User:Nickallen7/sandbox

Practice Experience Overview
I will be completing my practice experience at Highland Hospital in Oakland where I will be conducting research on health care access for immigrants and those experiencing homelessness. I will also be applying what I learn to carry out a community outreach project which seeks to raise awareness for the health care and health coverage options available to these marginalized populations. Also, for those who are interested, I will hold workshops to help them enroll in programs such as Medi-Cal to improve their access to affordable health care.

Healthcare availability for undocumented immigrants in the United States
The Bay Area - and the East Bay specifically - is home to a large population of immigrants of varying legal status. This population makes up a significant portion of the people I intend to serve during my practice experience. I think that the article is fairly well-written but can definitely be improved upon. Specifically, I think that it needs more information related specifically to California as this state is undoubtedly central to the issue. Whether this could fit into this page or would be better off as its own unique page is to be considered. I also hope to contribute to the "International Perspectives" section, researching policies that have succeeded or failed in dealing with this problem elsewhere.

Immigrant health care in the United States
This article details the struggles immigrants in the U.S. face obtaining proper health care. They may be restricted by health policies but in most cases are otherwise restricted from receiving the same care as those born in the United States. One aspect of my practice experience will be studying the impacts of the current political climate on immigrant health care, and thus I feel that I have a lot I can add to this article, particularly current information on the impact of discrimination on immigrants seeking out health care.

Article Overlap and Differentiation
As the two articles I have selected are very similar, this is how I plan to differentiate my work on the two. For the Area article, I will be focusing primarily on policy and access to health care. It seems that the biggest challenge with undocumented peoples' access to health care is political opposition, whether this directly limits their access or prevents them from seeking health care out of fear. I will be looking at this situation in the United States but also working on the "International Perspectives" section of the article that considers how different policies have been effective/ineffective elsewhere. In contrast, for the Sector article I will be focusing more on the quality of health care provided to immigrants, some of whom do not face legal barriers but tend to receive unequal treatment compared to U.S.-born citizens. I have begun looking into language and cultural discrepancies that perhaps discourage immigrants from seeking treatment or allow them to receive poor treatment.

Article Evaluation
I will be evaluating the page Healthcare availability for undocumented immigrants in the United States. The article is fairly brief especially given the relevance of this topic in the United States in the present day.

Evaluating Content

 * It appears to me that all of the information is relevant, but perhaps some is out of place. There are several sentences and facts that I feel belong in a different subsection.
 * None of the information is out of date but I think some current information is missing. Additionally, I think content could be added in many of the sections and possibly another whole section or two could be added. I think that a section on California could be relevant because the state is home to a huge proportion of the United States' undocumented immigrants and also has been at the forefront of many policy changes relating to healthcare for undocumented immigrants.

Evaluating Tone

 * The article does a good job of maintaining neutral tone in a sensitive topic, although there is a debate in the Talk page over whether "undocumented" or "illegal" should be used to describe immigrants in this context. The page currently uses "undocumented," and I see no reason to change this.
 * The article is proper in sticking to facts and I do not feel that any viewpoints are underrepresented or overrepresented.

Evaluating Sources

 * The citation links appear to be functional and the claims in the article are properly supported by the sources. I didn't pick up on any instances where the contributors went beyond what was stated in the source.
 * Although a couple are missing, the majority of the facts are properly attached to a source. The sources I checked were academic and reliable, but there are not very many sources considering that the article has a decent amount of material. These few references are cited numerous times each throughout the article. While they appear to be neutral, quality sources, I think the article could benefit from more perspectives.

Checking the Talk Page

 * The talk page is fairly empty, with only a brief debate about "undocumented" vs. "illegal" as described above. There is also an evaluation from a college student who compliments the quality of the article but feels that there is information to be added. I agree and hope that I can contribute.
 * The article does not appear to be rated, and is not a part of any WikiProject. It is included in two categories, Illegal Immigration to the United States and Healthcare in the United States.

Area
Biswas, Dan, et al. “Access to Health Care for Undocumented Migrants from a Human Rights Perspective: A Comparative Study of Denmark, Sweden, and the Netherlands.” Health and Human Rights, vol. 14, no. 2, 2012, pp. 49–60. JSTOR.


