Immigrants & COVID-19
Jasmyne Patel, MD
& Amy Zeidan, MD
Edited by Emily Cleveland Manchanda, MD, MPH
According to the Centers for Disease Control and Prevention (CDC), Hispanic or Latinx individuals are four times more likely to contract COVID-19 and/or experience severe illness as compared to non-Hispanic white persons. Countless stories fill the media with narratives highlighting this disparity. On May 24, 2020, a 34 year old Guatemalan man detained at Stewart Detention Center in Lumpkin, GA died due to Coronavirus. He was the second detained immigrant to die from COVID-19 at that time. The New York Times highlighted a devastating story of twin brothers who both died from COVID-19. Both brothers were born in Mexico; one who had legal status in the US and one who did not. The story highlights the innumerable challenges both men faced as they chose either to navigate the health system, or avoided doing so out of fear of discovery. Importantly, this article highlighted the pandemic as experienced by immigrants in the United States, and the abysmal federal response. Instead of supporting communities disproportionately impacted by COVID-19, the federal response has been the opposite; to intentionally make it worse.
Over the past four years, the Trump administration has been relentless in their attacks on immigrants, fueling anti-immigration sentiment and heightening fears among both immigrants who are citizens and those who are non-citizens. Despite alarming statistics of COVID-19 affecting immigrants disproportionately, the Trump administration has only amplified their dehumanizing efforts to target this already marginalized group, using COVID-19 as an excuse to further attack immigrants in the name of ‘public health’.
The disproportionate impact of COVID-19 on immigrants demonstrates the inseparable link between medical and legal rights influenced by underlying social determinants of health, many of which drive patients to the emergency department.
As we work to create and sustain an immigration-informed emergency department, it is important to understand the unique challenges faced by our immigrant patients. The hardships experienced by undocumented immigrants and those on temporary visas are almost certainly even more substantial than those faced by immigrant citizens.Immigrants face increased exposure to COVID-19 at work and in the community, increased barriers to medical care and COVID-19 testing, and limited access to federal benefits, all amidst an elevated risk of deportation.
Navigating the healthcare system before the pandemic was difficult for immigrants. The pandemic has exacerbated existing challenges and created new barriers for those with limited English proficiency and limited access to health care and health insurance. Access to health information specific to COVID-19, including online resources and hotlines, are primarily in English, and normal sources of care including community and federally qualified health centers have been operating with limited hours. In addition, in many parts of the country inaccurate and confusing messages from social media, politicians, and partisan organizations are more widely accessible than reliable language-concordant health information. Further, information about COVID-19 testing sites is primarily in English. Testing sites may be located in places that are challenging to access, especially for those who rely on public transportation. Studies have demonstrated geographic disparities in COVID-19 testing, with lower rates of testing in non-white, uninsured, and rural populations. As many clinics have been forced to operate using telehealth, these options are extremely challenging for those without access to internet and/or devices necessary for telehealth visits. For those who are hospitalized, in-person interpreter services have been suspended and wearing full personal protective equipment adds another communication barrier with telephonic services. Following hospitalization for COVID-19, coordinating post-hospital discharge plans and appointments for immigrants may be seen as futile, as few options exist for outpatient care.
Prior to COVID-19, non-citizens reported fear of discovery and subsequent deportation, which undoubtedly influences how and if an individual seeks medical attention. Unfortunately, this has persisted or worsened in the context of COVID-19, and with good reason.
Even with symptoms of COVID-19, non-citizens fear seeking medical attention due to immigration-related concerns. Under Trump’s administration,
ICE has expanded their workforce, increased deportations, and tightened their tactics, furthering the vulnerability of immigrants during COVID-19, even in previously designated “sensitive” locations such as medical facilities. Not surprisingly, the presence of ICE has influenced health seeking behaviors, resulting in fewer calls to physicians and fewer visits to the emergency department. This is especially concerning as we have observed the impact of rapid spread in high density, confined living spaces with few options for isolation and social distancing. For example, there are more than half a million immigrants living in the Bronx, where several generations share a single bedroom and bathroom. Chelsea, Massachusetts is the second most densely populated city in MA, with the highest percentage of foreign born residents in the state and many immigrant families living in multigenerational homes. In April, 2020, Chelsea was recognized as the ‘epicenter’ of COVID-19 in MA with the third highest number of COVID-19 cases in the state.
