Examining the Impact of Restrictive Federal Immigration Policies on Healthcare Access: Perspectives from Immigrant Patients across an Urban Safety-Net Hospital

Abstract

The Trump Administration instituted a series of restrictive policies including the expansion of the public charge ruling, which created barriers to healthcare access for immigrant communities. This study examined immigrants’ knowledge, attitudes, and health-seeking practices as a result of the public charge proposal. Thirty semi-structured interviews were conducted in English or Spanish with foreign-born adults at an urban safety-net hospital in Boston from May 2019 to August 2019. Thematic content analysis identified barriers and facilitators of healthcare access and usage. Approximately half of participants were aware of the public charge proposal. Six participants expressed concern about its implications, but only two discontinued benefits. Barriers to care included fear of deportation, interaction with law enforcement, and competing socioeconomic needs. Facilitators of care included supportive communities, immigrant-friendly environment, and personal beliefs. Hospitals can develop community-centered services for immigrant patients that offset the barriers to healthcare access resulting from adverse federal immigration policies.

Background

The landscape of immigration policy in the United States (US) has significantly shifted through the last five decades since the enactment of the Immigration and Nationality Act. Over the past few years, immigrants have faced relentless attacks in the form of restrictive immigration policies and anti-immigrant rhetoric. One such policy is the expansion of the existing public charge rule, proposed in October 2018 and finalized in February 2020. Public charge is a US government designation for someone who is considered primarily dependent on government-funded benefits [1]. Immigrants considered a “public charge” may be prevented from becoming lawful permanent residents or citizens [2]. Historically, non-cash benefits were excluded from the original determination [1]. However, the proposal now includes programs such as Medicaid, Supplemental Nutritional Assistance Program (SNAP), and public housing [1]. The final public charge ruling does exclude certain categories of immigrants: those with Temporary Protected Status (TPS), asylees, refugees, and petitioners under Violence against Women Act (VAWA) [1]. However, the chilling effect of this rule may cause immigrants of all statuses to avoid public benefits, ultimately leading to poorer health outcomes [3].

According to the Kaiser Family Foundation, an estimated 2 to 4.7 million immigrant families could withdraw from Medicaid coverage [4]. Lack of health insurance can lead to difficulty obtaining care [5], decreased preventive care use [6], and improper management of chronic diseases [7]. Public health implications include challenges to controlling infectious disease outbreaks, as demonstrated by the COVID-19 pandemic that has disproportionately impacted vulnerable populations, including immigrants [8]. The potential disenrollment from public benefits leaves many immigrant families at increased risk for adverse health outcomes and may harm public health more broadly.

There is little information about immigrants’ understandings of public charge provisions and its potential impact on healthcare-seeking practices. With 27% of Boston’s population being foreign-born [9], it is crucial to understand how public charge affects immigrants in the greater Boston area. Our qualitative study explores the impact of the proposed public charge ruling on immigrants’ healthcare utilization and their perspectives on healthcare access.

Methods

Participants

Eligible participants were foreign-born adult patients (age 18 and over) who were recruited between May 2019 and August 2019 in three outpatient departments: Internal Medicine, Infectious Diseases, and Pediatrics at an urban-safety net hospital. Purposive sampling techniques were used to identify and recruit participants based on country of origin, gender, and referring department. Hospital healthcare providers and case managers provided study referrals to the research team until saturation was reached.

Data Collection

Following a semi-structured open-ended interview guide (Table 1), English and Spanish-speaking researchers conducted interviews with each participant. Background information was collected and participants were asked to share their concerns about accessing healthcare services in the context of the public charge proposal and the current political climate. Participants were not asked to provide their immigration status.

Table 1.

