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How Do Undocumented Workers Receive Health Care in the United States? A Political Action Project GNUR 590 Health Policy: Local to Global March 23, 2009.

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Presentation on theme: "How Do Undocumented Workers Receive Health Care in the United States? A Political Action Project GNUR 590 Health Policy: Local to Global March 23, 2009."— Presentation transcript:

1 How Do Undocumented Workers Receive Health Care in the United States? A Political Action Project GNUR 590 Health Policy: Local to Global March 23, 2009 Brian Booth, BSN, RN, CEN Carlin Callaway, MS, RN, OCN, CHPN Sarah White Craig, BSN, RN Elizabeth Friberg, MSN, RN Sarah Huffman, BSN, RN, CCRN “On our honor as students, we have not given nor received aid on this assignment.”

2 The Issue An undocumented worker seeks health care for a blood sugar level of 800. A nurse attempts to intervene, but is told by other health care providers that undocumented workers are not be able to receive any insulin unless they privately pay for it. What should health care providers do? Does primary health care exist in the Charlottesville area for undocumented workers?

3 Project and Objectives Project: Five graduate nursing students (who) investigated (what) the issues related to provision of health care services for undocumented workers in the Charlottesville area (where) and prepared (what) a presentation for colleagues in March 2009 (when) that provides an explanation of the issue and available resources to facilitate appropriate response and referral (why) in addressing the health care needs of this population. Objectives: Using the Policy Problem Analysis Model (Mason, 2007), identify the historical, political, legal, regulatory, human rights, ethical, economic aspects and the stakeholders and their ideological positions as it relates to the delivery of health care for this population. Explore health care access/availability in the Charlottesville area for this target population. Distribute factual information and resources to graduate nursing students at the University of Virginia School of Nursing.

4 Rationale for Project Health care professionals encounter this type of dilemma daily. Regardless of personal or political beliefs, a framework is needed to address unmet health care needs. Government and political positions may not reflect the local realities of unmet health care needs and provisions of health care services. To serve the public, communities respond locally to resolve unmet health care needs. Health care providers need to be aware of resources available within their communities to address local health care needs.

5 Terminology is Key to Understanding “If you can control the words people use, you can frame the issue” (Cindy Rodriquez, The National Association of Hispanic Journalists, 2006). Pro-immigration Terminology Unauthorized /undocumented immigrants or workers: Refers to foreign citizens residing in the United States illegally. It applies to two categories of immigrants: those who enter the country without approval of the immigration process and those who violate the terms of a temporary admission. Terms usually used in congressional reports, by immigration supporters and in legal proceedings. Undocumented immigrant is preferred by proponents of open borders while illegal alien is used more often by persons who support stronger enforcement of immigration laws. Anti-immigration Terminology Illegal aliens/illegal immigrants: Terms also used to describe undocumented immigrants. Usually a negative connotation, invokes fear, often used by media and public to emphasize violation of immigration law and threat to US. The Mexican American Legal Defense and Educational fund (MALDEF) disputes the use of the term illegal alien to define the immigration status of an individual citing the fact that some legal immigrants lapse into illegal status while waiting for lengthy forms to be processed. The Colorado Alliance for Immigration Reform (CAIR) encourages the use of the term “illegal alien” to define a person illegally residing in a country in violation of immigration laws and emphasizes that other terms are misleading and “soft.” (, February 14, 2008;, March 27, 2008)

6 Immigration Policy Overview Our Collective Ambivalence Immigration Foreign-born legal permanent residents Legal temporary residents Undocumented workers (undocumented aliens, or illegal aliens) America is a nation of immigrants (Ewing, 2008). Native Americans came over the land bridge from Serbia. Successive waves of immigration came from all corners of the world. Northwest Europe in colonial & early US history Southeast Europe in late 1800s Latin America, Africa, & Asia in late 1900s There was no “right way to enter” prior to the late 1800’s [established exclusions] and early 1900’s [established quotas] (IPC, November 25, 2008). Biased; shaped by public fear and anxiety rather than public policy Contradictions between immigration laws and economic realities Random Schizophrenic Despite the proliferation of biased exclusionary laws, 30 million immigrants arrived between 1875 and 1920 (IPC, November 25, 2008). In 1890, 14.8% of the US population was foreign-born. In 2006, only 12.5% of the US population was foreign born.

