Produced by Design: How the Inequities Experienced by Immigrants During the COVID-19 Pandemic were Created

Margaret M. Sullivan & Mary T. Bassett

Abstract

Barriers to equitable health for immigrants in the United States are purposefully created by policies. Our long history of legislation restricting access to comprehensive health insurance, labor protections, and economic opportunities for immigrants set the stage for disproportionate morbidity and mortality during COVID-19. This is further exacerbated by anti-immigration policies which erode trust in public institutions and create fear. Attempts to improve access to healthcare, such as the Affordable Care Act, have left behind millions of immigrants and Medicaid still has not been expanded in several states where high shares of immigrants reside. This results in expected and foreseeable health inequities during a global pandemic.

Immigrant communities in the United States are remarkably diverse, heterogeneous, and generally defy monolithic characterization. However, the sociopolitical climate in the US periodically galvanizes itself around policies characterizing immigrants as uniformly not belonging, such as the 1882 Chinese Exclusion Act, the 1924 National Origins Act, the 1986 Immigration Reform and Control Act, the 1996 Illegal Immigration Reform and Immigrant Responsibility Act, and post-9/11 expansion of federal security agencies. The US’s current anti-immigration sentiment has more recently been codified in numerous Executive Orders, proclamations and new rules.¹ These policies, and many others, “set the table” for the barriers to health equity experienced by immigrants during COVID-19. These barriers to care existed long before the pandemic, which is currently exacerbating underlying inequities. This piece briefly describes structural barriers to equitable health outcomes faced by immigrants during this pandemic, including the limitations of health insurance coverage, lack of economic opportunity, unequal access to housing, and restrictive immigration policy.

Fragmented Access to Healthcare

In the United States, federal and state legislation limits eligibility for health insurance by immigration status. For example, undocumented immigrant adults are ineligible for most types of coverage and are prohibited from even purchasing their own insurance through the Affordable Care Act (ACA) exchange.² Unsurprisingly, nearly half of all undocumented immigrants in the nation are uninsured.³ There are dozens of types of immigration statuses in the US, each corresponding with their own complicated and bewildering bureaucratic web of eligibility.⁴

Beyond immigration status, eligibility for health insurance coverage and health care access is also determined by the location where one resides. States with expanded Medicaid, such as Massachusetts, offer broader access to healthcare compared to the 12 states where expansion is not adopted, including Texas and Florida.⁵ This is especially problematic as several non-expansion states are also home to large shares of unauthorized immigrant residents and workers, leaving millions of individuals to rely on under-resourced safety nets.⁶ Some cities within expansion states, such as San Francisco and New York City, have also offered their own expanded access to care.^7,8,9 Therefore, one’s eligibility for health coverage is not only determined by immigration status, but also by the state and city in which one resides, in addition to income, family size, and age. This ultimately makes for a uniquely complicated and fragmented access to care that exacerbates underlying social, economic, and racial inequities. Without reliable health insurance coverage, a usual source of healthcare, or confidence that seeking care won’t result in unaffordable surprise medical costs, COVID-19 will continue to have an outsized impact on those who are the most disenfranchised from access to care.

Underlying Economic Vulnerabilities

The inequitable conditions in which immigrants live and work are perhaps an even greater risk for the transmission of COVID-19 than inequitable access to healthcare. Immigrants comprise a disproportionate segment of the service industry, which consists of lower paying and informal jobs in fields like childcare, home health, janitorial/maintenance, agriculture, construction, or landscaping. Despite the lack of social protections these jobs offer, such as employer-based insurance, sick time, or family medical leave, many of them are designated as “essential”: they are vital to food security, the health and well-being of others, and economic mobilization. These jobs cannot be performed remotely and the economic pressure to continue working despite risk of exposure to COVID-19 is high. Competing priorities such as housing, food security, and limited employment options make exposure to COVID-19 an inevitability for many immigrant workers. And unfortunately, federal legislative attempts to ensure worker protections during the pandemic, such as the Families First Coronavirus Response Act,¹⁰ exclude many immigrants, particularly those in the informal economy. Lack of worker protections perpetuates impoverished living conditions like crowded housing, which has been associated with increased transmission of COVID-19. Healthcare cannot overcome the pervasive impacts of impoverished living conditions. Addressing economic factors, which in turn have the potential to improve one’s physical environment and health behaviors, contributes more toward positive health outcomes than clinical care alone.¹¹