Semi-structured interview guide

Healthcare utilization trends	1. Has there been a time in the last 6 months that you or a family member have been concerned or worried about coming to care at this hospital and why?
	2. How many times have you missed appointments? If you missed appointments, how have your health or the health of a family member been affected?
	3. How many times have you or your family member been worried or concerned about coming for your appointments?
	4. What fears do you have about coming for care? If yes, can you describe your fears about coming for care?
	5. For parents: Do you feel that your children have been fearful?
	6. How have concerns about your or a loved one immigration status affected you? Affected your children?
	7. Do you have any friends or people in your community who are afraid to seek care due to their immigration status? If yes, can you describe how they have been affected?
Use of public benefits	1. Did you apply for a public benefit in the past 6 months? If yes, where did you apply for care/benefits?
	2. When you applied, did you feel like you were respected?
	3. Can you give me an example of a time you were treated with respect?
	4. Can you give me an example of a time you were not respected or treated poorly?
	5. What are you hearing about applying for benefits, such as MassHealth/Medicaid, Medicare, public housing, food stamps (SNAP), WIC, and food pantry? a
	6. Do you have any worries/concerns about applying for benefits?
	7. Have you stopped using any benefits you have previously used because of worries/concerns?
Immigrant-related fears and concerns	1. What have you been hearing about immigration in your community or in the media?
	2. Was there a time that you felt afraid at this hospital? Can you give me an example?
	3. Was there a time that you felt afraid outside of this hospital? Can you give me an example?
	4. Given everything that is happening with immigration in this country, what can the hospital do to support you or family members to stay healthy?
	5. For parents: Have you prepared with your family in the event you might be separated due to immigration policies?

^aBased on the timing of our study, data on food pantries and WIC was included in our interviews and data analysis given that these benefits were included in the initial public charge proposal. However, these benefits were ultimately excluded from the final public charge ruling

Interviews lasted approximately 45 min and were conducted in-person in English (n = 25) or Spanish (n = 5) based on participant preference. Participants received a $30 gift card for interview completion. All interviews were audio-recorded with oral consent. Recordings were transcribed verbatim and destroyed thereafter. All transcripts were de-identified for participant and provider names and stored on a password-secure drive.

Analysis

Bronfenbrenner’s socioecological framework was used to examine individual, community, and institutional factors influencing healthcare-seeking attitudes and behavior [10]. Researchers developed an initial coding scheme from the interview guide. Three researchers independently read and refined the coding scheme for emerging themes. Finalized coded passages were compared for discrepancies between researchers to reach consensus. Percentage agreement (99.66%) and Kappa coefficient (0.84) were calculated to ensure validity and inter-rater reliability. Thematic content analysis was conducted to identify patterns of barriers and facilitators of care and potential solutions to policy challenges. NVivo Pro (QRS International) was used to facilitate coding and management of narrative transcripts.

Ethical Considerations

The study was reviewed and approved by Boston University Medical Campus Institutional Review Board.

Results

Demographics

Thirty participants (11 male, 19 female) represented 13 countries of origin. Average length of time in the US was 9.8 years (range: 10 months – 38 years). Although participants were not asked for their immigration status, many participants self-disclosed their status, which ranged from undocumented to citizen. See Table 2 for additional participant characteristics.

Table 2.

Summary of participants

Participant characteristics	Total participants, N = 30
Participant sex
Female	19
Male	11
Age of participant
Young adult (18–30 years)	3
Middle adult (31–65 years)	22
Older adult (> 65 years)	4
Undisclosed	1
Language distribution for interviews
English	25
Spanish	5
Country of origin
Total countries	13
Africa (Cameroon, Cape Verde, Ethiopia,Nigeria, Tanzania, Uganda)	14
Asia (India, Iraq, Nepal)	4
Central America and Caribbean (Dominican Republic, El Salvador, Haiti, Honduras)	12
Length of time in the United States
Mean, range (years)	9.84, 0.83 – 38
< 5 years	6
5–10 years	11
> 10 years	13
Marital status
Single	7
Married or has partner in the United States	17
Married or has partner in home country	6
Reasons for immigration (non-exclusive categories)
Political violence	17
Domestic violence	1
Family in the United States	12
Work/educational visa or opportunity	13
Health insurance status
Has Mass health/Medicaid insurance	19
Has private insurance	8
Currently in insurance Lapse	3
Never had insurance	0

Public Benefits Usage in Context of Public Charge Proposal

Of the 30 participants, 26 used public benefits included in the proposed public charge rule. Medicaid was the most commonly accessed public benefit by participants and their family members (19 participants). Other public benefits accessed by participants included SNAP (10 participants), public housing (9 participants), food pantry (10 participants), and Special Supplemental Nutrition Program for Women Infants and Children (WIC) (10 participants).

Of the 26 participants utilizing benefits, 11 were aware and 15 were unaware of the public charge proposal. Of those participants who were aware, five were unconcerned about potential consequences, citing having US-born children or perceived protected status. The other six expressed concern about immigration-related consequences and two of them discontinued their public benefits. These concerned participants self-disclosed as currently in the process of obtaining citizenship and discussed how using public benefits could “backfire” (Table 3). The four participants who retained their benefits despite concerns cited necessity in seeking medical care for their health conditions. One participant discussed his difficulty in needing Medicaid for HIV medications, yet fearing that public charge would impact his immigration status.

