You are on page 1of 3

The NEW ENGLA ND JOURNAL of MEDICINE

Perspective March 23, 2017

Chilling Effect? Post-Election Health Care Use


by Undocumented and Mixed-Status Families
KathleenR. Page, M.D., and Sarah Polk, M.D., M.H.S.

A
pregnant woman from Central America was proficiency and health literacy or
diagnosed with syphilis at the Baltimore City without health insurance or a
Social Security number. Many un-
Health Department in 2007. The outreach documented immigrants and their
team contacted her to discuss the need for, and families therefore go without
needed care, to their detriment
availability of, treatment. She mores mayor, Stephanie Rawlings- and sometimes that of others,
agreed to return to the clinic, but Blake, signed an executive order as in the case of a woman with
did not. When reached by phone, prohibiting all city employees, in- syphilis who is pregnant with a
she reported that on arriving at cluding police, from asking resi- future U.S. citizen.
the clinic she saw an armed se- dents about their immigration Trump administration com-
curity guard, and because I have status. In 2014, Governor Martin ments and actions regarding im-
no papers, I left. OMalley ordered a halt to the migration policy and enforcement
Highly publicized raids by the Secure Communities immigra- will most likely further dampen
U.S. Immigration and Customs tion-enforcement program, stating health care utilization. President
Enforcement (ICE) unit in Balti- that Maryland would not auto- Donald Trump has already signed
more during 2007 instilled fear matically honor federal govern- several executive orders consistent
in the immigrant community.1 ment requests to hold immigrants with his anti-immigrant rhetoric.
Charges of human rights viola- for deportation. On January 25, he signed one
tions and racial profiling were Although welcomed as impor- denying federal funding to sanc-
filed against ICE, but Latinos con- tant statements of intent, these tuary cities, jurisdictions that
tinued to feel targeted. The city executive orders did little to ad- choose not to cooperate with
subsequently adopted a more wel- dress common barriers to health federal efforts to deport undoc-
coming approach to immigrants care for Baltimores immigrant umented immigrants. Two days
as part of a strategy to reverse community. Navigating the health later, he stunned the world with
population decline and promote care system is particularly difficult an executive order temporarily bar-
economic growth. In 2012, Balti- for people with limited English ring entry into the United States

n engl j med 376;12 nejm.org March 23, 2017 e20(1)


The New England Journal of Medicine
Downloaded from nejm.org on March 31, 2017. For personal use only. No other uses without permission.
Copyright 2017 Massachusetts Medical Society. All rights reserved.
PERS PE C T IV E chilling effect?

of Syrian refugees and people grant Latinos and their families, munity sites, enrollment climbed,
from seven Muslim-majority coun- including U.S.-born children.3 and Latinos saw larger gains in
tries. The haste with which this Undocumented-immigrant parents insurance coverage than any other
order was enacted and its imme- reluctant to interact with staff at group.4
diate effect on U.S. immigrants, public agencies or to enter their Today, the ACAs fate is un-
even those with valid visas, sent information in government data- clear, with implications for mil-
a chilling message nationally and bases did not enroll their children lions of Americans.5 We cannot
internationally, but especially to in health plans or other benefits. predict how health care access
those living in the United States Low-income children who had the will be reshaped, yet its all but
without authorization. Soon after- most to lose from being left out certain that undocumented immi-
ward, an undocumented-immi- of safety-net programs were dis- grants who were never eligible
grant mother of two U.S.-born proportionately affected. for ACA benefits will not have
children was deported after re- In the intervening years, immi- better access to care. Access may
porting to a routine visit with gration-law enforcement and anti- be significantly reduced if finan-
immigration agents. In light of immigrant sentiment have waxed cial penalties are applied to states
these events, the community may and waned depending on the or cities that refuse to cooperate
lose confidence that information economy, current events, and the with ICE. Overt restrictions on
given to service providers, includ- political environment. Anti-immi- basic public services, such as
ing health care organizations, grant rhetoric reached an unprece schools or public health clinics,
will not be used for political pur- dented level during and after the are unlikely, given that such
poses, including deportation pro- 2016 election campaign, however. measures were ruled unconstitu-
ceedings. Undocumented-immi- A populist narrative, familiar in tional in the 1990s (California
grant parents of U.S.-citizen Europe and throughout history, Proposition 187), but access could
children may be especially con- blamed immigrants for many of be restricted by requiring govern-
cerned, given the risk that family the countys challenges, including ment-issued identification cards
members might be separated. the stagnation of wages and jobs or Social Security numbers at
The erosion of trust is not a for the middle class. This facile federally qualified health centers
theoretical concern. In 1996, Con- argument disregarded the uncom- or health department clinics. In
gress passed the Personal Re- fortable fact that almost all Ameri- addition, as our pregnant patient
sponsibility and Work Opportu- cans benefit to some degree from showed us, a climate of deporta-
nity Reconciliation Act restricting undocumented-immigrant labor tion may dampen the use of ex-
provision of federal- and state- when we eat in restaurants, enjoy isting resources, even among eli-
funded services such as welfare, clean commercial spaces, admire gible people.5
health care, retirement, and dis- new construction, or eat U.S.- To reduce barriers to care for
ability to undocumented immi- grown produce. immigrant families, the medical
grants.2 The stated goal was to Although the Obama admin- and public health community can
remove the incentive for illegal istration embraced diversity and engage in local and national poli-
immigration provided by the avail- acknowledged immigrants contri- tics and promote a welcoming,
ability of public benefits, although butions to our nation, progress inclusive environment in our prac-
restriction of benefits has not in immigration reform was disap- tices. Clinicians have access to
been shown to stem migration by pointing, and deportations reached powerful stories of human suf-
people fleeing violence. While mi- unprecedented heights. The Af- fering and strength. The current
gration from Latin America con- fordable Care Act (ACA) and climate presents a renewed op-
tinued to rise, there was a steep Medicaid expansion excluded un- portunity to partner with advo-
decline in public-service use among documented immigrants but still cacy groups and media to share
eligible Latinos, and health care benefited many Latino families, stories of human experience that
use shifted from preventive ser- including children. Initial uptake counter the Trump administra-
vices to higher-cost emergency among Latinos was slow, but once tions negative narrative about
care. Tighter immigration-law en- adjustments were made to dis- immigrants. The sharing of per-
forcement was associated with a seminate information and facili- sonal stories about the impact
chilling effect, reducing Medic- tate enrollment using bilingual of the temporary immigrant ban
aid participation by eligible immi- health navigators at trusted com- through social and mainstream

