Mennonite Health Journal

Mennonite Health Journal, Vol. 20, No. 1, May 1, 2019

Well-being for All: Providing Care for the Undocumented
Carissa Harnish
Student Essay Project 2019 Winner  [PDF]

As I walked down the hallway of the student-run free clinic with Naomi, a 40-year-old African patient, I observed the uneasiness with which she carried herself as well as the rounded outpouching of her abdomen. Once we entered the private exam room, I began to interview her about her concerns.

She had come to the United States with hopes of receiving needed health care, but had found herself unable to receive care once she got here. She knew she had multiple, large uterine fibroids, but still she hoped to have a biological child in the future. The fibroids had only returned after prior surgical intervention.

As I interviewed her, a sinking feeling came over me as I realized this appointment would probably lead to further disappointment. Medically, pregnancy seemed like a nearly impossible feat for this patient as the fibroids distorted her uterus and she was nearing the end of child-bearing years. Additionally, our health system, like many in the United States (U.S.), was unlikely to be able to provide elective, non-emergency care for this patient of little resources and questionable immigration status.  I deeply desired for this patient to be well, but it seemed the barriers were going to be insurmountable.

As a Christian third-year medical student, I feel strongly my role is to ensure the well-being of my patients and help them achieve their health-related goals regardless of the patient’s income, social status, race, or immigration status. Simultaneously, I am constrained to training within the system associated with my medical school and the broader U.S. health system. This only allows me to contribute to the well-being of patients permitted into the system, aside from volunteer work at the free clinic or elsewhere. I had thought little about this prior to entering medical school and marrying my husband, an immigrant with many friends and family of various immigration statuses.

Naomi is one of many facing similar barriers to receiving needed care. As of 2016, an estimated 22 million people living in the United States are noncitizens, nearly 7% of the population. Of those immigrants, an estimated 4 in 10 are thought to be undocumented immigrants.¹ They live in the U.S. without social security numbers and are ineligible for most types of insurance under the Affordable Care Act, including the Children’s Health Insurance Program (CHIP), Medicaid, Medicare and marketplace options. This leaves them with little access to the health care system and inability to be treated except at community health centers, safety net hospitals, or in emergency situations.²

Many states have stepped up to provide care to this population that circumvents the barriers placed by federal government, especially in regards to those requiring regular dialysis. Several states have applied for Medicaid waivers to allow them to enroll undocumented immigrants in the insurance programs, but there are fears this puts the undocumented immigrants at risk of deportation as other agencies may use this information in unintended manners.³ Hospital systems and states end up providing uncompensated care, leading to little financial incentive to provide care for undocumented immigrants.⁴ Concurrently, immigration and health care continue to be contentious topics while nationalism is strongly re-emerging and the economic cost of health care is growing.

I wrestle with how to live up to my Christian calling within the current U.S. health system. Matthew 25:34-36 says, “Come, you who are blessed by my Father; take your inheritance, the kingdom prepared for you since the creation of the world. For I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in, I needed clothes and you clothed me, I was sick and you looked after me, I was in prison and you came to visit me.” I understand this as tying my well-being directly to the well-being of the undocumented immigrant. How do we, as Christians, promote the well-being for all if the system that employs us turns away the poor, undocumented, and uninsured? Is simply caring for the sick that make it through the doors of our clinics and hospitals enough?

As I apply for residency this next year, the desire to ensure “well-being for all” must inform this process and future career decisions. I have decided my future work must allow me to care for the undocumented immigrant and the poor. What is yet to be determined is the setting in which I decide to live this out—whether it be volunteering in my free time, working at a system that provides a large amount of charity care, or being directly employed by a safety net hospital or federally qualified health center.  

For now, I plan to continue speaking up for the patients in my care and ensuring their well-being to my best ability within the confines of the system. For Naomi, I asked my attending at the free clinic to contact his colleagues about seeing this patient for surgical evaluation as charitable care. This was not guaranteed to fulfill her hopes and dreams, but it was one small step towards ensuring “well-being for all.” 

References

1. Passel J, Cohn DV. U.S Unauthorized Immigrant Total Dips to Lowest Level in a Decade. Pew Research Center;2018.
2. Foundation KF. Health Coverage of Immigrants. Kaiser Family Foundation. 2019. Published February 15, 2019.
3. Harper J. Another Cause of Doctor Burnout: Being Forced to Give Immigrants Unequal Care. Kaiser Health News. 2018.
4. Kelley AT, Tipirneni R. Care for Undocumented Immigrants – Rethinking State Flexibility in Medicaid Waivers. N Engl J Med. 2018;378(18):1661-1663.

About the author

Carissa Harnish is a medical student at Penn State College of Medicine who will graduate in 2020. She is planning on doing an internal medicine residency in the future. She is member of Neffsville Mennonite Church in Lancaster, PA and a 2015 graduate of Eastern Mennonite University. She lives with her husband in Hershey, Pennsylvania and enjoys eating tacos in her free time.