Implications of ACA for Mental Health and Social Work Practice

The enactment of the Patient Protection and Affordable Care Act (dubbed “Obamacare”) in 2010 sought to decrease the number of uninsured Americans. It targets to extend health coverage and reduce the number of uninsured Americans. The policy targets to improve health insurance coverage through the following ways: 

Individual insurance marketplaces. Individuals and families buy insurance directly from insurers. The online exchanges are operated by states or the federal government. Individuals whose incomes are in the range of 100 and 400 percent of the federal poverty level qualify for subsidies to enable them to buy coverage. 

Small Business Insurance Marketplace. Firms having 50 or fewer employees are accorded an online exchange referred to as Small Business Health Options to enable them to cover their employees. 

Medicaid Expansion. The Medicaid program is to be expanded to cover individuals earning up to 138 percent of the federal poverty level. 

However, despite targeting to increase the number of health insured Americans, the Affordable Care Act is exclusionary to immigrants (Perreira & Pedroza, 2019) . Immigrants account for part of the 19 million Americans who will be ineligible for Medicaid (Rand Health Care, n.d.) . Affordable Care Act restricts illegal immigrants from being part of Medicaid expansion or getting tax credits for marketplace plans. Rand Health Care (n.d) estimates that undocumented immigrants could account for up to 23 percent of the uninsured who are unqualified for public programs. Other individuals left out of the ACA policy coverage are those with higher incomes (more than 400 percent of FPL) and low-income individuals who are residents of states not expanding Medicaid. 

Scope of the Problem 

Mental Health America estimated the population of immigrants in the US in 2015 to be about 43.3 million, accounting for about 13.5 percent of the total human population in the US. The immigrants and US born children were accounting for about 27 percent of US population or an estimated 84.3 million. Padilla (1997) notes of the changing trends of immigrants into US. Primarily immigrants were from Europe or Canada in the 1960s, but this shifted to Asian or Latin American immigrants in the 1980s. Currently, immigrants into the US are from different parts of the world. The immigrants are not spread evenly across the various states in the US. About 74 percent of the immigrants tend to settle mostly in the states of California, Florida, Illinois, New Jersey, New York, and Texas (Padilla, 1997) . Most of the immigrants tend to settle in urban areas with less than 7 percent settling in rural areas. 

Immigrants are categorized into the following groups: 

Documented immigrants. These include immigrants who have already acquired US citizenship and legal residents. 

Undocumented immigrants. They are foreign-born individuals who are resident in the US without authorization. Includes persons who entered the US without migration documents and individuals who entered lawfully but extended their stay past expiration of their visa or status (Artiga, 2019). 

Children born to undocumented immigrants while their parents reside in the US. 

Those against the move to accord immigrants quality and affordable healthcare cite the reason that such a move would encourage an increase in number of illegal immigrants into the US in pretense of search for health care. Those in support of quality and affordable healthcare to immigrants argue that healthcare is a fundamental human right and should be accorded to all without discrimination. One of the government policies that have brought the debate back to the public discourse is the Patient Protection and Affordable Care Act. The Policy enacted in 2010 is bureaucratic to immigrants, and some would also label it as exclusionary. The Policy spells out some measures for immigrants to benefit from ACA programs. Undocumented immigrants are locked out of ACA Policy programs. 

This study seeks to explore the implications that ACA has had on immigrants. This includes impacts on their physical and psychological health and also the impacts on social work practice. 

Impact of ACA Policy on Immigrants 

ACA policy impacts immigrants through either their inclusion or exclusion from the program (National Alliance of State and Territorial Aids Directors, 2014) . As of 2014, legal immigrants in the US with more than five years of residency and earning 138 percent or less of FPLwill be eligible for Medicaid in states that will expand the Medicaid program. However, undocumented immigrants will be unqualified for the Medicaid program and its expansion rather than for emergency services only. 

Legal immigrants may buy a Qualified Health Plan under the ACA policy and are subjected to requirements for having minimum essential coverage. Individuals with incomes of 400 percent and below of FPL are qualified for premium tax credits to cover part of QHP. Persons earning 250 percent of FPL and below are eligible for cost-sharing reductions. Unauthorized immigrants are not qualified for Marketplace coverage, including tax credits and cost-sharing discounts. They will also not be subjected to a monetary penalty for not owning a health insurance cover. 

