by Joyceen S. Boyle RN, PhD, FAAN joyceenboyle@cox.com
Approximately 10.5 to 12 million or more undocumented immigrants are living in the U.S.1 Medical repatriation stands at the intersection of two highly controversial and complex political issues—immigration and health care policy. Current U.S. law prohibits undocumented persons, including DACA recipients from procuring health insurance through public exchanges, such as the Affordable Care Act, Medicaid, or Medicare. Some undocumented immigrants do receive health insurance through employers or private plans.
Medical repatriation is the transfer of undocumented patients in need of subacute care to their country of origin. Data on the prevalence and circumstances surrounding medical repatriation are extremely limited because documentation and reporting requirements do not exist.2 Medical repatriation occurs without the involvement of federal immigration authorities; it is carried out by individual health care facilities completely circumventing the federal government’s exclusive authority to deport individuals. Private medical transport services (emergency vehicles or air transport) are used to transport patients back to their countries of origin to a care facility or to family members.
Cost is a tremendous contributor to the practice of medical repatriation. Although hospitals are required to provide emergency medical care to patients regardless of their immigration status, this obligation ends once the patient is stabilized. At this point, federal law requires hospitals to create a discharge plan and transfer patients to “appropriate facilities” that ensure the health and safety of the patient.3 Medical repatriation also dramatically affects the lives of the patient’s family (mixed status families) or those family members in the home country. In addition, when critically injured or ill immigrants are repatriated to countries and families that do not have the resources or medical facilities to care for them, family members are often helpless to sustain the lives of their loved ones.
What is the role of nursing in the care of undocumented immigrants? In 2010 the American Nurses Association (ANA) issued a comprehensive position statement on nursing with undocumented immigrants. The ANA affirmed the claim that all people living in the U.S., including documented and undocumented immigrants, have a right to access health care, thus taking a social justice and human rights stance.4
Issues related to Informed Consent: Is informed consent necessary for medical repatriation if the patient has no right to reside in the U.S.? Is health care limited only to those who have legal status? Can consent be voluntary if the patient is asked to comply with an intervention that may not be in his/her best interest? Does the Patient’s Bill of Rights posted in every U.S. hospital apply only to U.S. citizens or those who have legal status? Who obtains informed consent from the patient? What is meant by “legal status”? Green card”? Asylum granted (asylee)? Refugee status? Protected status (TPS)? Migrant processed by ICE, released with court date?
Issues related to Multi-status Families: What about undocumented migrants who are heavily embedded in society through work, family, and friends? They pay taxes, their spouses and children are citizens. What goal is served when the U.S. deports an undocumented mother of U.S. children and the wife of a man with U.S, citizenship? Does it matter how long the undocumented person has lived in the U.S.? What about undocumented men or women who have served honorably in the U.S. military forces?
Other Issues about Medical Repatriation: What impact does medical repatriation have on the physician/nurse/patient relationship? What is the role of the hospital’s Ethics Committee? How about the hospital’s Board of Directors? Does medical repatriation have an impact on the community’s health care seeking behaviors? What impact does repatriation have on the community’s participation in public health activities?
I believe that nurses, especially transcultural nurses, have the moral courage to advocate effectively for undocumented patients by calling attention to the profound ethical issues raised by repatriation. I take heart at the expression coined by the late Senator John Lewis—about Getting into Good Trouble! Ask your congressional representatives to convene hearings to investigate the practice of medical repatriation by private hospitals. Ask your congressional representatives to ask the Department of Health and Human Services (DHHS) to develop regulations that prohibit and impose sanctions on any hospital that performs an involuntary repatriation. DHHS should develop a required process by which hospitals must document and report international patient transfers. Obviously, a comprehensive solution to medical repatriation will be complex and involve immigration and insurance reforms that establish streamlined paths to citizenship and insurance coverage for vulnerable immigrants. Nurses can call attention to the ethical and health care issues raised by repatriation and to help develop policies that protects the rights and health of immigrant patients.
References
- Kamarck, E. & Stenglein, C. How many undocumented immigrants are in the United States and who are they? Policy 2020 Brookings. November 12, 2019. Retrieved January 7, 2021 from: https://brookings.edu/policy2020/votervital/how-many-undocumented-immigrants-are-in-the-united-states-and-who-are-they/
- Discharge, Deportation, and Dangerous Journeys: A Study on the practice of Medical Repatriation. A joint project from the Center for Social Justice at Seton Hall Law School and the Health Justice program at New York Lawyers for the Public Interest. December 2012.
- Young, M.J., Soleymani, Lehmann, L. Undocumented Injustice? Medical Repatriation and the Ends of Health Care. The New England Journal of Medicine, 370;7, February 13, 2014.
- American Nurses Association Issue Brief. Nursing Beyond Borders: Access to Health Care for Documented and Undocumented Immigrants Living in the U.S.