As the country with the highest number of confirmed COVID-19 cases and deaths,[1] the United States continues to struggle with the impacts of the coronavirus pandemic. COVID-19 has drastically altered the lives of all people residing in the United States, citizens and immigrants alike.
The toll of the coronavirus has been particularly acute for the more than 43.3 million non-citizens living in the U.S., a group that includes lawful permanent residents (LPRs), “non-immigrants” (such as visitors, students, and temporary workers), and undocumented immigrants.[2] These immigrant and temporary foreign workers are more likely than U.S.-born workers to be employed in essential occupations such as healthcare and food service that may expose them to COVID-19. In addition, immigrant families tend to live in more crowded housing, making it difficult to isolate sick individuals and prevent household transmission.[3] Furthermore, LPRs, temporary workers, and undocumented people are significantly more likely than citizens to be uninsured, as research from the Kaiser Family Foundation found that 23% of lawfully present immigrants and 45% of undocumented immigrants are uninsured, as compared to only 9% of U.S. citizens.[4]
Like others lacking health insurance, these non-citizens are less likely to be able to afford paying out of pocket for medical treatment, even during a pandemic. This is particularly true for undocumented immigrants, who are already more likely to avoid seeking testing or treatment due to fears about being deported.[5] This dynamic poses a significant challenge to public health in the U.S. As one expert explained, “People who don’t seek care cannot be tested or treated, and their contacts won’t be traced.”[6] While immigrants and temporary workers have access to some testing and treatment resources, many lack access to health insurance and were excluded from many key benefits provided by Congress in recent COVID-19 relief legislation. For the good of public health generally and the health of these individuals, Congress should revisit these issues and extend testing and treatment resources to all immigrants, including the undocumented. Otherwise, the U.S. will not be able to completely manage the spread of the pandemic.[7]
Expanding healthcare access to combat COVID-19 has widespread public support, with the Pew Research Center finding large majorities in favor of providing testing and treatment to the undocumented population during the pandemic. Pew reports that more than 68% of American adults believe the federal government has a responsibility to provide medical care to undocumented immigrants affected by the coronavirus.[8]
COVID-19 Testing Resources Are Limited for Immigrants and Temporary Workers
Testing is the first line of defense against the pandemic, and it is crucial that reliable COVID-19 tests be made accessible and affordable to all. Test locations across the U.S. include government labs, hospital-run labs, clinician offices, and stand-alone clinical lab facilities, including large national chains or small facilities.[9] Despite this abundance of locations, COVID-19 testing in the U.S. has been limited, both by availability and by cost. Congress has passed several relief bills that include significant provisions for the expansion of testing to include both citizens and non-citizens.
The Families First Act, as amended by the Coronavirus Aid, Relief, and Economic Security (CARES) Act, only requires private insurance to cover COVID-19 testing and prevents “surprise bills” from being sent to the patient. The CARES Act provides limited access to free testing for immigrants and temporary workers across the country and gave states the option to provide testing of uninsured individuals through their Medicaid programs.[10] In addition to the $100 billion dollars granted to hospitals for Medicaid reimbursements, the CARES Act allocated $1 billion for free coronavirus testing and treatment at government-funded community health centers, which many immigrants, both documented and undocumented, rely upon.[11] Despite this allocation of resources, the nationwide shortage of tests has limited centers’ ability to provide tests to all patients who request them.[12] COVID-19 testing for non-citizens is therefore limited by insurance coverage, access to low-cost medical providers, and national availability of testing resources. Many community health centers and low-cost clinics that serve the uninsured offer access to COVID-19 testing regardless of immigration status, but these medical providers continue to rely on federal assistance to acquire testing kits and other resources.