Table 3.

Participant quotes about the public charge proposal concerns

Participant concerns about the public charge proposal
"They may deny you. You might get a green card but you can’t get the citizenship, I think…There are things that you can’t get, just because of that one thing that you did when you were in need and stressed. So I worry that it could affect me in the future or not."
"If I was not having this problem, I would also not be using any government medical insurance in worry for my asylum case. But I have no option because, I need the support. The medication I get, I cannot manage to buy, to have an insurance that will take for my medication."
"Es que, los que están recibiendo los servicios, también el seguro y los cupones y la vivienda, se afecta uno que aplica para residencia. Entonces yo lo quité también porque estoy en proceso, tratando de conseguir residencia." [It’s just that, those who are receiving the benefits, such as medical insurance and food stamps and housing, it can affect someone applying for residency. So, I quit them because I am in the process, trying to gain residency]

Barriers and Facilitators for Immigrant Populations Seeking Healthcare

Table 4 summarizes the barriers and facilitators impacting immigrant patients’ access to healthcare services. Three key barriers were fear of deportation and interaction with law enforcement, safety concerns when accessing healthcare services, and socioeconomic-cultural factors. Four facilitators supporting immigrants’ access to healthcare were supportive community networks, immigrant-friendly hospital infrastructure, positive interactions with hospital staff, and trust in being a ‘good citizen.’

Table 4.

Thematic categories and subcategories for barriers and facilitators

Barriers for immigrant populations in accessing healthcare services
Theme	Subtheme	Participant quote
Fear of deportation and interaction with law enforcement	Fear of federal immigration services	“Sometimes, it feels like they might bundle us up or in case you just suspected of something small, they could deport you. Sometimes feels like we are unwanted. Sometimes, I’m a bit scared.”
	Fear of outcomes from immigration proceedings	“My worry is will I get the asylum? I want to get my asylum. I need to get asylum. That is where my worry is, because I don’t want to go back to [country of origin]. They are killing people every day. Everyday people die. Politics in my country are not going in a good direction. People who die. If I get asylum and stay here, that will be better for me. I don’t want to go back to that country again.”
	Fear of law enforcement	“We have heard of some people being arrested from our community members. And the challenges they went through were not easy. When I was coming into [hospital], I met two police officers. It was a challenge, it was a fear. I thought, agh, why is it that the two officers are in the department I am going. I think, I think, let me go. It comes to anything, it’s all fear. It’s really fear. Fear of them.”
Safety concerns delaying healthcare access	Fear of leaving the home	“Yeah some people, when we are discussing in the community, some people tell us why you people go to [hospital]? If they arrest you there, what will you do then? That also brings a challenge. It may even stop others too. Because people fear to come to here and be arrested. But we still persisted, to come, to pick the medication and uh as soon as I get out of here, I cannot stay. For even more than ten minutes. And I don’t want to stay in [city], because the streets look extremely tight. We fear.”
	Fear stemming from word-of-mouth	“Yeah, a number of people are worried. Some of, some of people say if that day comes, that will be death. Some of them compare it to, they call it the doomsday. We share a lot of things. What will be the next step? We ask ourselves what will be the next step after here? And how will we go back if the government are to send us back. People begin discussing in different aspects. Some people reach to an extent, so say going back, they don’t want to die from torture, they would rather die from here. Like that. That’s the attitude we get.”
	Fear stemming from media	“Yeah, because when they talking on the TV, radio like that, so one day they said they will deport everybody. You know, I’m scared. I know they might take him or me.”
Socioeconomic-cultural factors impacting healthcare access	Insurance coverage	“We just worried about insurance. I know how long we are covered this insurance. And like, how many, this is like a year already working. Like will it working later?”
	Concerns with financial means	“Sometimes I don’t have the means to come. Like I don’t have money on my bus ticket. Yeah sometimes, like that. Those are issues. I just can’t visit.”
	Cultural adjustments	“In [country of origin], you don’t go to a doctor unless you are sick. And so this is the same pattern that they carry. None of the refugees have ever gone to the dentist even though MassHealth covers it for free, the dental insurance for free. Everybody thinks that only crazy people go to therapy. No one goes to therapy.”

