The man’s toe had turned from deep purple to black by the time his family went to the emergency room. Soon they would discover it was gangrene, a complication of undiagnosed diabetes, and a portion of the toe would be amputated.
But before that, as the days passed and the toe blackened, the family’s urge to go to the hospital was outweighed by fear that immigration agents could be lurking there.
The man and his wife are Mexican immigrants without insurance or authorization to be in the U.S. Sahida Martinez, a community health worker who urged the family to go to the emergency room, recalls the panic when their daughter, a U.S. citizen, asked her: “What will I do if they take my mother and father?”
“That case sticks in my mind,” said Martinez, who works at Enlace Chicago, a community group in the city’s Little Village neighborhood where the family first sought help. “That desperation, the sadness in her face. And above all what moved me was that they (initially) refused to take him to the hospital.”
Health care workers across Chicago say toughened immigration policies under President Donald Trump have had a ripple of medical consequences in immigrant communities. Many immigrants — some who are authorized to be in the country as well as some who are not — worry that going to the doctor or signing up for health benefits could leave them or their family members vulnerable to deportation.
How often that fear translates into people actually forgoing care is unclear, and some providers with large immigrant patient populations say they haven’t seen a change in the numbers of people seeking treatment.
The Cook County Health and Hospitals System, the largest provider of charity care in the state, has been tracking usage patterns at its two large hospitals and more than a dozen clinics, and it has not found any drop in patient volumes, including in Spanish-speaking communities, said Dr. Jay Shannon, CEO of the system.
Still, the impact of immigration fears are underappreciated, he said, and over the last year the hospital system has implemented a campaign to clarify, mostly through signage and brochures, that the hospital is not an extension of law enforcement and that it will take care of people regardless of their immigration background.
Other providers say the high-anxiety climate is not only discouraging some immigrants from seeking care, it’s also affecting their health.
Barbara Shaw, a nurse practitioner and assistant professor at Rush University of College of Nursing, works twice a week in a community clinic in Chicago’s Uptown neighborhood where 90 percent of her patients are immigrants, mostly Latino but also from all over Africa. She said she has never seen fear so severe in her 20 years as a nurse.
She sent an older woman with a bad hip injury to Cook County Hospital for some tests, but the woman never went for fear “la migra” — immigration — might be there, Shaw said.
Another patient, a young construction worker with poorly controlled diabetes, told Shaw he can’t come in for regular visits because money has gotten tighter as employers have become more stringent in asking for documentation when hiring.
Shaw says people have broken down sobbing in her office because they are overwhelmed with worry about what might happen to them or family members. She’s seen a rise in cases of insomnia, anxiety and reflux problems associated with heightened stress.
“The way that it’s affecting people is very hard to watch,” Shaw said. “I’m astounded by people’s strength even in the face of this.”
The fears revolve not just around deportation, which has been expanded in the first year of the Trump administration to target many more people without criminal convictions, but also future immigration status. This month Reuters reported on draft rules being considered by the Department of Homeland Security that could make it harder for people to get permanent residency if they or their American-born children use certain public benefits, such as health insurance.
As word spreads of the possible change, some worried patients are saying they want to disenroll from benefits such as food stamps and Medicaid, so that they won’t be excluded from getting green cards in the future, said Dalia Morales, head of outreach at Heartland Health Centers.
“What I usually tell them is that the change hasn’t happened yet,” she said. “But you don’t have control over anything, so you can’t promise there won’t be consequences.”
Adults without legal status — including those who have work permits through Deferred Action for Childhood Arrivals, a program for people brought to the U.S. illegally as children — do not qualify for most government-funded health benefits. All Illinois children under 18 qualify for Medicaid regardless of their immigration status.
But even those who qualify for benefits are not signing up because of deportation concerns, some providers say.
Dentist Alejandra Valencia, director of the Heartland Alliance’s Oral Health Forum, believes those fears are partly to blame for a dramatic drop in the use of a school-based program that offers preventive dental services to Chicago Public School students. Last year program enrollment dropped by roughly 25 percent — from 22,000 students to less than 16,000 students — across 52 schools identified as having some of the worst dental problems. Those schools are in primarily Latino neighborhoods on the city’s Southwest Side, where dental health centers and private dentists who take Medicaid are in short supply.
The factors behind the enrollment drop are complex. A recent change to how dentists can bill for Medicaid may be dissuading enrollment because of confusion about whether the in-school services will compromise visits to a community dentist, Valencia said. But parents also have expressed reluctance to enter their names or information into any system for fear it might get into the wrong hands, said Brenda Velasquez, a case manager for the dental program.
Jazmin, a 26-year-old mother of four who lives in the Brighton Park neighborhood, said she hears those concerns frequently in her community. Jazmin, who asked that her last name not be used for fear of reprisal from immigration authorities, came to the U.S. illegally from Mexico when she was 11 years old and has a DACA work permit, but it expires in December and so far Congress has not found a solution for the hundreds of thousands of young people like her who are uncertain if they will be able to stay. Trump in September announced he was ending the DACA program and set a March 5 deadline for Congress to act.
Jazmin is diligent about taking her children, all U.S. citizens, to regular dentist and doctor appointments, and she encourages her friends to use programs like the in-school dental exams because she worries that if the benefits go unused, they may be taken away.
But when it comes to her own health, Jazmin minimizes services so as not to draw attention. When she had a baby she used the state’s prenatal care but none of the postpartum services she qualified for, and last year she decided not to sign up for a women’s health program that allows her to pay a small fee for an annual checkup.
