Policy Recommendations to Address High Risk of COVID-19 Among Immigrants

The health and economic consequences of COVID-19 will be devastatingly widespread, but the populations that will suffer most are those who have experienced longstanding health disparities. For example, emerging evidence strongly suggests that incidence and case fatality rates are higher among Blacks than Whites.¹ Immigrants are among the groups most likely to experience disproportionate effects from COVID-19. Unlike race/ethnicity, however, nativity and citizenship status are not included on the Centers for Disease Control and Prevention’s (CDC’s) coronavirus case report form,² so data regarding testing and spread across immigrant groups are likely to remain scarce. Information from other health and social surveys—including data that I present in Table 1—suggest that noncitizens experience barriers to physical distancing that will place them at high risk of contracting COVID-19 and have high levels of disadvantage that leave them vulnerable to its economic effects. I recommend three policy changes to address the high health and economic risk among noncitizens, goals that are in the best interest of public health and the broader economy.

TABLE 1—

Economic Vulnerability, Factors That Affect Ability to Physically Distance, and Public Program Participation Among US-Born Citizens, Naturalized Citizens, and Noncitizens in the United States

	US-Born Citizens	Naturalized Citizens	Noncitizens
Economic vulnerability
Median household income (IQR),a $	64 021 (31 638–114 000)	65 005 (32 005–122 804)	51 401 (27 002–93 002)
Income ≤ 100% of federal poverty level,a %	11.4	9.9	17.4
Median ratio of housing costs to household income (IQR)b	20.4 (12.5–34.4)	23.7 (13.9–40.4)	28.3 (17.2–49.3)
Household tenure,a %
Own	66.9	63.4	36.6
Rent for cash	31.9	35.5	62.2
Occupied without payment of cash rent	1.2	1.1	1.1
Any current health insurance,a %	92.6	90.6	70.9
12-mo food security,c %
Food secure	88.4	91.3	86.8
Low food security	7.4	6.6	10.1
Very low food security	4.1	2.2	3.1
Physical distancing factors
Household size,d mean (SD)	2.34 (1.38)	2.86 (1.44)	3.14 (1.53)
Occupants per bedroom,b mean (SD)	0.90 (0.51)	1.12 (0.65)	1.49 (0.75)
Households with > 1 occupant per bedroom,b %	20.5	35.6	55.3
Units in housing structure,a %
One unit	78.0	65.9	56.9
2–9 families	11.9	16.1	20.6
≥ 10 families	10.2	18.0	22.4
Commutes via public transit,b %	4.5	9.3	11.1
Travel time among public transit commuters,b mean minutes (SD)	49.5 (29.0)	55.2 (28.8)	47.2 (24.7)
Internet access,b %	82.2	87.5	81.5
Computer ownership,b %	72.7	78.2	65.2
Public program participation
Live in public housing,a % of nonowners	9.7	11.7	5.9
Receive rental subsidies,a %	4.7	5.1	2.1
Receive food stamps,a %	9.1	9.4	12.1
≥ 1 child in household receives free or subsidized school lunch,a %	53.6	62.5	79.0

^a2019 Annual Social and Economic Supplement of the Current Population Survey (March).

^b2018 American Community Survey.

^c2018 Food Security Supplement of the Current Population Survey (December).

^d2020 February Basic Monthly Current Population Survey.

Noncitizens face barriers to physical distancing that leave them at high risk of contracting COVID-19. Compared with US-born citizens, noncitizens live in larger households and in homes with more occupants per bedroom and are more likely to live in multifamily housing structures. Just 57% of noncitizens live in a single-family housing structure, and 22% live in large units with 10 or more families. Noncitizens work in industries and occupations that cannot be performed remotely—data from the February 2020 Current Population Survey show that noncitizens make up 9% of the labor force but 22% of workers in the agricultural industry, 13% in the restaurant industry, 18% of construction workers, and 14% of warehouse workers. As the economy reopens, noncitizens may also experience increased risk related to their commutes to work, because they use public transit at nearly double the rate of US-born noncitizens.