Facilitators of care for immigrant populations in the healthcare setting
Theme	Subtheme	Participant quote
Supportive community networks	Support from religious affiliation	“I stayed at the church. I introduced myself to [pastor], I told him my problems. So he introduced me to the church members. So I stayed at the church. People at the church they were, they were people who would bring food for me. So I was so, so depressed, stressed, traumatized for what I went through in [country of origin]. So, I stayed there with [pastor]. I told him my problems of being, uh, of having HIV and that I had not come with my medication.”
	Support from cultural community	“I met friends here. [Ethnic group], they helped me. The first one was in [city]. I stayed in [city]. And after some time, she was a lady and she tell me nope, you should go and look for another friends. I’ve helped you for some time. Then I found another friend. And now I stay in [city].”
	Support from family members	“[Doctor] was saying things about that to me, but we said that we talked to our brother-in-law and he said to decline it. He said he will help until you start working. I think, he say what is it, he say it was social support. Until you have social security and working permit. You need that to do work. But you don’t need to worry. Right now, he is help us.”
Immigrant-friendly hospital infrastructure	Specific programs/services available	“Because I knew I needed a primary care doctor and I had some pain in me, so they recommended me to come here. So I started from the refugee center, ‘cause that’s where I went. I also needed to get legal representation. There are so many things I needed to know. So when I went to the refugee center, that’s when I got to know about everything that is here.”
	Perception of an immigrant-friendly environment	“They are the ones that receive people from other countries. I don’t know what other hospital does that but [hospital] that I know that be liked for the immigrants here. They are the ones that give life to immigrants here whether you speak English or you don’t speak English. They are attend you and they do everything that they say is good for you.”
Positive interactions with hospital staff	Case workers and social workers	“My mental situation was really complicated, because I was in the dark, in the dark. In the dark means, I didn’t know what to do, where to go. And I couldn’t see anything in front of me, so whenever I came here, I feel that oh, there are people they care. There are people, they show people the light… first person I remember is [case manager], so I call her. I said to [case manager], this is my situation now and I don’t know what to do. So [case manager] advise me. Whenever I feel confused or something happen very bad, scary, or worry, I used to talk to [case manager].”
	Doctors	“They check my blood and I got the bad news that I’m sick with HIV. And I get worried, but [doctor], said no, we can take care of you. And you can start the medication and live longer. And I said okay, then I accept that. And I talked to her, they helped me to get a lawyer, and I applied for my asylum. It was going slow, you know, and I wait. And now, I wait and I get a card.”
Trust in Being a ‘Good Citizen’		“To not do anything wrong. I hear people another thing. They drink alcohol. They end up making accidents, those are the things that take them to deportation. Such a things, at my age, I am mature enough. I cannot do such a thing. I am mature enough.”

Barrier: Fear of Deportation and Interaction with Law Enforcement

When asked about difficulties accessing healthcare, participants described uneasiness and fear of deportation. They mentioned themselves and community members being scared to be sent back to their home countries. Several participants mentioned never wanting to return to the violent, unstable political situations in their home countries. Participants described concerns of being “bundled up” and “agarrados por inmigración” [seized by Immigration and Customs Enforcement (ICE)] at hospitals or courts. Of those who voluntarily shared their immigration status, many feared being denied citizenship and their uncertain fate if deported to their home countries.

One participant described the all-consuming nature of his stress regarding immigration proceeding outcomes. His stress is “everyday” and he thinks about “what’s going to happen” and “what [he’s] going to eat.” Another participant shared his worry in waiting for work authorization and being scared to leave the house. Their fear extends beyond immigration agents to local law enforcement officers as well. One participant recounted the fear evoked by encountering police officers in the hospital elevator. He shared that, “The police here are not friendly, especially to our skin [color].” Another participant described being “scared that what [I] say will be used against [me]” by law enforcement.

Barrier: Safety Concerns Delaying Healthcare Access

The overarching fear of deportation and institutional authority, coupled with the perception of risk in public places, presented challenges when seeking healthcare services. In particular, participants described fear of leaving their homes for appointments. One participant shared that he cannot stay “more than ten minutes” at the hospital before wanting to leave due to fear of arrest and deportation. Participants expressed worries within their communities about ICE “picking up people” in the workplace and public spaces. One participant shared his community’s term for deportation as “doomsday” and concerns about commuting into the city to pick up medication. Another participant talked about her neighbor who was afraid to call 911 during a critical health emergency due to their immigration status. Participants cited media reports about ICE “deport[ing] everyone” and the US government’s lack of “interest in foreigners,” which worsen their fear of entering healthcare facilities.

