Pregnancy, Pandemics, and Public Health Policy: The Disparate Impact of the Novel Coronavirus Disease-2019 on Pregnant Immigrants

Abstract

Few communities in the United States have been more negatively affected by the novel coronavirus disease-2019 (COVID-19) pandemic than immigrants with low incomes. For pregnant immigrants, who must navigate health disinformation and fear of immigration enforcement while attempting to access prenatal care for a healthy birth, this situation is particularly troubling. Any efforts to curb the COVID-19 pandemic must take into account the unique dangers this crisis poses to pregnant immigrants and their families. Pregnancy care should be provided at no cost, regardless of immigration status, for the duration of the pandemic and beyond, and any relief efforts and policy solutions must include immigrants. Unique Challenges for Pregnant Immigrants Recent data from the Centers for Disease Control and Prevention indicate that pregnant people may be at increased risk for severe illness from COVID-19 compared with nonpregnant people (Ellington et al., 2020). This point is particularly true for patients of advanced maternal age with comorbidities like obesity, pulmonary disease, cardiac disease, and diabetes, which place them at greater risk for severe and critical care during hospitalization for COVID-19 crisis. Inadequate prenatal care for women with underlying risk factors also increases the risk of adverse COVID-19 outcomes. More than 250,000 births in the United States are to undocumented parents, but undocumented immigrants are less likely than other U.S. residents to access adequate prenatal care, even under nonpandemic circumstances (Fabi, 2019). This troubling disparity is in part due to a ban on the use of federal funding to support care for undocumented immigrants and other “unqualified” immigrants who have been in the United States for fewer than 5 years. Although some states use federal options to provide care to legally residing pregnant immigrants or the fetuses of undocumented immigrants with CHIP funding (through what is called the “unborn child” option), the majority of states do not provide publicly funded prenatal care to undocumented immigrants (Fabi, 2019). In these states, many seek care at Federally Qualified Health Centers, where they pay out of pocket on a sliding fee scale based on income. The exclusion of many immigrants from federally funded programs is not limited to just publicly funded health insurance, however. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed in March 2020, explicitly excluded undocumented immigrants, as well as their spouses and children, from receiving the benefits of the economic stimulus package. Although many undocumented immigrants work in essential jobs, unable to stay home to avoid transmission of COVID-19, many more find themselves unemployed and unable to pursue the economic relief necessary to keep their families housed and fed, even if their families include U.S. citizens. Several lawsuits have been filed by U.S. citizen spouses and children of undocumented immigrants in an attempt to secure relief, but the immediate impact of their exclusion from the CARES Act has been devastating (Bloomberg, 2020). Legally residing immigrants also face policy restrictions on their use of public benefits like Medicaid from the Trump administration's changes to the “public charge” rule, which makes it much harder for a visa holder to receive a green card if she has received public benefits. Although the administration has issued guidance indicating that public charge does not apply to COVID-19 testing or treatment, fear and distrust in immigrant communities have nonetheless hindered immigrants from seeking care. This situation is particularly harmful for pregnant immigrants, many of whom may delay prenatal care out of fear of public charge or immigration enforcement. This chilling effect can have dangerous consequences for a pregnant immigrant, even without the threat of a highly contagious and harmful disease (Page & Polk, 2017). In addition to policy restrictions that may impact access to care for immigrants, there are also very real fears of going into a clinical setting at all, even for patients with the ability to pay for care, owing to the perceived risk of being apprehended by immigration enforcement. Although some providers have attempted to increase their telehealth availability to provide a safer alternative to coming into the office, accessible telehealth depends on a reliable Internet connection and, for many immigrants, appropriate medical interpretation. For pregnant immigrants who lack these resources, this digital divide may mean delaying prenatal and other routine care, which could have negative effects on maternal and fetal health. Public Health Is Public Health The Trump administration has used the threat of COVID-19 to expand immigration restrictions and punish immigrants and their families. Given the unique risks of the COVID-19 pandemic faced by pregnant immigrants, such policies are not only bad for public health, but are also ethically impermissible. It constitutes a gross violation of justice to treat a group of vulnerable individuals differently on the basis of the morally irrelevant characteristic of their country of birth. What matters, from a public health and ethical perspective, is that undocumented pregnant people and their families are residents of the