COVID-19 Treatment Resources Are Also Limited for Immigrants and Temporary Workers
Access to testing is only half the battle; treatment for coronavirus patients requires extensive monitoring, often involving respiratory imaging, such as x-rays, ultrasounds, and electrocardiograms, and treatment may include over-the-counter medications and prescription drugs or, in more severe cases, hospitalization and the use of a ventilator.[13] The cost of COVID-19 treatment in the U.S. varies widely, given factors such as the severity and duration of symptoms and the individual’s insurance coverage. For a patient requiring an inpatient stay, hospitals charge an estimated $73,300 on average, which decreases to $38,221 for a privately insured patient due to negotiated agreements on charges.[14]
As part of the $1 billion in funding for community health centers mentioned above, the CARES Act included $100 million in grants to community health centers to provide treatment services to underserved communities. Almost 29 million people in the U.S., including many immigrants, rely on these neighborhood clinics, which are staffed by family doctors and cost substantially less than other primary care providers. During the pandemic, community health centers have provided tests, triaged patients, and reduced the burden on hospitals.[15] They are serving a crucial role in speeding the recovery of the country and acting as crucial sources of accurate coronavirus information in multiple languages and offer basic treatment at a low cost. However, like other medical providers, community health centers are experiencing revenue shortfalls due to the reduction in routine medical appointments. During the pandemic, they will be even more reliant on federal funding in order to provide services, including COVID-19 treatment.[16] Congress should provide additional much-needed funding to these important healthcare providers.
Barriers Faced by Immigrants and Temporary Workers in Obtaining Testing and Treatment
Lack of Access: Access to COVID-19 testing and treatment has been a major challenge for citizens and immigrants alike throughout the pandemic. As the virus began to spread across the U.S. in the first months of 2020, testing was largely unavailable to individuals, due to rationed testing supplies, limited lab capacity, and bureaucratic complications at the Centers for Disease Control.[17] Although widespread testing has recently increased, allowing for a more complete understanding of COVID-19’s spread across the U.S., access to both testing and treatment remain limited. Such issues are magnified for uninsured immigrants and temporary workers.
Affordability: Affordability of testing and treatment is another related problem. Given the mounting number of people losing their employer-provided insurance coverage during the current economic crisis,[18] many previously insured immigrants and temporary workers are finding themselves out of work and without coverage. Out-of-pocket costs for coronavirus tests run as high as several hundred dollars and treatment costs reach several times that amount, making medical care prohibitively expensive for many. With many families in the U.S. lacking the emergency savings necessary to cope the with the burden of economic downturn, job loss or income reduction, and increased medical costs,[19] these problems have only worsened.
Public Charge Rule: Due to the Trump administration’s recent “public charge” rule, other immigrants may also forgo testing and treatment, because they worry enrolling in Medicaid would make them ineligible for a green card. The rule, which went into effect in February 2020, deters qualified immigrants from accessing publicly funded healthcare, such as Medicaid and CHIP, by reinterpreting the term “public charge” to include immigrants who have previously received or are deemed likely to rely on certain forms of public assistance.[20] While U.S. Citizenship and Immigration Services (USCIS) announced on March 14, 2020, that “it won’t consider use of free testing services when evaluating whether immigrants will likely end up relying on public benefits,”[21] many immigrants are likely to be deterred from utilizing those benefits, either because they are unaware of the March 14 clarification or because it remains unclear how USCIS will implement it.[22]
Federal Restrictions on Benefits: The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) limits immigrant access to public benefits. Undocumented immigrants, including recipients of Deferred Action for Childhood Arrivals (DACA), are typically ineligible to receive federal public benefits such as Medicaid and health care insurance subsidies, but, in life-threatening situations, they may receive Emergency Medicaid and access to treatment in hospital emergency rooms.[23] The PRWORA instituted a five-year federally mandated waiting period for LPRs to receive federal benefits, but it gave states the ability to choose to use state funding to cover immigrants who are ineligible for federal assistance.[24] LPRs who apply to programs such as Medicaid and CHIP must adhere to the five-year waiting period instituted by the PRWORA, but states have the option to remove this requirement for children and pregnant women and to extend state-funded benefit programs to other categories of immigrants, although few have done so.[25]
Restrictions on Emergency Medicaid: Although undocumented individuals are prevented from accessing most public insurance, Emergency Medicaid, designed to meet sudden and critical medical needs, may be available to undocumented immigrants experiencing severe symptoms due to COVID-19. However, the Emergency Medicaid program is intentionally restrictive, and it requires that a doctor confirm a patient is experiencing an emergency medical condition and that the patient prove they meet certain maximum income requirements.[26] Given the realities of the current national health emergency, many uninsured patients with symptoms may be unable to obtain a COVID-19 test, which is required to demonstrate they have an “emergency” condition, until symptoms become life-threatening. Some states have modified their Emergency Medicaid programs to address the pandemic, but many more have not implemented substantive changes.[27] Expanding Emergency Medicaid to cover COVID-19-related symptoms and treatment for all uninsured individuals would allow more people to access testing and treatment, helping ensure that everyone is protected from the spread of the coronavirus.