Beyond health care, immigrants face significant barriers to accessing public benefits, including health insurance. A Migration Policy Institute analysis demonstrated that 7.7 million noncitizens lacked health insurance in 2018; a well established barrier to receiving adequate medical care. Many non-citizens are ineligible for public welfare due to their legal status, or work in sectors that do not require employer sponsored benefits. Despite these abysmal statistics, the federal government made it worse with the public charge rule that became effective as of February 24, 2020. This makes immigrants ineligible to obtain legal residence (green cards) if they have used, or are likely to use public benefits, including Medicaid or food and housing assistance. While later amended to allow medical treatment and preventative services during the pandemic, a great deal of fear remains among immigrant communities that seeking medical care will ultimately jeopardize their immigration status.
Approximately 6 million immigrants have been working on the frontlines during the COVID-19 pandemic. They work in hospital settings, grocery stores, agriculture and food-packing industries, often with a greater risk of exposure and fewer protections. Several meat-packing facilities around the country were designated COVID-19 hotspots, many of which employed a high number of refugees and immigrants. With the expansion of and unyielding power of ICE, non-citizens face a real threat of encountering ICE while working as an essential worker. Suspension and delays in immigration interviews under the pandemic have also placed noncitizens at risk for overstaying and violating their visa, increasing their vulnerability to ICE.
For immigrants, being an “essential worker” during COVD-19 equates to working under high exposure conditions amidst increasing arrests and deportations by ICE.
The economic toll of COVID-19 among immigrants is even more severe than that experienced by the general population. Approximately 6 million immigrants are among those hit hardest by widespread layoffs as a result of COVID-19. Restaurants, hotels, cleaning services, and child care, are just some of the many occupations once filled by immigrants. Of those immigrants who are suffering from the hardest-hit industries, 38% are in low-income households, 28% lack health insurance coverage and 55% have limited English proficiency. Under the CARES Act (Coronavirus Aid, Relief, and Economic Security), a one-time direct payment was issued to low-income families in light of the soaring unemployment rates. However, it excluded many immigrants from receiving financial relief by limiting it to those who filed taxes using a Social Security Number, despite the fact that many immigrants, especially those who are undocumented, file taxes appropriately under an IRS-issues Individual Tax Identification Number (ITIN). Moreover, US citizens and non-citizens who are themselves eligible for the direct payment are disqualified if they file jointly with an ITIN filer. Thus, in families where even one family member files using an ITIN, deems the entire family ineligible from receiving federally funded financial relief. To put this in perspective, approximately 4.35 million people filed tax returns using ITINs in 2015. Additionally, MPI estimates that 15.4 million people will be excluded from the stimulus payments. Lastly, while the government implemented the Families First Coronavirus Relief Act and the Paycheck Protection Program and Health Care Enhancement Act to both authorize COVID-19 testing to be covered under Medicaid, and to provide Medicaid the funds to cover testing and treatment, Medicaid coverage was limited to immigrants who had permanent lawful residents status for greater than five years, or were refugees and asylees. This left 3.7 million low-income uninsured non-citizens without coverage for coronavirus testing and treatment under Medicaid.
While the pandemic has been challenging for us all, it has been especially harrowing for our immigrants, both citizens and non-citizens. Despite being essential members of our frontlines and thus paramount to our pandemic response, immigrants are disproportionately suffering from this crisis.
They are facing higher rates of exposure and mortality, limited access to healthcare and health information, and are prohibited from receiving federal benefits, all amidst anti-immigration sentiments and heightened fears of deportation. This virus has further unveiled our dismal dedication and continued barriers to providing both protection and health to this vulnerable community, which contributes so profoundly to our society.