The immigrant population left out of the ACA policy federal programs will benefit from health programs offered by community health centers, low-income health providers, and public programs where they can receive preventive and primary care and treatment (Artiga, 2019) . State and locally funded programs in the areas of health care that do not discriminate against one’s immigration status can also benefit ACA policy, ineligible immigrants. Immigrants are also entitled to emergency care in all hospitals as provided for by federal law. Legal immigrants who are ineligible for ACA may also buy insurance plans outside the Marketplace program. However, unauthorized immigrants are not qualified to access public and private health insurance under ACA. 

Theoretical Framework 

At the enactment of ACA policy in 2010, lawfully residing noncitizens who had been in the country for five years or less would not be eligible for the Medicaid expansion program. Children of legally residing immigrants would qualify for the Medicaid program at state option despite living in the US for five years or less. Undocumented immigrants would be ineligible for Medicaid coverage. Undocumented adult and children immigrants will also not be qualified for health insurance subsidies (Kenney & Huntress, 2012) . They will also be prohibited from buying unsubsidized health insurance coverage from the exchanges. Eligible noncitizens are, however, qualified for exchange subsidies despite their length of stay in the US. Lawful immigrants with five years or less of US residency and without employer insurance are eligible for premium tax credits and cost-sharing tax credits towards health insurance plans. Included in this bracket are immigrants earning below 133 percent of the federal poverty level. 

Under the ACA policy, citizens and legally residing immigrants are entitled to minimum coverage. Undocumented immigrants are, however, not covered in this mandate. Also, excluded to this mandate are individuals with income below the minimum required to file federal income taxes or individuals who, after contributing to their health insurance and after subsidies, the contribution would exceed 8 percent of their income (Joseph & Marrow, 2017) . This is likely to affect immigrants who earn below 138 percent of the federal poverty level since some of their incomes will be below the tax- filing threshold. Dorn (2011) notes that even if the cost of accessing medical care for most destitute legal immigrants with five or fewer years of residency in the US may reduce due to premiums and subsidies, the immigrants may still not afford the cost of health care. This is because most of the immigrants will be excluded from the mandate as a result of being at the lowest income bracket, and hence their income is below the threshold for filing taxes. 

Under 30 immigrants with five or fewer years residency in the US and exempted from the mandate as a result of healthcare costing more than 8 percent of their income may benefit from ACA policy programs by paying low premiums and in return, being entitled to limited benefits. Uninsured immigrants who are 26 years or below will benefit from the health care coverage of their parents, including employer plans and plans bought in the non-group market. This is as a result of the expansion of the dependency age in the ACA policy. 

Artiga (2019) states that the shifting trends in immigration policies under Trump's administration have been causing fear and panic among undocumented immigrants. This has made them shy away from using programs and services for themselves and their US-born children even when eligible. These programs include the Child Health Insurance Program and Medicaid. Lack of access to these critical programs has negative impacts such as financial instability among families and unhealthy growth and development of children. Despite recent pronouncements of some democratic presidential candidates to expand health insurance coverage to undocumented immigrants, the frameworks and proposals of how this would be carried out are not yet put in place. 

Implications for the Mental Health System 

The various groups of immigrants in the US go through multiple forms of phycological and mental instabilities (Mental Health America, n.d.) . This adversely affects their mental health in various ways. Documented immigrants have been known to suffer from trauma, problems of acculturation, which consequently affects the family unit. Undocumented immigrants live in fear of being deported back to their countries. As such, they suffer from persistent and extreme stress, reduced self-esteem, helplessness, increased depression, anxiety, and hypervigilance. US-born children to undocumented immigrants and their parents experience mentally related illnesses. Parents suffer from the imminent risk of being deported and leaving their children under foster care (Veseley, Bravo & Guzzardo, 2019) . The parents are thus forced to designate legal guardians to their children to avoid putting them under foster care in case they are deported. On the other hand, children suffer from anxiety, fear, and depression due to situations that may arise as a result of an unknown future. It is estimated that 10 to 15 percent of children living in immigrant families show symptoms of depression. 

