As cases of COVID-19 continue to skyrocket in the United States, it is no surprise that pre-existing health inequalities are worsening. Health and immigration policies put in place long before the pandemic reached the United States set the stage for these inequalities and will contribute to unnecessary suffering, sickness, and fear during this crisis. It is essential to ensure that all community members, regardless of immigration status, have the resources they need to weather this storm. This is vital not only for the health of immigrants themselves, but also for the health of the broader public.
Barriers To COVID-19 Testing And Treatment For Undocumented Immigrants
Increased immigration enforcement around the country has led to understandable fear among undocumented immigrants, fear that has extended to accessing basic resources like education, economic assistance, and—perhaps most crucially at the moment—healthcare. Some immigrants have expressed concerns around even leaving the house because of threats of increased Immigration and Customs Enforcement (ICE) activity in their communities. Indeed, although ICE announced it would slow civil immigration enforcement actions during the pandemic, news reports suggest that enforcement has continued in some areas. Uncertainty also extends into clinical spaces, where immigrants worry about ICE presence or about staff sharing patients’ legal status.
Even those without active fears around immigration enforcement may be reluctant to access healthcare due to policies like the “public charge” rule change, which went into effect on February 24, 2020, just days before the first reported instances of community spread of the COVID-19 virus in the United States. The rule penalizes immigrants who have used forms of public assistance including Medicaid, making it harder for them to adjust their immigration status. In the months after its proposal, widespread confusion and misinformation around whom the rule would affect contributed to untold numbers of immigrant parents disenrolling their U.S. citizen children from Medicaid—a predictable “chilling effect” on healthcare utilization. Even as testing and treatment for COVID-19 has been explicitly excluded from the public charge rule and as the U.S. Citizenship and Immigration Services (USCIS) has explicitly encouraged immigrants to receive care, many immigrants had already acted to limit their interactions with medical institutions and their reliance on public assistance.
Notably, public health agencies, providers, and front-line medical staff at community health centers and hospitals have worked tirelessly to maintain immigrant patients’ trust, allay their fears, and encourage them to seek the care they need. Yet their assurances only have so much power when juxtaposed with anti-immigrant messaging and policies. These policies erode trust between immigrants and the clinics that serve them and may hamper efforts to treat and stem the spread of COVID-19.
Even aside from these concerns, millions of undocumented immigrants lack health insurance, in large part of course because they are barred from coverage through the Affordable Care Act, Medicare, and many Medicaid programs. Among the nonelderly population, fewer than one in ten U.S. citizens are uninsured, while more than four in ten undocumented immigrants lack insurance. Many of these uninsured immigrants will not have the option of complying with guidance to call primary care physicians in case of COVID-19 symptoms. The Families First Coronavirus Response Act provides free coronavirus testing for the uninsured. However, it does not cover coronavirus treatment. Although the Coronavirus Aid, Relief, and Economic Security (CARES) Act provides $100 billion to hospitals to treat the uninsured, it does not exempt patients from cost-sharing or physician bills. Alarmed about out-of-pocket medical costs, many undocumented immigrants will wait to seek care until their symptoms are life-threatening. If these policies encourage segments of the immigrant population to avoid health care, this will create pockets of infection that will be difficult to eradicate.
Access to care for undocumented immigrants with COVID-19 depends both on the availability of safety-net care as well as each state’s individually administered Medicaid and Emergency Medicaid benefits. Although the Emergency Medical Treatment and Active Labor Act restricts the use of federal Emergency Medicaid funds for the uninsured to “acute symptoms of sufficient severity” so as to cause “serious impairment,” bodily harm, or death, states themselves can define the diagnoses and services covered by Emergency Medicaid—and only a few include COVID-19 treatment.
More broadly, despite the fact that immigrants are disproportionately represented in sectors of the economy most impacted by the pandemic, undocumented immigrants are ineligible for unemployment insurance. Nor will those without Social Security numbers receive payments under the CARES Act, the recently passed federal stimulus bill. But the exclusion goes further: the CARES Act also excludes anyone who lives in a household in which anyone uses an ITIN (Individual Taxpayer Identification Number) to file taxes. This exclusion will disadvantage not only undocumented immigrants, but also the 8 million citizens living with undocumented family members, of whom 5.9 million are U.S. citizen children. In response, Democratic lawmakers recently introduced the Leave No Taxpayer Behind Act, which would amend the CARES Act to include taxpayers who use ITINs. To be sure, absent any systemic form of financial relief at the moment, immigrants who work in low-wage jobs without paid sick leave—even during state-mandated stay-at-home orders—may have few options but to continue working even if they are sick. Of course, this is not only detrimental to immigrants’ health but will help spread the pandemic.