7 Immigration Law Overview 1875-1920 Exclusion laws created 1921-1964 Quota laws initiated based on national-origin 1924U.S. Border Patrol established 1942-1964 Five million Mexican field workers admitted under “BRACERO Program” 1954 One million Mexican immigrants deported (“Operation Wetback”) 1965 Quotas eliminated; Created preference system, and “Touch Back Program” 1980Mexican immigrants limited to 270,000 1986 Immigration Reform & Control Act (IRCA) Undocumented workers could apply for citizenship. Created H2A visas (temporary seasonal agriculture workers) 1990 Immigration Act. Cap increased to 700K/yr thru 1994 and then 675K thereafter; increasing 65K/yr. H1B visas (highly skilled temporary) & 66K/yr H2B visas (temporary non-agriculture) 1996 Illegal Immigration Reform & Immigrant Responsibility Act (IIRIRA) & Welfare Reform Act (PRWORA). Created new rules for inadmissibility, mandatory detention, expedited removal and legal permanent resident (LPR) – “green card.” Determined LPRs ineligible for “means-tested public benefits” for 5-years and Medicare or SS for 10- years post receipt of green card. Undocumented barred from ALL public benefit programs despite paying payroll, property & sales taxes. 2001 Immigration control linked to National Security 2002 Registration system to identify foreign-born Muslims and Arabs 2005 REAL ID Act (required proof of citizenship for Medicaid application) 2006 Secure Fence Act (850 mile fence along the Mexican border) (Ewing, 2008; IPC, November 25, 2008)

8 U.S. Approach to Date Since the mid-1980s, tens of billions of dollars have been spent on law enforcement to eliminate undocumented immigration (ALIA, 2008; Ewing, 2008). Today, it is estimated that 12 million undocumented workers have entered the U.S. This represents 1/3 of the 37.5 million foreign-born population. Our national policies have not worked. Legislative attempts for comprehensive immigration reform to bring in line the economic & social realities that actually fuel undocumented immigration failed in 2006, 2007 & 2008 (Ewing, 2008; IPC, November 25, 2008). We continue to wrestle with our own historical identity as a nation of immigrants by changing the definitions of “legal” and “illegal” over time (IPC, September 8, 2008 & November 25, 2008).

9 Pew Hispanic Center. Retrieved January 27, 2008 from Undocumented Workers and the U.S. Economy 4% of the current US population

10 Important Points to Consider Despite paying payroll, property, and sales taxes, undocumented workers are prohibited from receiving most government benefits for at least five years after they come to America (IPC, September 8, 2008). Undocumented families may receive emergency medical care and immunizations for public health and safety concerns only (IPC, November 25, 2008). U.S. Immigration Policy is costly, complicated, confusing, contradictory, and ineffective. Undocumented workers have low criminal propensities (Faruk, 2008; ALIA, 2008). “Immigrants” do assimilate, learn English 2 nd (91% fluency) & 3 rd (97% fluency) generations and climb the socio-economic ladder over time (Faruk, 2008; ALIA, 2008). 45% of undocumented workers do not sneak across the border (Faruk, 2008). They entered legally and overstayed their visas. Being unlawfully in the U.S. is a civil offense, not a criminal offense.

11 Some Regulatory Aspects Medicaid Eligibility: Undocumented immigrants remain ineligible for Medicaid regardless of how long they stay in the U.S. (Staiti, 2006). Emergency Medicaid: Covers only emergency stabilization (including childbirth) for individuals not eligible for regular Medicaid because of their immigration status but does not include coverage for ANY preventative or routine care (Fremstad, 2004). SCHIP Eligibility: Federal regulations allow some flexibility, so states have the option to use SCHIP funds for prenatal care regardless of immigration status (National Immigration Law Center, 2003). CHIPRA 2009 retains this option through the "unborn child” provision. Seven states (AR, IL, MA, MI, MN, NE, RI) use federal SCHIP funds to provide prenatal care coverage regardless of the mother’s immigration status (not Virginia). This “unborn child” option essentially extends eligibility to unborn child, which is not considered to have any immigration status (Kaiser Commission, 2008). WIC Eligibility: Undocumented immigrants are eligible for Women, Infants, and Children program (WIC) including supplemental nutritious foods, nutrition education and counseling at WIC clinics, screening and referrals to other health, welfare and social services (USDA Food and Nutrition Service, 2008).