United States, members of our communities, and deserving of equal treatment in the face of a deadly disease outbreak. Excluding immigrants from coronavirus relief efforts and publicly funded health resources not only compounds the dangers they face in their own lives, but also heightens the risk to the communities in which they live. In their book The Health of Newcomers, Illingworth and Parmet (2017) argue that health is a global public good. Given the deep social embeddedness of immigrants in communities that include newcomers and citizens alike, and the globalization of health, especially in the case of communicable diseases like COVID-19, it makes little sense to prevent immigrants from accessing the same levels of care and resources as their fellow U.S. residents, or indeed, to deport them to their home countries, as the Trump administration has reportedly done to thousands of immigrant children and families. Illingworth and Parmet (2017, p. 132) argue that “Against the background of health as a global public good, newcomers should not be sent ‘home’ when they become ill, or denied access to medical care, but cared for as we would care for family.” It is particularly troubling that the needs of pregnant immigrants and their children continue to go unmet through this global pandemic. Although the Trump administration has demonstrated no qualms about excluding even the citizen children of undocumented immigrants from COVID-19 relief, taking policy actions that actively harm children on the basis of their parent's immigration status is both unethical and illegal. Depriving their parents of prenatal care at the peak of an infectious disease outbreak not only harms the immigrant parents, but could also create a lifetime of preventable disease burden for babies born without adequate prenatal care. Policy Solutions Given the public health and ethical imperatives described in this article, state governments must provide publicly funded prenatal care for all low-income state residents, regardless of immigration status, for the duration of the COVID-19 pandemic. This could be done using the CHIP unborn child option, as mentioned, or through a state-funded Medicaid lookalike program. Covering prenatal care for immigrants ineligible for traditional Medicaid has been shown to be a cost-effective way to increase prenatal care use and improve birth outcomes in this population (Rodriguez, Swartz, Lawrence, & Caughey, 2020; Swartz, Hainmueller, Lawrence, & Rodriguez, 2017; 2019; Wherry, Fabi, Schickedanz, & Saloner, 2017). Given the ethical concerns raised by the unborn child option's underlying presumption of fetal personhood, we recommend that states pursue a Medicaid lookalike (Fabi, 2019). Of course, there remains a concern that immigrants may mistrust or shun new services or programs; significant community engagement and public messaging will be necessary to ensure that immigrants are able to trust and securely use newly available services and insurance options. Clinics that serve immigrant patients can play a significant role in building trust in new programs by engaging community stakeholders and by practicing “sanctuary doctoring” and other evidence-based practices for creating welcoming and safe health care settings for immigrant patients (Kuczewski, Mejias-Beck, & Blair, 2019; Saadi, 2020). This point will be especially important in light of the distrust fomented by the Trump administration's anti-immigrant policies over the past 4 years. Pregnancy care provided through these programs must be accessible to immigrants who may lack the necessary resources to engage in effective telemedicine, such as high-speed Internet service. The federal government could expand access to broadband by passing a COVID-19 relief bill that includes mechanisms for eligible low-income households to receive an emergency broadband benefit, such as, for instance, the HEROES Act. Additionally, the federal government should include all U.S. residents in all COVID-19 economic relief efforts, because many pregnant immigrants may be suffering unemployment without the unemployment benefits available to their citizen neighbors. Unfortunately, congressional action is unlikely if the government remains divided after the Georgia run-off election (scheduled for January 5, 2021). The incoming Biden administration could also use administrative action to address access to care for undocumented pregnant people by reversing harmful Trump administration policies, such as the public charge rule and policies mandating the detention of all pregnant people apprehended at the U.S. border (Messing, Fabi, & Rosen, 2020). Policies like these must be entirely and indefinitely dismantled if we are to end their chilling effect on immigrant residents of the United States. Finally, the Centers for Medicare and Medicaid Services, under Biden's administration, could signal their openness to state waivers that seek innovative approaches to expand access to care for undocumented pregnant people. Waivers allow states to modify their Medicaid programs or change their implementation of certain provisions of the Affordable Care Act. For example, Medicaid waivers might expand program eligibility criteria, or Affordable Care Act waivers could allow undocumented immigrants to purchase insurance through state marketplaces, as was nearly implemented in California before the Trump administration took office (Fabi & Saloner, 2016).