 * This source ultimately argues for a pan-European approach to health care for undocumented immigrants. Their research is based upon official United Nations provisions regarding the human right to health and evaluates how Denmark, Sweden, and the Netherlands are succeeding or failing to meet their commitments to fulfill these established rights. I have already cited this paper in my Area article because it has direct relevance to the “International Perspectives” section. Although my practice experience is not based on advocacy or lawmaking, I think legal approaches of the United States and other countries will be essential to understand. The Area article has lots of room for improvement when it comes to international health care policies and how they could present an improvement to the United States’ policy. The Biswas paper will help me contribute on this front.

Filc, Dani, et al. “Is Socioeconomic Status Associated with Utilization of Health Care Services in a Single-Payer Universal Health Care System?” International Journal for Equity in Health, vol. 13, no. 1, Nov. 2014, p. 115. BioMed Central, doi:10.1186/s12939-014-0115-1.


 * A study on the Israeli health system, this source addresses a key debate topic that has thus far been left out of my Area article. It evaluates single-payer health care, a policy many feel can solve the problems associated with health care for undocumented persons. The main result of this study is that although single-payer is successful in offering access to all, it does not necessarily improve gaps in utilization across socioeconomic strata. The importance of utilization is essential to my practice experience, as a major part of my project is making marginalized individuals aware of the options available to them. The discrepancy in utilization is also a great component to add to the article, both in the discussion on single-payer health care and in other systems such as that of the United States.

Kullgren, Jeffrey T. “Restrictions on Undocumented Immigrants’ Access to Health Services: The Public Health Implications of Welfare Reform.” American Journal of Public Health, vol. 93, no. 10, Oct. 2003, pp. 1630–33. ajph.aphapublications.org (Atypon), doi:10.2105/AJPH.93.10.1630.


 * This source could be very formative to United States policy as it is narrowly focused on the country’s unique situation and argues against restricting health access to undocumented immigrants from a public health perspective. One specific statement I found interesting is that there was no evidence supporting that health care benefits were luring foreigners to enter the United States illegally. I think that, with my focus on policy for this article, this source will provide me with a detailed public health perspective, which has not yet been contributed at all. Its relevance to my PE is also clear as I work to help undocumented persons with access to healthcare for the betterment of public health and for their own personal benefit.

Liebert, Saltanat, and Carl F. Ameringer. “The Health Care Safety Net and the Affordable Care Act: Implications for Hispanic Immigrants.” Public Administration Review, vol. 73, no. 6, 2013, pp. 810–20.


 * An exploration of the Affordable Care Act's implications on undocumented immigrants, this source intends to make those responsible for implementation of the law aware of the consequences. A particularly surprising argument made was that (at the time of the law) the general public was strongly against allowing healthcare insurance for undocumented immigrants, and thus Democrats intentionally left this group out of the legislation. In a broader sense, this directly legal perspective is essential both for my Area article and for my practice experience. Working with undocumented immigrants at the hospital, I think it is very important for me to understand the complexity of health care legislation because this complexity is a barrier for many seeking healthcare. Considering how relevant this law is, the one paragraph dedicated to it in my Area article is not nearly enough. I hope to expand the "Federal Legislation" section with specific impacts the ACA has on the "Health Care Safety Net" such as free clinics, which are often utilized by undocumented immigrants.

Lu, Michael C., et al. “Elimination of Public Funding of Prenatal Care for Undocumented Immigrants in California: A Cost/Benefit Analysis.” American Journal of Obstetrics and Gynecology, vol. 182, no. 1, Jan. 2000, pp. 233–39. ScienceDirect, doi:10.1016/S0002-9378(00)70518-7.


 * I struggled searching for a different-viewpoint source that perhaps cited costs as a reason to limit health access to undocumented persons, and instead found this source. It provides further evidence (and very direct evidence) that eliminating public funding for undocumented persons' healthcare only increases costs in the long run. I feel that this source is relevant and important to my Area article because it approaches the issue from yet another perspective. Whereas I have explored the human rights perspective and public health perspective, this is an economic self-interest perspective. For many, including lawmakers, this is an important aspect of the debate and thus it is essential to include. As it is key to the policy debate, I think it helps push my research towards tackling the political economy side of poverty as discussed in my Problem/Needs analysis.

