How Trumps Immigration Crackdown Threatens Obamacare

As Obamacare open enrollment begins, health-care providers in immigrant communities worry that the Trump administration’s hard line on immigration will spook some immigrants and their U.S.-born relatives away from seeking health insurance.

In Baltimore, families with mixed immigration status “are telling us that they have a newfound hesitance to provide any information to the government” since Trump was elected, said Sarah Polk, a pediatrician at Johns Hopkins Bayview Medical Center.

President Donald Trump has cut outreach to promote health-insurance enrollment under the Affordable Care Act, also known as Obamacare. He’s also made curbing immigration and deporting undocumented residents a centerpiece of his presidency.

Polk says most of her patients are kids born in the U.S. to undocumented parents, including many who came to the U.S. fleeing violence in Mexico and Central America. One patient’s father was arrested after leaving his child’s school. Another man was detained outside the Walgreens pharmacy on Eastern Avenue, where many of her patients fill prescriptions.

About a quarter of all the children in the U.S.—or about 18 million, most of them U.S.-born—have at least one immigrant parent, according to Census data analyzed by the Migration Policy Institute.

And while those children may be eligible for coverage, fear of deportation could discourage their parents from seeking it. In the past, research has linked declines in enrollment in Medicaid, the state-federal health program for the poor, to stricter immigration enforcement. Adults who might be eligible for Medicaid or ACA coverage could also be discouraged from applying out of fear that it could draw attention to undocumented relatives.

About 17 percent of lawfully present immigrants under age 65 were uninsured in 2015, almost twice the rate of U.S. citizens, according to the Kaiser Family Foundation. (The rate was even higher, 41 percent, among the undocumented, who can’t get health coverage under the ACA or, in most states, Medicaid.)

In Dearborn, Mich., home to a large community of immigrants and refugees from the Middle East, people have been on edge since Trump was elected, but their fear intensified after dozens of Iraqi Christians were arrested in a June sweep, said Farah Erzouki, public health coordinator at a community health center. “People are obviously more reluctant to get enrolled,” she said. 

Should enrollment fall, it wouldn’t be the first time. A surge in immigration enforcement in the ’90s had a “chilling effect” on Medicaid enrollment among children, a 2014 economic study found: As arrests spiked in such places as Arizona and Nevada, Medicaid participation fell among the children of noncitizens. Enrollment was less affected in such places as California, where arrests didn’t rise so sharply.

In the most recent fiscal year, which ended Sept. 30, immigration arrests have risen, according to Immigration and Customs Enforcement. The agency made 133,528 arrests between Oct. 1, 2016, and Sept. 9, 2017—the latest available data, spokesman Matthew Bourke said in an email—compared with 110,104 in the prior fiscal year, from Oct. 1, 2015, to Sept. 30, 2016. Removals appear to have dropped: 211,068 in fiscal 2017 through Sept. 9, compared with 240,255 in the prior fiscal year, according to ICE data.

For immigrants living in the U.S. lawfully, it’s not just concern about bringing scrutiny to relatives that could depress enrollment, said Samantha Artiga, an analyst with the Kaiser Family Foundation. They might also forgo subsidized insurance through the ACA or Medicaid out of fear it could jeopardize their own bids for citizenship, she said. Using Medicaid isn’t supposed to count against somebody applying for citizenship, Artiga said, but many families are reluctant to seek any public benefits.

Among Hispanics in California, a 2016 Kaiser survey found that more than half of the uninsured worried that seeking coverage would draw attention to their or a relative’s immigration status.

Three years ago, California officials developed marketing materials intended to reassure people that “you didn't have to worry” about revealing immigration status while applying for health coverage, said Peter Lee, executive director of Covered California, the state insurance marketplace. They’re no longer promoting that message, he said; “we don’t know what to say about what the current administration might do.”

In focus groups with Californians who have undocumented family members, Lee said people’s concerns about the risk of arrest and deportation were secondary to their interest in getting insured. “It’s an undercurrent we hear about, but I don’t anticipate it’s going to have effects on enrollment,” Lee said. 

Polk, the Baltimore pediatrician, said parents seem committed to maintaining access to care for their children. But in immigrant communities, federal enforcement has taken a toll on people’s health. She’s seen a rise in mental health symptoms among kids, including acts of self-harm such as cutting—a sign of anxiety and depression. “There’s just a very high level of fear.”

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