Tuesday, December 23, 2014

Immigration policies and health care

I am a child of immigrants. My parents migrated from Taiwan to the United States in the 1950s and 1960s, my father as a graduate student and my mother as a toddler, at that time the youngest member of a family of seven. Both eventually became naturalized citizens.

The ship my mother's family took from China to the U.S.
It is much more difficult to immigrate legally to the U.S. today. Current policies overwhelmingly emphasize family re-unification, reserving two-thirds of "green cards" to persons who already have relatives residing in the U.S. Millions of highly skilled potential immigrants like my parents and grandparents - my father eventually programmed the Hubble Space Telescope, and my mother's father was a neurologist whose biography appeared in the 9th edition of Who's Who in the World - now compete for a comparatively small number of resident permits. Most must wait for years; many lose hope and return their talents to their native countries. As former Florida governor Jeb Bush wrote about the U.S.-Mexican border crisis earlier this year, "A chief reason so many people are entering through the back door, so to speak, is that the front door is shut."

My mother's family in 1950. The baby is my mother.
The recent deluge of unaccompanied minors from Honduras, El Salvador, and Guatemala through this "back door" has substantial physical and mental health needs. But Drs. Douglas Bishop and Rina Ramirez observe in American Family Physician that the legal status of these children, which can vary from state to state, complicates efforts to provide them with adequate medical care:

Those of us on the front lines of community medicine continue to struggle daily with the challenges that this vastly complex and heterogeneous population brings, and we look forward to others sharing best practices to care for and foster resiliency in these children. For now, physicians caring for unaccompanied minors need to begin developing office protocols and medical evaluations that fit with state laws and financial realities while working to engage these children and keep them out of the shadows.

Meanwhile, some undocumented residents who migrated to the U.S. before their 17th birthdays prior to June 15, 2012, better known as "Dreamers," have been completing college and applying to graduate schools. In a commentary in Academic Medicine, Drs. Mark Kuczewski and Linda Brubaker explained why Loyola University Chicago Stritch School of Medicine decided to welcome applications from academically qualified Dreamers and encourages other schools to establish similar admissions policies:

The ethical obligation to train the best potential workforce pulled from all of the best candidates intersects with the social justice value that requires medical schools to form physicians who have the capacity and skills, including cultural awareness and competence, to provide all patients with high-quality, compassionate care. ... Dreamer students represent a very valuable resource in achieving the diversity necessary to meet the health care needs of contemporary U.S. society.

Neither a porous southern border nor a too-narrow pathway to legal residency will benefit the U.S. in the long run. At least 10 million undocumented persons already live in the U.S., often doing jobs that citizens don't want, from child care to cleaning homes to construction. The idea that our country could somehow deport all of them is more of a fantasy than President Abraham Lincoln's early Civil War notion of resettling all 4 million African American slaves in a foreign land instead of granting them citizenship.

Me and my sister with my father's parents in the early 1980s.
Immigration policy is complicated, no doubt, and one might ask what fixing it has to do with medicine. Here are a few ways maintaining the immigration status quo harms health and health care in the U.S. There are millions more people to care for, and few options for them to access care in continuous, cost-effective ways. Loyola University Chicago aside, the best and brightest undocumented immigrants who arrived in the U.S. as children face huge obstacles to becoming part of the diverse health care workforce that America desperately needs. And the "front door" of U.S. immigration remains, for all practical purposes, firmly closed to foreign-born persons with aspirations similar to those my own parents had half a century ago.