Noy, Shiri, and Koen Voorend. “Social Rights and Migrant Realities: Migration Policy Reform and Migrants’ Access to Health Care in Costa Rica, Argentina, and Chile.” Journal of International Migration and Integration, vol. 17, no. 2, Jan. 2015. ResearchGate, doi:10.1007/s12134-015-0416-2.


 * By comparing the experience of undocumented immigrants seeking healthcare in different South American countries, this source will allow me to further strengthen the "International Perspectives" subsection of my Area article. Interestingly, Argentinian policy recently reversed course to allow immigrants access to healthcare after prior legislation had excluded them from such. As a result of the 2004 legal change, both "regular" and "irregular" migrants are granted access to free emergency healthcare, and pregnant women and children are entitled to free non-emergency care as well. Non-emergency care for other migrants is available, but not for free. Despite the recent changes, there are still barriers to healthcare for these groups based on the provider or province. This article is exactly what I was looking for following Saher's suggestion to research the policy of Global South countries with regards to health care for undocumented immigrants. It will be a great addition to the "International Perspectives" section which currently focuses on European countries. With regards to my PE, this can serve as an example when writing research papers and making policy suggestions.

Joseph, Tiffany D. “What Health Care Reform Means for Immigrants: Comparing the Affordable Care Act and Massachusetts Health Reforms.” Journal of Health Politics, Policy and Law, vol. 41, no. 1, Feb. 2016, pp. 101–16. read.dukeupress.edu, doi:10.1215/03616878-3445632.


 * Joseph explains that the ACA legislation was modeled after Massachusetts state health care reform of 2006 but notes a significant difference in the capability of undocumented immigrants to obtain healthcare under the two systems. The ACA explicitly excludes undocumented immigrants from federally subsidized insurance in accordance with prior legislation intended to limit undocumented immigration to the United States. By contrast, the 2006 Massachusetts reform established the Health Safety Net (HSN) program which provided health care for low-income individuals regardless of immigration status. This is valuable information for the Federal Legislation section of my Area article, as it provides context on the ACA while contrasting with the law it was modeled after. The Massachusetts program is also something that could be included in the research write-ups done during my practice experience. When being critical of current systems, it is essential to provide sensible alternatives and this could be one such example.

Holahan, John, et al. The Sanders Single-Payer Health Care Plan. Urban Institute, 2016.


 * This supplementary source details the health care plan of 2016 presidential candidate Bernie Sanders, a single-payer health care plan that many anticipated would include undocumented immigrants. It explains the economic impact of including undocumented immigrants, which the researchers estimate to be $77 billion. This is a 124% increase in federal funding for undocumented immigrants, the second largest proposed increase of any group behind the uninsured population (169.5%). This is not very relevant to my practice experience other than being useful knowledge for research paper discussions. For my Area article, however, this is a key piece that I will utilize in the "International perspective" section. It will help bridge the inclusion of information on Israel's single-payer system, explaining the relevance as similar systems appear to be gaining traction in the United States.

Sector
Read, Jen’nan Ghazal, and Megan M. Reynolds. “Gender Differences in Immigrant Health: The Case of Mexican and Middle Eastern Immigrants.” Journal of Health and Social Behavior, vol. 53, no. 1, 2012, pp. 99–123. JSTOR.


 * I incidentally came upon this source which highlights a discrepancy not only in immigrant vs. U.S.-born persons health and healthcare, but also a strong gap between the health and healthcare of immigrant men and immigrant women. One particular concept I found intriguing is the “healthy migrant effect” which is the strongly supported theory that immigrants arrive to the United States in better health than U.S.-born citizens, but this advantage declines over their time in the country. This has great implications for my PE, as it gives me motivation to think specifically about immigrant women and the quality of health care they are receiving. I may even see if the hospital is interested in specifically studying the gender gap in immigrant health care. The article also provides me with an untouched dimension to add to my Sector article, and I think I may be able to find a place to include the interesting “healthy migrant effect.”

