Featured Graduate Student Research: Cesar Vargas Nunez

Background

A large and increasing number of people are seeking refuge in European countries. They hope to find protection from violence and economic opportunities. Yet, the mass influx of refugees and oftentimes unauthorized immigrants has resulted in hostility and political backlash from the native population (Rechel et. al, 2013) This has pushed governments to seek stricter policies in order to curb immigration. While some of the recent policy changes aim to reduce the number of migrant inflows directly, most of them try to do so indirectly by restricting access to social services such as education or health (Derose et al. 2007). But how do immigrants respond to the sudden exclusion from social services? To date, little research has examined this crucial question. My project seeks to fill this gap in the literature and contribute to our understanding of how unauthorized immigrants react when they are excluded from accessing medical care.

As a response to the global economic recession, the Spanish central government issued Royal Decree 16/2012 in April 2012. This decree changed the Spanish healthcare system from one of the most welcoming into one of the most restrictive (Suess et. al, 2014). Almost overnight, nearly 500,000 adult undocumented immigrants lost access to public medical services (Prats, 2012). But the decree also carved out three exceptions for access: minors, pregnant women, and medical emergencies. Nevertheless, the decentralized nature of the health-care system allowed various states to defy the central government by refusing to implementthe decree’s exclusionary directives (Cimas et. al, 2016). The asymmetric implementation of the decree left undocumented immigrants facing different realities in access.

Figure 1b illustrates the estimated density of immigrants in Spain when the decree was implemented (INE, 2012). The map shows that immigrants are primarily concentrated in the states of Madrid, Andalusia, Catalonia and Valencia. This contrasts with Figure 1a from Cimas et. al (2016) that shows the variance in access across states. There did not seem to be a clear relationship between states that defied the decree and concentration of immigrants living within the state. Armed with this information, I wanted to research the impact of medical exclusion on undocumented immigrants affected emergency-care utilization? I hypothesized the states that applied the decree would have a marked increase in the rate of urgent-care. As the only aveneue left for adult undocumented immigrants to get medical attention, urgent care services could potentially serve as a substitute for primary care attention. Additionally, these states would also have a sharp decrease in the rate of primary care visits. Alternatively, those states that defied the decree’s implementation would not see major changes to the demand for primary or emergency care.

Fieldwork

The decentralized healthcare system that allowed states to defy the decree has also made it difficult for social scientists to empirically measure its impact. Currently, there does not exist a unique data set that encompasses emergency-care utilization at at the state-level. Thanks to funding from The Europe Center, I was able to travel to Spain this summer to visit government agencies and collect records of healthcare utilization rates and other related health outcomes.The funding from The Europe Center allowed me to submit open-data requests in Galicia, Asturias, Castilla y La Mancha, Madrid, Catalonia, Andalusia, Aragon and Valencia. I also had the opportunity to meet with civil servants and researchers at Universidad Complutense de Madrid to discuss my research project. I am hopeful these bonds will improve my ability to conduct research in Spain in the future. Overall, I have collected healthcare utilization datafrom 12 states: Andalucia, Aragon, Cantabria, Catalonia, Castilla y La Mancha, Castilla yLeon, Islas Baleares, Madrid, Murcia, Navarra, La Rioja, Pais Vasco. While I am still awaiting responses from a few states - namely Asturias, Galicia, and Valencia - the data I have collected (so far) show interesting results.

The (preliminary) results of figure 2a illustrate the changing evolution of primary care demands in Madrid and Andalusia. While the state of Madrid applied the restrictions of the decree, Andalusia remained defiant and continued to offer primary care access to everyone. The figure shows a time series plot of the change in primary care visits per resident over time. The plot suggests both states have a decrease in the rate of primary care visits. Though it would be premature to make inferences regarding the causes of this decrease, it is striking that Madrid had a much greater drop compared to Andalusia.

On the other hand, the (preliminary) results of urgent care, shown in figure 2b, illustrate a very different pattern. It is unsurprising that urgent care rates increased overall. But given that Andalusia did not limit undocumented immigrants to urgent care, it was surprising to find Andalusia’s rate increasing more rapidly than Madrid’s. Nevertheless, it would be premature to draw any inferences about the cause of this variance. Luckily, my dataset includes data outcomes on urgent-care visits that resulted in hospital admission (which can be used to tease out patients with ”true” emergencies from those that simply used the emergency-room as a substitute for primary care), along with population changes (which can severely affect urgent care demands). Currently, I am working on compiling all of the data collected into a single dataset to look more closely at the effects of the decree on healthcare utilization.

Conclusion

My trip to Spain allowed me to collect a wealth of data that will be used to create an original dataset to measure the impact of Royal Decree on emergency-care utilization. I am confident this new original dataset will have the potential to investigate the effect of the decree onother outcomes of interest. Future projects can use this dataset to investigate the decree’seffect on immigrant mobility, healthcare expenditures, and vaccination rates. This dataset will jumpstart my research agenda on provision of social services, immigration and health.

References

Cimas, M., Gullon, P., Aguilera, E., Meyer, S., Freire, J. and Perez-Gomez, B. (2016). Healthcare coverage for undocumented migrants in Spain: Regional differences after Royal Decree Law 16/2012. Health Policy, 120(4), pp.384-395.

Derose, K., Escarce, J., & Lurie, N. (2007). Immigrants And Health Care: Sources Of Vulnerability. Health Affairs, 26(5), 1258-1268.

Rechel, B., Mladovsky, P., Ingleby, D., Mackenbach, J., & McKee, M. (2013). Migration and health in an increasingly diverse Europe. The Lancet, 381(9873), 1235-1245. doi:10.1016/s0140-6736(12)62086-8

Prats, J., (2012). El Gobierno restringe el acceso a la sanidad a los inmigrantes irregulares. Retrieved from https://elpais.com/sociedad/2012/04/20/actualidad/1334935039248897.htm

Cesar Vargas Nunez is a PhD candidate in Political Science.