Contribute Try STAT+ Today

Pandemics have a way of testing us. Throughout history, societies have responded to plagues by blaming immigration and minority populations. Such approaches usually make matters worse.

If pandemics reveal anything, it is that our health depends in no small measure on how we treat the most vulnerable among us.

The Covid-19 outbreak is now testing the U.S. Some recent and not-so-recent immigration policies do not put us in a good position to combat it.

advertisement

On February 24, just one day before the Centers for Disease Control and Prevention warned Americans to prepare for the spread of Covid-19 inside the U.S., the Department of Homeland Security began enforcing its new public charge rule. Under a provision that has been in our immigration laws since 1882, many classes of immigrants are ineligible to receive a visa or permanent residency status if they are found likely to become a public charge. Prior to the new rule, the receipt of non-cash benefits, except for long-term care, did not enter into the public charge determination.

The new rule will change that, defining a public charge as someone who receives Medicaid (and other listed benefits) for 12 out of 36 months, and treating receipt of Medicaid after February 24 as a heavily weighted factor in the determination of whether the individual is likely to be a public charge in the future.

advertisement

To avoid being identified as a public charge, millions of non-citizens are expected to disenroll from Medicaid. Confusion and fear about the rule may also drive many parents to disenroll their children, even though the use of Medicaid by minors will not count against them.

Thus, just as more people are likely to start needing testing and treatment for a worrisome infectious disease, untold numbers of them may drop their health insurance and avoid health care for fear of being found a public charge. With more people uninsured, hospitals will likely experience drops in revenue, even as they need to purchase new infection control equipment, and cope with a surge of patients in emergency departments and needing intensive care. These totally predictable consequences do not bode well for our ability to mitigate the pandemic.

The public charge rule is not the only way in which our immigration laws and policies may impede an effective response to the pandemic. At least four other mechanisms warrant attention.

First, long before the new public charge rule, non-citizens faced numerous legal hurdles to accessing publicly funded health insurance. A 1996 federal law, for example, makes most undocumented immigrants ineligible for federal Medicaid except to cover emergencies. Undocumented immigrants are also ineligible to purchase insurance or receive subsidies under the Affordable Care Act.

Even lawfully present immigrants face barriers. Although they can purchase insurance on the Affordable Care Act exchanges, most lawfully present non-citizens are not eligible for Medicaid for the first five years of their lawful status.

As of result of these barriers, as well as the fact that non-citizens are disproportionately employed in jobs that don’t provide insurance, non-citizens are far less likely to have health coverage than citizens. Not surprisingly, they are also less likely to have an ordinary source of care. While always troubling for public health purposes, these barriers are likely to be especially dangerous during a pandemic.

Second, fear of immigration enforcement may deter immigrants from seeking health care or working with public health authorities. Under guidelines from Immigration and Customs Enforcement (ICE), health care settings are “sensitive zones” in which enforcement actions should not normally be conducted. Even so, since President Trump took office there have been highly publicized cases of individuals being detained by immigration agents on their way to seeking care. As a result, many undocumented immigrants have forgone medical appointments.

In an epidemic, that can have dire consequences for public health as those who are undiagnosed and untreated are particularly likely to spread the infection.

Equally concerning is the prospect that immigrants, as well as citizens, who are infected with the coronavirus will fear sharing with public health officials the names of undocumented contacts — a key part of containing any epidemic or pandemic. This classic public health tool will be undermined if patients fear that sharing names can lead to immigration enforcement actions.

Third, restrictive immigration policies may exacerbate shortages of health care workers, especially in nursing homes and other long-term care facilities, just when we need more such workers. Since Trump took office, legal immigration to the U.S. has been falling. The new public charge rule will almost certainly add to the decline, as many of its provisions will make it exceptionally difficult for low-wage individuals to receive visas to come to the U.S. That means trouble for nursing homes and other health care institutions that rely heavily on low-wage workers and that may need new workers as some take time off due to infection. About one-quarter of nursing, psychiatric and home health aides are currently immigrants — precisely the people who will likely be denied visas due to the public charge rule.

In addition, many existing workers, citizens and non-citizens alike, rely on Medicaid. Their inability to get the care they need due to their loss of health insurance will heighten the risk for their vulnerable patients.

U.S. border policies create further risk. In the last three years, at least seven children have died in immigration custody, mostly due to the flu. Adding to the risk was the fact the Customs and Border Control officials refused to vaccinate detainees against the flu. Immigrants who have been forced to stay in makeshift camps in Mexico due to the administration’s so-called Remain in Mexico policy are also facing health risks from living in overcrowded conditions without adequate hygiene or health care. Such settings are especially susceptible to outbreaks of contagious diseases.

What can be done? This week I joined more than 700 experts in law, public health, and human rights in writing an open letter to Vice President Mike Pence and other federal, state, and local policymakers outlining guidelines for a fair and effective response to Covid-19. Among our recommendations were that health care facilities must be immigration enforcement-free zones. We also urged the administration to ensure that individuals should not face any immigration consequences related to contact tracing. These policies, we wrote “should be clearly and unequivocally articulated to the public by the federal, state and local governments.”

In addition, the Department of Homeland Security should stay implementation of the public charge rule as a whole — or at least suspend the adverse consequences attached to using Medicaid until after the outbreak passes. There simply is no justification for rushing to implement a rule that may worsen a pandemic.

Fourth, the Department of Homeland Security must work to improve health care in detention facilities and relax the policies that are adding to crowding both north and south of the border. During a pandemic, overcrowding and unsafe conditions not only pose a risk for migrants, but can endanger the health of everyone.

