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We defined the index date as the date of transplantation. Patients were Non- Hispanic white or other, 3, (%), (%), 47 (%). Find out about the Latino experience in Marin at www. Save the date for the Novato Multicultural Commission's "Forum on Equity." Reserve your ticket today. PRUCOL would be eligible for SSI benefits.9 Individuals illegally . provided a 3- year deeming period beginning the date the noncitizen Latin America.

Yet, the lack of data on undocumented status continues to hinder the advancement of knowledge about the health of the undocumented population and the health impact of legal status. This growing body of literature shows the need to understand and assess the methods for measuring undocumented status.

Currently, recommendations about research with undocumented populations tend to focus on cautions of when to not measure legal status and there is limited methodological guidance of how to measure it in an ethically sound manner [ 45 ].

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Across existing studies and methodologies, no standardized measure exists to identify the undocumented status of participants. To date, there has been no examination of the approaches used to measure undocumented status in health research, although a recent study examined item response on surveys that ask about legal status [ 1 ]. Improved measurement of undocumented status will not only improve research methodology but will advance the principles of public health and other health research disciplines to address the fundamental causes of disease and respect the experiences of communities [ 17 ].

Given the risks involved in asking research participants about their legal status, an assessment of different approaches is critical to inform researchers in their selection of measures and methods. An assessment of existing measures of undocumented status can also inform the development of rigorous measurement methods. Therefore, in this paper, we examine the approaches currently used in health research to measure the undocumented status of immigrants in the USA, where a range of methodologies, such as population surveys and ethnographic studies, have been used to study undocumented populations.

We discuss the definition of undocumented status, conduct a systematic review of the methodological approaches currently taken to measure undocumented status, and discuss recommendations for advancement of measurement methods.

What is undocumented status? While the terms undocumented, unauthorized, or illegal are widely used in academic and popular discourse, they refer to a category that is not as clear as generally assumed.

The specific legal position of those who are undocumented varies from country to country because of distinct immigration laws. Similar to citizenship, undocumented status can be defined by identifying its legal and social boundaries and the implications that those boundaries have for the lives of immigrants. To establish a definition of undocumented status in health research, we describe its legal and social elements within the hierarchy of citizenship in the USA, where it was estimated that in that A central legal element of undocumented status is the US federal immigration law that creates the boundaries of each legal status.

The federal government has sole power to determine who can or cannot officially enter the country, determining who will be granted a lawful status. Federal, state, and local policies together form additional legal elements of undocumented status. These levels of government possess varying authority to establish the rights that correspond to each legal status group.

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Through federal laws and policies, those who are undocumented are excluded from authorized employment, most public benefits, and other social and economic resources [ 23 ].

These individuals do receive some constitutional protections, for example, the US Supreme Court decision Plyer v. Doe, US established that undocumented children have a right to public primary and secondary education. These legal boundaries define the significance of undocumented status in relation to the full rights of citizenship.

While legal elements of undocumented status are central in shaping its position in the citizenship hierarchy, the significance of being undocumented is not inherent to its position of formal legal exclusion.

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For example, undocumented status may result in stigma for some individuals as a result of social attitudes or practices in their workplace or school [ 31 ]. Untilsuch benefits were presumed to include health care. PRWORA The following discussion focuses on three groups who are treated differently in the post statutory context: For these purposes, the term "undocumented immigrants" is used to refer to persons who entered the U.

The effect of the statutory restrictions is the same for both groups. The Select Commission on Immigration, a government-appointed body whose recommendations had been adopted in several previous legislative initiatives, was strongly opposed to the denial of benefits to otherwise eligible legal immigrants, specifically noting that such restrictions impede immigrants' progress towards full social integration.

It is important to recall that under the Fourteenth Amendment to the U. Constitution, anyone born in the U. In contrast, a foreign-born child who entered the U.

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In addition to "ending welfare as we know it," PRWORA had the goal of substantial reduction in the federal social service budget. In the context of public health, it is startling to learn that forty-four percent of the expected savings to the federal government from PRWORA would have resulted from cutting off services for post-enactment legal permanent residents. A report sponsored by the Urban Institute estimated that these provisions, had they been enacted, would have increased the number of persons mostly immigrants below the federal poverty level by 1.

If the sponsored immigrant receives Medicaid or Supplemental Security Income "SSI" benefits, for example, an action to obtain reimbursement from the sponsor can be initiated by the agency that provided the benefits. The affidavit must be submitted for family-based immigrants, immediate relatives, and employment-based immigrants who will be working for a business owned by a relative.

Others who are required to use it include aliens seeking immigrant visas, adjustment of status, or admission as an immigrant. After the five-year bar, new immigrants with sponsors must include their sponsors' income when applying for federal means-tested benefits, a mechanism known as "deeming," until the immigrant attains citizenship or the sponsor s complete forty calendar quarters of qualifying work.

