The Trump administration’s ‘public charge’ rule and Covid-19: bad policy at the worst time

As Covid-19 sweeps across the country, many immigrant communities are being hit hard by the pandemic. Latino individuals are four times more likely to be infected with SARS-CoV-2, the virus that causes Covid-19, than non-Latino white individuals. Asian immigrant communities across the U.S. have also been hit hard by the pandemic.

Insights into why immigrants are at increased risk of contracting the virus can be gleaned from the hardships faced in places like Chelsea, Mass., and the Rio Grande Valley in Texas.

In Chelsea, a city of about 40,000 people just north of Boston, two-thirds of residents are Latino and nearly half are recent immigrants — and rates of Covid-19 are five times higher than the Massachusetts average. In the Lower Rio Grande Valley, where more than 90% of the population is Latino and one-third live in poverty, the surge of cases threatens to magnify inequalities even further.

Communities like these have large populations of workers who earn low wages and make ends meet by working in essential jobs such as food services and the hospitality industry in urban areas and agriculture in rural areas. Few of these jobs provide adequate — if any — paid leave. What’s more, immigrants often live in multi-generational households, with larger household sizes and in close quarters. These factors combine to create an environment that allows for rapid transmission of Covid-19.

To make matters worse, the Trump administration has enacted policies making the spread of Covid-19 in immigrant communities even more likely. On January 27, 2020 — just one week after the U.S. confirmed its first case of Covid-19 — the U.S. Supreme Court allowed the Trump administration to begin implementing a new rule related to the “public charge” immigration policy.

This rule determines the factors that can be used to deny immigrants permanent residency status (generally known as green cards). The administration’s new rule added the use of public programs like Medicaid, the Supplemental Nutrition Assistance Program (food stamps), and subsidized housing — in addition to overall health status — to the reasons for denying an immigrant a green card.

This policy may cause immigrant families to avoid seeking medical care during the pandemic. Without being tested, patients with mild symptoms may not realize they have Covid-19 and thus not take appropriate precautions to isolate themselves from others. Even worse, some may continue working while sick in order to pay their bills and secure food for their families, possibly to replace some of the social supports they normally would have received through public assistance programs.

Without testing, without treatment, and facing an economic necessity to work, these harsh realities undermine public health efforts to effectively combat the pandemic. Forcing immigrants to choose between their health and having food on their table, shelter over their heads, or safety from punitive immigration regulations will continue to perpetuate the cycle of infections and deaths from Covid-19.

In short, fear of the public charge rule will perpetuate the spread of Covid-19 in cities and towns across the country.

In our work as physicians in Boston, we see this play out in real time. Weeks before Covid-19 fully enveloped the region, a community health center that serves a predominately Latino immigrant patient population where two of us (F.M. and B.D.S.) work raced to contain the spread of fear and misinformation about the policy. The clinic’s triage line, and providers from doctors and mental health practitioners to social workers, saw an increase in anxious patients inquiring how to protect themselves against the rule. Other patients simply withdrew themselves from vital health and social services.

The evidence for this effect is not just anecdotal. In a recent survey we conducted in Texas, nearly half of respondents were concerned about how the rule might affect their families and friends, and nearly 1 in 8 low-income people reported knowing someone who had avoided public programs or medical care in the past year because of immigration-related concerns.

The Trump administration amended the public charge rule to clarify that seeking care for Covid-19-like symptoms will not be considered in an individual’s assessment, though enrolling in Medicaid and other public services like SNAP may still be used. The federal district court in Manhattan recently issued a temporary injunction halting enforcement of the new public charge rule during the pandemic, though the administration is likely to appeal that ruling.

Even so, given the general level of confusion and concern that the Trump administration has created among immigrant communities, it is unlikely that these nuances or a temporary reprieve will completely eliminate the policy’s negative effects.

So what can be done to address these policies and reduce Covid-19’s disproportionate impact in immigrant communities?

First, the administration should permanently reverse the change to the public charge rule and publicize that it has been eliminated. A public health emergency is the worst possible time for people to be avoiding medical care, and partial measures or temporary injunctions will leave many immigrants in limbo and fearful of obtaining care.

Second, states should create safe temporary housing for individuals who have tested positive and need to be isolated, and whose own homes do not allow for safe distancing from other family members.

Third, Congress needs to ensure adequate paid sick leave for individuals working low-wage essential jobs. While an earlier law requires Covid-19-related paid sick leave for many workers, large loopholes remain.

Fourth, U.S. policymakers must realize it is impossible to create a healthy and safe society when millions of our neighbors are in limbo, unsure of their futures in the country where they live, work, and — yes — pay taxes. As the United Nations and countless others have declared during the pandemic, “We’re all in this together.”

The coronavirus doesn’t check anyone’s immigration status. Until we start working to fight Covid-19 in all populations in the U.S., the virus will continue to spread.

The authors are physicians at Brigham and Women’s Hospital in Boston. Figueroa and Sommers are also faculty members in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health.