essential message regarding the US health care system is that the control of health care financing, and therefore of delivery, rests largely in the hands of an unbridled health care insurance industry whose sole interest is maximizing profit. This message, sadly, reflects the truth about our health delivery system -- a truth that is rooted in the emergence of health insurance behemoths following the Great Depression. That is, health insurance is left to the fate of the free market, so health insurance companies, with a few minor exceptions, act like any other corporation on Wall Street. To increase their profits, insurance companies charge high premiums (payments by individuals and groups to health insurance companies) and provide low reimbursement (payments by health insurance companies to practitioners and hospitals). Often insurance companies explicitly deny reimbursement for certain clinical services ("benefits"), boosting their profits even more, but in the process leaving individuals without access to these services or responsible for the bill despite having insurance. Thus, denial of benefits and coverage to patients as well as unilateral determination (and reduction) of reimbursement to health care providers directly impact the quality and level of care individuals receive -- often to the point where care is not provided, or where care comes at a very high price to the individual, such as with the almost 50 million Americans who do not have any health insurance whatsoever. The crucial determinants of how these decisions are made are not based upon any sense of what is ultimately good for the public health of the nation, nor for any community or any individual -- they are based upon the relentless drive for corporate profit.

For the last few decades, most of the proposals that have been presented to remedy this unjust system have focused upon mandating other players in the system who have less power or capacity to account for health care coverage, such as employers or individuals. An example would be the recent plan in Massachusetts, which has placed the impossible burden of spiraling health care costs upon residents of the state; a single person in his/her 50s earning an annual salary between $30,000 to $50,000 and -- without the benefit of employer-subsidized coverage -- would have as his/her only comprehensive health care plan option one that would cost $7,200 annually. As an "incentive", not signing up for insurance carries with it a tax penalty and fines that increase with every year that an individual is not covered. By the way, this individual would not qualify for public insurance, since he/she would be making far above the state's financial eligibility requirements.

Michael Moore rightly points the finger to the health care insurance industry -- the proverbial elephant in the room that progressives and health care activists have long been trying to draw attention to -- as a central factor in the health care crisis in the United States. For most of the film, he pulls no punches in attacking corporate greed and highlighting the suffering of millions of American residents who have either poor or no health care coverage. Moore refers to national health care programs that remove the profit making incentive as potential solutions that can provide universal health care access. Little mention is made of immigrants or of communities of color, who bear additional burdens in health care disparity through various forms of discrimination and bias until the focus is brought upon the detainees in Guantanamo Bay.

This is where the film takes an unfortunate turn -- rather than continue in the spirit of social justice and assail the doctors and psychologists who have played an integral role in physically and psychologically torturing largely South Asian, Arab, and other Muslim immigrants who have been stripped of their most basic human rights, including habeas corpus, he instead declares that the detainees receive excellent ongoing medical care that almost no American has access to. Moore relies almost exclusively upon reports from the Department of Defense as well as other government officials in making this claim, ignoring extensive evidence to the contrary. Before the film moves on to the Cuban health care system and justifiably highlights its progressive and rational aspects, he leaves Guantanamo Bay without providing any context with regards to the detainees' imprisonment as well as completely disregarding numerous reports of how the medical establishment and the federal government have collaborated in torturing and abusing these detainees. (Another point that is ironically ignored is the legacy of health care injustices inflicted upon immigrants in Guantanamo Bay, such as the detention and human rights abuses of HIV-positive Haitians who have sought and been denied refuge in the United States.)

South Asians have represented a significant proportion of those who have been detained -- one third were Pakistani male nationals and the sixth largest group were Indian male nationals. Additionally, detention and deportation, resulting from such draconian post-9/11 measures as the US Special Registration Act of 2002, have created tremendous hardships and health care access issues not only for the men, but for their families as well. Wives, who previously had little knowledge regarding their families' financial resources were suddenly thrust into the position of simultaneously becoming the sole breadwinner and caretaker for their children and the elderly in the family, while also being indefinitely cut-off from their life partner. As they have been facing the already mounting social and economic pressures of raising their families alone, many women (such as from largely South Asian communities such as Midwood and Coney Island in Brooklyn, NY) are finding that health issues (related to themselves, their children, or others they care for) are a particularly difficult burden for them to shoulder. In this context, navigating the bureaucratic and restrictive US health care system has been often too impossible to bear for many of these families.

