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Invisible Borders: Immigrants living with disabilities

Dr. Westy Egmont

While national attention returns to aggressive enforcement of immigration laws, a quiet drama intensifies across America. 

Immigrants with disabilities number in the millions. Invisible, overlooked and impacted especially by health care legislation, their need demands attention. Reflective of school statistics more than general national statistics because the average age of immigrants is younger, a projected 35.9%, or more than 5.1 million immigrants live with a disability in the U.S.  Fewer than 15% of disabilities are congenital and most emerge during one's lifetime, generally post migration, thus the foreign born are projected to have slightly fewer than 1 in 5 persons (the U.S. proportion) having a disability.

If the Americans with Disabilities Act (ADA) has successfully impacted this broad demographic, foreign-born Americans are still at particular risk. A professor of Spanish recently settled in the U.S. with a preschooler whom they discovered might be on the high end of the Autism spectrum. They sought help. Language, knowledge of the healthcare system, insurance coverage, cultural factors including lack of family backup to support intensified schedules, financial and treatment options impacted their access to care.  If that person were to be Somali or Syrian, pressure to find linguist tools and specialists for diagnosis, education planning and parental support would be increased. If that person settled near an automotive assembly plant in Claycomo, Missouri or Smyrna, Tennessee, the complexity of identifying appropriate services would be multiplied and could force relocation.

Current U.S. policies impact access to adequate health care services and educational resources to many newcomers to the country. A five-year bar limits access to most public assistance. Federal law (Welfare Reform) enacted in 1996 limits non-emergency Medicaid access to just a handful of categories of "qualified" immigrants, such as legal permanent residents ("green card" holders), veterans, refugees, asylees. Even here, LPRs (lawful permanent residents) must generally wait 5 years for eligibility to kick in. All other immigrants, including dozens of categories of immigrants with lawful presence, are excluded, though the ACA has allowed lawfully present immigrants to access private insurance through the state exchanges - which lowered the uninsured rate of non-citizens by 25%.

Even eligibility for naturalization can be negatively affected by a "public charge" classification. The term "public charge," as defined by the U.S. Citizenship and Immigration Services (USCIS), refers to an individual who is likely to become "primarily dependent on the government for subsistence, as demonstrated by either the receipt of public cash assistance for income maintenance or institutionalization for long-term care at government expense." Those disabilities that might limit employability or require special services can result in rejection by USCIS. 

Medicaid is the U.S. safety net and the primary means of payment for long-term medical costs, but millions who are out of status are deemed ineligible for the benefit. In the most recent Senate version of immigration reform, a 15 year ban to access which would impact millions of other foreign born legal residents was included. Under the current Administration, with the ACA replacement underway, less and stricter eligibility is predicted as pre-existing health conditions are grounds for rejection by insurers. Legislation before Congress would similarly limit immigrant access to the state health insurance exchanges to "qualified" noncitizens. This would especially hurt people with temporary protected status (a form of humanitarian relief) and people on professional, guest worker or student visas all of whom had access to the state exchanges.

Self-deportation to find affordable health care is one consequence and  medical repatriation by U.S.  hospitals due to medical costs that cannot be met regularly occurs.   Picture the Haitian heart patient who is uninsured or underinsured, here legally under TPS, and not yet qualified for ACA or its replacement.The American Hospital Association has confidentiality policies but has no policy about those without sufficient insurance such as the heart patient who is airlifted back to Haiti where few services exist. Subsequent deaths are regularly reported. The New England Journal of Medicine article "Undocumented Injustice? Medical Repatriation and the Ends of Health Care" connects the issues of health care, justice and immigration. 

Access to care for foreign born limited English speakers for a disability or multiple disabilities, ranging from the consequences of cancer, to living with MS or facing mobility challenges due to loss of limbs, remains remarkably scarce. This issue includes resources and helpful tools for understanding the array of barriers individuals encounter, and for staff trainings on providing appropriate services to immigrant and refugee persons also presenting with disabilities. Deaf Access Services at JFS of Buffalo is provided as an exceptional model demonstrating the power of combining services with community partners. Networks of healthcare and immigrant service providers across the nation need to address the issue with complementary services, identification of need and shared commitment to culturally appropriate and linguistically accessible services. Advocates need to be sure anticipated immigration legislation protects this doubly vulnerable population. On a policy level, each state has discretion and there are programs such as AABD in Illinois (Aid to the Aged, Blind, or Disabled) that provides a cash grant to certain low-income people with disabilities or who are blind and to people age 65 and over. Its purpose is to provide for the basic income needs of people with disabilities and senior citizens, and those with five years of qualifying status can apply; however such programs are far from universally accessible.

