Immigrant Health and the Moral Scandal of the “Public Charge” Rule

A long-anticipated policy change proposed by the Trump administration that would count the use of many federally-subsidized programs against immigrants currently eligible to use them threatens public health and would undermine ethical practice in health professions and systems.

The policy would expand the definition of a public charge, someone likely to become dependent on government assistance. Noncitizens identified as likely public charges would become ineligible for lawful permanent resident (green card) status and for family reunification visas. As reported by NPR, Vox, and other news outlets based on the administration’s  public notice last spring and on analysis of leaked drafts of the Department of Homeland Security’s proposed public charge policy, this change would likely strip low-income households of access to a wide range of health-related benefits. While noncitizens who are legal residents in the U.S. would remain eligible for these benefits, enrolling in them could jeopardize their immigration status.

By portraying settled immigrants and prospective citizens as drains on American society, the proposed policy change is profoundly morally troubling. It raises at least four specific challenges to ethical practice in health professions and systems.

First, it will accelerate chilling effects on health care access and use of health-related services by immigrant households. The Migration Policy Institute’s analysis of the draft rule indicates that the expanded definition of public charge will likely include use of Medicaid apart from emergency benefits; publicly subsidized health insurance; the Children’s Health Insurance Program (CHIP); the Supplemental Nutrition Assistance Program (food stamps); the Special Supplemental Nutrition Program for Women, Infants, and Children; Section 8 housing vouchers and means-test home energy assistance programs; Temporary Assistance to Needy Families (TANF) and other state or local income maintenance programs; and tax credits. Legally present immigrants are currently eligible for these programs if they meet income and other criteria; undocumented (unauthorized) immigrants are ineligible for these programs. By making it risky for immigrants to apply for and use publicly funded benefits intended for low-income individuals and families, the public charge policy would especially disadvantage certain immigrant populations. According to MPI, “it would become more difficult for children, the elderly, persons with lower levels of education and/or limited English proficiency, and those with incomes under 250 percent of the federal poverty level to enter and remain in the United States.”

Impeding immigrants’ access to health-related benefits undermines population health. In a recent commentary in the New England Journal of Medicine, Krista Perreira, Hirokazu Yoshikawa, and Jonathan Oberlander–three eminent social science researchers who have studied the effects of public policy on low-income families, including immigrant households–concluded, “if this rule takes effect, it will most likely harm the health of millions of people and undo decades of work by providers nationwide to increase access to medical care for immigrants and their families.”

Second, this move undermines trust between immigrants and systems that aim to support health. While federal authorities responsible for immigration services have long had authority to limit noncitizens’ access to publicly funded programs, earlier restrictions excluded use of medical, nutrition, and similar programs being used to deny permanent residency or citizenship on public charge grounds. If a physician, nurse practitioner, medical social worker, or case manager cannot responsibly encourage an immigrant parent to enroll her U.S.-born child in health insurance or encourage this parent to use other subsidized programs for which she and her family are eligible, health and social systems will be blocked in normal efforts to strengthen public health and immigrant integration in the communities they serve.

Third, the proposed policy change feeds a resurgent untruth – the canard of immigrants as freeloading “enemies of the people,” as explored in James Morone’s classic 1997 essay on the morality of health policy – and obscures truth: immigrants are relatively low consumers of health care and other public resources. Recent quantitative studies by physician and health policy scholar Leah Kallman and colleagues have concluded that immigrants are a “low-risk pool” within the American health care system who “almost certainly paid more toward medical expenses than they withdrew,” and that unauthorized immigrants – who, as noted, are ineligible for federally-funded benefits – actually subsidize care for older adults insured by Medicare. These studies update 2013 research from the Cato Institute, which similarly found that low-income immigrants are relatively light users of publicly funded resources compared to low-income US-born citizens. There is no economic case for further restricting public benefits to immigrants or for the notion that doing so will result in benefits to citizens. Rather, discouraging immigration by a population that is largely in the workforce and “paying into the system” will undermine public systems citizens rely on.