Moore's preposterous comparison between health care access for the detainees and that for the American population at large misguidedly attempts to rally support for a progressive, anti-corporate vision of health care reform by regarding South Asian, Arab and other Muslim immigrants as yet again the enemy of American interests -- not only are the detainees seen as the unquestioned face of terrorism, but they are also a representation of how unjust the distribution of health care in the US has become. That a prominent voice for what is considered the left wing of the American political spectrum in this country should scapegoat immigrants, particularly South Asian and Arab immigrants, is infuriating and divisive, but this is neither unique nor new. Indeed, the xenophobic populism that characterizes much of the American political landscape has led to many presumptions about immigrants and the US health care system's woes that are grossly inaccurate and misleading.

For example, often noted in the health care reform discussion is that the US spends per capita on health care more than double that of any other country in the world, despite having tens of millions of residents who do not have any health coverage whatsoever. Rather than logically relating this alarming discrepancy to the billions that the insurance and pharmaceutical industries have amassed from the health care business, a number of media figures (such as CNN news anchor Lou Dobbs, ironically admired in a 2007 Mother Jones article by South Asian journalist Sridhar Pappu) as well as government officials have been quick to attribute these inflated health care costs to the provision of health care services to the undocumented, claiming that such provisions divert scarce resources from US nationals. This has led to passing of legislation that has further restricted health care access for immigrants, both documented and undocumented. Unfortunately, the truth is that the undocumented are not even eligible for government financed health options, with a few exceptions such as PCAP (Medicaid for pregnant women), safety net institutions like New York City's HHC, and the increasingly stringent Emergency Medicaid.

A closer look reveals other reasons why the claim that the undocumented are to blame for elevated health care costs is completely unfounded. Per capita health expenditures for uninsured and publicly insured immigrants are 50 to 75% less than the US born, with Asian immigrants representing the second lowest group for these expenditures (after Latinos). Only 1.5% of total US medical costs are estimated to account for providing health care to all undocumented immigrants, which comprise double that percentage of the entire US population, and of which approximately 5% are of South Asian origin. While in recent years the largest rise in the undocumented has been that of Indians, undocumented immigrants still account for, according to the US Census, only 20% of the total numbers of uninsured and access health care services disproportionately less than uninsured US residents. The reality is that the undocumented, including South Asians, pose little of the burden that is claimed upon the American health care machine, as they utilize little to no public health insurance, consume government-subsidized health services at disproportionately lower rates than documented US residents, and do not represent a significant proportion of unaccounted-for health care expenses in the US.

Further, the little "burden" that undocumented immigrants may pose to the system is more than offset by the tremendous contributions made by these communities to the United States. Often missed in the discussions about immigration reform, many immigrants, like the large South Asian communities in urban centers such as New York City, are not only making significant contributions to the economy through their labor, but are also providing billions of dollars of revenue to the Social Security Administration (through payroll and other taxes) and yet paradoxically have much more limited access (if at all) to the public health services that they subsidize, unlike the US born or naturalized citizens. The IRS counted contributions totaling over $400 billion from documented immigrants in 2007, and a further $40 billion from undocumented immigrants -- two-thirds of whom pay payroll taxes according to the Social Security Administration. So, let's consider this for the undocumented, low-wage South Asian immigrant: a person that is dutifully filing taxes, sometimes paying back-taxes to make up for years he/she wasn't aware he/she had to pay (e.g. if they had been seeking asylum) still cannot use Medicaid nor Medicare dollars to finance his/her health care. To add insult to injury, despite primarily being workers in the United States, they will not get Social Security benefits when they reach retirement age.

In addition to the disparity between labor contributions and entitlements such as health care access, South Asians face financial hurdles both on the way to getting health care and while receiving services. Behind the "model minority myth" that shrouds the South Asian community lies the sad reality of the real poverty that many community members face, in particular our most vulnerable members. For example, one-third of South Asians who are living in poverty (from 50-125% of the federal poverty level) are children. Folks at the other end of the age spectrum also suffer -- as two-thirds of Bangladeshi seniors live below the poverty line currently. This largely stems from low wages that many South Asian community members are earning in the industries where they are most prevalent -- among the top 10 jobs for South Asians are cashiers, vehicle operators, and food preparation.

For example, take a young immigrant from India on a H1B visa who is fluent in English, has a graduate school degree and a job. He certainly has privileges, but what he doesn't have automatically is health insurance. He is healthy, works out, and keeps himself fit, but finds his blood pressure terribly elevated on a routine check. He feels dizzy and feels like he can't see out of his left eye at times. After a visit to the ER, he realizes he is at serious risk for a stroke -- this visit itself may jeopardize his hopes of getting a green card, but without this visit, his life itself could be in jeopardy. As an outpatient, he doesn't qualify for Emergency Medicaid, and because of his immigration status and his income, he can't qualify for Medicaid either. However, the hospital has also charged him a bill of $10,000, just for this initial assessment. How can he make the choice between paying his rent and paying this hospital bill? Sadly, it is also a choice he has to make between saving his immigration process and saving his life.

