The Trump administration’s colossal mismanagement of the Covid-19 pandemic isn’t over, and won’t be for a long time after the current president’s departure. There’s a sting in that administration’s tail, whose poison is already spreading through the US population. It has been invisible until now, at least in the higher echelons of power, but as the mass vaccination campaign moves into its next phase its effects are becoming painfully and tragically obvious. The sting has an innocuous-sounding name: the public charge rule.
The public charge rule links an immigrant’s eligibility for residency in the US – the famous green card – to the burden they place on the public purse, including their use of certain publicly funded health services. It has existed since the Immigration Act of 1882 stated that an immigrant who was “unable to take care of himself or herself without becoming a public charge” should be refused entry to the country. The law doesn’t define “public charge” and the term has always been open to interpretation, but no administration has interpreted it in as draconian a fashion as Donald Trump’s. The current version of the rule met huge resistance as it made its way through the country’s lawmaking machinery, but it is now effective in the majority of states, with the result that immigrants seeking the legal right to remain in the country are deterred from using health services.
Ironically, the supreme court ruling that paved the way for the new rule’s enforcement fell in January 2020, just as Covid-19 erupted in the world. Putting aside the dubious morality of a rule that runs counter to the World Health Organization’s founding principle that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being”, putting aside the libraries of research showing that it costs more to neglect immigrant health than to nurture it, the US is once again showing its inability to learn from history – and in particular, from past pandemics. There’s nothing like a globally rampant infectious disease to highlight the fact that the health of “natives” cannot be separated from that of “aliens”.
Even in those US states where everyone is eligible for testing and treatment for Covid-19, free of charge and without the need to identify themselves, the fear and confusion created by the rule and its patchwork implementation mean that people from immigrant communities are seeking out those services later than those from communities whose resident status is more likely to be assured – if they are seeking them out at all.
This is the case in New York, for example. Max Hadler, who directs health policy for the New York Immigration Coalition, told me that the feeling among immigrant groups there is that coming forward isn’t worth the risk, and that the rule is “unquestionably” contributing to higher Covid-19 infection and death rates in Black and Latino communities than in the rest of the population. Not only is it causing untold human suffering, it is undermining disease surveillance efforts – because of the missing test results – and now it will undermine vaccination efforts, too.
For the moment, in the US, vaccine rollout is restricted mainly to healthcare workers – many of whom are immigrants, including refugees – and residents of care homes. But some states are already moving into the next phase, where coverage expands to other essential workers including those employed in the food services, transportation and farming industries – the people, that is, who make everybody else’s lives possible. They will be required to show proof that they work in those sectors in order to receive the vaccine, but many non-resident aliens – to use the precise legal term – work in those sectors, and not all of them have the right to do so. Even if they have no objections to vaccination per se, they are unlikely to come forward. That means that the authorities’ cherished goal of herd immunity recedes a little bit further from reach.
To understand fully how self-destructive this anti-immigrant stance is, it’s helpful to look at the Scandinavian countries, which have some of the best-funded and most inclusive health systems in the world. Svenn-Erik Mamelund, a demographer at Oslo Metropolitan University in Norway, has been campaigning publicly for prioritising recent immigrants in the Covid-19 vaccine rollout, based on their greater vulnerability and evidence from the first wave of the Norwegian epidemic that good, targeted public health messaging is not enough to mitigate that vulnerability. He says that the authorities have so far resisted his calls, partly on the grounds that to prioritise those groups would be to stigmatise them (the solution to that, Dr Mamelund says, is to educate the rest of the population). Unlike the US, however, Norway hasn’t actively made it more difficult for immigrants to access healthcare than anyone else – and it still sees a disparity in Covid-related health outcomes.
The US isn’t alone in having drifted badly on this issue. The UK has gradually restricted access to the National Health Service in the last 15 years or so, such that the rules for accessing the NHS are now interpreted more strictly than they have been at any time since its creation in 1948. Tellingly, says Jessica Potter, a respiratory physician and public health expert at Queen Mary University of London, the rules themselves have existed for nearly four decades, but they weren’t implemented for most of that time because health authorities realised that doing so wasn’t cost-effective. “It cost more in bureaucracy than they were recouping,” she says. That changed in 2012, when the Cameron-Clegg coalition government decided to create a hostile environment for undocumented immigrants – a policy that ended up harming not just those it targeted but others perceived as foreign, too. The charity Medact reported in June that that policy was deterring immigrants from seeking treatment for Covid-19, even though such treatment is exempted from charges.
Perhaps this pandemic will have the silver lining of persuading these governments to take stock and ask if their policies are really achieving the desired outcome. That certainly happened in the 1920s, following the 1918 flu pandemic – the most devastating pandemic of modern times. That rethinking accelerated a shift towards more inclusive health systems, ones which recognised the socioeconomic factors that shape disease and understood the need to treat health as a population issue, as well as an individual one.
We’ve backslid, lately, and this pandemic will probably be over by the time we understand the consequences of that backsliding, but it’s not too late to prepare for the next one. The UK’s hostile environment, like the current public charge rule in the US, sprang not from the writing of new rules, but from the reinterpretation of old ones – which makes them easier to undo.
The incoming Biden administration could reformulate these policies quickly, and Hadler says his organisation will hold it to that. But we shouldn’t leave it to those who represent immigrants. Inclusive healthcare is in all our interests.