Finally, the proposed wide expansion of what counts toward deeming a person who is a member of American society a “public charge” hardens perceptions of low-income minority immigrants as a caste without rights, protections, or prospects beyond low-status work. This is a hypocritical notion in an immigrant nation and is specifically bad for the prospects of a nation that relies on the immigrant workforce, as the U.S. and all aging societies do. A recent U.N. report on “care and older persons” reinforced that the care workforce in aging societies characteristically relies on two groups: immigrant women and family members, usually women.  Good care in aging societies therefore intersects with the status of immigrants and of women in those societies. Discouraging immigration and making life hard for immigrants and their children is self-defeating for an aging society.

Fortunately, there is some good news out of Colorado, which as of September 1 will cover standard outpatient dialysis for noncitizens with end-stage renal disease under the scope of its emergency Medicaid program. This policy change was informed by a series of qualitative studies led by Lilia Cervantes, a hospitalist at Denver Health and the University of Colorado, to study the health consequences of emergency-only dialysis requiring weekly hospitalization. Dr. Cervantes’s studies found that management of a chronic, life-threatening condition through emergency provisions led to higher mortality and longer hospitalizations, higher symptom burden and psychosocial distress, and greater professional burnout and moral distress. (Disclosure: I served as a co-author on Cervantes’s study of the experiences of patients and families.) In announcing this change, Colorado’s Medicaid program commended Dr. Cervantes for heightening awareness of problems and solutions.

Nancy Berlinger is a research scholar at The Hastings Center. She codirects The Hastings Center’s Undocumented Patients Project.

This post was originally published in The Hastings Center’s Bioethics Forum.  Please click here to access the original post online.

Beyond Breaking News: Ways of Seeing Migrants and Their Children

In his iconic 1977 essay on migration, A Seventh Man: A Book of Images and Words about the Experience of Migrant Workers in Europe, John Berger wrote:

“To try to understand the experience of another it is necessary to dismantle the world as seen from one’s own place within it, and to reassemble it as seen from [another’s] . . . to understand a given choice another makes, one must face in imagination the lack of choices which may confront and deny [another] . . . The world has to be dismantled and re-assembled in order to be able to grasp, however clumsily, the experience of another. To talk of entering the other’s subjectivity is misleading. The subjectivity of another does not simply constitute a different interior attitude to the same exterior facts. The constellation of facts, of which [another person] is at the centre, is different.”

Amid the volume of coverage and commentary on the politics of immigration and the consequences of crackdowns and criminalization, here is a selection of recent work – analysis, personal essay, fiction, mixed-media – that can spark the moral imagination, as Berger’s work does.

To understand the constellation of facts concerning migration from Central America to the United States, Stephanie Leutert, an expert on Central American migration at the University of Texas-Austin and the lead writer for the “Beyond the Border” on Lawfare, offers a clear and thorough explanation of “who’s really crossing the border and why they’re coming.”

Drew Thompson, a doctoral candidate in philosophy at Loyola University in Chicago, analyzes the right of asylum in humanitarian law and sets out two moral objections to the “zero-tolerance” policy that has resulted in family separation and the criminalization of people with potential asylum claims. Thompson draws on Ursula LeGuin’s short story “The Ones Who Walk Away from Omelas” to help readers face in our imagination what many of us cannot see except through media documentation.

Novelist Edwidge Danticat reminds us how easy it is to forget people who have been concealed from public view. She writes that we must not forget migrant children – the fact that they, like the child in Omelas, continue to exist and to suffer – even as the news cycle inevitably moves on. Danticat’s essay, on her own experiences as a child who lived apart from her migrant parents also helps us to face in our imagination the choices, or lack of choices, that Central American parents face concerning how to ensure a future for themselves and their children. A recent conversation with Danticat also features Cristina Henriquez, whose short story “Everything is Far from Here” imagines a woman’s thoughts and experiences during migration. Novelist Valeria Luiselli uses an artifact of the immigration system – the 40 questions that unaccompanied minors are asked in immigration court to determine whether they may qualify for asylum – as the scaffolding for her 2017 essay “Tell Me How It Ends,” based on her experiences as a translator.

The Waiting Game, a new public education project of the investigative news service ProPublica and public radio station WNYC, uses game technology to dismantle the world from the viewer’s perspective and reassemble five worlds of asylum-seeking. Playing this game is an eerie experience if you have the choice to stop playing, to return from danger, or limbo, to safety.