12 Regulatory Aspects (continued) EMTALA (Emergency Medical Treatment & Active Labor Act of 1986 Consolidated Omnibus Budget Reconciliation Act (COBRA) Primarily a non-discrimination statute to prevent “patient dumping” (Fosmire, 2006) –Applies to ALL patients regardless of immigrant status or ability to pay –Requires that EDs provide appropriate “medical” screening exam to determine if an emergency medical condition exists If so, the hospital is obligated to provide stabilizing treatment or initiate appropriate transfer to another facility. A pregnant woman who presents in active labor must be admitted and treated until delivery is completed or appropriately transferred (Fosmire, 2006). A triage evaluation does not satisfy the requirement for a “medical” screening exam (Naradzay, 2006). Violation can yield significant penalties (Naradzay, 2006): –Hospitals and/or physicians may be fined up to $50k per violation and face civil lawsuits. –Hospital Medicare participation may be terminated. Medicare Prescription Drug, Improvement and Modernization Act of 2003, section 1011 Reimburses hospitals, physicians, ambulance providers for emergency care to undocumented immigrants (CMS, 2008) $250 million per year is set aside for these payments. Divided among states based on relative percentages of undocumented immigrants. Hospitals must document immigration status to obtain reimbursement (Spencer, 2007). Information collected by hospital for this purpose can not be used to enforce immigration laws (CMS, 2008). Criticisms (Spencer, 2007): Providers are encouraged not to directly ask patients about legal status. Process requires providers to ask indirect questions such as: “Are you eligible for Medicaid?” or “Do you have a social security number?” Gathering this information in emergency situations may be very cumbersome. Undocumented families may refuse or avoid care out of fear of deportation.

13 Federal Medicaid and SCHIP Eligibility Immigrant StatusEligible for Medicaid Eligible for SCHIPEligible for Emergency Medicaid Lawful Permanent resident (LPR ) > 5 yrs √ √N/A LPRs residing in US < 5yrs NO - commonly referred to as “five-year bar” NO - However, CHIPRA 2009 will allow states to cover children and pregnant woman during first 5 yrs in country √ Refugees/Humanitarian immigrants √ √N/A Pregnant Immigrants (both LPRs < 5 yr and undocumented) NO Only in a few states √ Undocumented immigrants who are not pregnant NONO - However, a few states offer state-funded coverage to undocumented immigrant children √ (Fremstad, 2004)

14 Stakeholder: Taxpayer/Citizen Anti Public funds/Fiscal impact/Taxpayers: State, local governments are required to provide emergency services to individuals regardless of immigration status and bear much of the cost of providing public services. Under federal budget, undocumented workers are only eligible for emergency services through Medicaid. Burden falls to local and state funds (Merrell, 2007). Most estimates over the past 20 years conclude that tax revenues of all types generated by immigrants (legal and unauthorized) exceed the cost of the services they use (education, law enforcement and health care). They have lower paying jobs, so they pay less taxes and have less disposable income to spend/sales taxes (Merrell, 2007). Anti-immigrant ideology include:  Respect and enforce existing immigration laws/close borders  Preserve the scarcity of economical resources and health services for American citizens only Pro The U.S. needs immigrant labor for jobs that the American workforce is not willing to fill, especially at lower wages and in poor working conditions. Immigrants are cheap labor—immigrants are welcome as a source to work, but they are excluded from services and benefits (Paral, 2005). Undocumented workers have been providing labor foundations for American for decades, yet health care is mostly nonexistent for these workers (Blewett, 2005). Pro-immigrant ideology include:  Reform immigration laws & policy/provide access to legal citizenship  Health care reform for the “uninsured” should provide preventative care and affordable accessible healthcare options.