Barrier: Socioeconomic-cultural Factors Impacting Healthcare Access

While only three participants reported a current lapse in health insurance, most shared a general difficulty in navigating health insurance policies. Participants mentioned foreign-born friends having difficulty with health insurance applications. Another participant described having to cancel two medical appointments due to her insurance lapse because otherwise “se va con un gran bill” [she would leave with a large bill]. Several questioned how long they would be able to maintain Medicaid coverage without repercussions. One participant explained how her child suddenly lost insurance coverage without clearly understanding the reason why. Participants were also concerned about having the financial means to maintain their health. One person recounted difficulty in rationing enough money for both transportation to appointments and purchasing food. Another shared that he sometimes cannot attend appointments because he “doesn’t have [bus] money.”

Cultural differences also posed challenges to participants when navigating the healthcare system. They mention being “scared to meet a medical professional” and how in their home countries they would go to a pharmacy to “self-medicate.” Accessing mental health services in the US poses a difficult cultural adjustment, especially for participants with a trauma history. One participant stated that “only crazy people go to therapy” in his home country.

Facilitator: Supportive Community Networks

Participants received community-based support from religious affiliations and self-identified ethnic groups. Several received recommendations for specific doctors from church members. One participant disclosed his HIV status to his pastor, who then provided him with housing and transportation to appointments. Other participants were provided housing by members of their ethnic communities upon arrival to the US. Many also cited their religious faith as a source of comfort. One participant discussed finding solace in hearing similar challenges faced by others, which caused him “to feel not alone.” Several described Boston as having a large population of “members from [my] country” and being a safe place to live.

Facilitator: Immigrant-Friendly Hospital Infrastructure

When asked what makes them feel comfortable with coming to the hospital, participants cited supportive aspects of the hospital infrastructure. Several participants referenced the hospital’s “refugee center,” a place that someone described as giving “life to immigrants whether you speak English or you don’t.” Others found the “refugee center” to be helpful with job preparation seminars and legal support resources. Additionally, participants considered the hospital “trustworthy” and “immigrant-friendly.” Participants were happy to have access to bilingual staff and interpreters who speak their native languages. Others enjoyed the posters on hospital walls that welcome patients in different languages.

Facilitator: Positive Interactions with Hospital Staff

On an interpersonal level, participants revealed that hospital staff improved their healthcare experience and all shared their satisfaction with the hospital’s services. One participant described finding comfort in calling his case manager whenever his “mental situation was really complicated.” Visiting the hospital reminded him that “there are people that care” and that “here, [I feel] at home.” Others similarly described their case managers guiding them toward much-needed resources and providing empathetic support: “My case manager…she is very gentle and nice. She feels our pain.” Participants appreciated doctors providing medical documentation to support their asylum cases and recognized these clinicians as going beyond standard medical care.

Facilitator: Trust in Being a ‘Good Citizen’

Some participants reported trusting that their status as a ‘good citizen’ would prevent them from being deported. One participant stated, “I don’t think they’re gonna deport me…I never get in trouble.” The same participant offered this status as the reason why he would not disenroll from his medical insurance out of fear of the new public charge rule. Another expressed a similar view, stating “no hecho nada ilegal” [I haven’t done anything illegal]. A third participant stated that he was “a good citizen” so was unafraid to attend appointments.

Discussion

Immigration laws and policies evolve over time and can have profound health consequences for immigrant communities. Restrictive immigration policies implemented by the Trump administration, including the expansion of the public charge policy to include benefits such as Medicaid, will have long-lasting consequences. It is promising that the Biden administration has issued an executive order that, while not rescinding the public charge policy, has begun the administrative process of dismantling this harmful policy [11]. Our study examined how the public charge proposal influenced immigrant patients’ use of public benefits at an urban safety-net hospital and the barriers and facilitators contributing to their healthcare-seeking practices. We found that while half of participants were unaware of the policy and continued their benefits, the current political climate did impact healthcare-seeking practices and attitudes for many patients.

As previously reported [12], the chilling effect of hostile anti-immigration policies like the public charge rule instills fear in entire immigrant communities. To document the predicted chilling effect of the public charge proposal prior to its finalization, Bernstein et al. analyzed national survey data and concluded that one in seven adults from immigrant families did not participate in public benefit programs out of fear of future ineligibility for legal permanent residence [12]. While only a few participants in our sample disenrolled from their benefits, their narratives still revealed themes of deportation fears and safety concerns, consistent with the predicted chilling effect. Among those who were concerned about the implications of the proposal, several retained their primary care with access to Medicaid and cited its medical necessity. While Bernstein’s national survey was performed immediately following the announcement [12], our study was conducted eight months later when public discourse and media coverage had declined, even while participants’ fears persisted.

