By Jaelyn Davis
In the United States, a period occurred where an influx of nurses and doctors were recruited from other countries to work in U.S. hospitals, reaching its peak between the 1970s and 1980s (healthandpolicy.org). An individual who was personally impacted by this migration of healthcare workers was Denise Hunter. She witnessed first-hand how her parents made the transition and immigrated to the United States from Jamaica to work as nurses. While Hunter’s mother was able to successfully work at the new hospital, it was not the same for her father. She discusses the impact her father’s unemployment had on his mental health:
“I bet you he was. I’ve never asked him [her father] but looking back – and I really even think he was clinically depressed for a little while too, if I was to look back and diagnose him on the whole thing.” (Hunter 06:29 – 07:15)
The experience of Denise’s father is not unheard of, especially within immigrant communities. Immigrants experienced, and still to this day, setbacks similar to Hunter’s father, regardless of their profession. While the United States was recruiting immigrants to work within its hospitals it was not creating policies that would support the transition or account for any potential obstacles. Hunter’s story is just the tip of the iceberg when it comes to how healthcare policies, directly and indirectly, affect the mental health of immigrant communities.
Only within recent years has the treatment of mental health begun to shift. New campaigns dedicated to reducing the stigmas that surround mental illness have paved the way for new inclusive policies (mentalhealth.org). Although a lot of progress has been made, stigmas continue to persist around the topic of mental health. “Amy” provides insight for this continuing issue as she discusses how stigma impacts the perception of mental health, especially in rural areas:
“The stigma to actually say you need help is quite profound. Also, I think a lot of folks with really strong roots in their church, in their religious communities, sort of believe it’s inappropriate to have both a therapist and a preacher, so they feel like they’re going against their family, their church. What else? Insurance.” (“Amy” 07:11-08:20)
“Amy” discussed these topics in an interview in July 2019. This conveys how the stigmas that have surrounded mental health continue to persist as recently as two years ago. These stigmas result in mentally ill individuals who resist seeking help. This resistance to treatment is observed even higher within immigrant communities for the reasons “Amy” claims, especially when it pertains to health insurance.
Health insurance within the United States can be broken into three main categories: Medicaid, Medicare, and private employee offered insurance. Americans age 65 and older are eligible for Medicare whereas women, children, and those with lower income usually fall within the eligibility range for Medicaid (medicare.gov). Individuals who are ineligible for either government-provided insurance often rely on private healthcare insurance provided by their employers, yet it is not guaranteed. Many Americans fall within the cracks of these three healthcare insurance plans and contribute to the striking number of the uninsured population (policyadvice.net). Acts have been passed by Congress in an attempt to combat these numbers. Arguably one of the most famous within the most recent years and the one that seems to be working the most effectively is the Affordable Care Act. Implemented in 2010 under the leadership of former President Obama, it aimed to expand coverage to hundreds of thousands of Americans across the nation. While it has proven to be successful in reducing the number of uninsured Americans, this significant number continues to be a problem (healthaffairs.org). Within both the uninsured and underinsured population within the United States, immigrants make up a large portion of both (kff.org). A major contributor to these statistics is the lack of access immigrants have to health insurance, let alone the ones that provide affordable coverage for physical and mental illness.
One of the biggest obstacles immigrants have to overcome on the road to obtaining health insurance is their citizenship status. Many immigrants, like Hunter’s parents, come to the United States on work visas and are not granted the status of a citizen. When their work visas expire so does their ability to remain in the country and along with it any benefits they may have received. Due to the Affordable Care Act, a large number of immigrants can qualify for health insurance. Immigrants present within the United States on account of visas or green card holders fall within those that can obtain coverage. Undocumented immigrants that do not contain any holder status are ineligible for non-emergent coverage provided by the ACA (nilc.org). When immigrants can obtain health insurance, they still face the problem of being underinsured. Higher premiums are often required on health insurance plans that cover wider ranges of physical as well as mental illnesses. These more expensive healthcare plans often are not within a range that many immigrants can afford and due to this they are not able to access mental health coverage on their plans.
As immigrants make the journey from their mother countries to their new destination, they have to leave everything they’ve known behind. Reported effects of this transition include feelings of isolation, discrimination, a loss of security, and an overall decline of mental health (psychiatry.org). Due to these findings, it may come as a shock to some, how rare mental health coverage is offered on health insurance plans for immigrants (healthcare.gov). Someone who may be able to provide further insight into this unfortunate reality is Psychiatrist Manuel Versola.
Versola’s perspective is unique, in the sense that he can provide a psychiatrist perspective about the ways he has personally seen his patients impacted by healthcare insurance policy, as well as the perspective of an immigrant from the Philippines. He voices his desire to leave the general practice of psychiatry after health insurance providers began to dictate the kind of care mental health patients receive:
“There are things that are driving me out of that general practice kind of orientation because of changes in the practice of medicine, also that the government or insurance system is telling us how long the patient should be in hospital based on whatever diagnosis you have, so the government is dictating these things” (Versola 53:50 – 55:29)
Versola’s own experience with healthcare insurance policy highlights another issue present within mental health being covered by health insurance plans. Providers often determine the quality and quantity of care patients receive once they can get mental health coverage on their insurance plan. This issue occurs more within immigrant patients as they often face discrimination in the kind of care, they receive based on preconceptions of them being unable to afford or sustain higher coverage (nih.gov). Discrimination policies such as these further contribute to the lack of mental health coverage that is offered for immigrants.
An organization that is dedicated to expanding mental health coverage for immigrant communities is the American Psychological Association. They recognize the disparities and stressors that are present within immigrant communities and advocate for change (apa.org). Leaving the change in the hands of organizations and private insurance providers still leaves too many immigrants eligible to fall within the cracks. This change to be sustainable, must come from a national level. A revision of the Affordable Care Act is a step towards achieving this goal as undocumented immigrants can be made eligible for a wider variety of health insurance plans. Health insurance providers being penalized for discriminating against immigrants would be essential as well as more power of care being in the hands of physicians instead of insurance providers which works to prevent the problem voiced by Manuel. Although the future of mental health coverage for immigrants may seem bleak it is still worth advocating for. The road ahead will be long and strenuous for health insurance providers as they must rework a system that was never made to incorporate immigrants in the beginning. Organizations such as the APA and others that share their mission goals provide a means of hope for a vapid problem prevalent throughout the United States. They make it more imaginable that there will one day be a world where immigrants can seek treatment for their mental health struggles without health insurance policies standing in their way.
References
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“Amy”. Interview with Caroline Efird. 27 July 2019 (Y-0095). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Versola, Manuel. Interview with Caroline Efird. 30 November 2018 (Y-0067). Southern Oral History Program Collection. (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Hunter, Denise. Interview with Ina Dixon. 10 April 2019 (Y-0103). Southern Oral History Program Collection. (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Policy, History. “Immigration and the National Health Service: Putting History to the Forefront.” History & Policy, 8 Mar. 2011, www.historyandpolicy.org/policy-papers/papers/immigration-and-the-national-health-service-putting-history-to-the-forefron.