key: cord-0903663-wzpgseay
authors: Hill, Jessica; Rodriguez, Darlene Xiomara; McDaniel, Paul N.
title: Immigration Status as a Health Care Barrier in the USA during COVID-19
date: 2021-03-20
journal: J Migr Health
DOI: 10.1016/j.jmh.2021.100036
sha: 8fbeb896e4a1889b137ed8ca614e33e77416941c
doc_id: 903663
cord_uid: wzpgseay

In the context of the United States of America (U.S.), COVID-19 has influenced migrant experiences in a variety of ways, including the government's use of public health orders to prevent migration into the country and the risk of immigrants contracting COVID-19 while in detention centers. However, this paper focuses on barriers that immigrants of diverse statuses already living in the U.S.—along with their families—may face in accessing health services during the pandemic, as well as implications of these barriers for COVID-19 prevention and response efforts . We report findings from a scoping review about immigration status as a social determinant of health and discuss ways that immigration status can impede access to health care across levels of the social ecology . We then explore how recent changes to federal immigration policies and current COVID-19 federal relief efforts may serve to create additional barriers to health care for immigrants and their families. Improving health care access for immigrant populations in the U.S. will require interventions at all levels of the social ecology and across vari ous social determinants of health, both in response to COVID-19 and to strengthen health systems more broadly.

In the United States of America (hereafter referred to as the U.S.), the COVID-19 pandemic has influenced migration in a variety of ways. Citing public health concerns, both the U.S. Department of Homeland Security (2020a) and the Centers for Disease Control and Prevention (2020a) enacted restrictions on persons entering the country. Additionally, a series of presidential proclamations barred entry to persons from specific geographic regions, as well as groups of migrants more generally, citing both health and economic objectives (Trump 2020a-g) .

Scholars and activists have critiqued these measures for restricting the movement of populations and denying legal processes to vulnerable groups, including unaccompanied children and asylum-seekers (Garcini et al. 2020; Ramji-Nogales and Lang 2020; Wilson and Stimpson 2020) .

Additionally, individuals held by U.S. Immigration and Customs Enforcement (ICE) in detention centers have been found to be at heightened risk of contracting COVID-19 as compared to the larger U.S. population, even after ICE stated that it implemented mitigation measures (Erfani et al. 2020) .

While the health implications of policies limiting migration raise important questions, this paper focuses on ways the COVID-19 pandemic intersects with health care access among immigrant populations already residing in the U.S. Highlighting barriers to health care for immigrant communities during COVID-19 is particularly important because of the way this pandemic has underscored health disparities among marginalized groups in the U.S., including immigrants and communities of color (Barry et al. 2020; Cholera, Falusi and Linton 2020; Choo 2020; Clark et al. 2020 ; AUTHORS NAMES REMOVED 2020; Page et al. 2020; Roberts and Tehrani 2020; Rollston and Galea 2020; van Dorn, Cooney, and Sabin 2020; Williams 2020) . As of December 4, 2020, CDC reported a total of 14,041,436 cases of 386 deaths (CDC 2020b) . Infection rates and mortality rates among Black, American Indian and Alaska Native, and Latinx populations are higher as compared to those of white populations, and these groups are over-represented in cases and deaths as compared to their representation in the larger population (Artiga, Corallo and Pham 2020; The COVID Tracking Project 2020). In addition to these reported COVID-19 cases, many more cases remain unreported. Therefore, these statistics do not give a clear picture about the pandemic's effect on immigrant populations.

These data-and the gaps in these data-led our team to reflect on our recent research about immigration and health in new ways.

This paper discusses immigration status as a social determinant of health, along with direct and indirect ways some immigrants have been excluded from COVID-19 prevention and response efforts. In particular, this paper focuses on barriers that immigrants of diverse statuses already living in the U.S.-along with their families-may face in accessing health services during the pandemic, as well as implications of these barriers for COVID-19 prevention and response efforts. We report findings from a scoping review about immigration status as a social determinant of health, and discuss ways that immigration status can impede access to health care across levels of the social ecology. We then explore how recent changes to federal immigration policies and current COVID-19 federal relief efforts may serve to create additional barriers to health care for immigrants and their families.

A social determinant of health is a social factor that impacts health outcomes (U.S. for a scoping study, which is a type of literature review that synthesizes diverse sources on a specific topic and disseminates key findings in a timely manner to inform broader research, policy, and practice initiatives. A detailed description of the methodology has been reported elsewhere (AUTHORS NAMES REMOVED 2020). After the COVID-19 pandemic began in the U.S., we revisited the scoping review and added resources related to COVID-19 prevention and response efforts.