“I live with the fear that they will come and they will take me,” said Jazmin, who works six days a week packing ingredients for a meal kit delivery service, earning Chicago’s $11 hourly minimum wage. She has been thinking of disenrolling from food stamps because “I don’t want them to think I am here to obtain benefits” and the current discourse has made her feel “like we don’t deserve it.”
“It’s not that I’m taking advantage, I use them for necessity to survive every day,” she said. “It’s not for oneself, it’s for the kids. All of the services are for the kids.”
At Erie Family Health Center, where nearly three-quarters of patients are Hispanic, there hasn’t been a drop in visits, thanks to the center’s long-term trusted relationships with patients, said Amy Valukas, chief operating officer.
But patients — even those here legally — are raising more concerns when asked to provide information for insurance enrollment, she said.
“We make sure that it is clear that we think it is critical for everyone to continue getting care,” Valukas said.
At Rush University Medical Center, social workers have seen some kids without health insurance because their parents, who are in the country without legal permission, worry about a section of the All Kids Medicaid application that requires them to provide their personal information, said Padraic Stanley, program coordinator in the social work and community health department.
Similarly, financial counselors have reported that immigrants are nervous about applying for charity care, a fund hospitals use to cover medical services for the poor, because it requires applicants to list their employers and other personal information, Stanley said.
Yadira Montoya, who leads Rush’s Latino education and outreach efforts, said people’s fears of a paper trail are affecting health research as well, which has long-term consequences for researchers trying to understand how diseases like Alzheimer’s affect immigrant communities. Fewer people are participating in community health education activities and those who do are wary of sharing their contact information for research follow up, she said.
While those concerns have always existed, “the current political climate has exacerbated that anxiety and apprehension,” Stanley said.
To address patient fears, the Illinois Coalition on Immigrant and Refugee Rights has formed an alliance, called the Illinois Alliance for Welcoming Health Care, that is crafting model guidelines on how hospitals can create a welcoming environment, said Luvia Quinones, health policy director for the coalition. The initiative — which includes 12 providers — will educate staff on what to do if Immigration and Customs Enforcement comes looking for someone at the hospital.
That has not happened in Chicago, immigrant advocates say, and on the whole, health care settings are considered safe from immigration enforcement. Since 2011 it has been ICE policy to avoid arresting, interviewing or searching people in sensitive locations like hospitals, schools and churches, with exceptions for special circumstances, such as national security. But several immigration arrests involving patients at or on the way to hospitals took place in Texas last year.
News of such enforcement actions often drives the fears that cause people to cancel medical appointments, Quinones said. When she is approached by worried immigrants, she reassures them that as long as they are honest — that is, not using fraudulent names or Social Security numbers — they are covered by patient privacy laws and their information won’t be shared.
Avoiding care is just one outgrowth of heightened fear. Providers are also describing rising mental health issues as mixed-status families grapple with worries that they could be split apart. Some teenagers are being instructed on how to take care of their younger siblings if their parents don’t come home, and “that’s a public health concern because no teenager should be responsible for that,” Quinones said.
At Saint Anthony Hospital in Little Village, a six-month waiting list for counseling services grew to 10 months after the 2016 presidential election, and has stayed that long since. “The sense of instability is adding to people’s existing trauma,” said Arturo Carrillo, the hospital’s program manager for mental health and family support.
To help provide counseling to immigrant families, the University of Illinois at Chicago recently partnered with Immaculate Conception Parish in the Brighton Park neighborhood on a project to bring such services into the community. The church counts some 4,000 Mexican-American families in its parish.
The project trained a dozen church parishioners in evidence-based tools that help combat anxiety, depression, post-traumatic stress and family conflict, conditions believed to be prevalent in a community highly stressed not only about immigration arrests but also violence, poverty, substance abuse and low-wage jobs. Those laypeople lead family support groups at the church, without any outside health professionals present, so that people can open up in an environment where they feel comfortable.
“We have noticed no reluctance to either come to the sessions or talk to people there,” said project founder Dr. Stevan Weine, a professor of psychiatry and director of global medicine at UIC. The hope is to share the model with other immigrant churches.
Providing counseling — sometimes culturally taboo in the community — in a faith context helps families feel supported, said Yadira Vieyra, a parishioner who is leading one of the sessions.
One goal is to help families communicate, without anger, about what they will do if they are forced to leave the country.
“Some of the teens don’t want to leave, they don’t want to go to Mexico, and that causes a lot of friction,” she said.
Beyond the fears and stress, providers say the greatest challenge for immigrant patients, many of whom are uninsured, is affording care.
Cynthia Magellanes, a registered nurse and supervisor of community health at Saint Anthony Hospital in Little Village, recalled a patient with diabetes who recently lost her job packing bread and was trying to stretch her last paycheck. She needed two vials of insulin, which cost $13.50 each, and couldn’t afford them. The hospital paid for the woman’s insulin out of a donation fund.
Janeth Vazquez, a member of Salud Sin Papeles, which translates to “Health Without Papers,” a Chicago-based group that helps immigrants who lack legal permission navigate the health care system, said the organization has been getting calls from hospitalized patients who can’t afford the medications or equipment they need once they leave.
But Vazquez, whose own family is in the country without legal permission, said the greatest challenge personally has been mental health. She has a DACA permit that expires next year, and as she completes her master’s in social work “my immigration status is on my mind every day.” Talking with peers in similar situations about how to cope with depression and anxiety helps.
Knowledge helps also. Vazquez said her parents aren’t afraid to seek medical care. “I think it’s because of the information that I bring,” she said. “I’m able to connect them to trustworthy clinics or providers.”
aelejalderuiz@chicagotribune.com
Twitter @alexiaer
