US Immigration Policies Pose Threat to Health Security During COVID-19 Pandemic

The COVID-19 pandemic struck the United States at a time of multiple intersectional public health challenges, including a chronically underfunded public health system, growing income inequality, racial and ethnic unrest, and profound political polarization. In the years leading up to the pandemic, the United States was in the midst of a wave of anti-immigrant sentiment, as Central American migrants arrived at the southern US border seeking asylum. In an attempt at fearmongering, political figures painted a picture of mass migrant attacks poised to overrun the United States. Migrant families seeking entry to the United States were separated in detention facilities and unaccompanied minors were held in detention centers operated by US Immigration and Customs Enforcement. ¹ Federal immigration policies in place in 2020 explicitly promoted deportation and family separation among individuals lacking lawful immigration status and expanded criteria for the public charge designation for people with permanent resident status who may have been seeking naturalization.^2,3

We contribute a representative case report from the undercounted and officially silent population of people who lack lawful immigration status in the United States; who are overwhelmingly Latino and employed in high-exposure industries including farming, construction, groundskeeping, and food production; and who are at high risk of health disparities including contracting COVID-19.^4-7 We connect these observations to the disproportionately high rates of hospitalization and death among people with COVID-19 who identified as Hispanic/Latino. We propose that this disparity in morbidity and mortality is in part a result of US federal immigration policies in place during the first year of the COVID-19 pandemic in the United States, causing people without lawful documentation status to disproportionately avoid accessing COVID-19 testing and other public services. As a result of policy-driven barriers to public health for vulnerable populations, the effectiveness of COVID-19 mitigation approaches were suboptimal, causing more widespread infection with attendant morbidity and mortality in the United States compared with other countries that did not have similar barriers to care for immigrant populations.^8-10 Most of the federal immigration policies in effect during the first year of the pandemic still pose a threat to health security.

US Federal Immigration Review

Current US immigration policies, including increased deportation programs and public charge policies, create real or perceived barriers to accessing COVID-19 testing for people of color, with disproportionately worse health impacts for Hispanic/Latino populations. As a result, COVID-19 is underdiagnosed in potentially vulnerable populations, posing a threat to public health and national health security given the highly communicable nature of COVID-19 infection.

In 2017, an estimated 45.7 million foreign-born individuals were living in the United States, more than half of whom were subject to existing immigration policies. ¹¹ An estimated 10.5 million (23%) lacked documentation status, 2.2 million (5%) had temporary lawful resident status, and 12.3 million (27%) had permanent lawful resident status. Individuals from Mexico and Central America compose nearly one-third of US immigrants, including the largest proportion of unauthorized immigrants, and are the least likely to pursue naturalization. ¹¹

The intersection of immigration policy and public health is difficult to study or characterize using traditional quantitative approaches because of immigrant avoidance of testing, which is the result of fear engendered by immigration policies and rhetoric. ¹² When immigrant communities avoid accessing services, including COVID-19 testing, they are nonusers who are silent in the technological system^13,14 and are not counted in communities that use a data-driven approach to inform COVID-19 mitigation strategies. Indeed, beyond case reports shared in the investigation for this research effort, collecting data for this commentary was challenging due to the lack of trust in healthcare and public health agencies and policies reportedly designed to help marginalized and underrepresented/underserved populations. In addition to official public health data not reflecting individuals who avoided COVID-19 testing due to immigration policy concerns, individuals who offered background information for this commentary were not willing to be quoted due to concerns about potential exposure of status to employers or public officials. As a result, some conversations were shortened and still others rescinded offers to share information. The people interviewed, often well-known colleagues, scrutinized the credibility and motives of the interviewers and explicitly withheld identifying information such as names, affiliations, and occupations. As a result, systematic data collection was not possible. Any effort to systematically study vulnerable immigrant populations from a public health data perspective in the future must first build community trust before proceeding with formal population research.

Case Presentation

In the spring of 2020, the COVID-19 pandemic experience in many parts of the United States was defined by fear, confusion, and frustration, as many, if not most, communities lacked extensive testing resources and public officials communicated confusing and contradictory messages about who should undergo COVID-19 testing. In an effort to mitigate confusion, many hospital systems (eg, Mayo Clinic, Dignity Health, Banner Health) established nurse triage phone lines as a resource for community members to access symptom screening and advice related to COVID-19.

