Navigating immigration policy and promoting health equity: Practical strategies for clinicians

Department of Social Sciences and Health Policy, CTSI Program in Community-Engaged Research, Wake Forest School of Medicine, Winston‐Salem, North Carolina, USA Departments of Medicine and Pediatrics, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA Department of Pediatrics, Prisma Health Upstate, Greenville, South Carolina, USA Office of Student Affairs and Admissions, University of South Carolina School of Medicine Greenville, Greenville, South Carolina, USA


INTRODUCTION
A myriad of factors may shape immigrants' health prior to, during, and after hospitalization, such as for the patient in this vignette. Immigrants in the United States are highly heterogeneous in country of origin, immigration status, economic status, education, and other demographic characteristics. 1,2 Immigrants' healthcare experiences and outcomes, particularly for those who are undocumented or in mixed immigration-status households, 3 are deeply impacted by complex intersections between federal, state, and local policies and other social drivers that disproportionately impact some immigrant groups. A recent meta-narrative literature review identified key social drivers of health for immigrant families, ranging from the individual patient level to public policy level, 4 and a policy scan of all US states and major metropolitan areas yielded 539 state and 322 municipal laws and policies relevant to immigrant health. 5 COVID-19 has highlighted many of these obstacles for immigrant families that predate the pandemic.
Prior to hospitalization, insurance status, limited access to primary care and preventive services (e.g., chronic disease management and COVID-19 vaccination), language barriers, inflexible work schedules, and transportation challenges may delay presentation or worsen morbidity for immigrant patients. 6,7 Immigrants who are undocumented or in mixed-status households may fear that seeking care could expose themselves or family members to immigration enforcement. 8 Additionally, lack of control over one's work environment and economic pressures may increase risk and detract immigrant workers from staying home from work if sick or exposed, contributing to disproportionate rates of COVID-19 among immigrant communities. 9 For hospitalized patients, costs may be covered by emergency Medicaid, which reimburses hospitals for providing care to individuals otherwise eligible for Medicaid except for their immigration status for conditions that without immediate medical attention could put the patient's health in jeopardy, 10 but immigrant patients and healthcare professionals may be unaware of eligibility. After hospitalization, immigration-related drivers of health persist, as lack of insurance and inconsistent preventive care impede adherence to follow-up care recommendations. 11 We have identified two priority areas of immigration-related policies that contribute to the health of hospitalized immigrant patients: interior enforcement and public programs access. Policies within these areas can be conceptualized as threats (i.e., policies that may adversely affect immigrant health), harm reduction (i.e., policies that may mitigate negative impacts of these threats), and aspirations (i.e., potential policies that, if enacted, may promote immigrant health; Figure 1). Of note, other policy areas, including the detention of newly arrived immigrants, may also impact hospitalizations, 12,13 but a detailed discussion of border policies is beyond the scope of this article. Through the lens of this vignette depicting an undocumented immigrant whose experiences may reflect those with similar lived experiences, we will explore interior enforcement and public program policy threats, harm reduction opportunities, and aspirations for advancing health equity in the context of hospital medicine.

Threats
Policies promoting collaboration between state and local law enforcement and federal immigration enforcement threaten the health of immigrants and contribute to issues of care avoidance such as in the vignette. Such policies include Section 287(g) of the Immigration and Nationality Act, through which Immigration and Customs Enforcement enters into agreements allowing state and local law enforcement to perform immigration enforcement activities (https:// www.ice.gov/identify-and-arrest/287g). Among persons from Spanish-speaking countries in Latin America living in North Carolina, such policies created practical barriers to accessing and utilizing health services, compounded distrust of services, negatively impacted physical and mental health, and compromised child health, due to heightened fears that driving to or visiting clinics could lead to encounters with local law enforcement with potential immigrationrelated consequences (e.g., initiation of deportation proceedings).
These effects were felt both in counties with and without 287(g) agreements and inhibited seeking needed services across county lines, as immigrants often travel within the state to receive health care. 14 Other researchers have documented similar effects of these policies on healthcare access and outcomes, [15][16][17] including potentially avoidable pediatric hospitalizations. 18 Similarly, state preemption involves the use of state law to restrict municipalities' authority to protect immigrants. Such laws limit the positive impacts of supportive municipal laws and policies, are confusing to both immigrants and health service providers, and have a chilling effect on the use of health services. 19 Specifically, interior enforcement concerns may contribute to immigrants' decisions to forgo care for chronic conditions or delay seeking urgent care, which both impacted the experience of the hospitalized patient in our vignette.

Harm reduction
Conversely, welcoming local and regional policies, such as "sanctuary city" policies that limit local cooperation with immigration enforcement, can mitigate these threats. Though these municipal laws and policies do not eliminate challenges faced by immigrants, they can increase trust in local health services and allow immigrants to feel safer seeking those services. 20 Harms are further reduced by federal policies preventing immigration enforcement in specific settings. Hospitals, schools, and

Aspirations
Ultimately, comprehensive federal immigration reform that includes a pathway to citizenship has the greatest potential to eliminate immigration enforcement-related threats. Policies granting realistic opportunities to adjust one's immigration status would remove concerns about interior enforcement and deportation from the decisionmaking process for many immigrants and their families when seeking care, and lessen the need for a patchwork of harm reduction approaches to mitigate these concerns. 21 Access to public programs of coverage for care outside the hospital has been identified as contributing to increased costs to the healthcare system by impeding immigrants' access to routine and follow-up care and thus leading to increased emergency department visits and hospitalizations. 26,27 Enforcement-related fears and transportation barriers can be mitigated through state driver's license programs. As of 2020, 16 states issue driver's licenses to undocumented residents. 28