e20(2) n engl j med 376;12 nejm.org March 23, 2017

The New England Journal of Medicine


Downloaded from nejm.org on March 31, 2017. For personal use only. No other uses without permission.
Copyright 2017 Massachusetts Medical Society. All rights reserved.
PE R S PE C T IV E Chilling Effect?

media has energized millions of since these adults are often invis- between immigrants health and
people to express opposition to ible in conventional databases be- the public health and health care
the ban. Portraits of scientists cause of barriers to care and in- costs of the United States.
and doctors affected by the ban sufficient collection of relevant Disclosure forms provided by the authors
highlighted its unintended con- sociodemographic data (i.e., eth- are available at NEJM.org.

sequences for science and health nic background, country of origin,


From the Division of Infectious Disease,
care. Telling human stories is an and language preference). Its im- Department of Medicine (K.R.P.), and the
effective rapid-response tool that portant to develop inclusive meth- Department of Pediatrics (S.P.), Johns Hop-
kins University School of Medicine, Baltimore.
we can use to advocate for our ods that account for the unique
patients. needs of hidden populations. This article was published on March 8, 2017,
Clinicians and public health Some existing measures, however, at NEJM.org.
practitioners can also join forces can provide indications of a chill-
to harness the power of data. We ing effect, including utilization 1. Constable P, Aizenman NC. 69 Immi-
grant workers held in Baltimore area raids.
can monitor and measure health of safety-net clinics for sexual and Washington Post. March 30, 2007 (http://
care utilization and health out- reproductive health care, timeli- www.washingtonpost.com/w p-dyn/content/
comes. Clinicians can pay atten- ness of prenatal care, domestic article/2007/03/29/AR2007032902359.html).
2. Public Law 104-193. 1996. Personal Re-
tion to patterns in health care violence reports, and hate crimes sponsibility and Work Opportunity Recon-
utilization among their immigrant (especially assaults resulting in ciliation Act of 1996. Washington, DC:Gov-
patients and communicate worri- emergency department visits). ernment Publishing Office (https:/ /
w ww
.gpo.gov/fdsys/pkg/PLAW-104publ193/content
some trends to public health pro- In 2007, our pregnant patient -detail.html).
fessionals. Some markers of child was represented by one data point 3. Watson T. Inside the refrigerator: immi-
well-being such as Medicaid in Baltimores syphilis statistics. gration enforcement and chilling effects in
Medicaid participation. NBER working pa-
enrollment rates among eligible We can work together to ensure per no. 16278. Cambridge, MA:National
children of foreign-born parents, that in 2017 such a case would Bureau of Economic Research, August 2010
teen pregnancy rates, uptake of not remain undetected in preg- (http://www.nber.org/papers/w16278.pdf).
4. Sommers BD, Gunja MZ, Finegold K,
supplemental nutrition assistance nancy only to appear in the regis- Musco T. Changes in self-reported insur-
programs, school attendance, and try of cases of congenital syphilis. ance coverage, access to care, and health
bullying reports are already There are many reasons to sup- under the Affordable Care Act. JAMA 2015;
314:366-74.
monitored, allowing comparison port equitable access to care for 5. Obama BH. Repealing the ACA without
of the pre- and post-election peri- all, regardless of nationality. Ob- a replacement the risks to American
ods. The elections implications jective and scientifically rigorous health care. N Engl J Med 2017;376:297-9.

for undocumented adults may be data analysis will be essential in DOI: 10.1056/NEJMp1700829
more complicated to evaluate, elucidating the interconnection Copyright 2017 Massachusetts Medical Society.
Chilling Effect?

n engl j med 376;12 nejm.org March 23, 2017 e20(3)


The New England Journal of Medicine
Downloaded from nejm.org on March 31, 2017. For personal use only. No other uses without permission.
Copyright 2017 Massachusetts Medical Society. All rights reserved.

You might also like