15 Stakeholder: Medical Community Anti Public health/ Potential communicable disease (tuberculosis, HIV, hepatitis): No screening for undocumented immigrants/unknown risk Expense of contagious disease outbreaks Tuberculosis was almost absent in VA until it spiked in 2002 with a rise of 188 % in Prince William County which public health officials related to “immigrants” (Cosman, 2005). Financial burden/Uncompensated health care/Uninsured: Study by Pew Hispanic Center (2004) estimated that 50% of children and 60% of adult undocumented immigrants were uninsured. Health care facilities who receive funds from the federal government are required to provide a certain level of services (emergency stabilization, childbirth) regardless of immigration status/uncompensated care (Cunningham, 2006). Do not seek preventative care due to expense and fear of deportation/ results in inappropriate use of EDs (Goertz, 2007) Children born to illegal immigrants become citizens/eligible for Medicaid benefits (14 th Amendment to the US constitution) Pro Undocumented immigrants are ineligible for most state and federal benefits—health care spending is approximately half that of citizens. Fear of deportation keeps majority from seeking healthcare and enrolling eligible citizen children for benefits such as Medicaid Often communicable diseases are identified during routine visits so allowing undocumented workers access to health care increases the chances of early identification and treatment before others are exposed (DeMaria, 2005).

16 What Are the Associated Costs? According to the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey, “immigrant” health care cost $39.5 billion in 1998. This was approximately 8% of the total amount spent on health care. When stratified by age, the health care expenditures for “immigrants” (in every age group except 65 and over) were 30% to 75% lower than those for American citizens. After multivariate adjustments were made, the per capita total health care expenditures of “immigrants” were 55% lower than those of Americans ($1139 vs. $2546). Health care costs for uninsured and publicly insured “immigrants” were approximately half those of Americans. “Immigrant” children had 74% lower per capita health expenditures than American children. However, “immigrant” children received emergency care at a of cost triple to those of American children. When “immigrant” children developed emergencies, their emergencies were rather costly. “Immigrants” are not consuming large amounts of scarce health care resources. Teenagers (ages 12-17) had difficulties accessing routine care. Yet, these children will likely enter the U.S. work force. (Mohanty, 2005)

17 The Costs According to Texas It was estimated that there were 11.1 million undocumented immigrants in America in 2005. 1.4 to 1.6 million (14%) undocumented immigrants lived in Texas. Undocumented immigrants comprise 7% of the Texas population. Texas paid $58 million in health-related expenses for them in 2005. Texas collected $500 million in revenue from undocumented workers. In 2005, undocumented workers generated $17.7 billion worth of the Texas gross state product. Produced $1.58 billion in state revenues, yet received $1.16 billion in state services Local governments paid $1.44 billion in uncompensated health care costs and local law enforcement costs not covered by the State. Undocumented workers and their families are transient. It is estimated that 2/3 of undocumented immigrants have been in the U.S. for less than 10 years. 40% less than 5 years Mostly adult males (58%) The majority of undocumented workers come from Mexico (56%), Latin America (22%), and Asia (12%). (Keeton Strayhorn, 2006)

18 The Costs According to New Jersey Undocumented workers and their families represent 4.3% of New Jersey’s overall population. The nation’s ninth largest concentration of undocumented workers live in New Jersey (3.4% of the estimated total). In 2005, New Jersey spent $2.1 billion on 372,000 undocumented workers and their families. Education, $1.85 billion Health care, $200 million Incarceration, $50 million The Centers for Medicare and Medicaid Services (CMS) paid for $5.3 million worth of health care expenses (11% of the total spent) delivered in New Jersey. It is estimated that each household (headed by a native-born resident) in New Jersey paid $800/year in taxes for undocumented workers and their families. Although New Jersey received $488 million in sales, income, and property taxes from undocumented workers, it is estimated that the New Jersey taxpayers ultimately paid $1.6 billion for undocumented workers and their families. (Martin, 2007)

19 Some Human Rights and Ethical Dilemmas Many believe that health care should be a universal human right, yet undocumented workers are denied access to health care. Children become American citizens when they are born in the United States. As they grow, these children also face barriers to health care. Their (non-citizen) parents are ineligible for care, and are often reluctant to seek care for fear of being “identified” to immigration officials. Children are innocent bystanders. Although Medicaid Emergency Fund pays for childbirth, undocumented immigrants do not receive funded prenatal care or family planning. If an undocumented immigrant is seen in a “free” clinic, their screening mammograms and pap smears may be covered. However, follow-up care for abnormal findings is most likely not covered.