Some of the mental health stressors for undocumented immigrants in the US are categorized as follows: 

Pre-migration stressors. These include the feeling of a sense of failure and trauma in their countries of origin. 

In- transit stressors. Dangers experienced during crossing borders stress immigrants. 

Post-arrival to the US stressors. Some of these stressors include: 

Discrimination and stigmatization 

Fear of deportation 

Finite resources 

Acculturation stress 

Marginalization and isolation 

Interpersonal stressors and conflict 

Exploitation and victimization 

Return to country of origin stressors. Upon deportation or return to their countries of origin, immigrants turn out stressed due to: 

Feeling frustrated as a result of not meeting their financial targets. The promise of better economic times is the primary reason for illegal immigration into the US. 

Disturbed and strained family relationships. 

Hard economic times in the country of origin. 

Mental Health America (n.d) notes the following as some of the mental health risk factors: 

The migration process into the US. The dangers involved during the migration can turn out to have adverse effects on a person’s mental health. 

Traumatizing experiences in a person's life. These include sexual and physical harassment, separation of families, and violent incidences in a person's upbringing. 

Unavailability of social support. This may result in a dysfunctional behavior such as substance abuse and domestic violence. 

Keeping one's residency status a secret, and thus one becomes hypervigilant of his environment and keeps changing their surroundings in fear of being found out as being an undocumented immigrant. 

Acculturation stressors depending on the age at which one migrated to the US. The stress is worse for persons who migrate to the US when older. 

The feeling of a loss of identity and one's demeaning their worth resulting in low self- esteem. 

Some of the mental health outcomes for stressed undocumented immigrants in the US turn out to be: depression, anxiety, post-traumatic stress disorder, substance use and abuse, and psychological stress such as acculturation stress (Alegría, Álvarez & DiMarzio, 2017) . 

Despite immigrants in the US, accounting for quite a considerable percentage of persons with mental health issues as a result of the various stressors listed above, immigrants face multiple barriers to mental health treatment. Some of these barriers are: 

Less access to mental health treatment as compared to US born citizens. This is since psychiatric health care treatment is quite expensive, and most of the individuals cannot afford the cost from their pockets. Additionally, individuals who are not covered by insurance health programs of ACA policy continue to suffer from mental health issues as they cannot afford the cost (Artiga, 2019). 

Cultural barriers. Cultural barriers to mental health treatment take various forms, such as: 

Stigmatization as a result of suffering from mental health issues. This results from a lack of information on mental illness. 

Search for informal support networks from friends, family, or a religious community first. This results in a delay in starting treatment until a crisis ensues. 

Different signs of distress and how an individual describes his illness. This has a considerable impact on help-seeking, diagnosis, and treatment. This is because one may fail to read a person’s sign of distress and thus fail to accord the necessary help. Mental health practitioners may also make a wrong diagnosis and administer wrong treatment to the patients. 

Structural barriers. The structural obstacles in seeking mental health treatment are categorized as follows: 

Cost and lack of insurance. Undocumented immigrants and low earning legal immigrants do not benefit from the ACA policy, such as Medicaid and subsidies and cost-sharing. The cost of private health insurance is prohibitive and beyond the reach of many of the immigrants. Consequently, most of the immigrants end up having no insurance cover plan (Artiga, 2019). The cost of mental health treatment being too high for them to cater from their own pockets leaves them with no option but to continue suffering. 

Long waiting times. Mental health professionals have long waiting times before one can get an opportunity to be attended. This discourages persons seeking appointments. By the time the individuals get the treatment, their condition is usually at a point of crisis. 

The cultural and linguistic barrier between immigrants and mental health professionals. Some of the immigrants are not proficient in the English language which results to communication breakdown when seeking mental health treatment. This inhibits the right diagnosis and treatment. 

The fear of seeking treatment due to one’s immigration status. Undocumented immigrants are afraid to seek treatment when they have a mental illness. They fear that this may tip off authorities resulting in their deportation. 

ACA policy, through various avenues, presents a chance of addressing mental health issues, especially among the older members of the US population (Golden and Vail, 2014). Firstly, ACA seeks to expand insurance coverage to cover mental health and substance abuse. Through the Health Insurance Exchanges and Medicaid programs. ACA also restricts insurance companies from denying individuals with pre-existing conditions health insurance coverage. This will significantly benefit mentally ill patients who were previously excluded. 

