Health disparities among illegal immigrants and homeless people in the USA: a struggle within

Undocumented immigrants in the United States face significant barriers in accessing healthcare services, which contribute to health disparities. This population is often affected by homelessness due to limited access to affordable housing, limited employment opportunities, language barriers, fear of deportation, and lack of social support. Homelessness and the fear of deportation can lead to stress, anxiety, and physical illness among undocumented immigrants, highlighting the need for healthcare services tailored to their unique needs. Access to healthcare is further hindered by a lack of health insurance coverage, financial constraints, language and cultural barriers, and the ineligibility for public health insurance schemes. Undocumented immigrants who are homeless encounter additional challenges, including difficulties in accessing resources, navigating the healthcare system, and facing societal discrimination. This article focuses on the barriers faced by undocumented migrants in the United States regarding healthcare access and proposes feasible solutions to promote health equity and advance universal health coverage in the country. The absence of health coverage for undocumented migrants undermines the concept of universal healthcare in the USA, as it excludes a significant portion of the population from accessing essential healthcare services. Hence, there is a need for comprehensive immigration reform and policies that ensure impartial access to healthcare. Practical solutions include establishing culturally competent care, implementing mobile clinics or street medicine programs, fostering collaborative relationships with nonprofit organizations, advocating for policies safeguarding the rights of undocumented immigrants, and enhancing data collection techniques.


Introduction
According to the Center for Immigration Studies, the number of undocumented immigrants in the USA was 11.35 million in January 2022, representing nearly 24% of the total USA population [1] .The U.S. Department of Housing and Urban Development reported that in 2022, there were 582 462 homeless individuals nationwide, equivalent to ~18 per 10 000 people.Among them, 66% were males, and half were White [2] .Over 50% of the undocumented population lacked health insurance, significantly limiting their access to and affordability of standard healthcare in the USA [2] .This disparity, combined with other social determinants of health such as poverty, lack of access to basic necessities like food and shelter, and limited education, contribute to poorer health outcomes for undocumented migrants compared to their counterparts.
Undocumented immigrants who are also experiencing homelessness in the United States face various challenges that contribute to health disparities [1] .The lack of health coverage for undocumented migrants undermines the notion of universal healthcare in the USA.This article aims to shed light on the barriers encountered by undocumented migrants in the USA and put forward feasible solutions to promote health equity and advance universal health coverage in the country.

Interplay between undocumented migrants, homelessness, and access to healthcare in the USA
Homelessness is a prevalent issue among undocumented immigrants, which can be attributed to a range of factors [2] .These include restricted access to affordable housing, limited employment prospects, language barriers, apprehension of deportation, and inadequate social support [3] .Moreover, they could be deemed ineligible for specific public assistance initiatives and encounter prejudice or abuse, thereby impeding their ability to secure permanent housing.
The state of being homeless and the apprehension of being deported can lead to a considerable amount of stress, anxiety, and physical illness among undocumented immigrants, thereby affecting their mental and physical well-being [4] .Health services designed to cater to the distinctive requirements of undocumented immigrants can aid in alleviating some of these difficulties [4] .
Undocumented immigrants often face obstacles when it comes to accessing healthcare [4] .While emergency healthcare is generally available regardless of immigration status, routine and preventive care may be limited.Some healthcare facilities, like community health centers and free clinics, provide medical assistance without considering an individual's immigration status.However, the availability and extent of these services may vary depending on the location.

Challenges faced by undocumented immigrants in accessing healthcare services
Undocumented immigrants encounter notable obstacles in obtaining healthcare services, resulting in restricted access to healthcare.Individuals may experience a dearth of health insurance coverage, restricted financial means, and linguistic and cultural obstacles.Inadequate documentation may render individuals ineligible for public health insurance schemes like Medicaid, thereby impeding their access to crucial healthcare services.
Undocumented immigrants often experience apprehension regarding deportation when accessing healthcare services, particularly in environments where immigration enforcement is closely linked to healthcare establishments [4] .The apprehension experienced by individuals can act as a deterrent, impeding their ability to promptly and indispensably seek medical attention.This can result in deferred diagnoses, intensification of health ailments, and inferior health consequences.
The absence of secure housing presents supplementary obstacles to the physical and mental welfare of undocumented migrants.Individuals who reside on the streets or in precarious housing situations are susceptible to inclement weather, physical harm, and unhygienic surroundings [5,6] .The aforementioned circumstances are known to augment the likelihood of contracting infectious diseases, experiencing mental health complications, and developing chronic illnesses.To put this into context, according to recent reviews, depression, anxiety, post-traumatic stress disorder, and substance abuse are prevalent mental health issues faced by undocumented migrants [3,4] .Moreover, undocumented Latinx has been shown to experience delays in HIV diagnosis [7] compared with Latinx with documentation, Blacks, and Whites [5] .A survey revealed that 4.4% of Latinx transgender women (LTW) reported living with HIV, 15 times higher than the overall HIV prevalence in the United States [8] .Emerging evidence suggests that legal status may be a contributing factor, as illegal immigrants who identify as LTW reported remaining in abusive relationships with their sexual partners, which often are high-risk people with HIV [8] .
Furthermore, the presence of language and cultural barriers may impede the ability of healthcare providers to effectively communicate with undocumented immigrants who have limited English proficiency and divergent cultural backgrounds.This phenomenon has the potential to result in misinterpretations, incorrect diagnoses, and insufficient therapeutic interventions [9] .Insufficient provision of culturally sensitive healthcare can potentially lead to decreased health literacy and limited availability of suitable preventive services [10] .
Undocumented immigrants who are homeless may encounter difficulties in accessing resources and navigating the complex healthcare system due to their limited social support networks.In the absence of dependable information and guidance, individuals may encounter difficulties in identifying suitable healthcare providers and availing themselves of the community resources that are at their disposal [11] .
Undocumented immigrants, even those who are homeless, are susceptible to societal discrimination and stigmatization.The phenomenon of healthcare providers or community members exhibiting bias or prejudice can result in substandard care, hesitancy to seek aid, and additional marginalization [11] .