Hacker, Karen, et al. “Barriers to Health Care for Undocumented Immigrants: A Literature Review.” Risk Management and Healthcare Policy, vol. 8, Oct. 2015, pp. 175–83. PubMed Central, doi:10.2147/RMHP.S70173.


 * This literature review reported on 66 articles to discuss some of the primary barriers to healthcare for undocumented immigrants. The source describes many well-studied inhibitions of immigrants in pursuing healthcare, mostly beyond the level of policy. This was my most important take-away, that 8/10 barriers to healthcare cited in the literature review were independent of policy. I plan to ensure the detailed inclusion of these non-policy barriers to my Sector article, where my focus is on discrepancies in immigrant vs. U.S.-born persons health care. In addition, this is a great source to have on hand for my practice experience. It essentially provides me with a list of problems to think about and even provides recommendation for how to break down these barriers.

Lauderdale, Diane S., et al. “Immigrant Perceptions of Discrimination in Health Care: The California Health Interview Survey 2003.” Medical Care, vol. 44, no. 10, 2006, pp. 914–20. JSTOR.


 * I felt that this source was important to include because it listens to those in need, allowing immigrants to define discrimination in healthcare their own way, and giving them a space to share their stories in hopes that they will lead to a change. The study, based in California, shows that Asian and Latino immigrants are significantly more likely to report discrimination in healthcare than U.S.-born persons, even when adjusted for ethnicity. As it focuses directly on the population I will be working with in the area I am working in, this study is clearly relevant to my PE. It encourages researchers like myself and the hospital to consider immigration status a key factor in healthcare discrepancy, and although it generally fails to present solutions, it is essential in that is clearly supports the presence of discrimination based on immigration status. I plan to use this source to make sure that this fact is clearly highlighted in my Sector article.

Gotlib, Anna. “Stories from the Margins: Immigrant Patients, Health Care, and Narrative Medicine.” International Journal of Feminist Approaches to Bioethics, vol. 2, no. 2, 2009, pp. 51–74. JSTOR, doi:10.2979/fab.2009.2.2.51.


 * To turn my research more towards solutions, I will utilize this source in which the author details "narrative medicine," an approach she feels can better limit the "double marginalization" of immigrants seeking health care. One interesting concrete concept that she introduced is the idea of the medical translator as a "cultural translator." This is one way to implement narrative medicine, which is the practice of understanding patients as complex individuals rather than as a set of symptoms. This is directly targeted at medical professionals and could potentially be explored further in my research in the emergency department at Highland Hospital. I think the concept of narrative medicine could potentially be worthy of a new subsection in my Sector article. It seems like a broad and agreeable solution (or step toward a solution), and the article currently lacks this. It has a decent section on "social barriers," but no presented solutions.

Pavlish, Carol Lynn, et al. “Somali Immigrant Women and the American Health Care System: Discordant Beliefs, Divergent Expectations, and Silent Worries.” Social Science & Medicine, vol. 71, no. 2, July 2010, pp. 353–61. ScienceDirect, doi:10.1016/j.socscimed.2010.04.010.


 * As I work to bolster the new subsection I hope to create on female immigrant health care in the United States, this source brings another perspective from a different community. The author explains that Somali women, who have sought refuge in high numbers to the United States(in particular Minnesota) find themselves in a very uncomfortable and vulnerable position when it comes to healthcare. One statement I found especially important is that Somali women have health beliefs that differ greatly from the principles of Western medicine. This article will help in many parts of my Wikipedia contribution, further advancing the subsection on women but also tying in nicely to the concept of narrative medicine. Narrative medicine is essential for these women, who may have beliefs that make it so what is considered the optimal care in Western medicine may not be optimal for them. This is also important to consider as I work with patients like this at Highland Hospital (and there are plenty).

Bauer, Heidi M., et al. “Barriers to Health Care for Abused Latina and Asian Immigrant Women.” Journal of Health Care for the Poor and Underserved, vol. 11, no. 1, 2000, pp. 33–44. DOI.org (Crossref), doi:10.1353/hpu.2010.0590.