ACA also seeks to improve mental health coverage through provisions such as free preventive services without copayment or coinsurance charges. This is important to mental health issues as it encompasses programs such as alcohol misuse counseling and depression screenings. ACA establishes the Community Health Center Fund to finance the operations and expansion of services and construction of more community health centers (Golden and Vail, 2014). These centers are essential in serving the health needs of undocumented immigrants, including their mental health. The ACA policy seeks to encourage enhanced coordination and integration of physical and mental health services by health service providers. This is crucial in the diagnosis and treatment of mental health issues. 

Different sections of the community need to be involved in curbing mental illnesses. They include religious institutions, counseling centers, community centers, and human rights and advocacy organizations. 

Implications for Social Work Practice 

Immigrants account for quite a considerable chunk of the US population. As such provision of social services to them is critical to ensure their seamless integration into the American community. Immigrant policies have been crafted to help facilitate this economic and social integration of immigrants. The policies revolve around areas such as health, education, social welfare, housing, and employment. Immigrants encounter events in their lives that necessitate the need for social services. Some of these events include family and community separation, dangers during migration, and relocation distress such as housing and employment search (Padilla, 1997) . 

To design service programs that respond to the needs of immigrants’ social workers have to consider various factors such as needs, experiences, and circumstances surrounding the different stages of immigration, such as premigration, transit, and resettlement. An understanding of the diverse cultural backgrounds is also important in social work to ensure appropriate integration of immigrants. 

With most of the immigrants originating from third world countries, their socio-economic status is low. They have lower education than US born citizens and are less skilled compared to US born citizens. A good percentage of immigrants also lack proficiency in the English language spoiling their prospects of securing jobs in the formal sector. Consequently, the poverty level in immigrants’ households is high since they are mostly working in low- paying jobs. Therefore, immigrant families are likely to suffer from economic hardships. 

Immigrant policies that seek to support the integration of immigrants into the US have been of little concern to consecutive government regimes. The current government regime under president Trump is quite vocal about anti-immigrant policies. The native Americans feel that the immigrants are taking away their jobs and depressing wages. Immigrants are also regarded as a drain to the economy due to the welfare programs directed at them. Rather than supporting immigrants, the shift has been mainly towards controlling immigration by discouraging it. This includes the exemption of legal and illegal foreign-born noncitizens from social welfare benefits. The ACA policy is another of the policies that seek to deter immigration, though in a hidden manner. By restricting the number of years, one has to be a resident in the US to benefit from some of the programs of healthcare insurance, the Policy delineates, and discourages immigrants. 

Access to healthcare for immigrants through the Medicaid program is left at the mercy of particular states that can either be for or against the program. Federal support for programs supporting immigrants has reduced (Padilla, 1997) . Provision of health, education, and social services have been mainly left to states and local communities. Most of the services are provided through private voluntary agencies. State’s programs for immigrants are dependent on factors such as the state's economy, immigrant constitution, and political characteristics (Zimmerman and Fix, 1994). States provide bilingual education to children with limited English besides offering emergency and prenatal medical services under the Medicaid program for unauthorized immigrants. In Massachusetts, social services in areas of health, child welfare, and mental health have been accorded to immigrant children, youth, and families. Immigrants in Texas have been receiving medical care through state health programs despite one’s legal status. However, failure to reimburse states for services accorded to immigrants by the federal government has made states with a sizeable immigrant population such as Texas, California, and Florida, to consider their immigrant welfare programs. 

Social workers are required to make an appropriate categorization of a client’s immigration status to determine whether they are eligible for government social welfare programs. This is because the use of public resources by ineligible immigrants can lead to deportation or denial of permanent residence in the future for the individual. Social workers can also help their clients apply for lawful migration status if they are qualified. Social workers and policymakers have the difficult task of ensuring a smooth transition for immigrants in terms of social and economic status. 

The social service needs of immigrants are dependent on the socio-economic background and the reasons for migration. Most of the immigrants into the US re labor migrants running away from poverty in their countries of origin. Some of the services that immigrants require to enable their socio-economic integration in the US include resettlement assistance, mental health services, and health care. Immigrants need resettlement assistance in terms of housing, food, clothing, education, language, and job skills training. In terms of health care support, most of the immigrants are not eligible to benefit from some of the programs of ACA policy except in emergencies. 