The decision to migrate and the migration experience itself has implications for one's health. Of particular significance is one's immigration status upon entering into the U.S., since it has implications for social determinants of health. The include stressors both before and after migration, the ways laws and policies influence access to benefits and services across different Yeo 2017) . Factors like country of origin, destination country, race/ethnicity, age, socioeconomic status, and immigration status influence health outcomes both before and after migration (Diaz et al. 2017; Shor, Roelfs and Vang 2017; AUTHORS NAMES REMOVED 2020) .

In 2019, about 45.8 million U.S. residents were born in countries other than the U.S., representing about 14% of the country's population overall (U.S. Census Bureau 2020a).

Residents who were born in other countries represented diverse regions of origin: 52% of immigrants originally migrated from Latin America and the Caribbean, 30% from Asia, 10% from Europe, and 8% from all other regions of the world (U.S. Census Bureau 2020b). The government has various classifications to describe residents born in countries other than the U.S.

For example, it distinguishes between foreign-born individuals with governmental authorization to reside and to be employed in the U.S.; foreign-born individuals with temporary authorization to be in the U.S. (which may or may not include permission to work); and "deportable aliens," or foreign-born individuals without governmental authorization to enter the U.S., or who remained in the U.S. after their initial authorized period (U.S. Department of Homeland Security 2018).

Findings from our scoping review indicate that differences between immigration classifications influence many aspects of health among immigrant communities in the U.S. Martinez et al. (2015) identified two main mechanisms through which laws and policies in various countries are hypothesized to impact health outcomes among undocumented immigrants: 1) by regulating access to resources like health insurance and health care; and 2) by influencing the overall environment in which immigrants make decisions about their health. While Martinez et al. (2015) evaluated experiences of undocumented immigrants specifically, other sources in our scoping review found that immigration laws impact health and well-being for both immigrants and their family members across immigration status classifications, as well as for residents who are members of racial and/or ethnic minority groups (Majumdar and Martínez-Ramos 2016; Morey 2018; Vargas, Sanchez, and Juárez 2017; Vargas and Ybarra 2017) . For example, Vargas, Sanchez and Juárez (2017) found that both Latino/a citizens and noncitizens who lived in states with a high number of immigration-related laws had decreased odds of reporting optimal health as compared to Latino/a respondents in states with fewer immigrationrelated laws. Regarding families in which members have different immigration status, Vargas and Ybarra (2017) compared parental reports of child health status across three different groups of Latino/a families: families in which the parent was undocumented and the child was a U.S. citizen, families in which the parent was a Legal Permanent Resident and the child was a U.S. citizen, and families in which the parent and child were both U.S. citizens. Vargas and Ybarra (2017) found that the undocumented parents were less likely to report optimal health for their child who was a citizen as compared to other families in the sample.

Such laws and policies also make the U.S. health care system complicated to navigate In 2018, almost one-quarter (23%) of authorized immigrants and almost half (45%) of undocumented immigrants in the U.S. did not have insurance, making noncitizens significantly more likely to be uninsured as compared to citizens (Kaiser Family Foundation 2020). In addition to ineligibility for many public health insurance options, another reason for low Page 8:30 insurance coverage among undocumented immigrants can be attributed to their overrepresentation in low-paying jobs that are less likely to have access to employee-sponsored health insurance (Garfield, Orgera, and Damico 2019; Parmet, Sainsbury-Wong and Prabhu 2017) .

While limited access to health insurance coverage is one barrier to care for many immigrant populations, the literature identified other barriers as well. Like social determinants of health frameworks, social ecological models posit that an individual's health outcomes cannot be isolated from larger, interconnected social systems the encompass individual, relationship, community, and societal levels (Bronfenbrenner 1979; Dahlberg and Krug 2002; Golden and Earp 2012; McLeroy et al. 1988; Stokols 1992; Stokols 1996) . Social ecological frameworks appeared in many of the sources in our scoping review because of the ways immigration status As examples, Hacker et al. (2015) and Derr (2106) are two robust literature reviews that presented similar barriers to health care access for immigrant populations using different categories within their social ecological frameworks. The first review by Hacker et al. (2015) focused on barriers to health care services for populations of undocumented immigrants in various countries that appeared in English-language sources in PubMed from 2005−2015 (p. 176). The purpose was to identify barriers to care for immigrant populations including but not limited to legal restrictions, as well as to classify different strategies to address these barriers . The second review by focused on mental health care services in the U.S. and included studies with populations representing different immigration classifications and different countries/regions of origin that were published in seven different databases from 1999−2013. The purpose was to identify differences and commonalities in immigrant experiences regarding mental health services that could inform increased health equity and quality of mental health services for immigrant populations in the U.S. (Derr 2016, pgs. 265-266) .