The lack of financial means presents hard choices for South Asian immigrants. For one, low salaries preclude many South Asians who do not qualify for public insurance from realizing health care coverage, just as their working class native born counterparts, if not more so. Nationally, the approximately 45 million uninsured make up 15% of the total US population. In urban areas such as New York City, however, where more recent South Asian immigrants work in a variety of independent contractor jobs that do not provide health insurance, many studies, such as one put out recently by the NYU Center for the Study of Asian American Health, have shown that the percentage of uninsured is significantly higher, ranging from 31 to 66%, even 80% in the case of South Asian taxi drivers. Data collected have indicated that 40% of South Asian women have no health insurance, and a recent report among South Asians in New York City demonstrated that nine out of ten domestic workers (child care, meal preparation, maid services, etc.) were not provided health coverage by their employer.

In this context, some immigrants have had to rely on other means, such as state sanctioned heterosexual marriage as a way to receive health care benefits, e.g., if one partner has health care access and the other does not. With the recent passing of Proposition 8 in California, as well as a slew of homophobic legislative measures in other states, Lesbian, Gay, Bisexual and Transgender (including hijra) South Asian immigrants, regardless of their documentation status, know that they do not even have the option of health benefits through one's life partner.

While South Asians face tremendous difficulty having any type of health care access, whether publicly or self-financed, the type of health care that is most readily available is that of emergency rather than primary care, another imbalance in our health care system that needs to be addressed as well. The industries mentioned above that working class South Asian immigrants find themselves in do not allow for the necessary flexibility for access to primary care. Add to this the inhibitions our community members feel with regards to being discriminating against because of skin color, dress, religion, and/or language. We know from studies, such as the Wirthlin Worldwide 2002 RWJF Survey, conducted with other immigrant communities that one out of five non-English speakers do not go to the doctor when they need to because of a perceived language barrier. South Asian public health professionals in New York City cite discussions with community members who have felt singled out in several different instances: women in waiting rooms wearing salwar kameez or head scarves, in-patients observing regular prayers, or men sporting beards. A delay in seeking attention for medical problems is hence commonplace, leading to complications and increasing severity, often to the point of requiring emergency intervention. When South Asian immigrants do finally seek out health services, they commonly encounter institutionalized discrimination, such as with lack of proper language interpreter services. In a survey of Indian immigrants in New York City completed in 2004, 43% of respondents felt that their doctor didn't understand or acknowledge their culture.

To summarize, both documented and undocumented South Asian immigrants, even though they provide significant contributions to the US economy, face numerous hurdles in accessing health care in this wealthy, resource-rich country. Socio-economic class disparity, restrictive immigration barriers, and the relative paucity of sufficient public entitlement measures such as Medicaid and safety net hospitals all mean that South Asian immigrants confront tremendous difficulty in engaging with the US health care system; when they do, they face the additional barriers of language and cultural discrimination. In the present US health care reform debate, despite the specific issues that we have raised, not only is there little discussion of how the needs of South Asian and other immigrant communities will be addressed, South Asian immigrant communities are in fact often unjustly scapegoated as the source of health care financing and delivery woes. Our analysis of the cost burden and availability of resources reveals that far from being the drain on the US health care system that has characterized this grossly distorted portrayal of South Asians and other immigrants, exactly the reverse is true. The reality is that these communities do experience a benefit-contribution disparity, but one in which they reap an unacceptable loss, in that they are providing far more to US society than they receive in benefit.

But more importantly, a just, humane system would provide comprehensive health care for all, regardless of their ability to provide contributions to society. Health care is, after all, a basic human right, and such rights are not contingent upon cost burden and resource considerations or the outcomes of the free market. It is this value that has prompted US society in general in being more amenable to the provision of health care for the disabled as well as children. We would argue that all residents as well as immigrants, documented and undocumented, can be subject to a myriad of barriers in accessing the means to live, let alone health services, and that concern over costs cannot and should not ever be allowed to impinge upon this right. It is all too obvious in the US that such concerns have led to the denial of the right to health care for so many, and South Asian immigrants in particular are feeling this impact.

In order to establish a system that can embody this important ideal -- of health care as a right for all -- we agree with the growing progressive movement, which acknowledges the need to confront the burden of excess costs by removing the third party payer profit motives, such as with the single payer proposals. We believe that no one should be left out, and that immigrants, including South Asian immigrants, should be explicitly considered in the proposals for US health care reform, so that they can realize their rights in accessing health care services as other residents do, free from discrimination, free from fear of reprisal and vilification, and without cultural and linguistic barriers.

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