In September of 2009, as President Obama was addressing Congress regarding the Healthcare Reform Act, representative Joe Wilson (R-S.C.) stood up and yelled, “You lie!”

This outburst was in response to President Obama’s statement that the healthcare coverage expansions would exclude undocumented immigrants. This heated incident between Obama and Wilson is a perfect example of the polarizing nature of debates regarding undocumented immigrants and health care.

In fact, Obama was not lying. Although the Affordable Care Act will provide 32 million more Americans with better access to health care, undocumented workers are excluded from this mandate.6

Like many Americans, Congressman Wilson holds a strong belief that providing health coverage for undocumented workers would drastically increase the cost for American taxpayers.

What many people do not realize is that there is already a high healthcare cost associated with undocumented immigrants. In order to reduce these costs and to improve individual and community health outcomes, we need to provide immigrants with regular sources of primary and preventative care, including access to medical insurance.

Since the Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986, EDs are required to treat patients regardless of their ability to pay and/or legal status.1As a result, undocumented immigrants facing a wide range of health issues either ignore treatment or rely on the ED for temporary and often inappropriate care.  

Not only is this inefficient, it is ultimately more expensive. For example, a study of undocumented immigrants with end-stage renal disease found that those who were treated with only emergent dialysis in the ED had hospital costs that were almost four times higher than undocumented immigrants treated with the same standard of care provided to U.S. citizens.7

The hospital system, insurance companies and ultimately American citizens absorb these costs.4 Provision of even basic medical insurance, with a focus on preventative care, would provide relief from the stark economic realities caused by overuse of the ED.

Although a portion of undocumented workers has health insurance through their employers, more than half of undocumented adults (59%) and their children (55%) have no health insurance. This is nearly four times the rate of U.S.-born uninsured. 4

To further complicate matters financial, language and cultural challenges, including fear of deportation, make it extremely difficult for undocumented immigrants to access primary and preventative. 3

We see this reflected in healthcare utilization rates. Low-income, immigrant adults are twice as likely as low-income American citizens to have no regular source of health care, whereas low-income immigrant children are four times more likely to lack a usual source of care compared with low-income U.S.-born children. 6

This lack of access to a primary care provider puts undocumented workers and their families at extreme risk for deteriorating health overtime.

Limiting healthcare access to undocumented workers is short-term thinking. Reducing reliance on emergency care through increased access to preventative care and medical insurance provides an opportunity to reduce spending in the long run.

Along with reducing spending, granting medical access to undocumented immigrants will improve healthcare among more than 11.5 million vulnerable people.5

Congressman Wilson is a politician, and is far removed from the frontlines of healthcare delivery. As providers, we interact with vulnerable patients every day and need to advocate for their rights. That includes advocating for undocumented immigrants who live among us, who work with us, and whose children are our children’s classmates in school. 

Caitlin VanderWindt is an nurse practitioner candidate in the University of Pennsylvania’s Pediatric NP Program.


  1. Brown LW. International Journal of Management. 2013; 30(2): 421-433.
  2. DeParle N. “The affordable care act helps america’s uninsured.” The White House. Retrieved October 15, 2013, from
  3. Derose K et al. Med Care Res Rev. 2009; 66(4): 355-408.
  4. Garlanaeu C. J Health Care Poor Underserved. 2011; 22(2):422-428.
  5. Hoefer M et al. U.S. Department of Homeland Security, Office of Immigration Statistics. Population Estimates March 2012. Retrieved from website
  6. Sanchez GR et al. J Health Care Poor Underserved. 2011; 22(2): 683-689.
  7. Sheikh-Hamad D et al. Tex Med. 2007;103(4):54–58, 53.