Published on: December 19, 2016

Health Care Access for Undocumented Immigrants under the Trump Administration

Updat­ed Feb­ru­ary 27, 2017

Health care access is local; cre­at­ing, financ­ing, expand­ing, or restrict­ing health care access for a low-income pop­u­la­tion involves local, state, and fed­er­al poli­cies. Dur­ing the Oba­ma admin­is­tra­tion, health insur­ance for the esti­mat­ed 11 mil­lion undoc­u­ment­ed immi­grants in the Unit­ed States remained severe­ly restrict­ed by this population’s broad exclu­sion from fed­er­al­ly financed pub­lic ben­e­fits such as Medicare, Med­ic­aid, the Children’s Health Insur­ance Pro­gram (CHIP), and Afford­able Care Act (ACA) insur­ance sub­si­dies. This same peri­od saw moves by some states and major cities to expand health care access for the nation’s remain­ing unin­sured, includ­ing many undoc­u­ment­ed immi­grants. These state and local ini­tia­tives have includ­ed the cre­ation of pro­grams offer­ing low-cost pri­ma­ry care through pub­lic and non­prof­it facil­i­ties, plus care coor­di­na­tion, in San Fran­cis­co (Healthy San Fran­cis­co), Los Ange­les (My Health LA), and New York City (Action­Health­NYC), and leg­isla­tive efforts in Cal­i­for­nia and New York to expand pub­lic insur­ance cov­er­age, using state funds, for some undoc­u­ment­ed immi­grants.

The Oba­ma Administration’s 2012 exec­u­tive action estab­lish­ing Deferred Action for Child­hood Arrivals (DACA) to allow young undoc­u­ment­ed immi­grants to work legal­ly sparked the cre­ation of fur­ther state, local, and insti­tu­tion­al efforts to sup­port this group. Some of these reforms mir­rored ACA ini­tia­tives tar­get­ing mil­len­ni­als and aimed for equi­ty for undoc­u­ment­ed immi­grants exclud­ed from the ACA. Cal­i­for­nia enact­ed leg­is­la­tion to allow income-eli­gi­ble DACA recip­i­ents to enroll in Medi-Cal using state funds; DACA recip­i­ents in New York State became eli­gi­ble, under 2001 case law rel­e­vant to cer­tain undoc­u­ment­ed immi­grants, to enroll in state-fund­ed Med­ic­aid. Cal­i­for­nia also expand­ed Medi-Cal to include undoc­u­ment­ed chil­dren. New York City’s pop­u­lar com­mu­ni­ty ID pro­gram, IDNYC , launched in 2014 to pro­vide local res­i­dents with a rec­og­nized form of iden­ti­fi­ca­tion for access to city facil­i­ties and ser­vices, is being used to con­nect undoc­u­ment­ed immi­grants with the city’s pub­lic health and hos­pi­tal sys­tem, with ben­e­fits such as phar­ma­cy dis­counts, and as a mem­ber­ship card for the Action­Health­NYC direct-access pilot pro­gram now under­way.

What will be the fate of these state and local efforts under the new admin­is­tra­tion? Three sets of issues in health care financ­ing for low-income peo­ple in the U.S. are impor­tant to watch dur­ing a peri­od of uncer­tain­ty and appre­hen­sion for immi­grants, and in the con­text of the con­tin­u­ing chal­lenge of pro­vid­ing med­ical­ly appro­pri­ate health care to low-income pop­u­la­tions lack­ing access to pub­lic insur­ance. These issues over­lap with health care access for spe­cif­ic undoc­u­ment­ed pop­u­la­tions, such as immi­grants in deten­tion cen­ters and vic­tims of traf­fick­ing and with access to types of health care, such as pre­na­tal care, that are like­ly to be used by the undoc­u­ment­ed pop­u­la­tion due to its demo­graph­ics. They also over­lap with efforts to pro­tect the basic civ­il rights of undoc­u­ment­ed immi­grants, oth­er immi­grants, and mem­bers of minor­i­ty groups as per­sons enti­tled to equal pro­tec­tion under the law.

Cities as sanc­tu­ary and safe­ty-netPub­lic pol­i­cy at fed­er­al, state, and local lev­els, even if not direct­ly relat­ed to health, can affect local health care access for immi­grants if it rein­forces civ­il rights, or, by con­trast, rein­forces undoc­u­ment­ed immi­grants’ avoid­ance of sit­u­a­tions in which they fear being asked for iden­ti­fy­ing infor­ma­tion or con­front­ed by author­i­ties. One ques­tion fol­low­ing the Feb­ru­ary 21, 2017 release of new Depart­ment of Home­land Secu­ri­ty rules expand­ing cri­te­ria for depor­ta­tion is whether this pol­i­cy will affect health care access.  Two pub­lic health stud­ies from Ari­zona sug­gest that crack­downs change health-seek­ing behav­ior.