While risks of inadequate care are sufficient subjects for attention by human service and policy making professionals, the issue also touches on the need for culturally-appropriate professional care. Ironically perhaps, the shortfall of diverse workers calls for more immigration, not less. Nationally, approximately 26% of the current direct care workforce is foreign born. In some states, the percentage is much higher: NY (63%), NJ (50%), DC (46%), CA (45%), and FL (42%). Approximately half of these workers are naturalized citizens and others have legal status, but a portion is estimated to be unauthorized. All Americans living in need of care depend on a healthy, robust, diverse immigrant workforce: immigrant MD's make up 27% of all doctors, and foreign born heath care employees constitute 22% of the total workforce!  

Social workers in education and health care, resettlement workers, and all those who have direct contact with newcomer populations need to be cognizant of whole family needs and educate clients  about ADA, IDEA, Disability Exceptions to Naturalization while seeking to engage families in creating plans which address unmet needs.  Explaining self-advocacy and serving as advocates ultimately will save lives and make the integration process for those living with disabilities much more feasible.

Image Source: Pinterest. (2017).

Westy Egmont, Director
BCSSW, Immigrant Integration Lab

Hamel, M. B., Young, M. J., & Lehmann, L. S. (2014). Undocumented injustice? Medical repatriation and the ends of health care. 
The New England journal of medicine,  370 (7), pp. 669.

McCabe, K. (2017). Foreign-born health care workers in the United States. Migration Policy Institute. Retrieved from:

Special Needs Alliance. (2012). The Voice Newsletter. Retrieved from:


With local partners all over the country, The Hebrew Immigrant Aid Society (HIAS) works to partner with local representatives, such as  Jewish Family Services of Buffalo  and  Deaf Access Services , to provide refugees with disabilities with the care they need. With a multisystemic approach to care, HIAS collaborates with local partners to increase individuals' chances in obtaining culturally competent rehabilitation services. HIAS recognizes that many people come to the United States after being forced out of their homelands due to a number of conflicts, including persecution, torture, threats, or harassment due to race, religion, nationality, sexual orientation, or political beliefs. HIAS aims to provide refugees with the services and resources they need, to heal, regain strength, and learn to thrive in their new country. These services include legal protection, psychosocial and health care, and providing avenues to creating self-sufficient livelihoods.

HIAS provides an excellent model for an agency which works with local partners to provide refugees presenting with disabilities with the best array of services they can provide. HIAS is funded by private and public donors, and has received excellent ratings from organizations evaluating the work of non-profits. Their dedication to assisting refugees all over the world is made possible by contributions arising from fundraising, management, and programs.  With its headquarters in Maryland, and a New York Office, the Hebrew Immigrant Aid Society (HIAS), partners with local Refugee Assistance Organizations all over the country. Dedicated to promoting integrity, transparency, and discipline in the multifaceted approach to service delivery, HIAS works collaboratively with refugees and stakeholders in order to accomplish their mission of rescuing individuals whose lives are in danger, just for being who they truly are. They aim to protect the most vulnerable refugees, through reuniting them with family members and advocating for their protection. They are guided by Jewish values and history, and for over 130 years have provided services to refugees from every corner of the globe. HIAS accepts donations, as well as individuals wishing to partake in policy lobbying and political activism. Their current platform provides a written message to Take Action for Haitians Facing Deportation for individuals to send to their elected officials.

Brassart, E., Prévost, C., Bétrisey, C., Lemieux, M., & Desmarais, C. (2016). 
Journal of Child and Family Studies, 26(4), pp. 1230-1244
Immigrant parents raising a child with a disability have multiple barriers to treatment engagement, such as divergent beliefs between families and service providers on the child's diagnosis and treatment, a poor therapeutic alliance, external barriers, limited language proficiency, daily stressors, a complex health care system, and lack of cultural sensitivity training for providers. This qualitative study included interviews with 21 service providers in Canada who work with children with a language, motor, hearing, or visual disability on a regular basis. Strategies to overcome these barriers highlighted by service providers included overcoming the language barrier, especially through the use of interpreters, developing a shared understanding of the child's disability, developing a partnership with parents throughout the therapeutic process, and helping the parents to understand the treatment process. A conceptual framework suggests that adaptations are needed within health care services to increase the level of treatment engagement by immigrant parents as well as greater respect for the parents' ability and desire for level of engagement.

