Slipping Through the Gap: Exploring the Influence of Social Health Insurance on Access to Healthcare for Older Migrant Workers

Of the 150 million international migrant workers (IMWs) worldwide, 95% reside in the five WHO regions in which cases of coronavirus disease 2019 (COVID-19) have been confirmed. The absence of a coordinated response for IMWs highlights a key deficiency in public health planning. Compared with other international migrants (ie, international students), IMWs encounter more barriers in accessing health services in host countries (eg, inadequate health insurance), particularly migrant domestic workers. 2 Under normal conditions, IMWs have a high burden of common mental disorders (eg, depression) and a lower quality of life than local populations.2, 3 This situation could worsen during the COVID-19 epidemic due to the potential and fear of governmental-imposed quarantine and lost income. For instance, some migrant domestic workers in Hong Kong and Macau have lost their jobs because their employers have left the territory. Many domestic workers cannot obtain masks from the pharmacy because they must stay with employers and adhere to government-recommended self-quarantine. 4 In the absence of reliable information in their own language, IMWs may also not recognise the seriousness of the epidemic or receive accurate information on how to protect themselves from infection. 5 However, most IMWs have smartphones, 3 which can be a useful aid in providing informational and social support during the epidemic, like during the previous MERS epidemic. 5 For instance, WeChat (a Chinese social network platform) is used by IMWs in Hong Kong and Macau for sharing key health messages and official information to the community and providing one another with emotional support. It can, however, also spread inaccurate information and panic that could lead to IMWs delaying visits to health centres due to stigmatisation of those who are infected. 5 Regardless of IMWs communities' self-reliance and resilience, addressing their health needs should be made an urgent public health priority because infection among these individuals could also lead to community infection, eventually affecting the entire population's health. For instance, during the epidemic, IMWs should be provided more accessible health care. Public health campaigns should be available in multiple languages and diffused through various communication channels and networks of IMWs as soon as possible. In addition, more countries should ratify the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families to provide global health equity and ensure that migrant workers' health is not neglected in future epidemics and disasters.

With the unprecedented international migration seen in recent years, policies that limit health care access have become prevalent. Barriers to health care for undocumented immigrants go beyond policy and range from financial limitations, to discrimination and fear of deportation. This paper is aimed at reviewing the literature on barriers to health care for undocumented immigrants and identifying strategies that have or could be used to address these barriers. To address study questions, we conducted a literature review of published articles from the last 10 years in PubMed using three main concepts: immigrants, undocumented, and access to health care. The search yielded 341 articles of which 66 met study criteria. With regard to barriers, we identified barriers in the policy arena focused on issues related to law and policy including limitations to access and type of health care. These varied widely across countries but ultimately impacted the type and amount of health care any undocumented immigrant could receive. Within the health system, barriers included bureaucratic obstacles including paperwork and registration systems. The alternative care available (safety net) was generally limited and overwhelmed. Finally, there was evidence of widespread discriminatory practices within the health care system itself. The individual level focused on the immigrant’s fear of deportation, stigma, and lack of capital (both social and financial) to obtain services. Recommendations identified in the papers reviewed included advocating for policy change to increase access to health care for undocumented immigrants, providing novel insurance options, expanding safety net services, training providers to better care for immigrant populations, and educating undocumented immigrants on navigating the system. There are numerous barriers to health care for undocumented immigrants. These vary by country and frequently change. Despite concerns that access to health care attracts immigrants, data demonstrates that people generally do not migrate to obtain health care. Solutions are needed that provide for noncitizens’ health care.

Fragmentation in social health insurance schemes is an important factor for inequitable access to health care and financial protection for people covered by different health insurance schemes in China. To fulfil its commitment of universal health coverage by 2020, the Chinese Government needs to prioritise addressing this issue. After analysing the situation of fragmentation, this Review summarises efforts to consolidate health insurance schemes both in China and internationally. Rural migrants, elderly people, and those with non-communicable diseases in China will greatly benefit from consolidation of the existing health insurance schemes with extended funding pools, thereby narrowing the disparities among health insurance schemes in fund level and benefit package. Political commitments, institutional innovations, and a feasible implementation plan are the major elements needed for success in consolidation. Achievement of universal health coverage in China needs systemic strategies including consolidation of the social health insurance schemes.