Health Impacts of Anti-Immigrant Climate and Fear

Each one of these determinants that increase the risk of COVID-19-- health coverage, economic opportunity, and housing conditions-- are the direct result of policies and decisions set in motion long before 2020. The current anti-immigrant climate created by past policy further fuels fears of deportation, family separation, eviction, firing and medical bills. Particularly, these fears can prevent immigrants from seeking necessary healthcare, COVID-19 testing, or demanding personal protective equipment (PPE) in the workplace. The extent of these fears can even compel immigrants to continue working despite potential exposure or experiencing COVID-19 symptoms. For example, fear has been fanned throughout the country through 287(g) agreements, which require local law enforcement to be trained and function under the supervision of ICE officers. For many immigrants, these agreements undermine trust in local law enforcement and public spaces occupied by law enforcement, making activities like driving, calling 911, or being in emergency departments, schools, or courthouses, feel unsafe. 287(g) agreements exist in at least 22 states and expanded under the Trump administration, being most prevalent in states where significant immigrant populations reside such as Texas, Florida, and North Carolina.¹² Instead of increasing public safety, 287(g) agreements instill fear and deter immigrants from seeking healthcare and health-promoting services.¹³ Punitive policies like these, which have been shown to discourage health seeking behaviors, should be rescinded to address health disparities.

Piecemeal Legislation Cannot Overcome Barriers to Accessible Care

While legislation can be highlighted as solutions to health access for immigrants, these piecemeal approaches are often insufficient. For example, the Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986 to prevent hospitals from refusing treatment to patients with emergency medical conditions, regardless of insurance or immigration status. However, the definition of “medical emergency” is subject to interpretation, does not include life threatening conditions that are not emergent, and is not a substitute for comprehensive health care. As others have said, while EMTALA might prevent someone from dying at the doorsteps of a hospital, it will send that same person home to die slowly. The implementation of EMTALA also depends on trust in public systems, which is periodically eroded by anti-immigrant legislation and sentiment. Fortunately, early in the pandemic, testing and treatment for COVID-19 was declared free to all, regardless of immigration status or insurance. However, this stipulation did not protect individuals from receiving unexpected hospital bills nor does it cover the myriad of additional tests and treatments commonly accompanying any emergency room visit.¹⁴ Fear of wage/job loss related to positive COVID-19 results, large medical bills, and sharing of personal information with public health authorities continues to limit the utilization of COVID-19 testing – apart from the underlying slow and inconsistent availability of testing supplies.

A Path Forward

Throughout the pandemic, several state and federal legislative efforts have attempted to decrease the risk of COVID-19 among immigrants. In Massachusetts, attempts to protect workers during the pandemic include instituting emergency paid sick time¹⁵ and stimulus relief to immigrants¹⁶. At the federal level, the proposed Coronavirus Immigrant Families Protection Act would not only extend food stamps and cash relief to immigrants, but also extend work authorization and modify immigration policies deterring immigrants from seeking healthcare.¹⁷ Yet, we can and must do more. Additional strategies include expanding healthcare access to immigrants regardless of immigration status, or at a minimum focusing on insuring older adults as in California.¹⁸ We can also minimize transmission of COVID-19 by releasing individuals from immigration detention, ending transfers between detention centers, and ceasing deportation of immigrants who tested positive for COVID-19. If we continue to erect and fortify policy barriers to the equitable distribution of healthcare and economic opportunities, the impact of COVID-19 will remain disproportionately experienced by our immigrant neighbors, colleagues, and friends.

About the Authors

Margaret M. Sullivan, FNP-BC, DrPH, is a Postdoctoral Research Fellow, François-Xavier Bagnoud Center for Health and Human Rights at Harvard University. Email: mmsullivan@hsph.harvard.edu.

Mary T. Bassett, MD, MPH, is the Director of the François-Xavier Bagnoud Center for Health and Human Rights and FXB Professor of the Practice of Health and Human Rights in the Department of Social and Behavioral Science at the Harvard T.H. Chan School of Public Health. Email: mbassett@hsph.harvard.edu.

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