A nurse who staffed a COVID-19 triage line for a large hospital system in the southwestern United States described a pattern of troubling calls related to COVID-19 testing. One such call was from a man who reported symptoms highly suggestive of COVID-19 and a suspected workplace exposure. When the nurse told him that he should either schedule a telemedicine evaluation with a provider or make an appointment for a COVID-19 test, he asked the nurse to hold on for a moment. A female voice then explained to the nurse that she was the caller's niece. She said he was afraid to get COVID-19 testing himself because he was undocumented and concerned about the risk of deportation. The niece asked to be directed to testing locations that do not request identification or insurance information. She deferred having her uncle accompany her for fear of immigration or law enforcement patrols near the testing sites. Because she and her uncle lived in the same household, she decided she would get tested, assuming that if her uncle had COVID-19 she would likely have been exposed to the virus from close contact with him. Essentially, she would serve as a test proxy so that he could avoid the risk of deportation. This experience was similar to findings in other case reports of undocumented immigrants navigating the healthcare system for COVID-19.^15,16

This brief case description highlights a pattern of healthcare avoidance. Where there is fear of being targeted, immigrants choose isolation, which causes undue suffering because of distrust and leads to public health data silence. ⁷ This lack of data is in no small part the result of immigration policies that pose a direct threat to public health efforts—and, therefore, national health security efforts—to mitigate and contain a deadly pandemic. In an infectious disease outbreak emergency, the maintenance of health security relies on the effective deployment of public health mediation strategies to characterize and contain the spread of the outbreak, including population monitoring of test positivity and contact tracing efforts. Any policy that results in the avoidance of public health disease testing efforts among vulnerable populations poses a threat to local and national health security.

US COVID-19 Statistics Exemplify Impacts of Structural Racism

Despite profound silence in the data, the impacts of public health inequity due to structural racism is revealed in available COVID-19 hospitalization and mortality data. Since the earliest months of the COVID-19 pandemic in the United States, beginning with the emergence of New York City as an uncontrolled hotspot, Hispanic/Latino communities experienced disproportionately high rates of both serious illness requiring hospitalization and mortality, compared with White communities. At the end of November 2020, the US Centers for Disease Control and Prevention reported that compared with people identifying as White, Hispanic/Latino people had a greater than fourfold risk of hospitalization and nearly threefold risk of death from COVID-19. ⁸

The COVID-19 experience is, in many ways, unsurprising in light of the long history of disproportionately poor health outcomes in ethnic communities, including migrant workers.^17-19 While there are critical differences to consider between the experiences of structural racism and health inequities in undocumented immigrant communities and nonimmigrant Black and Brown communities in the United States, the intersectional experience and similarity in outcomes is significant for immigrant populations.

US Immigration Policy Impacts

Unauthorized Immigrants

The Immigration and Nationality Act of 1952, amended in 1965, ²⁰ legislated America's immigration system, which began with the Immigration Act of 1882²¹ and was codified in the Immigration Act of 1903. ²² The Immigration and Nationality Act excluded unskilled workers from established prioritization quotas that preferentially admitted skilled workers through lawful immigration channels. The omission of unskilled laborers from immigration quotas led to the growth of an undocumented immigrant population in the United States that was employed in unskilled labor roles in critical infrastructure sectors, but without a lawful path to documentation and citizenship.

Throughout American history, unauthorized immigrants have been subject to deportation. In the COVID-19 era, immigration policy including Executive Order 13768 in 2017² expanded priorities for deportation and generally increased high-profile deportation events. From 2017 through early 2020, the high-profile raids conducted by federal Immigration and Customs Enforcement officials—coupled with sharp reductions in the numbers of refugees admitted to the United States and large-scale detentions and deportations including family separation—dramatically reduced the willingness of unauthorized immigrants to seek engagement with real or perceived government entities including healthcare services. Raids and deportations continued into the COVID-19 pandemic era until Executive Order 13768 was revoked by Executive Order 13993 on January 20, 2021. ²³

In addition to immigration policies that may dissuade unauthorized immigrants from engaging with healthcare services, extant healthcare regulations and public health policies may further discourage unauthorized immigrants from seeking COVID-19 testing. For example, subsidized COVID-19 testing often requires phone or internet preregistration including identifying information such as name, date of birth, and address including email address. This type of data collection was related to federal regulations for CLIA (Clinical Laboratory Improvement Amendments)-certified laboratories that require collecting contact information to notify individuals of test results in accordance with the HIPAA (Health Insurance Portability and Accountability Act) Privacy Rule. ²⁴ In addition, public health authorities collect and communicate individual information for communicable disease reporting ²⁵ including in the setting of the pandemic emergency. While access to personally identifiable information is critically important for pandemic response, ²⁶ mandatory collection of this information poses a threat to immigrants who have a dual increased risk of workplace virus exposure common in unskilled labor settings ²⁷ and deportation as a result of federal immigration policies in place during the COVID-19 pandemic. Individuals who lack lawful immigration status were, therefore, substantially less likely to engage in COVID-19 testing. Undertesting, thus, resulted in underdiagnosis of COVID-19 and likely increased transmission in vulnerable communities by individuals who were unaware of their health status.

