In this issue of Pediatrics, Cholera et a1 used a controlled interrupted time series design to examine differences in health care use of Latinx children as it relates to federal immigration policy enacted in 2017. Electronic medical record data from four major health care systems in North Carolina were analyzed before and after restrictive immigration policy was enacted after the 2016 election. Among Latinx children in the outpatient setting, they found a sustained increase in visit cancellation for the uninsured subgroup, a proxy for undocumented immigrant children in North Carolina.1
One aim of the study was to explore whether restrictive immigration policy resulted in a “chilling effect” for all Latino children. A chilling effect is defined as a deterring effect on the behavior of an individual or group through fear of legal action.2 Widely used during the 1996 welfare reform, today, like then, it refers to immigrant families’ decision not to participate in the use of public benefits and services out of fear, confusion, or perceived threat. This phenomenon is of particular concern for the public charge rule changes that were enacted in 2019 (but leaked to the public in 2018), which broadened the reasons why immigrants may be denied legal permanent residence or extension of a temporary visa on the basis of their use or possible use of public benefits, including Medicaid. Several organizations estimated the impact to be far reaching in that it includes the 10.5 million children, mostly American citizens, in benefits-receiving immigrant families.3,4 In a study reported by the Urban Institute, researchers found that in 2019, 1 in 5 adults in immigrant families with children avoided public benefits and 31.5% did so in low-income families.5
Although there was no chilling effect found in the use of services by insured Latino children in this study, Cholera et al1 add to the many past and, likely, future studies that continue to reveal that policies of exclusion have negative impacts on the health of immigrant communities.6,7 Cholera et al1 remind us that such policies can further marginalize low-income undocumented immigrant communities and that the relationship between immigration status and health requires further investigation from a social determinants of health framework to truly appreciate inequities created by social structures, policies, and institutions.8 Furthermore, that the Latino community was chosen to explore immigration policy effects on health speaks to institutional racism driving immigration reform and enforcement. Using a criminal framework that describes and categorizes people as “illegal” allows for the systematic and intentional dehumanizing of Black, Latino, and other racialized immigrant communities. Black immigrants are more often detained and deported on criminal grounds, made to pay higher bail bonds, and denied asylum.9,10 Restrictive and punitive immigration policy and enforcement is highly racialized, targeting low-income communities and people of color, and is rooted in the forced displacement of Indigenous people and human trafficking of African people for chattel slavery as well as the continued restrictions and violations of their rights as citizens.11,12
By focusing their investigation on North Carolina, Cholera et al1 also remind us that federal immigration policy effects on health can be mitigated or exacerbated by state-level actions. The use of resources and health services may differ between citizens and noncitizens and between documented and undocumented noncitizens, depending on how state policies influence inclusive versus exclusive climates. The cumulative outcome of policies in several sectors, such as health, education, employment, and immigration enforcement, shape social and economic conditions that influence well-being for immigrant communities.13,14
A growing collection of literature reveals that inclusive policies benefit the health of immigrants and communities as a whole. Immigrants already contribute significantly to the economy.15 The United States refugee program, for example, has resettled >3 million refugees, who have become important members of their communities and revitalized several cities across the country.16–18 Sanctuary policies in municipalities do not harm public safety but, instead, reduce deportations without any measurable effect on crime.19 The Deferred Action for Childhood Arrivals is associated with increased participation in the Special Supplemental Nutrition Program for Women, Infants, and Children and decreases adjustment- and anxiety-disorder diagnoses among the children of recipients.20–22 Extending prenatal care for low-income immigrant women is shown to be cost-effective; increase earlier detection of complications, and improve measures of child health.23–25 Providing state drivers licenses to undocumented drivers supports mobility and, potentially, improves traffic safety.26 We should continue to explore these benefits and use the evidence to extend the compassion and respect that immigrant communities deserve.
We are invested in the health of immigrant and refugee children and their families because they are our patients and have the right to the same level of care as any other person. We should continue to explore health inequities fueled by immigration policies of exclusion and specifically name discrimination and racism as drivers of such policies. By investing in and studying inclusive policies, we are investing in the future of children in immigrant families and our communities. After all, they will grow up to be our essential and frontline workers; our community organizers, activists, and social justice leaders; our teachers, scientists, and health care workers; our artists, creators, and leaders; and our vice-presidents and more.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2020-0272.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.