Immigrants in the US adopt survival tactics for lack of the necessary support from the government. These tactics include having many wage earners, including children to increase their family income, sharing residences with relatives and other families, and forming kin networks for assistance such as sharing resources and services e.g., childcare. 

The unmet needs of immigrants have various implications for social work practice. Social workers need to be aware of the challenges faced by immigrants, such as long working hours, poor living conditions, school dropouts, and lack of considerable help in navigating these problems. At research and policy formulation level, social workers can play the crucial role of calling to attention the adverse effects that the unmet needs of immigrants will have on the broader social, educational, and economic outcomes in the US (Padilla, 1997) . They can also provide testimonials on the reason that immigrants require social welfare since they have the first-hand experience of the conditions they go through. This can help shape policies and laws, such as the allocation of grants for welfare programs to states. 

To support immigrants in integration in the US and helping them avoid issues such as mental illness, social workers can help immigrants strengthen their cultural bonds and values, and social support from their families and communities. This can be achieved by integrating them with US citizens from their countries of origin who have been in the US for more extended periods. This has been found to provide a coping mechanism for immigrants. 

To respond to the needs of immigrants where state and federal welfare programs do not reach immigrants, social workers can arrange for community-based services and form coalitions to attend to the immigrants’ needs. The services may include shelter and food provision. 

To respond to health care needs for immigrants who are not covered under the ACA Policy programs, social workers can engage nongovernment entities to support the needs of their clients. These may include sponsors and volunteer organizations that can cover total or part of medical costs for the immigrants. 

Recommendations for Mental Health Practice 

According to Mental Health America (n.d), some of the protective measures that can be adopted in mental health treatment include: 

Providing social support to individuals who have a mental illness. The social support can be accorded by friends, family members, and religious groupings. 

Showing empathy for the marginalized groups such as immigrants and offering them the necessary support to help them acclimatize to their new environment. 

Counselling mentally ill individuals and those prone to help them hold an optimistic view of the future. 

Creation of a Basic Health Program (BHP) by states to cover low-income adults, especially between 133 and 200 percent of the federal poverty level, would help to ensure poor legal immigrants benefit from health insurance (Kenney and Huntress, 2012). This would help individuals who are ineligible for Medicaid. The states can create programs that require low premiums and out of the pocket settlement. States could also create a program that assimilates the coverage given under Medicaid. This would help ensure that poor immigrants feel integrated into the community, and this would help reduce mental health issues. 

According to Padilla (1997), efficient mental health intervention requires the use of different elements by the service providers. These are: 

Using trained bilingual and bicultural mental health professionals 

Training health care professionals on disorders linked with migration experience such as post-traumatic stress disorder. 

Creation of linkages between social service programs and the immigrant community members. 

The abolition of policies that lead to family separation among grandparents, parents, and children when seeking entry into the US or during deportation is necessary for curbing mental health issues (Veseley, Bravo & Guzzardo, 2019) . Instead, policies that target to keep family units together even as they go through immigration hearings should be legislated. This is because separation causes anxiety and depression. The parent-child relationship is crucial for healthy psychological development among children. Children separated from their parents exhibit trust issues with adults and institutions, interrupted schooling hence low educational attainment, anxiety, and aggression. 

Conclusion 

US continues to be a favorite migration destination to a large number of people globally. The primary reasons for immigration into US are search for better job opportunities, reunion with families and safer environment. Illegal immigration should be discouraged and instead urge individuals to use right immigration procedures when seeking entry into US. Social welfare programs should be accorded to immigrants. This would help them to be well integrated into the US community and improve their socio-economic status. This would consequently reduce incidences of mental illnesses among immigrants. 

More importantly, the ACA policy should be reviewed to adequately accommodate legal immigrants and especially those in the bottom earning level, so that they benefit from the quality and affordable health care and not just medical emergency aid. Immigrants are an important component of the US population. Most of the immigrants are hardworking members who make a positive contribution to the US community.They add to a highly motivated workforce and create thriving small and large businesses that contribute to growth of the US economy. 

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