Limitations to Immigrant Coverage Prevent Full COVID-19 Treatment and Put All Communities at Risk
Immigration and health care policies may not only discourage immigrants from receiving the testing and treatment they will need during this crisis, but they may also complicate clinicians’ efforts to provide them with quality care. Regardless of legal status, all individuals who meet federal income guidelines are eligible for coverage through Emergency Medicaid for emergency medical care. In the wake of the pandemic, the Centers for Medicare and Medicaid Services recently expanded Medicare coverage for telehealth services and many states are now including telehealth as a benefit covered under Medicaid. Emergency Medicaid benefits are state determined, however, and so far, only a few states such as New York have expanded them to cover coronavirus testing or treatment. It is considered best practice for physicians to send patients with COVID-19 home with oxygen if they require oxygen therapy and monitor them closely via telehealth when they no longer require hospitalization. Because Emergency Medicaid does not cover these services, even those undocumented immigrants who could otherwise be discharged will need to remain hospitalized. This will keep undocumented immigrants from receiving the standard of care and run counter to the goal of freeing up hospital beds.
Potential Solutions
Ensuring that all members of the public receive timely testing and treatment for COVID-19 is not only a matter of health equity, but also of sound public health. Local, state, and federal officials can implement bold new policy changes to protect immigrants and the public.
First, state, county, and municipal governments and public health agencies should double down on linguistically and culturally appropriate messaging and outreach that acknowledges immigrants’ concerns around accessing care in a climate of fear and distrust. Safety-net clinics and hospitals should pro-actively contact immigrant patients and make sure they have necessary information, resources, and plans in the event of illness.
Second, states must immediately modify their Emergency Medicaid definitions or provider billing manuals to include comprehensive COVID-19 treatment, including services such as diagnostic testing, telemedicine, primary care, and oxygen. These services are critical right now to reduce transmission and facilitate the discharge of hospitalized patients. During the pandemic states should also consider using their own funds to open Medicaid to the undocumented, as California has done for youth in the past.
Third, federal law prevents states from including undocumented immigrants in their unemployment plans, but states can act to include categories of immigrants they previously excluded. Some have already taken such steps. For example, California, Colorado, New York, and Texas allow DACA recipients (Deferred Action for Childhood Arrivals) to receive unemployment benefits. States should go even further. States can extend unemployment insurance not only to DACA recipients but also to those with Temporary Protected Status (TPS) and those who have applied for asylum or a green card. Moreover, states should also conduct outreach to ensure that immigrants are aware that unemployment benefits do not count towards public charge determinations, and that the US Citizenship and Immigration Services has said it will also take the pandemic into consideration when reviewing immigrants’ work history. This will ensure more immigrants can meet their basic needs during the pandemic and comply with shelter-in-place orders meant to stem the spread of COVID-19.
Fourth, constituents concerned about community health during COVID-19 should press their local legislators to support inclusive measures at the federal level. For example, The Coronavirus Immigrant Families Protection Act, unveiled on April 3, would extend COVID-19 testing and treatment to undocumented immigrants, provide $100 million to the CDC for linguistically appropriate outreach on the coronavirus, allow immigrants to access relief funds with ITIN numbers, further limit ICE activity, and suspend the public charge rule. Indeed, although US Citizenship and Immigration Services recently clarified that coronavirus testing will not count towards public charge determinations, immigrants are likely to remain skeptical. Suspending the rule at least during the coronavirus outbreak would make immigrants more confident that their use of benefits will not impact future status adjustments.
Finally, any future stimulus bill must include immigrants, regardless of documentation status, as beneficiaries. In the meantime, and especially if the Leave No Taxpayer Behind amendment to the CARES Act and The Coronavirus Immigrant Families Protection Act do not gain traction, state and local governments should immediately allocate relief funds specifically for immigrants who do not qualify for benefits from the CARES Act so they can stay afloat during the crisis even if they are unable to work. For example, Chicago has made undocumented immigrants eligible for all of its assistance and disaster relief programs, including a COVID-19 Housing Assistance Grant, and California is considering rectifying the CARES Act’s oversight by creating its own stimulus bill that would provide relief regardless of immigration status.
The coronavirus pandemic has struck at a moment when immigrant communities are wary of public health authorities, of clinics, and of clinical care. Inclusive actions on the part of the federal government are essential, but barring those, local governments, county and state public health agencies, state Medicaid offices, and community clinics must work to rebuild trust with immigrant communities and forestall unnecessary suffering and death. These measures will not only help avert a crisis in immigrant communities but also help curb the pandemic. In a pandemic, we are only as healthy as the most vulnerable members among us.