Nancy Berlinger is a research scholar at The Hastings Center. She recently completed an academic writing residency at the Bellagio Center of the Rockefeller Foundation, for a book project on migrants as social citizens. She codirects The Hastings Center’s Undocumented Patients Project, a knowledge hub on health care access for unauthorized migrants and mixed status families in the United States that includes a searchable database.

This post was originally published in The Hastings Center’s Bioethics Forum.  Please click here to access the original post online.

Migrants’ Lives, Immigration Policy, and Ethics Work

The Russian poet Anna Akhmatova was a mother separated from her child by a state policy of terror. During the 1930s, she and other mothers would gather outside a Leningrad prison, desperate for information. One day, after 17 months of “waiting in prison queues,” another woman whispered to her, “‘Could one ever describe this?’ And I answered, ‘I can.’” Akhmatova’s poem cycle Requiem reflects on the anguish of family separation from the perspective of a parent, who “stood for three hundred hours/And no-one slid open the bolt.”

The U.S. Justice Department’s April decision to jail and criminally prosecute adult migrants apprehended after crossing the U.S.-Mexico border and separate children from parents, explained here, and here in visual form, has produced its own narratives of terror. The most horrifying thus far is the recording of the voices of children in a Border Patrol detention facility, pleading for their parents. In the recording obtained by ProPublica, a Salvadoran girl is determined to shape her own story, to “describe this.” She has memorized her aunt’s phone number, and begs a consular official to make a phone call. Any adult who has been responsible for a young child would recognize how this little girl’s mother has prepared her for a separation, by teaching her crucial information and explaining how to find an adult to trust.

ProPublica also spoke with the child’s aunt, who said, “‘Imagine getting a call from your 6-year-old niece. She’s crying and begging me to go get her. She says, ‘I promise I’ll behave, but please get me out of here. I’m all alone.’” The listener’s hope that this child had found a way out of her terrifying situation was dashed by the reality of her aunt and cousin, whose years-long process of seeking asylum has been jeopardized by the recent Justice Department ruling that people fleeing gang or domestic violence would no longer qualify for protection. They, too, are terrified.

In the past six weeks, 2,342 children have been separated from their parents; as yet it is unclear how the June 20 executive order ending family separation will be implemented. Journalists and immigrant rights advocates have done heroic work on the ground, describing injustice and working for justice. Attorneys have had to swiftly adapt ethics policies and related protocols designed for interviewing teenagers. As one attorney explained to a journalist: “Our duty as attorneys is to represent the child’s express wishes. Sometimes, when they are really young, it’s difficult to ascertain those wishes . . . because they can’t express as much…It is very emotional on me, and everyone else on staff. It is very hard to see very young children . . . .I feel like if we don’t do this, who else is going to? As upsetting as it is, we have to do it.”

What should the field of bioethics do, beyond lending our names, as citizens and professionals, to the outcry? Here are three recommendations for our field, reflecting the continuing importance of migration as a phenomenon shaping our world.

  1. In clinical teaching and learning, frame and analyze challenges concerning care for migrants as problems of justice.

Providing good care to migrants whose legal status is uncertain or threatened is often experienced as an ethically fraught aspect of practice. While acknowledging practitioner moral distress, bioethics education should aim for a higher standard of basic knowledge concerning the situation of migrants in a society. Research insights on how a system’s leaders and administrators influence professional behavior concerning a stigmatized population should be part of this analysis.

  1. In teaching and learning, organizational ethics, and public service, aim to understand and reflect the local implications of national policy.

Worldwide, most migrants live in cities; most immigrants to the U.S. live in just 20 metropolitan areas. Professionals in safety-net health care in these cities are likely to encounter patients whose lives are shaped by a nation’s immigration enforcement policies. Professionals who work near immigrant detention facilities will also encounter national issues locally. Learning from local colleagues with expertise in immigration law and immigrant health advocacy contributes new knowledge to our field. Our vocabulary can help these colleagues reflect on their own ethical challenges.

  1. In ethical theory, account for the migrant and her children.

Theories of justice that specify duties of wealthier to poorer regions concerning health-related resource allocation and development may not fully account for the relationship between aid and migration, or speak to the status of migrants. Bioethicists interested in the global dimensions of public health can contribute to theory, research, and policy recommendations concerning duties to migrants, and to their children.