Dur­ing and fol­low­ing the 2010 enact­ment of Ari­zona SB 1070, a high­ly con­tro­ver­sial law reflect­ing state law­mak­ers’ goal of “attri­tion through enforce­ment,” pub­lic health researchers con­duct­ing an unre­lat­ed study  of child­hood obe­si­ty among res­i­dents of a Lati­no neigh­bor­hood in Flagstaff noticed that the new law was cre­at­ing “a gen­er­al­ized cli­mate of fear … In a neigh­bor­hood with no major gro­cery store and sev­er­al fast food and gas sta­tion mar­kets, fear of trav­el in pub­lic could severe­ly skew food pur­chas­ing and con­sump­tion behav­iors … Res­i­dents also report­ed reluc­tance to allow their chil­dren to engage in phys­i­cal exer­cise out­side the home.” Com­mu­ni­ty health pro­fes­sion­als inter­viewed “not­ed dra­mat­ic changes in clin­ic intake and ser­vice use, sug­gest­ing rapid behav­ioral change” among neigh­bor­hood res­i­dents. A lat­er study that focused on the impact of SB 1070 on health-seek­ing behav­ior among fam­i­lies of Mex­i­can ori­gin found that par­ents were less like­ly to take babies to the doc­tor, and ado­les­cents were less like­ly to seek rou­tine health care. These effects were not lim­it­ed to immi­grants; U.S.-born cit­i­zens were also reluc­tant to use pub­lic assis­tance.  The study’s authors con­clud­ed that “this law is like­ly asso­ci­at­ed with height­ened per­cep­tions of fear and lack of com­mu­ni­ty safe­ty, even among … US cit­i­zens.”

In 2012, the U.S. Supreme Court struck down cer­tain pro­vi­sions of Arizona’s law, and deci­sions by low­er courts weak­ened sim­i­lar laws in oth­er states.

The pas­sage in Octo­ber 2015 of North Car­oli­na HB 318 (“Pro­tect North Car­oli­na Work­ers Act”) sug­gest­ed the con­tin­u­ing appeal of state-lev­el immi­gra­tion pol­i­cy­mak­ing. In addi­tion to pri­or­i­tiz­ing coop­er­a­tion with fed­er­al immi­gra­tion author­i­ties, HB 318 pro­hib­it­ed local “sanc­tu­ary city” poli­cies and the issuance of “com­mu­ni­ty IDs” to help city res­i­dents with­out oth­er iden­ti­fi­ca­tion to gain access to pub­lic facil­i­ties, includ­ing hos­pi­tals and clin­ics. In the imme­di­ate after­math of the 2016 pres­i­den­tial elec­tion, the may­ors of many major cities affirmed “sanc­tu­ary city” poli­cies lim­it­ing coop­er­a­tion with fed­er­al author­i­ties in efforts to enforce fed­er­al immi­gra­tion law. The con­se­quences of these actions remain to be seen, and could include cut­offs of fed­er­al aid. New York City’s may­or has fur­ther affirmed that he will delete the IDNYC data­base if ordered to dis­close these records to fed­er­al author­i­ties. Sanc­tu­ary cities (also states and insti­tu­tions such as cam­pus­es and hos­pi­tals) may serve as impor­tant sources of civic iden­ti­ty, val­ues, and action; the need for cities to make this dec­la­ra­tion under­scores the grav­i­ty of the nation­al prob­lem.

DACA, immi­gra­tion pol­i­cy, and the states: Immi­grants and their advo­cates are brac­ing for the pos­si­bil­i­ty that DACA, as a process of the Depart­ment of Home­land Secu­ri­ty, could be elim­i­nat­ed. This action would imper­il the immi­gra­tion sta­tus of the 740,000 indi­vid­u­als who have qual­i­fied for this pro­gram (and who, along with their par­ents, are now on record as undoc­u­ment­ed), and also call into ques­tion whether state-lev­el Med­ic­aid access, finan­cial aid, eli­gi­bil­i­ty for licen­sures, and oth­er pro­grams tied to DACA sta­tus will sur­vive. Advo­cates are report­ing an increased demand for health ser­vices among the DACA pop­u­la­tion that reflects the high stress over their uncer­tain sta­tus and future prospects.

Oba­macare and Med­ic­aid: Even though undoc­u­ment­ed immi­grants were for­mal­ly exclud­ed from the insur­ance pro­vi­sions of the ACA – name­ly, Med­ic­aid expan­sion in 31 states, and fed­er­al­ly sub­si­dized insur­ance poli­cies – this pop­u­la­tion ben­e­fits indi­rect­ly from Med­ic­aid block grants to states that finance safe­ty-net health care pro­grams, such as pri­ma­ry care clin­ics. This pop­u­la­tion may also have ben­e­fit­ed indi­rect­ly from expand­ed Med­ic­aid cri­te­ria, which reduce hos­pi­tals’ unre­im­bursed expens­es and in the­o­ry free up funds for ser­vices to the remain­ing unin­sured. Med­ic­aid spend­ing is a like­ly ear­ly tar­get of the Repub­li­can-led Con­gress, despite the cru­cial role of Con­gress in the financ­ing of hos­pi­tals, nurs­ing homes, and clin­ics. If the cur­rent fed­er­al Med­ic­aid pro­gram, which match­es eli­gi­ble state expen­di­tures, is replaced by block grants to states, waivers of state-lev­el require­ments for par­tic­i­pa­tion, or a mix of both, the  result will cer­tain­ly be reduced safe­ty-net ser­vices cou­pled with more demand for exist­ing ser­vices. As peo­ple who are cur­rent­ly cov­ered by Med­ic­aid become inel­i­gi­ble, or under­in­sured rel­a­tive to their health care needs, they will turn to the same safe­ty-net ser­vices – name­ly, emer­gency depart­ments and com­mu­ni­ty health cen­ters – that the undoc­u­ment­ed and oth­er unin­sured pop­u­la­tions already rely on.

See Also: Quick Guide to State and Coun­ty-Lev­el Data and Resources: Undoc­u­ment­ed Patients in the Local Safe­ty-Net

Suggested citation

Nancy Berlinger and Michael K. Gusmano, "Health Care Access for Undocumented Immigrants under the Trump Administration," Undocumented Patients web site (Garrison, NY: The Hastings Center), originally published: December 19, 2016. Available at http://undocumentedpatients.org/issuebrief/health-care-access-for-undocumented-immigrants-under-the-trump-administration/