Zechella, A., & Raval, V. (2016).
Journal of Child and Family Studies, 25(4), pp. 1295-1309
Asian Indian immigrant parents of children with intellectual and developmental disabilities in the United States have unique challenges and experiences. For example, many Asian Indians strongly emphasize academic achievement and may also experience stress as a result of being a minority. This qualitative study used interviews with 15 Asian Indian parents of children diagnosed with Down Syndrome, Autistic Disorder, or Pervasive Development Disorder in the United States. Many parents discussed religious and cultural beliefs around the cause of disability, in some cases leading to the family or community struggling with acceptance. Positive and negative impacts of the disability were also discussed, such as migration to the U.S. for better resources for persons with disabilities, personal acceptance, discovering a larger purpose in life, and the multilayered impact on the sibling(s). Factors contributing to greater stress included a lack at least one of the following: family support, broader social awareness and acceptance, access to resources, and access to sources of support. Along with fears and hopes for the future, parenting approaches were discussed as well, which included adjusting academic aspirations for the child, shifting to a practical "one day at a time" approach to caregiving, and passing on Asian Indian cultural heritage.

Empowering immigrant patients with disabilities: Advocating and self-advocating
Li, C., Kruger, P., & Krishnan, K. (2016). 
North American Journal of Medicine and Science, 9(3), pp. 116-122.
Individuals with disabilities face interpersonal obstacles reified through discrimination, bullying, and structural barriers including accessibility, unemployment, and homelessness. Immigrants who also present with disabilities encounter additional layers of challenges such as linguistic impediment and acculturative stress. In accessing healthcare, immigrants with disabilities confront inappropriate equipment and examination rooms, and lack of physician understanding and support. The authors suggested that health providers can empower their immigrant patients with disabilities through a) providing culturally sensitive care, b) availability of language support, c) educating oneself about the Americans with Disabilities Act (ADA), the Individuals with Disabilities Education Act (IDEA), and other federal and state policies that protect people with disabilities, and d) disseminating this information and other related-services to their patients. Furthermore, healthcare providers need to develop a reciprocal relationship with their patients in order to empower the latter through self-advocacy. One tool of self-advocacy is teaching patients assertiveness through behavioral modifications including eye contact, body posture, effective use of facial expression and voice tone, listening, and the use of "I statements." Through implementing these tools, health inequities and structural barriers can be challenged and reduced. 

Cummings, K.P., & Hardin, B.J. (2017)
Early Childhood Development and Care, 187(1), pp. 115-127
There is a paucity of research surrounding immigrant families with children with disabilities. This study examines the experiences of four pairs of immigrant parents with children with disabilities from Mexico, Peru, Vietnam, and Burma. Findings show that the children's disabilities were either diagnosed by a healthcare professional early or were later confirmed by a professional, after initially being observed by the parents. Nevertheless, parents had a difficult time understanding symptoms and diagnosis of these disabilities since many came from rural areas. Once their children were diagnosed, parents shared their experiences navigating services for their children with disabilities. Parents discussed varying experiences including not finding sufficient support for their children in schools, which often led to home-schooling, and others found support through in-home services for speech development, and through community spaces such as the church. Immigrant parents are also hindered by the language barrier between themselves and the professionals who work with their children who often only provide support in English. Thus, immigrant parents feel that they are not able to advocate for their children or utilize the tools that their children are learning in the home. The authors suggest that providers should be cognizant of the context of migration of immigrant families which can influence how many perceive and understand disabilities, engage parents more to actively participate in meeting their children's needs through cultural and language support, and implement constant communication between the family and service providers to foster further participation. 