Conclusion
Immigrants and temporary workers continue to suffer the effects of the COVID-19 pandemic alongside American citizens. In the next COVID-19 relief package, Congress should expand testing and treatment to cover immigrants and temporary workers, including providing much needed funding for community health centers and removing barriers to permitting coverage under Emergency Medicaid. Without bipartisan legislative solutions addressing costs and removing barriers faced by immigrants, this critical population will continue to bear a disproportionate burden, which will put public health at risk for citizens and immigrants alike.
The National Immigration Forum would like to thank Nicci Mattey, policy intern, for her extensive contributions to this article.
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Endnotes
[1] John Hopkins Coronavirus Resource Center, “COVID-19 Dashboard by the Center for Systems Science and Engineering at Johns Hopkins University,” June 16, 2020, available at https://coronavirus.jhu.edu/map.html.
[2] Michael Nicholson, “The Facts on Immigration Today: 2017 Edition,” Center for American Progress, April 20, 2017, available at https://www.americanprogress.org/issues/immigration/reports/2017/04/20/430736/facts-immigration-today-2017-edition/.
[3] Randy Capps and Julia Gelatt, “Barriers to COVID-19 Testing and Treatment Fact Sheet,” Migration Policy Institute, May 2020, available at https://www.migrationpolicy.org/research/covid-19-testing-treatment-immigrants-health-insurance.
[4] Kaiser Family Foundation, “Healthcare Coverage of Immigrants,” March 18, 2020, available at https://www.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants/.
[5] Kay Summers, “How COVID-19 Affects Undocumented Workers,” American University School of International Service News, April 6, 2020, available at https://www.american.edu/sis/news/20200406-how-covid-19-affects-undocumented-workers.cfm.
[6] Miriam Jordan, “‘We’re Petrified’: Immigrants Afraid to Seek Medical Care for Coronavirus,” New York Times, May 12, 2020, available at https://www.nytimes.com/2020/03/18/us/coronavirus-immigrants.html.
[7] National Immigration Law Center, “The HEAL Act Expands Access to Health Care Regardless of Immigration Status,” May 20, 2020, available at https://www.nilc.org/2020/05/20/heal-act-expands-access-to-health-care-regardless-of-immigration-status/.
[8] Pew Research Center, May 20, 2020, available at https://www.pewresearch.org/fact-tank/2020/05/20/americans-favor-medical-care-but-not-economic-aid-for-undocumented-immigrants-affected-by-covid-19/.
[9] Brookings Institution, “How the CARES Act affects COVID-19 test pricing,” available at https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2020/04/09/how-the-cares-act-affects-covid-19-test-pricing/.
[10] Nicole Narea, “Cory Booker’s new bill would expand immigrants’ health care access during the pandemic,” Vox News, May 20, 2020, available at https://www.vox.com/2020/5/20/21263978/booker-immigrant-health-care-insurance-coronavirus.
[11] Jorge Loweree, “Coronavirus Relief Package Fails to Provide Aid to Millions of Immigrants, Including Many on the Front Lines,” American Immigration Council, March 27, 2020, available at https://immigrationimpact.com/2020/03/27/coronavirus-relief-bill-immigrants/#.XwXiKmpKigR.