Nancy Berlinger is a research scholar at The Hastings Center. She recently completed an academic writing residency at the Bellagio Center of the Rockefeller Foundation for a book project on migrants as social citizens. She codirects The Hastings Center’s Undocumented Patients project, a knowledge hub on health care access for unauthorized migrants and mixed status families in the United States. Rachel Zacharias, a project manager and research assistant at The Hastings Center, provided background research.

This post was originally published in The Hastings Center’s Bioethics Forum.  Please click here to access the original post online.

Shocking the Conscience: Justice Department versus the Health of Immigrant Women and Children

In April, the U.S. Justice Department announced that it would criminally prosecute migrants who had been apprehended after crossing the U.S.-Mexico. border. An immediate consequence of this announcement, explained in detail here, is the separation of children from their parents.

Rather than being allowed to stay with their children in an immigrant detention center while awaiting a hearing on deportation before an immigration judge, adults are being sent to federal jail to await a hearing before a federal judge, with the potential of serving time in federal prison prior to deportation. Once their parents are in the federal jail system, children are rendered “unaccompanied minors”–even though they crossed the border with their parents–and put into the custody of the Office of Refugee Resettlement, under the Department of Health and Human Services. This separates parents and children administratively as well as physically.

Professional societies such as the American Psychiatric Association and the American Academy of Pediatrics have issued statements opposing family separation, based on evidence that it risks immediate and lasting harms to children. Prior to this move by the Justice Department, public health experts and immigrant health advocates had drawn attention to other public health consequences of the Trump administration’s immigration enforcement priorities. These include the health-related dangers to children who fear a parent’s detention and deportation, adverse effects on learning, and health risks to parents who fear deportation and to families who forgo health-related public benefits to which they may be entitled out of fear of scrutiny of immigration status.

The official aim of the family separation protocol is to deter unauthorized border crossings. Its moral shock, regardless of one’s position on immigration, is that doing damage to children is central to its implementation. As journalist Masha Gessen has explained, threatening or harming children is a tactic that should have no place in a democracy’s public policy. Even if this policy is rethought and rescinded, children will have suffered avoidable harm.

[Update: Ethicists petition President Donald J. Trump, Attorney General Jeff Sessions, and Secretary of Homeland Security Kristjen Nielsen to end the policy of separating children from their parents. See the petition here.]

In another Justice Department move with public health implications, Attorney General Jeff Sessions yesterday overturned an historic 2014 federal Immigration Court ruling that recognized the asylum claims of women subjected to violence in domestic relationships. The 2014 ruling concerned a woman from Guatemala who with her three children had fled a physically and sexually violent marriage, seeking asylum in the U.S. This ruling upheld her asylum claim in accordance with longstanding international criteria, grounded in the 1951 Convention on Refugees. It recognized the respondent’s credible fear of persecution as a member of a group– namely, women in relationships–unable to prevent or leave situations of life-threatening violence or to rely on state protection. In arguing that U.S. would no longer recognize fear of domestic violence or gang violence as grounds for asylum, the attorney general has framed domestic violence as “private behavior.” This reasoning ignores well-known structural factors, such as local violence, weak or corrupt public systems, and cultural perceptions, which often undermine the interests of less-powerful groups and make it impossible for people targeted for violence to remain free, alive, and confident of legal protection in the society where they live.

This ruling has repercussions regionally, especially for women in Central America for whom the U.S. may be the safest haven from continuing local threats and lack of protection, and internationally, as it contradicts decades-long efforts to recognize gender-based violence as a form of persecution that calls for structural responses, including refuge. It should also be troubling to American citizens, as it suggests a deeply retrogressive characterization of violence within relationships as a “private” matter.

Nancy Berlinger is a research scholar at The Hastings Center and a June 2018 resident at the Bellagio Center of the Rockefeller Foundation, where she is working on a book project on migrants as social citizens. She codirects The Hastings Center’s Undocumented Patients project, a knowledge hub on health care access for unauthorized migrants and mixed status families in the United States. Rachel Zacharias, a project manager and research assistant at The Hastings Center, provided background research.

This post was orig­i­nally pub­lished in The Hastings Center’s Bioethics Forum.  Please click here to access the orig­i­nal post online.