There are precedents for these four steps. After 9/11, the Immigration and Naturalization Service (the predecessor agency to Immigration and Customs Enforcement), announced that it would “exercise discretion in a compassionate way towards families of victims during this time of mourning and readjustment.”

With a pandemic upon us, it doesn’t require compassion to ensure that our immigration policies don’t threaten public health. It just requires common sense.

Wendy E. Parmet, J.D., is professor of law and director of the Center for Health Policy and Law at Northeastern University School of Law and professor of public policy and urban affairs at Northeastern’s School of Public Policy and Urban Affairs.

  • Does a person who owns property in US but not citizen although currentl lives able remain without penalty during corona virus outbreak. Person currently has a ticket but have telling them they should stay not sure what is right

  • An honest title for this piece would read “A Liberal’s Repugnant Use of Coronavirus to Argue For Increasing the Numbers of Likely Democrat Voters Via the Free Flow of Taxpayer-Dependent Immigrants”

    • exactly! the dems love to make an excuse for anything, especially to make up for their obvious yet embarrassing defeat with Trump’s ridiculous impeachment process…maybe they should try doing their jobs that they are paid for by TAX PAYING CITIZENS, instead of trying to coax politically uneducated people to remain ignorant to get their vote. stop the blame game and get things under control!!

  • I am a legal immigrant and naturalized citizen and extremely offended by this article for a variety of reasons.
    1) Equating implicitly illegal immigration (a crime) with legal immigration and / or citizenship which many of us have sacrificed a lot for and played by the rules
    2) Using my (and others) tax and health care resources to cover those who can’t support themselves and are here illegally when there are many with chronic conditions and burdensome health costs who are US citizens (like me)
    3) The gaslighting logic used when a contagious foreign disease enters the country thanks to lax border controls (and sadly near-universal opposition to sensible travel bans) to then argue for even looser / open borders that rewards

    • best comment I’ve heard period. My family immigrated here legally back in the day… also and I’ve also been denied help while sitting next to illegal immigrants who once they crossed the border and had their baby, were given help over those of us who are naturalized and legalized citizens. it upsets me that i could never get help but others can. they’ve given a heart transplant to an illegal alien while denying to help those who were born here and paid taxes all their lives. it’s disgusting

    • @Suzanne when are illegal immigrants given more help than citizens? What kinds of programs / situations?

  • Ms Parmet, you are batting 0/0. Fortunately your readers graduated from college decades ago before academia rewrote history in it’s own image.

  • More academic drivel. I guess living in a bubble of theoretical nonsense justifies an existence free from the reality common sense provides so many.

    Using the term” non-citizen “was an obvious and feeble attempt to avoid confronting the real issue of “illegal aliens”.
    It’s not about “non-Citizens”. Some of my relatives and business colleagues are non-citizens working here in the USA LEGALLY. They have health insurance they pay taxes and they have no problems with immigration laws or enforcement.
    And most of them resent the individuals who do violate the immigration laws!
    Maybe an academic perspective would help you.
    It’s illegal to present fake degree certificates and transcripts as genuine documents. Under the Fraud Act 2006, it can result in a prison sentence of up to ten years!
    Why don’t you advocate for the right of anyone to teach by presenting fake degree credentials or if you prefer eliminate the requirement for someone who presents themselves as a PhD to provide any documentation.
    You can call it The “Sanctuary” University Policy.
    Invite individuals to come and teach and promise them that no one will check or verify their credentials.
    (Sadly, with the state our Universities are in it couldn’t possibly make it worse… Maybe even an improvement ?)

  • The exact same information could be used to formulate a “illegal immigration puts US citizens at risk” story. Legal immigrants can get a job, use healthcare facilities and report illness and contact. It is illegal immigration that is the cause, not US law.

    • The article focuses on, and much of the text discusses, documented immigrants who have visas that allow them to live and work in the United States. In many instances, these workers do not have health insurance through their employers and cannot afford it privately. Such individuals will now avoid taking up Medicaid because a 24 February rule change means that Medicaid will be considered as a public charge that could prevent them from obtaining permanent residency.

  • This is just more “blame Trump Mad-Libs”. You are assuming that having medical insurance stops the spread of the virus, which it doesn’t. You are using scare tactics to push welfare programs. The health authorities are prescribing self-isolation, travel bans, and quarantines. I’m all in favor of immigration liberalization, but immigration restriction decreases domestic exposure to infected populations. This is one of the few net benefits of immigration restriction. Could that be any more obvious?

  • Trump cause the corona virus? I believe you forgot the word “didn’t” good sir. What you obviously meant to say was, “Trump didn’t cause the corona virus.”

  • I came to this country in 1956 and am a naturalized citizen and on my “papers” that public charge and many others were in place. Who, why, and when was it removed from the process? When immigrants came to this country there were strict health requirements for entry into the United States, something as minor as a case of pink eye and back to your homeland you were sent. No borders, no requirements, no country. Mexico, Australia, and a few other civilized countries have and enforce strict conditions to enter and live in their countries. It’s a shame the United States has less regard for it’s sovereignty.

    • “doesn’t require compassion to ensure that our immigration policies don’t threaten public health. It just requires ”
      that we keep migrants from crossing the border, or arriving by air and sea. IOW, travel bans.

  • If I was in charge I would let the whole world into our southern border because that would be the best way to fight extremely contagious diseases!

Comments are closed.