 * This source sheds light on and investigates a rarely discussed aspect of immigrant women's health care: domestic abuse. Not only are immigrant women regularly abused, but the author states that Asian and Latina immigrant women face strong barriers to abuse treatment, and being a victim of abuse makes these barriers even more difficult to navigate. Previously discussed barriers such as social isolation and language differences remain, but are compounded with relationship issues like marital devotion and dedication to children. I think this issue is often forgotten and it could potentially find a place in our research at Highland Hospital. At the least, it might be a good article to bring up to the providers so they can be on the lookout for patients in need of help. As for my Sector article, this information fits perfectly in the new "Women" subsection that I am looking to create. I felt that this group (female immigrants) in particular deserved focus for their unique struggles, and this article represents a great example.

Lo, Ming-Cheng Miriam. “Cultural Brokerage: Creating Linkages between Voices of Lifeworld and Medicine in Cross-Cultural Clinical Settings.” Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine, vol. 14, no. 5, Sept. 2010, pp. 484–504. DOI.org (Crossref), doi:10.1177/1363459309360795.


 * Only lately has "culturally competent healthcare" entered into the conversation as a focus in the medical field. Lo argues that the best way to provide culturally competent healthcare is through a patient-centered approach and communication. While training of medical professionals can happen during medical school or later in their career, Lo expresses that there is a limit to what can be taught. The patient population is so diverse that providers cannot be prepared for every cultural background. Instead, they must be prepared to listen attentively, ask open-ended questions, and practice "power-sharing" during patient interactions. Although I will simply be a researcher and not a medical provider during my PE, I think these same guidelines apply and I will certainly keep them in mind. As for Wikipedia, this piece coordinates nicely with the discussion on narrative medicine that I have begun in my Sector article. Together these sources will bring the article a solid overview of the patient-centered approach.

Area
There are many approaches to resolving the issues with undocumented persons' health care. States often have their own policies within the overall United States health care policy, and the Healthcare availability for undocumented immigrants in the United States article has a section that covers international approaches as well. There are several debates held within this topic. Some feel that the expenditures created by providing health care to undocumented immigrants are validation for excluding them from the country. Others use this situation to argue for a policy change to single-payer health care. In 2016, presidential candidate Bernie Sanders brought single-payer healthcare into the national conversation. His healthcare plan was presumed to include undocumented immigrants, with an estimated $77 billion in federal funding provided for health services for this group. Israel, which has a healthcare system that approaches single-payer, still sees a discrepancy in utilization of the healthcare system across socioeconomic status, where undocumented immigrants are generally crowded in the lower strata.

Biswas expresses criticism for a couple European healthcare systems from a human rights perspective. Many countries have agreed to uphold U.N. definitions of the human right to health, and Biswas argues that not all are holding themselves up to standards on the front of undocumented immigrants. The Netherlands, Sweden, and Denmark have varying levels of healthcare availability for undocumented persons, but only Denmark's healthcare system seems to be offering these people the right to health as defined by the U.N.

Kullgren and Lu et al. present self-interest perspectives to Americans, showing how providing health services to undocumented immigrants is beneficial to everyone. Kullgren explains the public health point-of-view, arguing that if undocumented immigrants are blocked from accessing levels of health care then preventable diseases will be spread at a higher rate through the entire community. Additionally, since undocumented persons are often ineligible for preventive care, they will be more likely to catch disease and cost the overall system. This relates to the economic considerations brought by Lu et al., who use data from cases of pregnant women to perform a cost-benefit analysis. Their findings suggest that eliminating public funding for comprehensive care only leads to higher long-term expenditure of these funds. Specifically, undocumented women and their children when denied prenatal care were more likely to cost the healthcare system in the long run.