Fair Care

Emma’s story, in showing the reality of global economic migration, raises significant questions about global ethics. The current system has many benefits: poor nations receive remittances from family members working abroad, while rich nations are provided with a labor source for low-status work and with a market for goods used primarily by low-wage migrants. Employers encounter few, if any, restrictions. The people who are hurt by the system are most often the workers themselves, usually undocumented women, and sometimes their children. Female workers are especially vulnerable to wage theft and other forms of exploitation, and are less empowered to speak up. In the absence of significant economic changes that would create better-paying jobs for workers in their own countries, what should we do? For a start, we can begin to value care work as a social good, respecting workers and protecting them from harm.

Nancy Berlinger

Michael K. Gusmano

Co-Directors, The Undocumented Patients Project, The Hastings Center

Garrison, N.Y.

This let­ter was orig­i­nally pub­lished as a let­ter in The New Yorker’s May 23, 2016 Issue. Please click here to access the orig­i­nal let­ter online.

The Supreme Court and Health Care Access for Undocumented Immigrants

The fol­low­ing com­men­tary is re-posted from Bioethics Forum, a blog of The Hast­ings Cen­ter.

The Supreme Court announced that it will hear a legal challenge to President Obama’s 2014 executive action to protect an estimated five million undocumented immigrants from deportation and permit them to work legally. The implementation of the Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA) program and an expansion of the Deferred Action for Childhood Arrivals (DACA) program created through a 2012 executive action have been held up in court due to legal action initiated by the Texas attorney general.

Texas and other states have argued that they will suffer injury due to the consequences of the executive action on state expenditures. Texas, for example, has restricted drivers’ licenses to immigrants who are “lawfully present.” According to an August 2015 report from the Pew Charitable Trusts, 10 states plus the District of Columbia issue drivers’ licenses to qualified drivers without restrictions based on immigration status; most states exclude undocumented immigrants. Because the process of enrollment in a federal program such as DAPA or DACA involves a determination that an individual is lawfully present, increasing the number of immigrants who are lawfully present also increases the number of people who may be eligible for drivers’ licenses.

What’s the connection to health care access?  For an undocumented immigrant, the process of securing relief from deportation by securing “deferred action” status through a mechanism such as DACA or DAPA involves being designated by the federal immigration system as Permanently Residing under Color of Law (PRUCOL). A person designated as PRUCOL is known to the immigration system and is unlikely to be deported. While undocumented immigrants are ineligible under federal law for a range of federally-funded benefits, it is up to each state to decide which state-funded benefits are available to this population. Some states have long used PRUCOL as a threshold for providing some benefits to undocumented immigrants. Notably, New York and Massachusetts permit state residents who are PRUCOL to apply for Medicaid.

The 2012 executive action that created DACA also created a large new PRUCOL population, raising fresh state-level questions about health care access.  If some undocumented immigrants were now eligible for state-issued driver’s licenses, why not also state-funded health insurance? In 2013, California answered this question by extending Medi-Cal  to income-eligible residents enrolled In DACA.  If the 2014 executive action is upheld by the Supreme Court (look for arguments in April and a decision in June) and implemented in the last months of the Obama administration, many more undocumented immigrants could secure public health insurance in these three large states.

Nancy Berlinger is a research scholar at The Hastings Center and the co-director of the Center’s Undocumented Patients project.

No ID in NC: Undocumented Immigrants and the Identification Problem

The following commentary is re-posted from Bioethics Forum, a blog of The Hastings Center.

On October 28, North Carolina Governor Pat McCrory signed HB 318, the “Protect North Carolina Workers Act.” This new example of state-level anti-immigrant legislation, a trend that had been curtailed by the U.S. Supreme Court’s 2012 decision in Arizona v. United States, is aimed at restricting local efforts to protect undocumented and new immigrants and support their integration into society. The Center for American Progress has analyzed the foreseeable consequences of this type of legislation: measures that ostensibly aim to protect one group of workers from another – to protect “us” from “them” – in fact wind up weakening local economies.

Under one provision of the new law, North Carolina cities are prohibited from accepted non-governmental identification, such as “community IDs.”  ID cards issued or recognized by cities have been introduced in recent years as a workaround for a problem many people face: the lack of a driver’s license or passport as identification. This problem affects undocumented immigrants because they are prohibited from obtaining driver’s licenses in most states. It also affects people who do not or cannot drive (due to disability, for example), and people whose gender identity does not correspond to their birth records.