Though fewer participants discontinued benefits than anticipated, the barriers created by federal anti-immigration policies are highlighted in the narratives shared by participants. Fear of deportation was prominent among our participants and is supported by current data. ICE raids, arrests, and deportations have risen by 46% since 2016 [13]. In 2019, the number of immigrant detainees reached a record-high daily average of over 50,000 [14], contributing to the fear and stress experienced by immigrant communities. Furthermore, for our 17 participants who cited political violence as the reason for leaving their home countries, deportation might equate to a death sentence.

Fear of detention by law enforcement also speaks to the unease experienced by immigrants in the greater Boston area. The social justice movement against police brutality of spring 2020 highlights an additional fear experienced by Black immigrants. Black immigrants faced disproportionately higher rates of deportation based on criminal grounds, yet there is no evidence showing that they commit more crimes than other immigrant groups [15]. This fear is corroborated by our participant who feared police due to his skin color and presence as a “foreigner.”

Another notable finding is the effect of low health literacy and socioeconomic factors on immigrants’ healthcare-seeking practices. While unauthorized persons nationally lack health insurance at quadruple the rate of US citizens [16], Massachusetts provides healthcare coverage, albeit limited, for all state residents [17]. However, despite universal coverage, poor understanding of health insurance was a barrier to healthcare access. Half of participants were also unaware of the public charge policy, further underscoring the need for patient education on policies that may affect their citizenship pathway. Additionally, seeking healthcare was often challenged by difficulties of rationing money between transportation, food, and rent. When faced with this economic decision, healthcare was forgone by some participants and their community members.

Despite the barriers found in our sample, we identified a number of facilitators that reinforced immigrants’ engagement in healthcare and opportunities for healthcare systems to provide support. Examined through a socioecological framework, these factors at community, institutional, interpersonal, and individual levels can be strengthened to improve immigrants’ healthcare access.

At the community level, our participants voiced strong, trustworthy connections to religious and ethnic communities. These networks can be utilized to disseminate accurate information on healthcare access and immigration resources. Effective outreach can be accomplished by identifying and working with community leaders. On an institutional level, hospitals can serve as a hub to connect patients to comprehensive health, legal, and social services. The hospital’s Immigrant and Refugee Health Center integrates an immigration navigator into clinical care to connect patients to community resources [18]. The hospital also established an Immigrant Task Force that responds to challenges in the evolving immigration landscape. The Task Force has provided guidance on issues such as medical documentation, ICE presence on campus, and family separation. These measures may have contributed to our participants’ relative sense of safety and satisfaction with their medical care. At the interpersonal level, interactions between hospital staff and patients are crucial to creating a welcoming, empowering environment for immigrants. Case managers can promote engagement in healthcare by providing empathetic care while directly connecting patients to resources. On an individual level, some participants noted that being a ‘good citizen’ enhanced their sense of security against deportation. While this view is not shared unanimously, this finding highlights the importance of personal beliefs that contribute to one’s healthcare-seeking practices.

Limitations

This study had a convenience sample of 30 patients and, therefore, is not generalizable to all immigrants. By limiting our study to hospital-based recruitment, our participants had already established medical care and perhaps were less concerned with public charge as compared to those not connected to healthcare services. Our sample had lower rates of disenrollment from public benefits, possibly due to the immigrant-specific services that the hospital provides. Further research is warranted to understand how the public charge policy impacts those without established healthcare access. Despite these limitations, a breadth of immigrant perspectives was captured through our interviews as participants came from different communities throughout the greater Boston area. Though we utilized purposive sampling, which subjects our study to selection bias, we interviewed participants of varied backgrounds, in accordance with the diversity of patients treated at the hospital.

New Contribution to the Literature

To our knowledge, our study is the first to directly include immigrants’ voices and perspectives about the public charge proposal. In our sample of immigrants, the public charge policy was not a deterrent to participation in government benefit programs for the majority of participants. Although most participants did not discontinue their benefits, their fear of deportation still exists and is exacerbated by hostile anti-immigrant policies, which adversely impact their healthcare-seeking practices and attitudes. Our study adds to the literature by identifying facilitators of care that encourage immigrant patients to access healthcare despite their fears. Creation of immigrant-centered programs in the healthcare setting may mitigate barriers and facilitate utilization of healthcare services, even during times of extreme adversity.