The Ethics and Economics of Establishing Sanctuary Protections to Ensure Immigrant Access to Health Care

In February 2017, the U.S. Immigration and Customs Enforcement agency (ICE) handcuffed and detained a young asylum-seeker with a brain tumor, shuttling her after surgery from her hospital bed to a detention center. During another incident in August 2017, ICE agents aggressively questioned an undocumented man as he wept at the bedside of his critically ill teenage son. And in October 2017, ICE agents lurked outside the hospital room of a ten-year-old girl with cerebral palsy, preparing to deport her when she exited. 

These stories highlight the cruel ways America’s deportation machine has infiltrated the healthcare system, interrupting care and terrifying patients,  caregivers, and providers. Congress has not required ICE to follow its supposed “sensitive locations” policies – which say that the agency is “committed to ensuring that people seeking to...utilize services provided at any [medical treatment or healthcare facility] are free to do so without fear or hesitation.” These stories and others that remain untold demonstrate that American healthcare systems are not safe for many immigrant patients and families. Many of these families already face barriers to quality healthcare due to poverty, racism, and lack of insurance. Adding extra fears that using health services can lead to deportation only makes things worse. Public health and healthcare professionals have an ethical obligation to ensure safe and equitable access to healthcare services for all. To prevent disruptions and serious harm in the current climate, they should carefully consider pushing for legally enforceable sanctuary healthcare policies.

The Consequences of Fear

Some communities have implemented “sanctuary city” policies as attempts to protect undocumented immigrant residents from federal immigration enforcement. Although such sanctuary cities encourage positive relationships between immigrant communities and local law enforcement, they cannot actually shield anyone from deportation. Moreover, sanctuary policies vary widely and often include troubling and arbitrary “carve-outs.” So far, these measures have failed to explicitly protect health care settings. In consequence, there is no legal way to prevent ICE from targeting health care facilities or services – which ICE recognizes and exploits. The lack of specific and consistent legal grounds for protecting all people’s ability to access health care has far-reaching, detrimental consequences for health outcomes and access to needed care. The lack of clear legal protections can also adversely affect health care budgets and society as a whole.

• A 2012 study reported that 40% of medical providers noted that ICE activities produced negative health effects among their immigrant patients – exacerbating problems like depression, anxiety, high blood pressure, and severe stress.

• Fear can cause people to avoid health facilities and fail to get needed services. Medical providers continue to accrue evidence that shows both documented and undocumented immigrants are missing more appointments, failing to refill prescriptions, and cancelling their participation in other social welfare programs such as Medicaid and the Food and Nutrition Service for Women, Infants, and Children to avoid detection and detention from ICE officials. These downstream effects often prompted by fears about ICE activities mean chronic diseases like diabetes and hypertension remain unmanaged and uncontrolled, infectious diseases spread, injuries worsen, and emergency rooms become the site of last resort for healthcare delivery when problems escalate.
• Not only does the fear instilled by current immigration practices harm the health of patients, it also threatens the ability of public health officials and health care practitioners to effectively and ethically serve their patients. It is impossible for providers to “first do no harm” when the very act of entering a healthcare facility instills deep anxiety in immigrant patients, and exposes them to possible deportation. Reports highlighting increased burnout or even suicide among medical providers unable to provide the level of care their immigrant patients need have been circulating as well.

• Fear also affects the bottom line of medical providers, employers, and taxpayers. When immigrants and others are forced to rely on emergency room visits because they are afraid to access outpatient care and other preventive services – hospitals are drained of resources, wait times are elongated, and the cost of care rises. Additionally, according to the Surgeon General, health problems for workers reduce productivity and raise costs for employers. Furthermore, taxpayers and public hospitals end up covering the increased costs that result from unmanaged conditions and unnecessary emergency room visits. When immigrant enforcement fears are ratcheted up in ways that keep people from accessing routine health care, these costs should be considered along with the social costs paid by immigrants and their communities. 

Given all of these costs, urgent action is necessary to protect health care access for immigrants and their families. Even if healthcare is not viewed as a basic human right, and even if one ignores the community-wide implications of untreated chronic and infectious diseases, the broader ethical and economic problems we have outlined make the case for corrective steps. 

What Can Be Done?

Professionals and leaders in the health care system, along with other civic leaders and advocates, should seek legal changes to dismantle or at least limit the reach of disruptive ICE activities in healthcare settings. Health professionals and leaders can support sanctuary ordinances that explicitly protect health care services for all people and prohibit facilities and providers from cooperating with harmful immigration enforcement efforts. Opportunities for Sanctuary Healthcare policies exist at state, local, and institutional levels.

Such legal changes may arrive slowly – and in the meantime there are actions healthcare and public health professionals can take right now – such as setting up safe spaces for care, letting patients know their rights, providing legal assistance, and holding conferences to plan institutional and professional efforts. To protect and serve all patients, health care organizations and professionals have an obligation to act. 

In the Chicago area, a coalition of 19 public health, healthcare, immigrant rights, grassroots organizing, and other community-based groups, called Public Health Woke – a local chapter of Public Health Awakened — joined together to pressure their local health and hospital system to adopt policies that protect their immigrant patients. Public Health Woke and Public Health Awakened can and should serve as models for other communities and healthcare systems. Please contact the authors for more information on Public Health Woke’s efforts and resources.