[12] United We Dream, “Healthcare access for Undocumented Folks in the Time of COVID19,” available at https://unitedwedream.org/2020/03/healthcare-access-for-undocumented-folks-in-the-time-of-covid19/ (state-by-state list of medical providers that receive federal funding and serve patients regardless of their immigration status).
[13] National Institutes of Health, “COVID-19 Treatment Guidelines: Management of Persons with COVID-19,” June 11, 2020, available at https://www.covid19treatmentguidelines.nih.gov/overview/management-of-covid-19/.
[14] FAIR Health, “The Projected Economic Impact of the COVID-19 Pandemic on the
US Healthcare System,” March 25, 2020, available at https://s3.amazonaws.com/media2.fairhealth.org/brief/asset/COVID-19%20-%20The%20Projected%20Economic%20Impact%20of%20the%20COVID-19%20Pandemic%20on%20the%20US%20Healthcare%20System.pdf
[15] Bradley Corallo and Jennifer Tolbert, “Impact of Coronavirus on Community Health Centers,” Kaiser Family Foundation, May 20, 2020, available at https://www.kff.org/coronavirus-covid-19/issue-brief/impact-of-coronavirus-on-community-health-centers/.
[16] Will Stone, “Under Financial Strain, Community Health Centers Ramp Up Coronavirus Response,” Kaiser Health News, March 27, 2020, available at https://khn.org/news/under-financial-strain-community-health-centers-ramp-up-coronavirus-response/.
[17] “Coronavirus Testing Delays in the United States: What Happened?” Pew Charitable Trust, May 1, 2020, available at https://www.pewtrusts.org/en/research-and-analysis/articles/2020/05/01/coronavirus-testing-delays-in-the-united-states-what-happened.
[18] Urban Institute, “How the COVID-19 Recession Could Affect Health Insurance Coverage,” the Robert Wood Johnson Foundation, May 4, 2020, available at https://www.rwjf.org/en/library/research/2020/05/how-the-covid-19-recession-could-affect-health-insurance-coverage.html.
[19] Catherine Kim, “Low-income immigrants are afraid to seek health care amid the Covid-19 pandemic,” Vox News, March 13, 2020, available at https://www.vox.com/identities/2020/3/13/21173897/coronavirus-low-income-immigrants.
[20] Jacinta Ma, “Public Charge Regulation Summary,” National Immigration Forum, September 4, 2019, available at https://immigrationforum.org/article/public-charge-regulation-summary/.
[21] Nicole Narea, “The missing piece in the coronavirus stimulus bill: Relief for immigrants,” Vox News, April 1, 2020, available at https://www.vox.com/2020/4/1/21197017/immigrants-coronavirus-stimulus-relief-bill.
[22] National Immigration Law Center, “Understanding the Impact of Key Provisions of COVID-19 Relief Bills on Immigrant Communities,” May 27, 2020, available at https://www.nilc.org/wp-content/uploads/2020/04/COVID19-relief-bills-understanding-key-provisions.pdf.
[23] National Immigration Forum, “Fact Sheet: Immigrants and Public Benefits,” August 21, 2018, available at https://immigrationforum.org/article/fact-sheet-immigrants-and-public-benefits/.
[24] Audrey Singer, “Welfare Reform and Immigrants,” Brookings Institution, May 1, 2004, available at https://www.brookings.edu/research/welfare-reform-and-immigrants/.
[25] National Immigration Forum, “Fact Sheet: Immigrants and Public Benefits.”
[26] Washington D.C. Department of Healthcare Finance, “Emergency Medicaid,” available at https://dhcf.dc.gov/service/emergency-medicaid#:~:text=Emergency%20Medicaid%20provides%20medical%20coverage,have%20experienced%20a%20medical%20emergency.
[27] Kaiser Family Foundation, “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” June 29, 2020, available at https://www.kff.org/coronavirus-covid-19/issue-brief/medicaid-emergency-authority-tracker-approved-state-actions-to-address-covid-19/.