Undoubtedly the most relevant legislation to the issue, the Affordable Care Act of 2010 explicitly excludes undocumented immigrants from purchasing health insurance, which essentially inhibits their access to most health services. According to Liebert and Ameringer, this exclusion was based on the general public's hesitance to offer health services to undocumented persons. They additionally evaluate the impacts of the law on what is known as the "Health Care Safety Net" - free clinics and hospital emergency rooms that do not deny uninsured people. Looking at free clinics and community health centers, the article projects that the overall increase in government regulation and specific provisions of the bill will interrupt these organizations. It is also likely that not as many physicians will be serving these programs. The ACA was modeled after a 2006 Massachusetts health care reform but did not follow the state's precedent of inclusivity. Prior to the ACA, Massachusetts' Health Safety Net (HSN) program allowed all low-income persons, regardless of immigration status, to obtain health coverage without any premium and with minimal co-pays. The HSN was and still is primarily funded by a tax on hospital revenue, but this funding has declined as a result of fewer uninsured residents since the implementation of the ACA. Regardless, it shows that Massachusetts remains intent on providing health coverage for undocumented immigrants while federal legislation attempts to exclude them.

Noy and Voorend detail how Argentina has recently reversed course in their policies on health care for undocumented immigrants. Previously barred from health services as a result of the Videla Law, legislation from 2004 now allows undocumented immigrants full access to healthcare. Public emergency care is free for all undocumented immigrants, while non-emergency care is free to undocumented pregnant women and children. While this legislation opens the door for undocumented immigrants to receive sufficient healthcare, barriers still exist. Many health providers require Argentinian identification, and some institutions misinterpret or ignore the law. Additionally, the decentralization of Argentina into provinces allows for regional variations on the legislature and its application.

Sector
While most legal immigrants don't have official legal barriers to health care, they can still be marginalized by language and culture barriers. Immigrants generally arrive in the United States in superior health compared to U.S. born citizens. However, they can be discouraged from seeking care out of fear for unfair treatment. Immigrant women seem to face especially poor health as compared to immigrant men. This could be partially explained by their increased likelihood of seeking treatment.

Hacker details a multitude of barriers that immigrants face when seeking fair and equitable health care. Aside from communication issues, the complexity of the health system deters many immigrants who are not sure where they can seek treatment. They are also often lacking in motility and otherwise financially unable to seek proper healthcare. The study additionally cites shame/stigma as a barrier to immigrants who don't want to be seen as a burden to society or thought of as such by the public.

Perhaps the single largest obstruction of equitable healthcare for immigrants is the threat of discrimination at the hands of healthcare providers. This can deter immigrants from seeking healthcare in the first place, but it can also prevent those who do pursue treatment from receiving fair and proper care. This was described by Asian and Latino immigrants in California, who are significantly more likely to report discrimination in healthcare than U.S.-born citizens, even when adjusted for ethnicity. This suggests that immigration status alone is correlated with injustice.

Ensuring fair and equitable healthcare for immigrants is a difficult task, but Gotlib proposes a partial solution through what she calls "narrative medicine." This concept is based on understand the full "narrative" of patients and treating them as complex individuals rather than isolating them from their symptoms. Implementation of this strategy is difficult, but Gotlib offers a couple actions that could move providers towards this goal. She mentions employing translators, many of whom are already employed at hospitals, not just to directly translate language but to help medical professionals understand the patient and their circumstances as a whole. She calls this "cultural translation." Gotlib seems to suggest that the direct education of medical professionals is the best way to work towards the overall goal. Hiring translators, especially those expected to understand cultural backgrounds, is difficult and can be unreliable at many health centers. Instead, encouraging or requiring medical professionals to take part in cultural education and listening practice can allow them to pick up on spoken or unspoken cues that can allow them to provide the best treatment for each individual patient.

Tying into some of the existing information on female immigrant health and narrative medicine, Pavlish et al. discuss Somali women who have sought refuge in high numbers in Minnesota. The study notes that the health views of these women tend to be starkly different than the biology-based methods of Western medicine, and because of this and their inability to obtain insurance they are discouraged from seeking healthcare. They also lack confidence in the ability of medical professionals to communicate efficiently with them. As a result, chronic conditions show a higher morbidity rate among this community. When they do seek healthcare, these women tend to have frustrating experiences. They are accustomed to immediate action from healthcare providers, and can become upset when asked to schedule and appointment or wait on the results of lab tests or scans. Many even feel that physicians in the United States make their health worse, and think it is best to avoid them. Like many immigrants, the complexity of the healthcare system brings confusion to the Somali women participating in thr research study. They also expressed their hesitancy to take pills on a regular basis, tying back to their unfamiliarity with chronic disease.

