As the novel coronavirus has spread across the globe and throughout the US, the health and financial impacts have been widespread and devastating. Vulnerable populations, including undocumented workers in the US, face steep challenges and receive less assistance than other Americans. We asked SIS professor Nina Yamanis to explain how a lack of access to health care and financial assistance by undocumented workers can affect us all in dangerous ways.
Q: On a normal day, how does our health care system address the needs of undocumented workers?
As a society, we largely do not address the health needs of undocumented workers—those who lack legal permission to live/work in the United States. Undocumented workers are eligible for emergency services, meaning that if they go to the emergency room for health care, the hospital is required to attend to them. There is a law in place called the 1986 Emergency Medical Treatment and Labor Act that makes it illegal for a hospital to deny them care. However, undocumented workers’ ability to access other kinds of services, like primary care or treatments for chronic conditions, depends on whether or not they have health insurance or the ability to pay out of pocket. Undocumented immigrants were excluded from the Affordable Care Act; thus, they cannot access health insurance through Medicaid or state insurance exchanges. They also typically work low-wage jobs, which limit their ability to pay for expenses out-of-pocket. There are a few places, including Washington, DC, New York City, and California, that offer health insurance programs for people who are excluded from federal health insurance programs, including the undocumented. However, in general, undocumented workers’ limited access to health insurance in the US means that they are typically relying on smaller, local community health centers for their health care.
Q: Again, on a normal day, what are the specific fears of undocumented workers related to immigration enforcement that might keep them from seeking health care?
We just published a review paper on undocumented immigrants where we looked at the factors that keep them from seeking health care. Undocumented immigrants living in states or cities that have more anti-immigrant policies are less likely to access health services. In these areas, surveillance by police and immigration authorities make the undocumented anxious and fearful. The undocumented fear that if they are detected, they will be deported, and they fear that health care providers are aligned with immigration officials. Several studies have shown that after immigration raids in their area, undocumented immigrants have higher levels of stress and lower access to health care. In addition, fear of immigration authorities results in decreased mobility for undocumented immigrants. They prefer to stay home rather than moving about freely. The decreased mobility also disrupts their ability to access health services.
Additionally, on February 24, 2020, the Trump administration put the public charge rule into effect. This rule allows the Department of Homeland Security to consider immigrants’ access to federal health programs as grounds for denying immigrants’ applications for citizenship, residency, visas, or other legal statuses. Research shows that this rule will have a negative effect on health care access. The Kaiser Family Foundation reported that one in five adults from low-income immigrant families expressed fear of enrolling in public benefit programs because it could put at risk their chances of getting a green card.
Q: From your research, do undocumented workers tend to work in jobs that have been affected by closures/layoffs, or do they tend to work in what are considered “essential” jobs?
Many undocumented workers work in construction, and those jobs are not deemed essential, although that probably depends on the state. Others work in housekeeping or food service. Undocumented workers who work in food service or as home health aides will probably continue to work. For the other workers, it probably depends on their state’s stay-at-home or shelter-in-place orders and what the state deems essential work.
Q: How have Congressional responses to the coronavirus to date left out undocumented workers, either from health care or from financial assistance?
Undocumented workers are not eligible for federal relief. This means they were excluded from the stimulus payments that went out to Americans whose family income fell below a certain threshold. Moreover, Congress initiated a waiver for coronavirus responses that allowed health providers to bill for telemedicine through the Coronavirus Preparedness and Supplemental Appropriations Act. Telemedicine is essential during this outbreak because it allows health providers to meet with patients while maintaining physical distance, thus protecting health care workers. Through telemedicine, patients can reach out to their healthcare provider when they are sick to learn if they have symptoms consistent with coronavirus infection, how to treat it if they do, and how to isolate from family members. Or, if patients have other chronic illnesses such as cancer or diabetes, they can meet with their provider without needing to go to the health care center, thus protecting themselves from getting infected. We know that community health centers provide most of the health care for the undocumented. Unfortunately, Congress did not include community health centers as “eligible providers” in the telemedicine waiver. Thus, community health centers cannot bill insurance for providing telemedicine to the undocumented. Community health centers are already overstretched and under-funded, so we need to find ways to support them in reaching the undocumented.
Q: When a large population is left out of aid or relief in this way, what can happen to them in a health crisis?
First of all, not being able to access health care when needed means that they are at greater risk of severe illness and possible death. In the case of the coronavirus, if they can’t be isolated from their family members by going to the hospital, it means their family members will also get sick. Further, if they are sick and continue working in their communities, other community members will be at risk of getting the virus. Also, a lot of undocumented workers send remittances to family members in their countries of origin, so when they cannot work and have no economic relief, it means that their extended families also will suffer.
Q: Given the need to “flatten the curve” of infection, what are the dangers to everyone when a large group of people is left unassisted in the way that undocumented workers have been?
There is danger to all of us. Undocumented workers pick our vegetables, stock our shelves, cook our food, maintain our homes, and take care of our elderly. This virus is indiscriminate; it affects everyone equally. Thus, when one part of our population is vulnerable to the virus, it threatens all of us.
Q: If the goal is to flatten the curve of infection and keep the most vulnerable safe until treatments or a vaccine can be developed, what is the smartest course of action for the US government vis-à-vis undocumented workers?
In terms of health care, state and local health departments can support telemedicine efforts to reach the undocumented. The federal government lifted the public charge rule for the coronavirus crisis, but community health workers need to explain this shift in stance to the undocumented. Trusted advocates and health workers need to explain that police will be present in communities to help ensure public safety, not to deport people. Health care facilities should make clear that they do not cooperate with immigration enforcement.
In terms of economic activities, employers should encourage undocumented employees to stay home if they are sick, and they should enforce six-feet physical distancing practices while working. For those undocumented who lost their jobs, advocates are urging state and local governments to provide economic relief to the undocumented, since they were excluded from federal programs. Private foundations can also release grant dollars or pivot already dispersed grants toward providing relief for those who are unemployed. Food banks should partner with trusted community health organizations to deliver food to undocumented immigrants, especially those who are sick and quarantined.