Article by Medha D. Makhlouf
Too often, people living in the United States are compelled to take extreme measures to get the medical care they need. Most often, due to the cost, they delay or go without care. They also decline to fill prescriptions or take less medication than prescribed. Many rack up enormous debts to health care providers and other lenders. Others stand in long lines for free clinics, or they spend hours filling out applications for hospital financial assistance programs and gathering copious documentation to support them. Some people seek care from alternative providers or traditional healers because of cost concerns, while others seek discounted care or prescriptions in other countries—what scholars have referred to as “medical tourism.”
It is a variation of this last extreme measure that Professor Jayesh Rathod discusses in Pressured Exit, which introduces the new conceptual category of “pressured migrants,” who he defines as “[p]eople who are compelled to leave the United States because of conditions of vulnerability, yet who exercise varying degrees of agency in the process.” Rathod describes two broad categories of vulnerabilities faced by those who choose to permanently resettle abroad: those who have experienced identity-based harms and those who have experienced hardships because of inadequacies in the U.S. social welfare system. Among the conditions of vulnerability faced by those in the latter category is the unaffordability of long-term care.
Professor Rathod makes an important contribution to immigration law literature by theorizing a new form of migration: “a subtype of human mobility that lies at the interstices of refugee flows and lifestyle migration, somewhere between involuntary and voluntary migration.” And by focusing on outmigration from the United States, as he has done in other work, Rathod provides a new perspective on how passport privilege works for U.S. citizens experiencing health-related conditions of vulnerability. Similarly situated citizens of low- and middle-income countries have fewer opportunities to engage in such geographic arbitrage because of international travel restrictions based on nationality.
For health law scholars, policymakers, and advocates, Pressured Exit underscores the barriers U.S. citizens face in accessing long-term care and shines a light on one extraordinary strategy for bypassing them. Although the option has been discussed in news articles and Internet forums for at least a decade, it has received little attention in U.S. legal scholarship, particularly when compared with the relatively comprehensive analyses of legal issues associated with medical tourism. It also raises critical questions about what structural and funding decisions regarding long-term care subsidies signify about the United States’ relationship to its elderly and others in need of long-term care.
In this Response, I expand upon Rathod’s analysis by examining the structural conditions that compel U.S. citizens to seek long-term care overseas. Pressured exits starkly illustrate the inadequacy of the U.S. health care system to meet the population’s health needs, potentially resulting in harm to the people who need care, their family members, and their communities. In addition, I argue that medically pressured exits implicate global health justice. The reason some U.S. citizens feel compelled to permanently resettle in countries where they can stretch their dollars to purchase care is that the United States has failed to ensure that high-quality long-term care is affordable and otherwise accessible to its citizens. This poses a moral question: does the migration of citizens of Global North countries to Global South countries for the purpose of accessing care exacerbate global health inequalities and, if so, what should be done about it?
About the Author
Medha D. Makhlouf. Elsie de R. and Samuel P. Orlando Distinguished Professor, Professor of Law, and Director of the Medical-Legal Partnership Clinic, Penn State Dickinson Law.
Citation
98 Tul. L. Rev. Online 1 (2024)