This document summarizes key issues around immigrant access to health care under the Trump administration. It notes that immigrants are generally younger and healthier but less likely to have insurance or access primary care. Several laws, including PRWORA and the ACA, restrict immigrant access to federal health benefits. Repeal efforts threatened coverage for those eligible. Community health centers face funding cuts despite serving many immigrant patients. Draft executive orders aimed to expand "public charge" determinations and reimbursement requirements in ways that could deter immigrant health care use. Surveys found immigrants reluctant to seek care due to fears of deportation. The case of a detained child in need of surgery highlighted tensions between immigration enforcement and medical privacy. Conditions in detention facilities are a concern.

1. Immigration and Health Care:
Access Under the Trump Administration
Wendy E. Parmet

2. Immigrants & Health
Immigrants are:
- Younger
- Healthier
- Utilize fewer health
resources
- Less likely to have access
to primary care
- Less likely to be insured
- Ineligible for many public insurance programs

3. Legal Barriers
• Personal Responsibility and Work Opportunity Reconciliation Act
• Bars nonimmigrant non-citizens and undocumented immigrants from
federally-funded health benefits; except for for public health and
emergency services.
• Bars most classes of authorized immigrants (excluding refugees) from
receiving federally-funded health benefits for 5 years.
• Other federal laws permit coverage for children and pregnant women.
• Affordable Care Act
• Did not repeal or modify PRWORA
• Excludes immigrants who are not “lawfully present” from participating on
the exchanges
• Did not cover Dreamers
• Imposed new verification requirements.

4. “Repeal and Replace” Efforts
• Would have limited premium support to those who are
qualified under PRWORA, a narrower class of immigrants than
those covered by the ACA, which requires only lawful
presence.
• New verification requirements would have threatened
coverage for immigrants otherwise entitled to coverage
• Repeal of Medicaid expansion would hit the immigrant
community especially hard.

5. Community Health Centers
• Congress has failed to renew vital funding for community
health centers – funding that accounts for 70% of
community health center grant dollars.
• Continued uncertainty about funding poses an especially
significant threat to immigrants who otherwise lack access to
care.
• Recent analyses estimate that as many as 9 million patients
could lose care due to lack of community health center
funding.

6. Public Charge Determinations:
Draft EO
• In January 2017, a draft Executive Order was leaked that, if
implemented, would have drastically changed the way in which
public charge determinations are made.
• Under the draft order, the use of health benefits would have
constituted a public charge that would render an immigrant
deportable.
• The draft order also instructed DHS to seek reimbursement for
benefits used by immigrants from their sponsors.

7. Climate of Fear
A poll conducted by the Migrant Clinicians
Network found that two thirds of clinics
that responded claimed that immigrants
were reluctant to seek healthcare
following the election.
Clinicians report a dramatic increase in
the number of immigrant patients who
choose not to attend their health care
appointments.
Deportations are up 25 %.

8. The Case of
Rosamaria Hernandez
• 10 year old Rosamaria Hernandez was stopped at a Texas Border Patrol
checkpoint while en route by ambulance to a hospital for emergency gall
bladder surgery.
• Agents followed Rosamaria’s family to the hospital and proceeded to wait
outside her room until she was released.
• The agents detained Rosamaria after failing to persuade her family to sign
a voluntary departure form for her and have her transferred to a hospital in
Mexico.
• The ACLU successfully sued arguing that the government violated federal
law on unaccompanied minors and endangered her health.

10. Hospitals as Sensitive Locations
• Both ICE and CBP recognize hospitals as sensitive locations, meaning they
are typically avoided by immigration officers seeking to conduct
enforcement actions.
• As a matter of policy, ICE will not conduct an enforcement action at a
sensitive location unless the action is approved by a designated official.
• Officials “will give special consideration to requests for enforcement
actions at or near sensitive locations if the only known address of a
target is at or near a sensitive location.”
• Exception: “exigent circumstances”
• These are only guidelines.

11. Privacy Protections of
Medical Information
• Immigration status is Protected Health Information (PHI) under HIPAA
• A health care entity may not disclose PHI to law enforcement, including
ICE, in the absence of proper documentation.
• A health care entity may, but is not required to disclose PHI if it is
requested by a warrant, subpoena, or signed administrative warrant.
• Most ICE warrants are administrative requests, which are not signed by
judges. Health care providers need not disclose PHI unless they are
presented with a warrant signed by a judge.

12. Health Care Conditions
in Detention Facilities
• In 2016, Human Rights Watch report on medical practices in
immigration detention facilities, cited an “overreliance on
unqualified medical staff, delays in emergency responses, and
requests for care unreasonably delayed.”
• Privately-owned detention facilities are highly variable in terms of
the quality of their health care services. Members of Congress have
cited one facility for “egregious” medical errors.
• The Trump Administration seeks to expand their use.

13. Garza v. Hargan
• Jane Doe, 17 years old and pregnant, was apprehended and placed in detention
after attempting to cross the the border in Texas.
• When she asked for an abortion, federal officials cut off her access to the
procedure.
• The ACLU sued on her behalf. DOJ argued that the government is not obligated
to facilitate access and “may legitimately express a preference for childbirth
over abortion.”
• In October, the D.C. Circuit en banc issued an order allowing Doe to obtain an
abortion.
• In dissent Judge Henderson questioned whether undocumented immigrants
have a constitutional right to an abortion.
• DOJ has sought S.Ct. review and has accused Doe’s lawyers of misconduct.

14. 2018:
Some Predictions
• Reduced access to care by immigrants of all legal statuses.
• Increasing rates of untreated health conditions.
• Increases in uncompensated care (regardless of the
fate of the ACA).
• Challenges to the health privacy of immigrants,
with troubling implications for physician-patient relationship.
• Additional instances in which contentious health care
issues are debated in the context of immigration.