Supporting language and literacy development for additional language learners with disabilities
By Haager, D., & Aceves, T.
Wiley Blackwell (2017)
As schools and classrooms across the world become more inclusive of students with disabilities, teachers increasingly need to coordinate closely with special education professionals to ensure higher quality of learning for all students. This is particularly important for students with disabilities who are also additional language learners (ALLs). In this chapter, the authors provide a review of research on how educators can best promote literacy among ALLs who also have or are at risk of presenting with a disability, including learning disabilities. The chapter particularly focuses on research conducted in the "urban, high-poverty" classrooms "where the majority of ALLs are educated." Through a discussion of best teaching practices in language and reading instruction, this text addresses school and environmental factors as well as teacher knowledge and skills necessary to ensure high-quality instruction for ALL students with disabilities. 

Special education considerations for English language learners: Delivering a continuum of services (2nd Edition)
By Hamayan, E., Marler, B., Sánchez-López, C., & Damico, J.
Caslon Publishing (2013)
A very practical guide for teachers, special education professionals, and other educators who work with English Language Learners (ELLs), many of whom are immigrants and refugees. The authors seek to provide guidance for educators who are conducting special education assessments, determining the nature of ELL students' special education needs, implementing evidence-based interventions, and evaluating the outcomes of these interventions. Several chapters are dedicated to helping educators identify and understand the range of factors - including family, psychological, and past schooling - that impact ELL students with special education needs. The appendices also include reproducible resources for educators to utilize in their classrooms.

Disability and difference in global contexts: Enabling a transformative body politic
By Erevelles, N.
Palgrave Macmillan (2011)
The study and understanding of disability intersects with every other major form of identity - including race, ethnicity, class, gender, sexuality, and citizenship or immigration status. Erevelles' work adopts an intersectional approach to the study of disability in a global context as it examines the ways in which disability has been historically constructed and conceptualized across the world. Throughout this book, the author resists the traditional power relations and system of domination that has been a hallmark of neoliberal capitalist economic systems. Critiquing "standards of normalcy and acceptance in society", Erevelles offers an empowering and emancipatory "transformation" of the disability studies field.

Culture and disability: Providing culturally competent services
By Stone, J.
SAGE Publications (2005)
With a focus on improving the quality of rehabilitation services for immigrants with disabilities, this volume offers a valuable framework for health care professionals and other service providers involved in providing rehabilitation services for clients from culturally diverse backgrounds. Stone integrates generalist practices for service providers to navigate conflicts that may stem from different cultural understandings of disability along with chapters focusing on the intersection of culture and disability within specific immigrant groups in the U.S. Utilizing a "cultural broker" perspective, seven chapters in this volume are written by immigrants to the U.S., representing seven major cultural groups. These chapters discuss how each culture conceptualizes and understands disability, the "role of the family and community in rehabilitation", and practical suggestions for service providers to incorporate into their rehabilitation work with clients from each cultural group. The knowledge presented in this book should be useful for both students in disability-focused training programs as well as professionals who offer any sort of rehabilitation service to immigrant clients.


Social Security Administration (2017)
This document provides  a general guide explaining who is eligible for SSDI, how to apply, and how the claim is approved. Available in 18 languages.

Deaf Community Action Network (2016)
The featured video displays a conversation with immigrants and refugees about life in the U.S. from the Deaf CAN organization in Pennsylvania which holds classes for refugees with hearing disabilities. In ASL with subtitles.

Gulf Coast Jewish Family and Community Services (2015)
An information sheet explaining the criteria for seeking exceptions to educational requirements for naturalization, and how to conduct community trainings on the matter.

United Nation's Women's Refugee Commission (2014)
Information documenting positive practices and ongoing challenges to promote disability inclusion across UNHCR's and its partners' work in multiple countries and multiple displacement contexts. Has a humanitarian aid focus.

Cultural Orientation Resource Center (2012)
A webinar discussing domestic and global challenges of life as a disabled refugee and delivery of orientation services to those who need disability resources.

Colorín Colorado (2012)
A webinar on ELL students with LDs and effective assessment strategies and interventions.

United States Committee for Refugees and Immigrants (2007)
A resource guide aimed at providing information for service providers and resettlement workers. Although dated, it provides a comprehensive guide on benefits, housing, legal issues, and services.

Follow Professor Egmont on  Twitter @wegmont
EDITORS: F. Crutchfield-Stoker (Managing Editor), E. Camacho, W. Egmont, B. Schmid, E. Siskind, A. Spratley, M. Tepper, & D. Maglalang