Immigrants with Lawful Resident Status

Early US immigration policy began after the Civil War with the Immigration Act of 1882, ²¹ which established immigration preference for individuals likely to contribute additive resources to the United States and banned entry for persons deemed “likely to become a public charge” and dependent on government resources. Further delineation of immigration policy occurred with the Immigration Act of 1891, ²⁸ which expanded the public charge description to include “persons suffering from a loathsome or a dangerous contagious disease.” These descriptions of public charge restrictions were codified in the Immigration Act of 1903. ²²

In the COVID-19 era, the 2019 federal immigration policy rule change ³ in place before the start of the pandemic clarified the public charge designation by expanding the list of government benefits that may trigger exclusion from legal immigration processes or deportation. These benefits include Supplemental Security Income, Temporary Assistance for Needy Families, Supplemental Nutrition Assistance Program, nonemergency Medicaid, and Section 8/Housing Choice Voucher Program housing assistance. The rule change also considered applicants' employment history, assets, English-language ability, and medical status to determine admissibility or deportability, even without accessing government benefits. The National Immigration Law Center ²⁹ characterized the 2019 immigration policy rule change as likely to have “dire humanitarian impact” even without the additive threat of a deadly pandemic.

Immigration and Public Health Policy Reform

In the context of an infectious disease outbreak, any policy that disincentivizes a group of individuals from seeking or accessing public health services is likely to have a negative impact on public health for both the targeted group and the broader public due to the nature of such outbreaks. In the context of a global pandemic of a disease like COVID-19, such policies pose a direct threat to health security by effectively obscuring the true burden of disease in communities, and the nation, and hampering the capacity of the public health system to identify and respond to localized outbreaks or deploy mitigation measures including vaccinations.

The 2021 revocation of the 2017 Executive Order ² by Executive Order 13993²³ to temper the threat of deportation with emergency public health testing was an important policy change to alleviate health security threats from COVID-19 in the undocumented immigrant population. However, it is unreasonable to think that simply repealing a single executive order would erase the fear and lead to widespread public health testing engagement among people who lack lawful immigration status. Significant public communication and trust building will be necessary to reverse the deeply held distrust and fear in immigrant communities in order to overcome the health security risks that immigration policies have engendered.

Even with the fear of deportation reduced, immediate immigration policy reform is still needed to protect US health security. During an infectious disease outbreak, public health and healthcare services related to the outbreak, including testing, disease treatment, support for quarantine and isolation, and vaccination, must be clearly excluded from the public charge consideration for all individuals regardless of lawful documentation status. The 2019 expansion of the public charge rule ³ should be adjusted accordingly.

Beyond revoking public charge laws specifically related to healthcare and social services for COVID-19 and other widespread public health emergencies, public charge laws merit broader reexamination. In light of the long-standing intersectional health inequities experienced by immigrant communities, regardless of documentation status, any policy that may pose a material or perceived barrier to accessing preventive and primary healthcare services can be understood as exerting a negative impact on the broader public. Further cost analysis research may offer empirical support to build broad political will for overhauling the public charge constructs in US immigration policy.

In addition, future work is needed to build local trust with immigrant communities to enable research to better understand the deep and entangled intersectional factors impacting individual and population health. The type of knowledge that may emerge from high-quality population health research in communities that have remained intentionally invisible as a coping strategy can enable the design and implementation of more effective solutions to address the social determinants that pose visible or invisible barriers to achieving health for immigrant communities. Strategies to build local trust may include leveraging resources tailored for relevant language and cultural factors using a transcultural care approach both for immigrant groups directly and the healthcare providers who care for them.^30,31 Building trust strategies into nongovernmental health observatory centers focused on population health in vulnerable communities, including immigrant communities, may provide an effective mechanism to better understand the challenges facing immigrant communities and to plan effective strategies including public health interventions and policy changes to address those challenges. ³²

Conclusion

Early media analysis of vaccine distribution in the United States in January 2020 ³³ reflects race and ethnicity-related disparities in morbidity and mortality with COVID-19 infection among Hispanic/Latino groups. They found that Black and Hispanic/Latino people were vaccinated at significantly lower rates, died of COVID-19 at a rate 3 times higher, and were hospitalized at a rate 4 times higher than White people. These findings reinforce the intersectional threats observed with regard to COVID-19 testing and policies related to public health operations and immigration, which negatively impact public health priorities and pose a threat to health security. For example, the identification requirements to access vaccination at public sites in many states may pose a barrier to individuals who, due to historical concerns about deportation or public charge regulations, are reluctant to engage with government healthcare systems. Moreover, the massive drive-through sites prioritized for testing and vaccination in many locations—and highlighted by the White House as exemplary public health strategy—have posed barriers to groups without access to private transportation, and the lack of adequate internet services to complete required registrations pose a barrier for vulnerable populations and contribute to health insecurity broadly. ³⁴ Public health and immigration policy reform opportunities may emerge to address inequity-driven threats to health security during the COVID-19 pandemic and future public health emergencies.

Near-term opportunities may exist to leverage emerging technologies such as distributed ledger technology (eg, blockchain) or other similar digital approaches that may protect vulnerable populations from individual threats related to immigration policies while supporting public health priorities and thus national health security. Policies to leverage such technological approaches may present an opportunity to reconcile competing interests across policy sectors to promote public health and safety as a shared value toward national security. Such policies merit focused exploration and inclusion in federal funding priorities.