The Detroit URC: fostering health equity through 
community-based participatory research (CBPR)
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Public Charge Rule’s Impact on the Community

toddler parents holding hands backs to camera

When deciding on medical care for their children, some parents have to juggle competing concerns, such as whether it is more important to get immunizations early in the season and maybe be a little late to soccer practice or whether it is better to wait a few weeks for immunizations so as not to miss extra-curricular activities. 

For other parents, however, medical care decisions are far more complicated:  is it worthwhile to get immunizations and medical care at all and risk having the family be broken up or is it better to forgo medical care in order to maximize the likelihood that the family is able to stay together?

Parents forgoing medical care for their children is one of the many consequences of the “public charge rule” proposed by the Trump administration, according to recent research from Paul Fleming, Assistant Professor, Department of Health Behavior and Health Education (HBHE), University of Michigan  School of Public Health (U-M SPH), Richard Bryce, Chief Medical Officer, Community Health and Social Services Center, Inc., and their research team.  

Fleming and Bryce received a grant from the Detroit URC and Poverty Solutions to look into the patterns of health and social service utilization among immigrant communities in southeastern Michigan. The research team interviewed dozens of people, from healthcare and social service providers to patient advocates to immigrant patients themselves.

In their recent Detroit Free Press op-ed, Fleming and Bryce describe one of the patients they interviewed.  “Rosa,” a young mother in her 20’s, who was too fearful to have her real name used, has been living in the Detroit area for nearly half of her life.  While cradling her infant at a recent medical appointment, Rosa explained to health care providers that she was considering withdrawing her child from health insurance and from nutritional programs because she fears that keeping her child in these programs would hurt other family member’s chances at citizenship later.

Under the proposed public charge rule, immigrants who use government health care, nutritional programs, or housing programs could be ineligible to receive a visa or United States citizenship.  Although Rosa’s child was born in the US, and is thus a US citizen, fully eligible for all public assistance benefits, Rosa is fearful of utilizing services because not all of her child’s family members are US citizens.  

This situation is exacerbated, according to Fleming, because many immigrants are ineligible for the Affordable Care Act insurance exchanges, so they cannot even buy into insurance in some cases.  Furthermore, many restrictions on immigrants’ work eligibility often force them into low wage jobs, even if they have the educational background to work middle-class jobs that provide insurance.

As Fleming and William Lopez, Clinical Assistant Professor, HBHE, U-M SPH, another researcher on the project, explain in their article for the Conversation, their research indicates that many immigrants -- even those who are here legally and whose tax dollars help fund these programs-- decline using public assistance programs out of fear that it would make it impossible for them and their family members to eventually receive a visa or US citizenship.

In addition to the fear generated by the proposed public charge rule, researchers found an overwhelming climate of fear in many immigrant communities relative to several years ago.  When interviewed, medical staff report that many patients are too fearful to even go to their medical appointments.

Fleming and Lopez describe another such immigrant mother who participated in the interviews.  This respondent was also too fearful to have her real name used, so the researchers gave her the pseudonym “Ximena”.  Ximena, a pregnant mother who fled her native Guatemala to escape violence over 10 years ago, explains that “I have to miss my appointments, because it scares me to leave, because of the fear that one day they’re going to arrest me.  And what would happen to my kids?”

A long-time staff member at the clinic where Ximena cancelled her prenatal appointment points out that many of their clients feel the same way. “They are so much more fearful now than they were two, three, four, five, 10 years ago … huge huge impact, huge difference.”  

This decrease in medical and social service utilization within the immigrant community also has ramifications for the broader community.  

After reviewing the Fleming and Bryce’s research, Kimberlydawn Wisdom, Senior Vice president of Community Health & Equity and Chief Wellness &  Diversity Officer at Henry Ford Health System, sums up the perspective of many health care providers:

“I am very troubled by the consequences for families, and also the unintended consequences that impact the community-at-large. Children and families who are not provided the opportunity to access these type of resources are also not likely to access other important services - like vaccinations - either. The unintended consequences result in suffering for families who contract infectious diseases as well as the general community. If we are truly going to have healthy communities then our practices and policies need to be aligned with that vision.”  

As long as policies and practices make it difficult for some members of the community to decide in favor of vaccinations and healthcare, then mothers like Rosa and Ximena may continue to decide to forgo even basic health care, and the well-being of the entire community will also suffer.

 

The Detroit Community-Academic Urban Research Center
University of Michigan School of Public Health (U-M SPH)
1415 Washington Heights
Ann Arbor, MI 48109
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