Tougher immigration enforcement is taking a toll on healthcare

The Trump administration's more aggressive policy of detaining and deporting undocumented immigrants is posing new challenges for healthcare providers who serve immigrant communities.

While there is no definitive proof yet, leaders of community health centers and hospital emergency physicians say they see anecdotal evidence that immigrant patients are making fewer appointments and not coming in for follow-up care. They worry chronic conditions will worsen and infectious diseases will go untreated.

They attribute this to heightened patient fears of leaving home and thus risking apprehension and deportation by federal authorities.

"The providers say they've heard there are some families and patients who are concerned about coming to the center," said Dr. A. Scott McNeal, chief medical officer of Delaware Valley Community Health in Philadelphia. "There also was a rumor circulating that our organization had given out information to (Immigration and Customs Enforcement) agents, which we are very upset about. We tried to dispel that rumor quickly."

Providers and others who work in immigrant communities say anxieties have spiked in the wake of President Donald Trump's election. Trump's campaign platform included calls to deport all undocumented residents. His executive orders have broadened the focus of deportation efforts from convicted criminals to individuals with minor offenses.

Some clinic leaders say they frequently discuss whether elevated patient fears about immigration enforcement are hurting care and how to address these fears with colleagues. But they have no good solutions other than emphasizing to patients that no information will be shared with immigration authorities.

"In talking to our member centers, they're seeing more appointments being canceled, and they're asking the same questions you are asking," said Jose Camacho, executive director of the Texas Association of Community Health Centers.

Some clinics and hospital EDs are considering posting signs or other gestures to reassure immigrant patients that they are protected from immigration enforcement while they are in these healthcare settings. But some experts aren't sure that's helpful.

"I think bringing attention to the issue actually incites fears, because some patients may not have thought of it before," McNeal said.

At a community health center in Woodburn, Ore., the issue became acute in late February after ICE stopped two vans carrying 19 flower nursery workers and detained 11 of them.

"Our no-show ratios increased, and we experienced a tremendous amount of phone calls and expressions of concern from patients," said Carlos Olivares, CEO of the Yakima Valley Farm Workers Clinic, which operates the Woodburn facility in a heavily Latino community located south of Portland.

Olivares said his organization is most concerned about women with high-risk pregnancies who stop coming in for prenatal care, patients with chronic conditions such as diabetes who don't come in for monitoring and medication refills, and patients with major dental problems who discontinue treatment.

"When you look at parents who want a healthy baby and have been coming in during the first and second trimesters of pregnancy and all of a sudden stop coming, it makes sense to assume they are fearful of driving and finding themselves in the position of getting picked up and deported," he said.

Previous studies have found that anxiety about deportation has negative effects on immigrants' health and healthcare utilization. A study published in 2012 found that more than 40% of providers surveyed reported that ICE activities produced negative health effects among their immigrant patients, including severe stress and avoidance of the healthcare system.

"Immigrants, particularly the undocumented, don't tend to use the medical system that much to begin with," said Dr. Karen Hacker, director of the Allegheny County (Pittsburgh) Health Department, the lead author of that study. When there is a greater threat of deportation, "you just get more avoidance. They don't show up until they are doing really poorly."

During such times, immigrant patients become more fearful that healthcare organizations and staffers will provide information about them to federal immigration authorities, said Dr. Robert Rodriguez, a professor of emergency medicine at the University of California, San Francisco. A 2013 study he co-authored found that 12% of undocumented Latino immigrant patients at two California hospitals expressed fear they would be discovered and deported by coming to the hospital.

"They don't really understand that we don't report patients and that they are safe in coming to the emergency room," Rodriguez said.

In January, Puentes de Salud, a free clinic in Philadelphia, posted signs to reassure its predominantly Latino patients that federal immigration agents were not allowed on or near the premises. "Private property, access without permission is prohibited," the sign reads.

Carlos Pascual, the clinic's administrator, said the purpose of the sign is to tell patients that ICE agents aren't allowed there and that they can "feel faith in the space." Since the beginning of the year, more patients have raised questions about immigration issues and how they can be prepared for raids. The clinic now has a lawyer available to advise patients on these issues.

Current ICE policy "directs agency personnel to avoid conducting enforcement activities at sensitive locations unless they have prior approval from an appropriate supervisory official or in the event of exigent circumstances," said Dani Bennett, an ICE spokeswoman.

But that policy appears to offer the agency some flexibility in where it can conduct raids. And official policy pronouncements likely will do little to quell word-of-mouth alarms spread in frightened immigrant communities, especially after raids like the one in Oregon that took place not far from a clinic serving Latino immigrants.

Olivares said he's now trying to reach out to ICE to discuss how the agency's activities may be affecting healthcare. "Our objective is to connect with ICE and say, 'You do understand this is causing a significant problem in our community,'" he said. "But who do we call? That's our dilemma."

Rodriguez said one girl recently arrived at the ED of his hospital, San Francisco General, complaining of abdominal pain. After examination by the staff, it became clear her symptoms were related to her intense worries about her parents being deported.

"This president's rhetoric is having a negative impact on patient care," he said.