20 Relationship to Nursing Theory Complex Adaptive Systems Theory All of our actions are interconnected. Systems theorist refer to this concept as the “butterfly effect” (Holden, 2005). “A complex adaptive system is a collection of individual agents with freedom to act in ways that are not always totally predictable, and whose actions are interconnected so that one agent’s actions changes the context for other agents (Plsek, 2001).” Concerning primary healthcare for undocumented aliens, nursing must consider the consequences of acting versus not-acting. “The application of the understanding of health care as a complex adaptive system involves cultivating an environment of listening to people, enhancing relationships, and allowing creative ideas to emerge by creating small non-threatening changes that attract people (Holden, 2005).” This theory is a framework that may help nurses look at ways to develop an arena in which policy for primary health care of undocumented immigrants may be created.

21 Relationship to Health Policy Theory Incrementalism Model Enacting small changes on the margins of a dysfunctional or failing system: This is the concept currently used to treat undocumented immigrants. EMTALA requires that anyone must be treated in an emergency. If patients were offered primary care, these emergencies might be avoided as well as associated financial and emotional burdens. Stage-Sequential Model Stages in which the functions of problem solving occur (issue identification, agenda setting, formulation, implementation, evaluation): This model is a structured way to develop reform and a better system to provide primary care. More extensive change may be possible under the Obama Administration. (Mason, 2007)

22 Principles of Distributive Justice The first two principles of distributive justice may be used as a framework to help establish primary healthcare for undocumented workers (Mason, 2007). 1.To each the same thing  strict equality for all Lawmakers must determine what services are basic necessities to all and the logistics of providing these services. 2.To each according to his need  everyone deserves basic rights and liberties

23 How Do We Enact Change? Anticipatory change is the best method of enacting new policy. The financial and social impact of poor healthcare in undocumented aliens must be studied and understood to emphasize the need for providing healthcare (Mason, 2007). Political action project plan and timeline: Study the literature & other resources (research) January 31 - February 14, 2009 Develop an understanding of the policy issue at the national & state level (analysis) February 14 – February 28, 2009 Investigate current non-governmental strategies to address the issue in the Charlottesville community & schedule interviews (agency/organizational interviews) February 16 – February 28, 2009 Compile our findings for peer dissemination (presentation) January 31 – March 14, 2009 Clarify misconceptions re: what services are/are-not available to this population and how services are utilized/provided March 23 – 29, 2009

24 Political Action Findings We identified local resources that serve undocumented workers in the Charlottesville area and conducted interviews with their organizational leaders: Creciendo Juntos-Growing Together (February 11, 2009) Social Services (February 11, 2009) Church of the Incarnation (February 11, 2009) Southwood Trailer Park (February 11, 2009) Legal Aid Justice Center (February 20, 2009) Interviews were conducted in person by one or two group members. Interviewees were eager to discuss their local initiatives, the scope of this issue, their strategies, and their encountered barriers.

25 Creciendo Juntos Creciendo Juntos-Growing Together (CJGT) “an inter-agency and inter-community network for issues related to the Latino/Hispanic community in Charlottesville City, Albemarle County and surrounding areas.” Organized in Spring 2005 under the leadership of the Piedmont Housing Alliance (PHA), CJGT now involves over 100 agencies/institutions and 200+ staff and individuals dedicated to building knowledge, sharing information, and seeking ways to collaborate and integrate across the cultural divide. Participating organizations include health, housing, communication media, business, legal, UVA, local & regional planning, public safety, education, transportation, social services, churches, chambers of commerce, and real estate among others. Executive committee meets monthly with designated social, health, legal, and housing workgroups. CJGT works with similar networks in Richmond, Harrisonburg, and elsewhere.

26 Social Services Pam Benton, Benefit Programs Supervisor City Hall Annex, 120 7 th Street N.E., Charlottesville, VA 22902 Interviewed on February 11, 2009 Undocumented families are not eligible for food stamps, temporary assistance to needy families (TANF), WIC or other federal/state funded programs. (Our research indicated that WIC is available.) To be eligible for programs, applicants must live in Virginia, be American citizens, or be legal immigrants. Undocumented families may only receive emergency stabilization to include childbirth. Because it may take 45 days to process the claim and receive payment, the hospital is paid well after the undocumented family member is discharged from the hospital. Children born to Illegal immigrants are citizens. Therefore, they are eligible for all state and federal programs. Most of the Agency’s encounters with undocumented families occur through their eligible children. The University of Virginia Patient Financial Assistance Office helps when undocumented workers require hospitalization.

