Adam Sonfield is a senior public policy associate at the Guttmacher Institute, the leading policy research organization in the field of sexual and reproductive health.
Immigrants—regardless of legal status—are often accused of abusing the nation’s system of government assistance. Rarely do the critics acknowledge, or even consider, that the use of public benefits may actually benefit the public, even as they help the immigrants themselves. A case in point is the crucial area of sexual and reproductive health services.
The most significant recent changes in U.S. policy regarding immigrants’ access to such services have been designed with one simple goal in mind: to limit their access. This approach is questionable from both a moral and public health perspective. Moreover, it has inadvertently harmed those who undeniably remain eligible to receive these services.
A 1996 law, notably, required most legal immigrants to wait five years before becoming eligible for health coverage under Medicaid, an enormously important source of coverage for family planning services and supplies, pregnancy-related care and testing for and treatment of HIV, other sexually transmitted infections and cervical cancer. More recently, a 2006 law required states to ensure that Medicaid enrollees who claim to be citizens provide documentary proof. Passports top the list of acceptable documents, even though many low-income Americans do not possess one. An original birth certificate, or a state-certified copy, along with a driver’s license would qualify as second-tier documentation.
According to the late Rep. Charlie Norwood, R-Ga., one of the law’s chief sponsors, the provision was designed to counter “the outright theft of Medicaid benefits by illegal aliens”—despite the fact that a July 2005 report by a federal inspector general identified no major flaws in the then-current practice of allowing applicants to self-declare their citizenship, under the penalty of perjury.
Both policies have had severe consequences, in some ways unintended. After the 1996 law, Medicaid enrollment dropped precipitously among both the recent immigrants targeted by the change and long-standing legal residents, who should not have been affected. Those long-standing residents, who are fully entitled to Medicaid coverage, are now only half as likely as U.S.-born citizens to have such coverage and 70 percent more likely to be uninsured. No comprehensive data are yet available on the 2006 law’s impact, but initial reports indicate that citizens—not Norwood’s “illegal aliens”—are the ones at risk of lost or delayed coverage and care because of the time, expense and difficulty of obtaining acceptable documentation. A February 2007 report by the Center on Budget and Policy Priorities highlights problems in 11 states, including unexpected enrollment declines, backlogs in processing applications and significant administrative costs.
Delays and interruptions in Medicaid coverage may be particularly problematic when it comes to sexual and reproductive health services. Lack of timely access to prenatal care, for example, can have negative consequences for the health of both pregnant women and newborns. Similarly, delays in obtaining or refilling a prescription for birth control can lead to unplanned pregnancy, and delays in treating sexually transmitted infections may impair efforts to curb their spread in the community.
Obtaining the proper documents may be particularly burdensome for young, extremely poor mothers—the typical recipients of Medicaid-funded reproductive health services in most states. A fee of perhaps $20 for a new birth certificate or nearly $100 for a U.S. passport may be daunting—even before such additional expenses as lost wages, transportation and child care that may accompany a trip to a government office.
The documentation requirement may be especially problematic in the 25 states that have obtained federal approval to broadly expand eligibility for family planning services under Medicaid. These expansion programs have served millions of women and men and, moreover, have been proven to save tens of millions of dollars for individual states and the federal government. Unfortunately, they may become financially less attractive for the government in the face of increasing enrollment expenses, and family planning providers in several of these states are reporting substantial drops in the programs’ clients.
Even if these Medicaid policies had done only what their supporters asserted they would do—withhold Medicaid services from certain groups of immigrants—their wisdom is highly questionable. From a practical standpoint, these policies create serious financial and logistical problems for the nation’s already strained system of safety-net clinics—including Title X family planning providers, maternal and child health clinics, and community and migrant health centers—which remain available to serve immigrants, regardless of legal status.
But at the core of the issue are these questions: Is it really in the national interest to deny prenatal and postpartum care to immigrant women whose babies will be U.S. citizens? Who benefits from withholding voluntary family planning services from immigrant women who themselves do not want to become pregnant? What is gained by denying immigrants services for communicable diseases such as HIV and other sexually transmitted infections?
As Congress renews its debate over comprehensive immigration reform, it should resist the compulsion to cater to anti-immigrant sentiment and instead acknowledge the obvious answers to such critical questions.