Because immigrants remain eligible for emergency services regardless of these conditions, another section of the IIRIRA provides for reimbursement to state and local governments for the expenses incurred providing care to undocumented immigrants, to the extent that other reimbursement is not available. There are several limited exceptions to the affidavit of support requirement, but two deserve special mention.

First, benefits cannot be denied when immigrants are granted permanent resident status as battered children or spouses. As summarized by one commentator, in order to qualify: Second, an immigrant who is battered by her sponsor who filed an affidavit of support after immigrating is not required to take the abusive sponsor's income and resources into consideration when her eligibility for means-tested assistance is determined. However, these exceptions do not apply to many common domestic violence scenarios, such as women who are abused by non-spousal partners and children who need services that are not directly related to the abuse.

Another provision of the IIRIRA requires the Attorney General to develop procedures for verifying the immigration status of persons applying for federal public benefits including Medicaid and SSI "in a nondiscriminatory manner. The apparent motivation for this action was the perception that naturalized citizens were bringing their frail elderly parents to the U.

A widespread expression of outrage at the harm done to these highly vulnerable persons led to the inclusion of less harsh provisions in the Balanced Budget Act of Other details of this amendment are discussed in Part II. C of this Article. Emergency Care One of the few bright, if ironic, notes in this discussion is the continued availability of emergency Medicaid, regardless of immigration status.

Immigrants become eligible for emergency Medicaid if they require emergency care and meet all state eligibility requirements for Medicaid other than verified legal immigration status. Health care providers must follow the same procedure with all emergency cases under the Emergency Medical Treatment and Active Labor Act, and immigration status is no more of an impediment to receipt of emergency care than lack of insurance coverage.

To qualify for emergency Medicaid coverage, an immigrant must have an emergency medical condition, defined as a medical condition including emergency labor and delivery manifesting itself by acute symptoms of sufficient severity including severe pain such that the absence of immediate medical attention could reasonably be expected to result in-- A placing the patient's health in serious jeopardy, B serious impairment to bodily functions, or C serious dysfunction of any bodily organ or part.

The Medicaid regulations require that there have been a "sudden onset" of an illness or injury. Courts have interpreted "sudden onset" to mean that the condition occurred unexpectedly over a short period of time, as in the case of a stroke, heart attack, or an auto accident.

However, treatment does not necessarily need to occur immediately after the onset of the illness or injury in order to be covered under emergency Medicaid. The effect of denying health care access to recent immigrants was evident in emergency departments even before PRWORA. For example, a analysis reports that "[u]ndocumented individuals continually live with the fear of deportation because of their illegal status.

This fear often prevents them from seeking any type of medical care. Therefore, they arrive most often in emergency rooms only after the medical situation has elevated to a crisis.

This prohibition holds even when states and localities fund health services without federal dollars, unless the services are authorized by legislation passed after the August 22,PRWORA enactment date.

State-specific legislation funding services regardless of immigration status would thus have to be re-enacted in states where it was already a matter of law.

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The Balanced Budget Act of provided some mitigation of these harsh provisions for immigrants who resided in the U. If states with high numbers of otherwise ineligible immigrants had not opted to cover immigrants without federal matching funds, some 1. The Congressional Budget Office estimated that if the PRWORA had been fully implemented, by the Medicaid bar for new legal immigrants would have resulted in the denial of health care to approximatelyelderly legal immigrants, 65, disabled immigrants,other adult immigrants, andchildren who would otherwise qualify for Medicaid.

Eligibility is limited to lawful permanent residents; refugees and asylees; certain Cubans, Haitians, and Amerasians; aliens paroled into the U. While the PRUCOL doctrine defined eligibility broadly and excluded only narrowly-defined immigrant categories, the PRWORA takes the opposite approach by excluding all but those who fall within the seven categories of "qualified alien," plus battered women and children who are in the process of acquiring qualified status.

The immigrants who were arguably out of status and yet qualified for benefits under the PRUCOL doctrine would not meet the "qualified alien" test and thus would be found ineligible for federally-funded means-tested benefits like Medicaid and SCHIP.

A battered spouse can achieve "qualified" status by presenting a prima facie case for approval of a visa petition or cancellation of removal formerly known as "suspension of deportation" to the INS as the battered spouse or child of a citizen or resident alien.

The agency whose benefits are sought by the battered spouse must find that the immigrant's need for assistance is connected with the abuse. To qualify for this exception, the visa petition or application for cancellation of removal must at a minimum have been filed, but need not have been approved.

Eleven specific social welfare programs are also exempted from the five-year waiting period, including in-kind forms of emergency assistance, Head Start, and the Job Training Partnership Act programs. The specter of half a million frail, elderly immigrants being rendered destitute finally overcame congressional anti-immigrant sentiment, and the Balanced Budget Act of amended the PRWORA to continue eligibility for immigrants who were receiving SSI on or before August 22,and remained otherwise eligible.