It is important to give a distinct focus to female immigrants because they face unique challenges when seeking fair and equitable health care. Bauer et al. detail one of these challenges, domestic violence, which both creates health issues among immigrant women and inhibits their ability and willingness to obtain treatment. Immigrant domestic violence victims are less likely to seek healthcare for many reasons including lack of system familiarity, language barriers, fear of deportation and more. They also can be hesitant as a result of children's involvement or desire to maintain their marriage.

Narrative medicine is essentially an attempt to provide "culturally competent healthcare" as described by Lo. In recent decades it has become clear that certain groups, including immigrants, receive suboptimal health care in the United States. The need for cultural competence first caught on in mental health in nursing, but now is being recognized throughout the healthcare system. Lo expresses that the most feasible way to approach cultural competence is through medical professionals practicing active listening, asking open-ended questions, and sharing power during their interactions with patients. This creates a "patient-centered approach" that can minimize the discrepancy in healthcare provided to immigrants and other marginalized groups. While this requires education of healthcare providers, it is less intensive than full cultural education which many consider unfeasible given the diversity of patient populations.

Key
Bold text = My planned additions

Regular text = Existing article

Subsections listed are already present unless otherwise noted.

International Perspective
Other foreign countries are also wrestling with questions related to the access of undocumented immigrants to national healthcare services and insurance programs. In particular, physicians who are often the point of contact in providing care have become increasingly vocal in these discussions.[10] In Europe, pediatricians have been advocating for the extension of the UN convention to immigrants, refugees, and “paperless” children.[10] '''Swedish pediatricians have openly opposed statewide policies excluding asylum-seeking children from gaining access to medical care and worked to create an alternative state-funded health program for these children in particular.CITE [10] Since 2000, Sweden has allowed asylum-seeking children the same access to medical care as Swedish citizens. '''

'''The Videla Law of 1981 barred immigrants lacking documentation from receiving health care in Argentina. In 2004, new legislation reversed this policy and stated that all immigrants should have the same access to health as Argentinian nationals. This includes free emergency care for all undocumented immigrants and free non-emergency care for those who are pregnant women or children. In practice, barriers to healthcare remain for undocumented immigrants. Individual provinces and providers have interpreted the law differently, and many require that patients provide official identification. '''

'''Single-payer healthcare has recently entered the debate in the United States, most notably as part of the platform of 2016 presidential candidate Bernie Sanders. Sanders' plan was estimated to allocate $77 billion to health services for undocumented immigrants. Israel's universal single-payer healthcare system allows full access to health services for undocumented immigrants, but a 2014 report notes that there remain heavy discrepancies in healthcare utilization across socioeconomic strata. '''

Political Debate
...

Research has found that because immigrants come primarily to the U.S. in search of employment, excluding undocumented immigrants from receiving government-funded healthcare services will not reduce the number of immigrants.[5] Those who support more inclusive healthcare policies argue such provisions would ultimately harm the well-being of U.S.-born children living in mixed status households, since these policies have made it more difficult for these children to receive care.[5] '''Impeding undocumented immigrants from receiving health care has been shown to increase the spread of preventable diseases through communities. Financial justification for withholding services does not appear feasible. A study from the UCLA School of Public Health showed that eliminating public funds for prenatal care for undocumented pregnant women led to greater use of public funds for the health care of these women and their children in the long run. The National Research Council concluded that immigrants collectively add as much as $10 billion to the national economy each year, paying on average $80,000 per capita more in taxes than they use in government services over their lifetimes, and these patterns of expenditures and usage also extend to undocumented immigrants.[6] The''' ongoing debate and subsequent policy-decisions have important implications for the healthcare of undocumented immigrants residing in the United States.[5]