We highlight these two literature reviews for several reasons. They were sources that we found during our original scoping review about immigration and the social determinants of health, and they were published only one year apart. They had a shared purpose of identifying barriers to care for immigrants across the social ecology, though the populations included in each review differed. Additionally, both studies were published within the last five years, and so their findings also are relevant to understanding potential barriers to care that immigrant communities may face during the current COVID-19 pandemic. Table 1 provides a side-by-side comparison of the barriers identified by both Hacker et al. (2015) and . Though these two studies identified many of the same barriers for immigrants seeking care, they differed in both the social ecological models that they use and the level at which they categorize specific barriers. For example, Hacker et al. (2015) and Derr (2016) both identified barriers such as lack of insurance, experiencing discrimination, and resource constraints like concerns about missing work, lack of transportation, language barriers, and absence of provider cultural competency. Additionally, both Hacker et al. (2015) and found that fear of deportation, high cost of care, and lack of knowledge about resources and the health care system were barriers for immigrants accessing care. Derr (2106) also identified several barriers to immigrants accessing mental health services that were not identified in the review by Hacker et al. (2015) , such as lack of collaboration between social services and November 12, 2020). We point out these differences in social ecological models and levels not to critique or favor one representation over the other, but rather to highlight the ways different conceptualizations of the same barrier may influence how public health efforts might address it.

As discussed above, our team considered how framing immigration status as a social determinant of health might inform COVID-19 prevention and response efforts in the U.S. In this section, we synthesize various sources to better understand how recent changes to federal immigration policies, along with current COVID-19 federal relief efforts, may serve to create additional barriers to health care for many immigrants in the U.S.

We found that federal immigration policies may intersect with COVID-19 related efforts in ways that result in both regulatory and environmental barriers to health care for immigrants from 2020 expanded free COVID-19 testing for uninsured individuals, they did not explicitly cover treatment expenses (National Immigration Law Center 2020). Additionally, the Recovery Rebate sent to taxpayers under the CARES Act ($1,200 for individual taxpayers and $2,400 for taxpayers who filed jointly) required a Social Security Number, thereby excluding many immigrant households and mixed-immigration status households for which one or both taxpayers filing jointly used Individual Taxpayer Identification Numbers (National Immigration Law Center 2020). In this way, being uninsured and undocumented limited access to both COVID-19 treatment services and to economic relief measures related to the pandemic. Furthermore, the federal legislation did not explicitly ban immigration enforcement actions from happening at medical facilities (National Immigration Law Center 2020). Though ICE (2020) has stated that it would not implement enforcement operations at health care facilities, except in "extraordinary" circumstances, it did not define what constitutes such circumstances.

Other changes to federal immigration policies may also influence immigrants' access to healthcare during the COVID-19 pandemic. In August 2019, the U.S. Department of Homeland Security (DHS) issued the final rule for Inadmissibility on Public Charge Grounds, which it started implementing on February 24, 2020 (USCIS 2020). The "public charge rule" states that the government can deny visas and lawful permanent resident status to noncitizens who had used public benefits for more than 12-months within any 36-month period while residing in the U.S., and/or who are deemed likely to use public benefits in the future (USCIS 2020). After the COVID-19 pandemic began, USCIS (2020) reported that it would not consider testing, treatment, or preventative care associated with COVID-19 under the public charge rule.

However, immigrant families still may avoid accessing health services and other public benefits-even ones that would not be considered under the public charge rule-due to concerns for their future immigration claims and/or fear of enforcement activities Duncan and Horton 2020; National Immigration Law Center 2020; Page et al. 2020; Wilson and Stimpson 2020) . Inequitable health policies towards immigrants also create distrust in public health systems (Parmet, Sainsbury-Wong and Prabhu 2017) . Such distrust may serve as an additional barrier to COVID-19 prevention and response efforts.

Building on the robust work by Hacker et al. (2015) and Derr (2106) , our team reflected that some policies are designed to transcend across sociological levels, meaning that they present challenges or facilitators to health care access at the policy, systems, and individual levels.

Though literature regarding social ecological models generally recognizes the interactions that exists between the different levels represented (for example Stokols 1992 Stokols , 1996 , the sources that we found in our scoping review consistently assigned each specific barrier or facilitator on one level or another. However, several different policies can also intersect with each other to create additional barriers throughout the social ecology (AUTHORS NAMES REMOVED 2017; AUTHORS NAMES REMOVED 2019; AUTHORS NAMES REMOVED 2019). Such influences became increasingly apparent to us as we researched developments regarding COVID-19 prevention and response efforts and their impact on immigrants and their families.

To illustrate this, Figure 1 provides a conceptual outline of how three recent federal policies-the final rule for Inadmissibility on Public Charge Grounds, the CARES Act, and FFCRA-may influence one aspect of health care access for uninsured immigrants and their families during COVID-19: access to public health insurance. We used the social ecological levels presented in Hacker et al. (2015) : policy level, health system level, and individual level. Figure 1 outlines how these three policies may interact with one another and influence insurance eligibility for undocumented immigrants during the COVID-19 pandemic (Cholera, Falusi and Linton 2020; Clark et al. 2020; Duncan and Horton 2020; Hacker et al. 2015; Page et al. 2020 ; National Immigration Law Center 2020; Wilson and Stimpson 2020).

