Community Engagement and Equitable Policy

Access to High Quality Health Care for Children in Immigrant Families

Limited access to health care is fundamentally stressful [9]. In North Carolina, 39% of children rely on public insurance (ie, North Carolina Medicaid or the Children's Health Insurance Program [CHIP], known as North Carolina Health Choice) [10]. Immigrant children with legal status who are otherwise eligible for Medicaid and CHIP can enroll in these programs upon arrival to the United States [11]. However, North Carolina does not offer public insurance to children without legal status, nor can children without legal status be enrolled in private coverage through the Affordable Care Act Health Insurance Marketplace [11]. Furthermore, although 59% of children in immigrant families in North Carolina have a resident parent who has difficulty speaking English, North Carolina Medicaid does not offer reimbursement for medical interpretation [1]. Public health departments, Federally Qualified Health Centers (FQHCs), school-based health centers, and charity care programs such as HealthCare Access can bridge gaps in access for pediatric services for all immigrant children. Previous immigration enforcement policies in North Carolina have been associated with mistrust and avoidance of health services, resulting in children failing to receive appropriate and timely diagnoses, care, and treatment [12].

Care coordination can offer critical support to families of children with special health care needs (CSHCN) [13]. Care Coordination for Children (CC4C), a North Carolina at-risk population management program, is accessible to all children under age 5, regardless of immigration status. However, children ages 5 and older without legal status (ie, ineligible for Medicaid or North Carolina Health Choice) do not qualify for public care coordination support.

Mental Health

The mental health of children in immigrant families is threatened by current state and federal policies. Many children in immigrant families, particularly those who are foreign-born, Latino, and/or Muslim, are subject to bullying, racism, and discrimination [7]. For children in mixed-status families (in which at least one member is a US citizen and at least one does not have legal status), fear of family separation or parental deportation is a stressful daily reality [7, 12, 14, 15]. Beyond threatened deportation, families affected by actual deportation face additional burdens, including economic instability, emotional distress, and family dissolution [14]. Children who have recently immigrated to the United States are at particular risk for past exposure to trauma, including personal histories of physical or sexual abuse, witnessing interpersonal violence, human trafficking, actual or threatened separation from parents, and exposure to armed conflict, which add to more recent stressors of integration and collectively threaten mental health [16].

Social Determinants of Health

In the setting of increased immigration enforcement at the US border and within communities, reports have indicated decreased utilization of public services, including the Supplemental Nutrition Assistance Program (SNAP) and Women, Infants, and Children (WIC) [17]. Although recent data suggests families are still seeking care, they may change appointment timing to avoid excess travel or may decline home visitation services [7]. In 2018, the Department of Homeland Security proposed a regulation that would consider use of public services, such as SNAP, Medicaid, and housing assistance in determining immigrants' ability to attain lawful permanent residency in the United States. Consequently, fear and uncertainty about being regarded as a “public charge” may exacerbate poor health outcomes and impact immigrants' likelihood of utilizing key services, even some not included in the proposed regulation [18]. In response to this proposed regulation, more than 210,000 public comments were submitted during the 60-day public comment period [19]. State-level policies in North Carolina create further challenges to accessing public services. Specifically, House Bill 318 restricts acceptable forms of identification that parents may need to enroll children in health care, public services, and education [20].

In North Carolina, individuals without legal status are ineligible to obtain a driver license. Lack of reliable, accessible means of transportation frequently limits access to health care for immigrant children and pregnant mothers. For immigrant CSHCN, transportation barriers can result in children missing medical appointments and caregivers missing time at work [21]. Moreover, Immigrations and Customs Enforcement (ICE) recently gained a contract for access to a national database of license plates for “investigatory or enforcement activities,” raising concerns for potential cross-over impact, such as arrest or deportation, on non-criminal immigrants who do not have legal status [22].