27 Legal Aid Justice Center Tom Freilich – Director of the Immigrant Advocacy Program 1000 Preston Ave, Charlottesville, VA Interviewed on February 20, 2009 Four offices: Charlottesville, Richmond, Petersburg, and Falls Church- over 40 lawyers & public policy experts Interviewed Tim Freilich - Director of the Immigrant Advocacy Program Program offers free legal assistance and representation to low-income immigrants (including undocumented immigrants) Main goal is to eliminate abuse and exploitation of immigrants “ “Can You Pay Me Now” Campaign- Helped low-income immigrants recover over $300K in unpaid wages from Verizon Promote public policies and systemic reforms that recognize the contributions of hardworking immigrants Carefully monitor proposed legislation (both at the federal and state level) Because their organization represents undocumented immigrants, current law prevents them from receiving any federal funding Mostly funded by private organizations and individuals, some funding from city and county governments “Many undocumented immigrants do not seek care or outright refuse care even when faced with severe illness or workplace injury out of fear of deportation or profound mistrust of government agencies.” Tim Freilich (personal communication, February 20, 2009) “We are beginning to see a shift in public policy at both the state and national level…taking a turn away from the anti-immigrant policies that have imposed barriers to adequate health care for immigrants.” Tim Freilich (personal communication, February 20, 2009)

28 Coalition: A Local Non-Governmental Solution to a Local Problem Church of the Incarnation Southwood, Inc. (434) 979-0856 Habitat for Humanity of Greater Charlottesville Blue Ridge Medical Center/Rural Health Outreach Health Promoter/Promotor de Salud Group

29 Political Interest Groups American Immigration Lawyers Association Mexican American Legal Defense and Education Fund (Ford Foundation) Migration Policy Institute National Council of La Raza National Immigration Law Center National Network for Immigration and Refugee Rights Open Society Institute: Soros Foundation Southern Poverty Law Center

30 Group Reactions In spite of considerable contradictory information and mis- information, there are extreme views on all sides. There is no perfect way to identify correct information. American economic and social realities are not reflected in American immigration policies. This is a very emotional topic. Ultimately, people will believe the perspective that best matches their personal/political ideology. Because undocumented families remain in our communities, the group consensus was to provide basic primary care services to ensure public safety and basic human dignity. Charlottesville has responded with non-governmental approaches to provide some primary health care to undocumented workers. Nurses need to be aware of these efforts and how to access services for their patients independent of their own political or personal views.

31 References American Immigration Lawyers Association (AILA). (March 10, 2008) ALIA Top 5 Immigration Myths of This Campaign Season. Retrieved January 27, 2009 from Blewett, L.A., Davern, M., & Rodin, H. (2005). Employment and health insurance coverage for rural Latino populations. Journal of Community Health, 30(3), 181-195. Centers for Medicare and Medicaid Services. (2008). Fact Sheet: Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens. Retrieved January 15, 2009 from: Cosman, P. M. (2005). Illegal Aliens and American Medicine. Journal of American Physicans and Surgeons, 10 (1). Creciendo Juntos-Growing Together: Immigration myths and facts. (n.d.). Retrieved January 23, 2009 from Ewing, W. A. (November 25, 2008). Opportunities and exclusions: A Brief History of U.S. Immigration Policy. Retrieved January 23, 2009 from 08.pdf 08.pdf Fosmire, S. M. (2006). Frequently Asked Questions about the Emergency Medical Treatment and Active Labor Act. Retrieved February 1, 2009 from: Grever, M. (2007, July 23). Immigration debate continues: Who should get health care? National Conference of State Legislatures State Health Notes, 28, Issue 496. Retrieved January 23, 2009 from