At the policy level, legislation provided funding for testing of uninsured populations, but not treatment services. This policy-level barrier to care could then impact health systems because reimbursement for treatment may not be assured. Additionally, uninsured individuals may decide not to seek needed services due to concerns that they will not be able to pay for them. At the same time, policies like the public charge rule may also increase individual-level barriers to care because of increased fear among immigrants that accessing services will block future opportunities to adjust their immigration status, despite assurances from USCIS (2020) that services associated with COVID-19 will not be considered. It should be noted that Figure 1 does not represent several additional layers of complexity related to location-specific laws.

Much public health literature that utilizes social ecological models already supports comprehensive approaches to health promotion at various levels of the social ecology (for example, Dahlberg and Krug 2002; Earnest 2006; Edberg et al. 2017; García 2012; Golden and Earp 2012; Siemons et al. 2017; Stokols 1992; Stokols 1996; Williams and Purdie-Vaughns 2016) . As Figure 1 illustrates, certain barriers to care that generally appear in social ecological models under one level (i.e., policy) simultaneously impact other levels as well (i.e., systems and individual levels). The ways that immigration status influences access to care across all Page 14:30 sociological levels are another reason that focusing on one level in isolation of others is unlikely to be effective, especially during a public health emergency.

In the context of COVID-19 in which a significant proportion of the population may need to access health care services quickly and at the same time, the link between health insurance coverage and health care is significant for all populations, and especially among populations who may experience significant barriers to care. Additionally, immigrants-along with people of color more broadly-represent a significant proportion of essential workers in sectors such as health care, groceries, pharmacies, manufacturing, and agriculture (Gelatt 2020) . These concerns, along with the recognition that inclusive measures support the health and safety of all populations, underscore the need for more comprehensive prevention and response measures (Barry et al. 2020; Clark et al. 2020; Duncan and Horton 2020; Gelatt 2020; National Immigration Law Center 2020; Roberts and Tehrani 2020; van Dorn, Cooney, and Sabin 2020; Wilson and Stimpson 2020) .

Framing immigration status as a social determinant of health underscores challenges many immigrants and their families face accessing health services. Improving health care access for immigrant populations in the U.S. will require interventions across levels of the social ecology and across varied social determinants of health, both in response to COVID-19 and for health systems more broadly.

Laws and policies impact health outcomes for immigrants and their families across immigration and citizenship classifications through regulating access to resources like health insurance and health care, and through influencing the overall environment in which immigrants make decisions about health-seeking behaviors (Martinez et al. 2015; Majumdar and Martínez-Ramos 2016; Vargas, Sanchez, and Juárez 2017; Vargas and Ybarra 2017) . Such laws and policies contribute to structural racism by excluding certain racialized groups-like undocumented immigrants and others-from accessing health care and other services, which then leads to disparities in health outcomes (Barry et al. 2020; Gee and Ford 2011; Ko Chin 2018; Morey 2018; Patler and Laster Pirtle 2017) . Tia Taylor Williams (2020) , Director of the American Public Health Association's Center for Public Health Policy, writes that "Racism, not race" is the cause of such disparities, emphasizing that the disproportionate burden of COVID-19 among communities of color and other marginalized groups is due to inequitable policies and treatment at the individual, community, and systems levels.

COVID-19 prevention and response efforts also must be receptive to the many diverse experiences across and between immigrant communities in the U.S. Future research that engages larger diversities of racial/ethnic immigrant communities is necessary to have a more complete understanding of the health needs of immigrant communities in the U.S. Future research may also consider how to visually represent in a model the many different U.S. legal classifications for immigration status-such as refugee, asylee, foreign-born individuals with and without authorization, and immigrants with Temporary Protected Status-and how different classifications influence immigrants' access to care at different levels within social ecology frameworks. However, demonstrating that immigration laws and policies create preventable and inequitable health disparities is effective only if health equity is an agreed upon goal (García 2012) . It remains to be seen if the COVID-19 pandemic creates the political will to overcome barriers to health care access, for example through expanding eligibility for public health insurance options and/or through changes to the public charge rule. (3), 265. The review includes 62 articles in total, but only 23 were included in the discussion of barriers. Other cultural-level barriers that identified, but are not included in Table 1 include: cultural norms related to mental illness (17%), preference for other types of services (9%), lack of trust in providers (9%), reliance on self or family (9%), and challenges with acculturation (4%); additional structural barriers not included in Table 1 include lack of collaboration between services and churches (4%) competing health demands (4%) and other barriers (4%) 

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