Current efforts and recommendations
Policy considerations surrounding healthcare and support services for undocumented immigrants exhibit significant variation across diverse states and localities [12] .Certain regions have established initiatives or regulations aimed at catering to the healthcare requirements of this demographic, whereas certain other regions have imposed constraints that curtail their ability to avail such services.It is imperative to contemplate all-encompassing immigration reform and healthcare policies that strive to furnish impartial admission to healthcare for all individuals, irrespective of their immigration status. [12]ne recommendation for improving healthcare services is to establish and promote culturally competent care that is sensitive to the needs and backgrounds of undocumented immigrants.This entails the provision of interpreters, bilingual personnel, and healthcare providers who possess cultural competence to effectively navigate linguistic and cultural obstacles.The proposed strategy involves executing focused outreach initiatives aimed at educating homeless undocumented immigrants on the healthcare resources and services that are accessible to them.Establish partnerships with community-based organizations, shelters, and advocacy groups to facilitate the dissemination of information and implementation of health education campaigns pertaining to preventive care, chronic condition management, and emergency service accessibility.
Another potential strategy for providing healthcare to homeless individuals in underserved areas is the implementation of mobile clinics or street medicine programs [13] .These initiatives involve bringing healthcare services directly to the homeless population through mobile clinics or healthcare professionals who provide care on the streets.These programs can offer fundamental healthcare services such as primary medical attention, immunizations, health assessments, and recommendations for additional medical interventions.
Establishment of Collaborative Relationships with Nonprofit Organizations.Facilitate collaborative relationships between healthcare providers and nonprofit organizations that specialize in providing aid to homeless communities.Through partnerships with these organizations, healthcare providers can expand their outreach efforts and provide services to homeless undocumented immigrants.
Advocate for policies that safeguard the rights of undocumented immigrants, such as ensuring their access to healthcare.It is recommended to advocate for legislative measures that guarantee access to healthcare services for all individuals, irrespective of their immigration status [12] .Additionally, collaborating with advocacy groups to enhance awareness regarding the health disparities encountered by this demographic is crucial.
It is also crucial to establish coordinated care models and case management systems.These approaches can help to ensure that individuals receive consistent and comprehensive care, even as they navigate complex healthcare systems and face barriers to accessing services.This entails establishing connections between individuals and primary care providers, mental health services, substance abuse treatment programs, and social support services.Enhancing healthcare access for homeless undocumented immigrants is to foster collaboration between community health centers and local government agencies.This approach could facilitate the provision of comprehensive healthcare services to this vulnerable population.Healthcare centers frequently provide cost-effective or variable fee structures and offer a diverse array of healthcare services, encompassing primary care, mental health, and preventive care.
The enhancement of data collection techniques is imperative to ensure the acquisition of precise and reliable information regarding the health requirements and inequalities encountered by homeless undocumented immigrants.The aforementioned data has the potential to facilitate the identification of areas that require improvement, provide guidance for policy-making decisions, and enable the effective allocation of resources.
Additionally, it is imperative to adopt a compassionate stance toward this matter, acknowledging that the provision of healthcare services constitutes an essential entitlement of every human being.The successful implementation of these solutions necessitates the cooperation of healthcare providers, government agencies, nonprofit organizations, and community advocates to guarantee impartial healthcare availability to all individuals, irrespective of their immigration status or housing circumstances.
To tackle these obstacles, a comprehensive strategy is necessary, which prioritizes alterations in policies, enhanced availability of healthcare facilities, better language support, culturally proficient care, and outreach programs for the community.The endeavor to disentangle immigration law enforcement from healthcare facilities has the potential to assuage apprehensions and enhance healthcare accessibility for undocumented immigrants.Furthermore, the provision of resources and support for stable housing alternatives can enhance the general health outcomes of this susceptible demographic.

Conclusion
It is noteworthy that the matter of homelessness and health inequalities among undocumented immigrants is complex and impacted by wider societal, financial, and governmental elements.The challenges at hand necessitate a comprehensive approach that encompasses affordable housing options, enhanced access to healthcare services, and comprehensive immigration reform.