Do Sanctuary Hospitals Boost Undocumented Patient Access to Care?

Healthcare organizations with cultures of inclusivity and that focus on delivering care to traditionally marginalized populations may be well-positioned to circumvent care access or utilization issues posed by immigration enforcement, according to a research note published in JAMA Network Open.

The data, collected by researchers from the Immigration Policy Lab at Stanford University, specifically found that a San Francisco health system that delivers care to individuals who cannot access public insurance options curbed the threat immigration enforcement places on patient access to care.

Immigration enforcement events—local Immigration and Customs Enforcement raids or immigration enforcement executive orders, for example—have long been of concern for healthcare organizations working to improve population health.

Many medical professionals do not regard immigration enforcement part of their obligations; instead, many they feel compelled to improve the health of all patients.

Leading medical groups like the American Academy of Family Physicians (AAFP) and the American Medical Association (AMA) have issued statements outlining how clinicians can treat patients who are undocumented, suggesting that these people are still deserving of care and health improvement regardless of their immigration status.

But that health improvement is not always accessible for patients who are undocumented.

Patients who are undocumented may be reticent to access healthcare when they anticipate a local ICE raid, allowing their health to deteriorate. This could cost the healthcare system more in the long run.

Previous research has given credence to this concern. In Arizona, state law SB 1070 decreased preventive care access for adolescent mothers of Mexican descent and their children. These patients may have feared deportation should they access preventive healthcare, the researchers posited.

But this may not be the case in sanctuary cities, like San Francisco, where patients are given asylum in medical facilities regardless of their immigration status. The Stanford research team looked specifically at Healthy San Francisco, a health system that focuses on healthcare delivery for individuals who cannot access public health insurance.

Using access to Healthy San Francisco as a proxy for undocumented immigration status, the team looked at how immigration enforcement events affected healthcare utilization. The team used Healthy San Francisco access as a proxy for immigration status because following Medicaid expansion it was primarily undocumented patients who were excluded from private or public insurance.

Overall, the researchers found no significant difference in healthcare access among Healthy San Francisco patients before and after immigration enforcement events. This was true across various healthcare settings, including primary care, urgent care, and emergency care, the researchers said.

This likely has something to do with San Francisco’s sanctuary city status and the fact that patients cannot be reported to immigration enforcement officials when they access healthcare in a San Francisco healthcare facility.

“We did not find systematic evidence of an association between enforcement events and changes in utilization among patients with potentially undocumented immigration status in San Francisco,” the researchers said. “This suggests that a local environment with inclusive health care policies may mitigate the consequences of immigration enforcement actions.”

These findings could suggest some policy considerations. As suggested above, many clinicians feel a moral obligation to provide healthcare to all individuals in need. Ensuring any patient feels safe accessing healthcare—regardless of immigration status—may be of concern for some medical professionals.

But there are also some logistical reasons for ensuring safe access to care for undocumented immigrants. Previous studies have found that undocumented patients are more likely to access the emergency department than their US-born counterparts.

This could be because undocumented patients are worried about immigration enforcement efforts in primary or urgent care settings and forego care. Health status may consequently deteriorate, landing the patient in the ED. Patients may also know EDs are not allowed to turn away patients in need of care.

The emergency department is a notoriously expensive place to deliver healthcare, and with undocumented patients utilizing the ED at a high rate, it could result in high healthcare spending. Ensuring patients are safe to access primary care could help ameliorate some healthcare costs.

Additionally, ensuring safe access to care for undocumented patients has been essential during the COVID-19 pandemic. The virus does not know immigration status, and can affect anyone. Couple that with the fact that many undocumented patients are also positive for other risk factors, like living in crowded multigenerational homes, and access to care and testing are critical.

Ensuring undocumented patients would be safe from immigration enforcement as they seek COVID-19 testing and prevention will be key to curbing virus spread.