Most of the estimated 11 million undocumented residents of the U.S. have no health insurance and are ineligible for public insurance programs. They are prohibited from obtaining insurance under the 2010 Patient Protection and Affordable Care Act.

When they become sick or injured, these low-income patients have limited access to health care. Organizations that are federally mandated to provide some level of care on the basis of medical need, such as emergency departments, federally qualified health centers, and health programs for farm workers, face difficult resource allocation challenges when undocumented patients' medical needs exceed available resources.

"Health care professionals can be deeply troubled when they encounter situations that seem unfair," says Nancy Berlinger, a Hastings Center scholar who is co-director of the project. "How to provide good care to patients who cannot afford to pay for care is one of those situations. When a patient is also undocumented, the situation becomes even more complex. This project aims to help clinicians and organizations by exploring the difficult questions of how ethical obligations compete with economic constraints, conflicting mandates, and political considerations."

Michael Gusmano, the other co-director of the project, adds, "We will review existing policies and regulations and identify how they shape access to care for undocumented patients.

"We know that some laws and programs are designed to provide access to health care for this population and others explicitly forbid the use of public funds to pay for care for this population," he says. "This creates a complex policy environment that causes difficulties for the patients, health care professionals, and health care organizations. Our project seeks to clarify, as much as possible, these policy choices and identify their consequences."

At a meeting in September in New York, the project's advisory group discussed several questions: Is there a right to health care implicit in the U.S.? In a society with a large immigrant population like the U.S., how are our social values expressed in how we view undocumented patients? What ethical guidance may help health care organizations and state and federal policymakers in a challenging economic environment at a time when the regulations are changing under the ACA.

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