In New York City, IDNYC– “one card for all of us” – has been a tremendous success with undocumented immigrants and middle-class parents alike, useful for everyday interactions such as showing ID to get into a public school for a parent-teacher conference. New York City plans to use IDNYC to facilitate enrollment in Direct Access, the city’s new program to create a citywide network of primary care medical homes for undocumented uninsured city residents. This plan reflects insights from Los Angeles, San Francisco, and other cities that have created programs to improve health care access for undocumented immigrants through the coordination of safety-net services; ID cards make it easier for these patients to use the system, and have the additional benefit of providing a form of identification.

The signing ceremony for HD 318 was held in the city of Greensboro, which had begun to accept a community ID card created by a local nonprofit organization, with support from the local police department, intended for community residents without access to government-issued ID.  Under the new state law, which was opposed by Greensboro city officials, city agencies are now prohibited from recognizing the card.

Read more:

Nancy Berlinger is a research scholar at The Hastings Center and the codirector of the Undocumented Patients project.

Get with the Program

Jeffrey Toobin, in his article about the Floreses, a mixed-status family, describes a “comprehensive breakdown in public policy” with regard to immigration reform (“American Limbo,” July 27th). I write as a co-director of the Undocumented Patients Project at the Hastings Center. Families like the Floreses have also been systematically excluded from public benefits that provide access to health care; owing to the parents’ ineligibility for Affordable Care Act insurance subsidies or for Medicaid, the Floreses have limited coverage options, and are buying insurance on the open market to help pay for a U.S. citizen’s cancer treatment. Only a handful of states have elected to use state funds to cover undocumented children. Only New York, Massachusetts, and California offer access to state-funded Medicaid for those enrolled in the Deferred Action for Childhood Arrivals program. The undocumented population is generally young, but people do get sick, and undocumented workers tend to be employed in jobs—food services, construction, farm labor—that expose them to a heightened risk of injury. Our patchwork of safety-net programs, federal and state exclusions, and expensive “emergency” provisions makes neither economic nor moral sense.

Nancy Berlinger
New York City

Nancy Berlinger is a research scholar at The Hastings Center and a co-director of the Undocumented Patients project. 

This letter was originally published as a letter in The New Yorker‘s August 24, 2015 Issue. Please click here to access the original letter online.

Medical Education as Mission: Why One Medical School Chose to Accept DREAMers

Mark G. Kuczewski and Linda Brubaker, “Medical Education as Mission: Why One Medical School Chose to Accept DREAMers,” The Hastings Center Report 43, no. 6 (2013): 21-24. DOI: 10.1002/hast.230

Abstract: In October 2012, the Loyola University Chicago Stritch School of Medicine amended its eligibility requirements for admission. In addition to U.S. citizens and permanent residents, persons who qualify for the Deferred Action for Childhood Arrivals program of the United States Citizenship and Immigration Service are now eligible for admission. Simply put, we extended the educational opportunity of medical school to people who are in a particular category of undocumented immigrants. We became the first medical school in the United States to have an intentional, transparent policy of eligibility for persons eligible for the DACA program. This expanded admissions policy has gained some attention in the popular press and brought us many expressions of support. It has also dismayed a few members of our school’s circle of faculty and alumni.

We wish to walk you through the history of our policy’s development. We believe that viewing it as it developed will make clear three pertinent ideas: this policy flows directly from the mission of medical schools, it suits a positive notion of social justice and is also compelled by a duty not to discriminate on arbitrary grounds, and educators who steward educational institutions must have the moral courage to place considerations of institutional mission and social justice above the political views and negative responses of some alumni and donors.

Read the full essay in the November-December 2013 issue of the Hastings Center Report. This article is available for free on Wiley Online Library.


Undocumented Patients and the Not-So-Safe Safety Net

Caroline Rath,” Undocumented Patients and the Not-So-Safe Safety Net,” Hastings Center Report 43, no. 5 (2013):  inside back cover. DOI: 10.1002/hast.212

Abstract: Working in an urban safety net facility, my colleagues and I daily face any number of challenges. In some respects, an undocumented immigration status is just another one of those challenges. However, it is a particularly interesting one given the context created by political, social, and ethical debate about immigration.