32 Faruk, A. ( October 2008). Virginia Interfaith Center: immigration fact sheet. Retrieved January 23, 2008 from id=577 id=577 Fremstad, S. & Cox, L. (2004). Covering New Americans: A Review of Federal and State Policies Related to Immigrants’Eligibility and Access to Publicly Funded Health Insurance. Washington, D.C.: Henry J. Kaiser Family Foundation. Retrieved February 1, 2009 from: Goldman, D.P., Smith, J.P. & Sood, N. (2005) Legal Status and Health Insurance Among Immigrants. Health Affairs, 24 (6), 1640-1653. Retrieved February 14, 2009 from Holden, L. (2005) Complex Adaptive Systems: Concept Analysis. Journal of Advanced Nursing 52(6), 651-656 Immigration Policy Center (November 25, 2008) De-romanticizing Our Immigrant Past: Why claiming “My family came legally” is often a myth. Retrieved January 23, 2009 from Immigration Policy Center (September 8, 2008) Separating Fact from Fiction: refugees, immigrants and public benefits. Retrieved January 23, 2009 from 9-8-08.pdf 9-8-08.pdf

33 Kaiser Commission on Medicaid and the Uninsured. (2008). Five Basic Facts on Immigrants and Their Health Care. Washington D.C.: Henry J. Kaiser Family Foundation. Retrieved February 1, 2009 from: Kaiser Commission on Medicaid and the Uninsured. (2009). Medicaid: A Primer. Washington D.C.: Henry J. Kaiser Family Foundation. Retrieved February 1, 2009 from: Keeton Strayhorn, C. (2006, December). Special report by Office of the Comptroller: Undocumented immigrants in Texas-A financial analysis of the impact to the state budget and economy. Retrieved January 23, 2009 from Martin, J. (2007, January). The costs of illegal immigration to New Jerseyites: A report by the Federation for American Immigration Reform. Retrieved February 10, 2009 from Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2007). Policy and Politics in Nursing and Health Care. St. Louis, MO: Saunders Elsevier Inc Mohanty, S. A., Woolhandler, S., Himmelstein, D. U., Pati, S., Carrasquillo, O., & Bor, D. H. (2005). Health care expenditures of immigrants in the United States: A nationally representative analysis [Electronic version]. American Journal of Public Health, 95, 8, 1431-1438. Naradzay, J. F. & Wood, J. (2006). COBRA Laws and EMTALA. Retrieved February 1, 2009 from:

34 National Immigration Law Center. (2003). Issue Brief: Prenatal Coverage for Immigrants Through the State Children’s Health Insurance Program. Retrieved January 15, 2009 from: coverage through SCHIP.pdf coverage through SCHIP.pdf Paral, R. (March 2005) Essential workers: immigrants are needed supplement to the native-born labor force. Washington, DC: Immigration Policy Center. Passel, J.S. (June, 14, 2005) Unauthorized Migrants: Numbers and Characteristics (background briefing prepared for the task force on immigration and American’s future. Washington D.C., Pew Hispanic Center) Retrieved February 14, 2009 from Pew Hispanic Center (October 2, 2008) trends in Unauthorized Immigration: Undocumented inflow now trails legal inflow. Retrieved January 27, 2008 from Plsek P. & Greenhalgh T. (2001) The challenge of complexity in health care. British Medical Journal 323, 625–628 Spencer, A. C. (2007). Federal Law Reimburses Hospitals for Treating Undocumented Immigrants: A Primer on Section 1011. Washington D.C.: National Conference of State Legislatures. Retrieved February 1, 2009 from:

35 Portes, A. (September 24, 2007). The fence to nowhere: the American prospect. Retrieved 28 February 2009 from (February 14, 2008). What is illegal immigration? Retrieved January 23, 2009 from answers.asp. answers.asp (March 27, 2008).Should the term “illegal alien” be used to define persons in violation of immigration law?. Retrieved January 23, 2009 from: Social Security Advisory Board, Issue Brief No. 1, The impact of immigration on social security and the national economy (report prepared by Joel Feinleib and David Warner, December 2005). Retrieved 1 March 2009 from Staiti, A.B., Hurley R. E. & Katz, A. (2006). Stretching the Safety Net to Serve Undocumented Immigrants: Community Responses to Health Needs. Washington D.C.: Center for Studying Health System Change. USDA Food and Nutrition Service. (2008). Women Infants and Children. Retreived Februrary 1, 2009 from:

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