Federal Legislation
In 2010, President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law. '''To match public opinion and boost popularity for the legislation, the ACA contains language that explicitly excludes undocumented immigrants from being able to purchase health insurance coverage. CITE [1] Community health centers and clinics play an integral role in implementing provisions of the ACA and are heavily relied upon by undocumented immigrants.CITE [1] The ACA does provide additional funding for these "safety-net" services, but many physicians are expected to leave these clinics as a result of the higher demand for doctors working with the increased number of insured persons.  The Gruber MicroSimulation Model estimates that the rise in uninsurance rates of undocumented immigrants will be negligible nationwide with higher coverage rates for the rest of the population under the ACA.[1] At a state level,''' the impacts of the ACA will vary depending on the percentage of uninsured illegal immigrants among their statewide population. '''The ACA was modeled after a 2006 Massachusetts health care reform but the state's intention to provide health care for undocumented immigrants was not met in the federal legislation. The Massachusetts Health Safety Net (HSN) program was established to provide health coverage with no premiums and low co-pays to low-income individuals regardless of immigration status. After the ACA took effect in 2014, the state lowered HSN funding from hospital revenue tax as a result of the reduction in uninsured persons. '''

Possible New Subsection: Women
'''Studies have found that immigrant men are significantly healthier than immigrant women, and that this health gender gap is even larger than that present in U.S. citizens. Recent research suggests that this discrepancy could partially be a result of improved awareness of health issues among female immigrants. Immigrant women who become ill in the United States face multiple levels of marginalization from their immigration status, health status, and gender status. Somali women who have sought refuge in Minnesota voiced their frustrations with Western medicine, citing the complex healthcare system, the inefficiency of the diagnosis and treatment process, and ineffective communication with medical professionals. '''

'''Immigrant women who suffer from domestic violence face a multitude of obstacles to obtaining professional help. Focus groups of abused Asian and Latina immigrant women revealed unique barriers on top of the social and linguistic obstructions to healthcare faced by the general immigrant population. Women expressed their hesitance to seek healthcare as a result of their lack of extended family in the United States and unwillingness to harm their children and/or their relationship. '''

Policy challenges and proposed solutions
...

In addition to proposed reform bills, alternative routes to improving health coverage rates have been sought, namely via the means of direct immigrant outreach initiatives. Studies indicate the overall effectiveness of state-funded coverage programs in reducing the immigrant-citizen health care disparities, but other efforts have been suggested for further results.[5] For instance, states can encourage and promoter greater use of health services by reducing enrollment barriers—e.g. dispersing more information about eligibility, reducing language difficulties, etc.[5] (PARAGRAPH BREAK)

'''Public health scholars have acknowledged that certain marginalized groups, including immigrants, experience a lower quality of healthcare. In order to provide culturally competent healthcare, many believe that providers should receive more education about communication patterns, others’ perceptions of health and fatality, and traditional folk medicines.[30] Narrative medicine is a growing field that seeks to better educate medical professionals to see patients as complex individuals rather than an isolated set of symptoms. Proponents believe this practice can reduce the discrimination immigrants face at the hands of healthcare providers, but implementation remains an obstacle. Proposals vary from the employment of "cultural translators" to mandating cultural education and listening practice by medical professionals. Patient-centered care, which primarily focuses on improving communication between providers and marginalized patients, is considered a more feasible approach. This is achieved through preparing medical professionals to be attentive listeners, ask open-ended questions, and practice power-sharing during patient interactions. Continued efforts are necessary to overcome immigrant skepticism of American medicine and ensure fair and equitable health care for immigrants regardless of cultural background.'''

Social Barriers
There is also a climate of fear and distrust that prevents immigrants, especially those without documentation, from actively seeking out health services. Fear arises largely from the idea of risking deportation or becoming ineligible for citizenship.[14][15] Although the Immigration and Naturalization Service has stated that receiving Medicaid or SCHIP benefits (with the exception of long-term care) does not jeopardize residency status, many immigrants are still unaware and perceive otherwise.[12] '''Unfamiliarity with the U.S. health care system has been repeatedly cited as a barrier to health care for undocumented immigrants. Hesitance to seek health services can also result from the perceived stigma associated with immigrants' utilization of welfare. A 2003 study found that Asian and Latino immigrants who seek healthcare are more likely to report discrimination than U.S. nationals, even when adjusted for ethnicity. '''