Linking undocumented immigrants with primary care services significantly reduces emergency department use
The Affordable Care Act (ACA) allowed many in the U.S. who had never before had health insurance to finally be able to acquire that vital benefit. However, undocumented immigrants—who often turn to emergency rooms for care—are not eligible for coverage under the ACA.
Wilson Family LEO Assistant Professor Adrienne Sabety and a colleague from the Massachusetts Institute of Technology (MIT) partnered with the New York City Department of Health and Mental Hygiene to determine how access to primary care would affect both undocumented immigrants' health and the use of emergency departments for routine care.
The intervention study provided nearly 2,500 undocumented immigrants access to nine primary care clinics in New York City. The 14-month project showed that average-risk patients increased their doctors' office visits by 17%, which lowered emergency department visits by 21%, saving emergency departments nearly $200 per person. The results for high-risk individuals was even more dramatic, with a 42% decrease in emergency room use, which led to a 68% reduction in costs for non-admitted high-risk patients (equaling a savings of almost $500 per patient). The results of their research are available today as a NBER working paper.
Prior research shows that undocumented immigrants make up nearly a quarter of the uninsured in the U.S., and they have little chance of obtaining coverage. This lack of healthcare is not only affecting the current generation of undocumented immigrants, but also their children, many of them citizens by birth. While undocumented immigrants largely do not have access to health insurance, they can access primary care at safety-net clinics, like federally qualified health centers and community health clinics, although these care options are underused.
Sabety and her colleagues wanted to test their idea—of making initial appointments for patients at primary care, safety-net clinics—to relieve stress on already overburdened emergency departments. This provides access to healthcare while avoiding issues with insurance expansion.
"Formally insuring undocumented immigrants remains politically untenable; direct access programs may be a more politically palatable method for expanding access outside of the typical 'insurance' framework," Sabety and her co-author wrote. "Expanding access to undocumented immigrants is even more relevant in the context of the COVID-19 pandemic, which has had a disproportionate impact on low-income and immigrant populations, exacerbating longstanding healthcare disparities."
According a 2017 report from the New York City Mayor's Office of Economic Opportunity, just over 1 million New Yorkers live in a household with at least one undocumented immigrant, and about 88% of the 276,000 children in these households are lawfully resident New Yorkers. The same report specifies that median annual earnings for undocumented immigrants ($25,300) is significantly lower than earnings for U.S.-born citizens ($45,500) and, since they are not eligible for most public benefits, their poverty rate is high relative to other immigrants (the foreign-born poverty rate is 22.1 compared to 28.8 for undocumented immigrants).
The 14-month study was too brief to confirm a substantially decreased long-run mortality, but the results are very promising. Individual patients who visited participating clinics were 16.2 percentage points more likely to receive a chronic condition diagnosis, 33.8 percentage points more likely to receive a diabetes screen and 45.4 percentage points more likely to receive a blood pressure screen. According to several studies conducted by other academics from 2010–2019, the increase in diabetes and blood pressure screens alone translates into a 12% reduction in long-run mortality from cardiovascular disease.
The data collected by Sabety and her co-author is a vital addition to the body of work focused on better characterizing the demographics of undocumented immigrants, as well as their healthcare and economic situations. Their baseline survey—translated into 32 languages—consisted of 75 questions and established that only one-quarter of undocumented immigrants have access to a primary care physician. This is a striking deficiency compared to the 60% of Medicaid-eligible individuals with access to care. Their study also inspired similar programs in Los Angeles and San Francisco that have been popular among those cities' undocumented populations.
"The belief that undocumented immigrants don't use healthcare services because they are unable to obtain insurance is wrong," Sabety said. "Instead, by providing undocumented immigrants better access to primary care, they decrease their use of more costly settings, like the emergency department. This is a win-win."
The team's research perfectly exemplifies the mission of Notre Dame's Wilson Sheehan Lab for Economic Opportunities (LEO), based on the belief that academic researchers, service providers and policymakers all play a critical role in ending poverty. LEO matches top researchers with passionate leaders in the social service sector to conduct impact evaluations that identify the innovative, effective and scalable programs and policies that help people move permanently out of poverty.
It is a long-established fact that undocumented immigrants have high poverty rates. "A higher percentage of immigrant New Yorkers live in poverty despite working more hours and participating in the labor force at the same or greater rates than U.S.-born New Yorkers," according to the 2020 New York Mayor's Office of Immigrant Affairs (MOIA) annual report.
"We are incredibly grateful to our partner, New York City's Department of Mental Health and Hygiene, which worked with us on this project," Sabety said. "Together we'll be able to take these results to other cities to guide their thinking around caring for their own undocumented populations."