A sense of safety in communities is in part related to trust in law enforcement. Since implementation of the 2017 executive orders that increased immigration enforcement, declines in crime and domestic violence reporting have been described in the Latino community [17]. Additionally, Section 287(g) of the Immigration and Nationality Act and the Secure Communities program authorize ICE to “enter into agreements with state and local law enforcement agencies to enforce federal immigration law during their regular, daily law enforcement activities” [12]. While Section 287(g) was initially intended to “target and remove undocumented immigrants convicted of serious or violent crimes,” in 2015, over 80% of immigrants arrested through the program in North Carolina were charged with misdemeanors such as traffic violations [12, 15]. Regarding the direct impact of these policies on health, in a 2015 study looking at utilization of prenatal care both pre- and post-implementation of 287(g), many Hispanic women reported “fearing immigration enforcement policies, avoiding health services, and thus sacrificing their own health and the health of members of their families” [12].

In response to recent increases in immigration enforcement, local faith communities have engaged in broad efforts to promote the health of immigrant families. For instance, churches throughout North Carolina have offered sanctuary to immigrants with deportation orders [23]. Through their Immigrant Assistance and Resource Center, Greensboro-based FaithAction International House assists immigrants with basic needs such as housing, health care, interpretation services, and food as well as offering computer, language, and job readiness classes throughout the year. They also have a widely successful community ID program, as HB 318 explicity bans use of identification issued by foreign consulates [20].

DACA

DACA, created under the Obama administration, grants renewable work permits, deferrals from deportation, and temporary Social Security numbers to individuals who immigrated to the United States without legal status as children and who meet other specific criteria. DACA has been shown to benefit the health and well-being of DACA youth and their children [24, 25]. People with DACA also contribute immensely to the health care workforce and to the North Carolina economy, including more than $58 million in current state and local taxes [26]. As of September 2017, North Carolina has 25,560 individuals with DACA, and 37,000 were eligible [5]. On September 5, 2017, the US Attorney General announced that the government was terminating the DACA program, although ongoing litigation has led to continued acceptance of renewals [27]. The threatened loss of protections afforded by DACA places this population at risk for deportation and economic instability and perpetuates a climate of fear and uncertainty that compromises their health and that of their families.

Legal Resources for Children Seeking Safe Haven

Of all 50 states, North Carolina has one of the lowest legal representation rates for children presenting to immigration court [28]. Medical-legal partnerships receive federal funding and operate under Legal Services Corporation guidelines (such as Legal Aid of North Carolina) that preclude representation of most immigrants without legal status, with the exception of certain cases of domestic violence, serious crime, or human trafficking. Programs such as the Battered Immigrant Project (a branch of Legal Aid of North Carolina) and those run by the North Carolina Justice Center, US Committee for Refugees and Immigrants (USCRI), Legal Services of the Southern Piedmont, and the Elon Humanitarian Law Clinic offer pro- or low-bono work but lack the capacity to meet the needs of many immigrant families who require services. Children and families facing immigration proceedings must therefore either hire private immigration attorneys or represent themselves in court. Self-representation in court increases risk of deportation [29] and is often traumatizing for children and families [11].

Refugee Health

The health status of immigrant children who arrive in North Carolina as refugees is of particular concern, especially in the context of recent federal orders, such as those banning immigration from certain nations and the drastic reduction of the resettlement program. SDOH for refugees include food insecurity, housing insecurity, unemployment, poverty, and transportation barriers. Barriers to care coordination are exacerbated by differences of language, culture, and religious customs. For many refugees who have been granted legal status in the United States, poor health outcomes are further exacerbated by loss of support from refugee resettlement agencies via the Department of State's Reception and Placement program after three months of living in the United States. This is insufficient time for refugee families to learn to independently navigate health care and other critical systems (eg, education, employment). Consequently, many families are left isolated in their communities with unmet physical and mental health needs.

Farmworker Health

The North Carolina farmworker population, likely numbering over 100,000 and comprised predominantly of Latino and foreign-born individuals [30], contributes significantly to the state's economy and agricultural productivity. Nevertheless, many farmworkers and their family members face economic insecurity (often including less than minimum wage payment) that impacts housing conditions, access to food, and access to health care. Farmworkers and their families also may face risks to physical and mental health and limited access to care [30-32]. More than half the children of North Carolina farmworkers have an unmet medical need [31]. Obesity, anemia, gastrointestinal infections, respiratory conditions, and stunted growth may be more common among children of farmworkers than other US and Mexican-American children [32]. Depression is prevalent among mothers in Latino farmworker families [30]. Programs such as the North Carolina Farmworker Health Program seek to improve access to health services for farmworkers and their families.