Legally present immigrants who were not yet receiving benefits, but were residing in the U. The applicant cannot rely on any quarter of coverage earned after December 31,if the person received any federal means-tested benefit during that quarter. Spouses may be credited with one another's qualifying quarters if they were earned during the marriage and the couple remains married.

Immigrants are also entitled to rely on the quarters of coverage earned by their parents before the child's eighteenth birthday. It is thus possible, that five, rather than ten, years of at least part-time employment in the U. The policymaking process that led to this harsh provision is an enlightening illustration of the way incorrect information takes on a life of its own in political rhetoric. Robert Rector of the Heritage Foundation wrote in that without reform, three million elderly immigrants would be receiving SSI in However, the INS estimated that the total number of elderly immigrants was less than 2.

Pressure from immigrant advocates and the Clinton administration led Congress to restore eligibility for SSI and food stamps to some immigrants already in the U.

But even with these changes, approximatelyimmigrants lost eligibility for food stamps, and the restrictions on recent immigrants remain in place.

Fourteen states extend Medicaid coverage to legal immigrant children who would otherwise not be eligible, and ten serve some recent immigrant children in child health insurance programs funded through SCHIP. These state-specific programs vary considerably. For example, Washington provides full Medicaid benefits to low-income, post-PRWORA immigrants who have lived in the state for more than a year, while California provides coverage to all legal immigrants. Minnesota coordinates state-funded benefits witemergency Medicaid for eligible immigrants who are in the process of becoming citizens, and New York has retained benefits "for PRUCOL immigrants who were in institutions in August In New York, a similar federal decision has given new momentum to coverage initiatives that comply with the federal restrictions.

Eligibility restrictions under the PRWORA have had the intended effect of shifting costs away from the federal government, generally bringing the financial burden closer to the place where care is delivered. Where states have elected to fund these benefits themselves, costs have been transferred from the federal government to the states.

Where state-funded benefits for ineligible immigrants are not available, costs have shifted to the municipal funders of safety net providers such as public hospitals and clinics. This phenomenon, which will increase in the absence of legislative change or effective immigration enforcement, is yet another burden on the increasingly stressed safety net of health services for low-income U.

Overall, thirty-four percent of non-citizen immigrants are uninsured, compared with approximately fourteen percent of non-immigrants. Among non-citizens, forty-three percent of children and twelve percent of those sixty-five and older are uninsured. Some fifty-five percent of low-income immigrant parents were uninsured incompared to twenty-eight percent of low-income citizen parents. This finding is hardly surprising, given the tendency of low-income immigrants to be employed in service and construction industries where employer-sponsored health benefits are not widely available.

Communicable Disease Because immigrants are less likely than U. The following analysis will focus on tuberculosis because of its prevalence, contagion, and in most cases amenity to treatment. However, many of the same findings could be made with regard to other communicable diseases that are more prevalent in third-world countries than in the U.

A recent assessment of tuberculosis among foreign-born persons in the U. However, other investigators have noted the substantial presence of tuberculosis in the undocumented population and their recourse to treatment strategies that allow the patient to avoid contact with the health care system.

The inability of the U. Immigrants suffer respiratory and other infectious diseases because of the concentration of undocumented immigrants among the migrant farm worker population, their substandard living conditions, and the prevalence of infectious disease in their countries of origin. Even when immigrants are given access to tuberculosis screening, the estimated ninety percent who have the latent form of the disease are unlikely to be detected.

While tuberculosis is not contagious unless airborne particles containing viable bacilli are actually expelled, the more important public health issue in tuberculosis care is that well-established treatment regimens can keep patients from reaching the active stage.

Nevertheless, multi-drug-resistant tuberculosis patients can continue to transmit the disease for as long as it takes to develop an effective course of treatment, a period which may continue as long as the patient survives. The increased rate at which immigrants in the U. It is difficult enough for public health authorities to convince latent tuberculosis patients to undergo complex six-month drug regimens when they are asymptomatic.

By erecting barriers to appropriate testing and treatment for undocumented immigrants and those who arrived after PRWORA enactment, current policies make it highly unlikely that they will receive the care needed to reduce the danger of transmission. Provisions of IIRIRA that facilitate deportation provide an even greater incentive for undocumented immigrants to avoid revealing their presence to entities that they perceive as agents of the government, meaning that they are unlikely to seek treatment even with active tuberculosis.

Although the PRWORA ban on health care access exempts diagnosis and treatment of communicable diseases, this provision is unlikely to provide much relief. Latent tuberculosis is by definition asymptomatic, and the symptoms of early disease stages are easily overlooked. If treatment is deferred until the patient qualifies for emergency care, many others may have been exposed.