COLLECT CITIZENSHIP DATA AND INCREASE TESTING

The first step toward addressing disparities in the spread of COVID-19 is to collect citizenship or nativity data. The federal government should revise the CDC intake form or, as an alternative, local agencies should collect and report citizenship data. Some segments of the noncitizen population, particularly undocumented immigrants, will likely be undertested because of low health insurance coverage and other barriers to accessing health care.³ Local agencies should overallocate tests to neighborhoods with high immigrant density, particularly those with high rates of poverty and crowding. Doing so will protect public health by reducing the time between exposure and case identification, thus facilitating isolation and contact tracing.

ELIMINATE PUBLIC ASSISTANCE RESTRICTIONS

All undocumented immigrants are ineligible for federal means-tested public assistance programs, as are authorized immigrants in the first five years after they gain eligible status. These programs include federally funded Medicaid, housing assistance, Supplemental Nutrition Assistance Program (SNAP), Supplemental Security Income (SSI), and Temporary Assistance for Needy Families (TANF). Despite these exclusions, noncitizen households are more vulnerable than others to economic shocks and thus most in need of temporary public assistance. Median household income among noncitizens is 20% lower than among US-born citizens, despite the fact that noncitizen households are nearly a full person larger. Seventeen percent of noncitizens live in households with income below the poverty threshold compared with 11% of US-born citizens. Noncitizens also spend a greater portion of their income on housing costs, primarily rent or mortgage and utilities—one quarter spend half of their income or more on housing costs. Collectively, this means that noncitizens are more likely than others to be living paycheck to paycheck but, because many have jobs that cannot be performed remotely, they are at high risk of being laid off or furloughed. Noncitizens that do get COVID-19 may also experience barriers to accessing health care because nearly one in three lack health insurance.

Federal policymakers should eliminate the five-year waiting period for legal immigrants for all means-tested programs and extend benefits to undocumented immigrants for programs that are directly linked to public health, including Medicaid, SNAP, and housing assistance. Increasing access to Medicaid will facilitate early testing and treatment and help prevent safety-net providers that care for the uninsured from becoming overwhelmed by people who have recently lost employer-based insurance. Housing assistance and SNAP can help prevent housing instability and food insecurity, both of which are linked to longer-term health outcomes and health care costs.^4,5

AMEND THE PUBLIC CHARGE RULE

Effective February 24, 2020, the US Citizenship and Immigration Services issued guidance that immigrants who receive a broad range of cash and noncash benefits will be considered ineligible to apply for citizenship and residency. While the idea of a “public charge” test is not new, it has historically been applied to a narrow range of cash benefits (i.e., SSI and TANF). Now, the public charge test will include use of Medicaid, SNAP, and housing assistance.

This revision was largely unnecessary because, despite their higher economic vulnerability, noncitizens have historically participated in public assistance programs at levels comparable to or below participation rates of citizens. Noncitizens are less likely than others to receive housing assistance and have only slightly higher participation in SNAP. Ironically, the primary exception is that many children in households headed by a noncitizen participated in the free or reduced-price school lunch program. Because many schools have now shut down, noncitizen families will have to increase food spending to feed children that normally receive free lunch.

Penalizing immigrants for using noncash public assistance programs—which they used at comparatively low rates even in normal economic times—is unreasonable in the face of the pandemic and will threaten public health if it prevents immigrants from receiving timely testing or treatment. Congress should pass legislation that specifically and permanently excludes consideration of noncash benefits in the public charge determination.

CONCLUSIONS

Maintaining the health of noncitizens is in the best interest of the economy and of public health. Measuring the scope of the epidemic among noncitizens and expanding access to public assistance programs that can buffer its effects are clear and necessary steps. Expanding access to public assistance programs, in particular, contrasts with the anti-immigrant positions expressed by the Trump administration. It is the responsibility of the public health community to clearly and consistently articulate the need for these policy actions, particularly among constituents, coalitions, interest groups, and lobbyists that have influence with the administration and with other key legislators.⁶