State Preemption of Municipal Laws and Policies that Protect Immigrant Communities: Impact on Latine Health and Well-Being in North Carolina

Abstract

Background

Some U.S. municipalities have proclaimed themselves “sanctuary cities” and/or adopted laws and policies limiting local involvement in enforcement of federal immigration policies. Several states, however, have adopted laws that preempt municipal laws and policies designed to protect immigrants. We explored the consequences of House Bill (H.B.) 318, one such preemption law in North Carolina (NC), on the health and well-being of Latine immigrants.

Methods

We conducted focus groups with Latine immigrants (n=49) and in-depth interviews with representatives from health, social service, and immigrant-serving organizations and local government (including law enforcement) (n=21) in NC municipalities that, before HB 318, adopted laws and policies supporting immigrants. Data were analyzed using constant comparison.

Results

Twelve themes emerged, including the positive impacts of municipal sanctuary laws and policies are limited by preemption and other state and federal actions; laws and policies like HB 318 are confusing, have a chilling effect on health services use, and make life harder overall for Latine communities; intensified federal immigration enforcement has increased fear among Latine communities; Trump administration policies worsened anti-immigrant climates; and use of community identification cards and greater information dissemination and inter-organization coordination can lessen the consequences of preemption and other restrictive laws and policies.

Conclusion

State preemption of protective municipal laws and policies negatively and profoundly affects immigrant health and well-being. However, creative strategies have been implemented to respond to preemption. These findings provide critical data for decision-makers and community leaders regarding the detrimental impacts of preemption laws and mitigation of these impacts.

What do We Already Know About This Topic?

The negative impacts of restrictive immigration laws and policies and positive impacts of protective laws and policies on access to services and health outcomes have been increasingly described in the literature.

How Does Your Research Contribute to the Field?

Municipal sanctuary laws and policies remain understudied, and even less research has been conducted on state preemption laws related to immigration enforcement; accordingly, our research explored the consequences of a state law that preempted municipal laws and policies designed to protect immigrants on Latine immigrant health and well-being.

What Are Your Research’s Implications Towards Theory, Practice, or Policy?

Our findings provide support for applying a health equity lens to immigration policy development and can inform future decisions about protective municipal laws and policies, state preemption laws, and other immigration-related laws and policies and ways to mitigate negative health impacts.

Introduction

Municipalities (counties and cities) range from being hostile to “welcoming” towards immigrants. ¹ More welcoming municipalities include those often referred to as “sanctuary cities,” or that have adopted laws or policies that limit local cooperation with immigration enforcement (i.e., enforcement of federal immigration policies) or protect immigrants in other ways.^2-6 Protective laws and policies promote health and well-being among immigrants, their families, and communities by reducing stress levels, increasing access to health and other services, and addressing broader social drivers of health such as employment, housing, education, and transportation.^7-11

State preemption is state legislation that nullifies a municipal law or policy or restricts a municipality’s authority to take action regarding a specific issue. State preemption laws have been passed in various policy areas, including environmental regulation, labor law, non-discrimination, firearm safety, and nutrition.^12,13 At least nine states have passed laws preempting municipal laws and policies designed to protect immigrants, and more than a dozen others have considered similar preemption laws.^14-19 In 2015, North Carolina (NC) passed and enacted House Bill (H.B.) 318, which preempted municipal sanctuary laws and policies and limited the actions municipalities could take to support immigrants. H.B. 318 included a component forbidding municipalities from prohibiting or discouraging local law enforcement from collecting—or sharing with the federal government—information about individuals’ immigration status. H.B. 318 also restricted certain local government officials from accepting identification cards (IDs) issued by foreign consulates or local community organizations ²⁰ ; such IDs had been used in some municipalities to allow individuals without state-issued IDs (e.g., driver’s licenses), including immigrants, to identify themselves to access services and in interactions with government officials.

The negative impact of restrictive immigration laws and policies on services access and health outcomes, including for adults and for children and young people, has been increasingly described in the literature.^21-25 For example, recent research has documented the detrimental impacts of federal actions such as changes made in 2019 to the public charge rule, which dictates how receiving government benefits affects eligibility for legal permanent residency.^26,27 However, municipal sanctuary laws and policies remain understudied,^28,29 and even less research has been conducted on state preemption laws related to immigration enforcement. ¹⁴ Accordingly, our community-based participatory research (CBPR) partnership, the North Carolina Community Research Partnership, comprised of representatives from community organizations, academic institutions, and local Latine ¹ immigrant communities, ³⁰ explored the consequences of H.B. 318, and its intersections with federal, state, and local policy contexts, on the health and well-being of Latine immigrants and their families.

Methods

Data Collection

In August 2019–February 2020, we collected data in NC municipalities that were diverse in size, represented geographically distinct locations, and prior to H.B. 318 had adopted municipal laws and policies supporting immigrants and limiting cooperation with federal immigration enforcement. Five focus groups were conducted with Latine immigrants, one per municipality in five study municipalities. We focused on Latine immigrants because they comprise the largest immigrant group in NC. ³¹ We also conducted semi-structured in-depth interviews with representatives from local organizations and local governments in five study municipalities. Study municipalities were primarily urban or suburban, with one rural municipality.

Standardized focus group and interview guides were developed in English and Spanish. The guides included open-ended questions exploring experiences with immigration and/or serving immigrants, perspectives on protective municipal laws and policies and state preemption laws and their effects on immigrant health and well-being, and the impact of other immigration-related laws and policies.

Working with local immigrant-serving organizations in each municipality, we recruited focus group participants using purposive snowball sampling, social media advertising, and word-of-mouth. Eligibility criteria for participating in a focus group were being ≥18 years of age, self-identifying as Hispanic/Latine, speaking Spanish, being an immigrant, and having lived in the municipality where the focus group was held since at least 2014.

Interview participants were identified and recruited through our partnership’s networks of community organizations and government officials throughout NC and through word-of-mouth; interview participants also nominated potential participants for subsequent interviews. Eligibility criteria for participating in an interview were being ≥18 years of age and representing an organization that provides health or social services, an immigrant-serving organization or group, or the local government (including law enforcement) in one of the study municipalities.

Focus group participants’ demographic data were collected using a written assessment that included age, gender, country of origin, length of time in the U.S. and NC, educational attainment, employment status, languages spoken, health insurance coverage, and immigration status. Interview participants were asked to provide basic demographic data including gender and race/ethnicity.

Focus groups and interviews were conducted by bilingual staff experienced in qualitative data collection, health research, and immigration policy; staff included a native Spanish-speaking Latine woman, a native Spanish-speaking Latine man, and a Spanish-fluent non-Latine white woman. Two moderators were present during each focus group and one or two interviewers were present during each interview. Focus groups and interviews were conducted at times and locations that were convenient for participants; childcare was provided during focus groups. All focus groups were conducted in Spanish. Interviews were conducted in English (n=8) or Spanish (n=13) based on participant preference. Focus groups and interviews averaged 106 and 67 minutes in length, respectively.

Protocol approval and study oversight were provided by the Wake Forest School of Medicine Institutional Review Board. Verbal informed consent was obtained from all participants. Focus group participants were compensated for their time with a gift card ($40.00 U.S.) and received a meal.

Data Analysis

Focus groups and interviews were audio-recorded, transcribed verbatim, and translated into English if applicable. Transcripts were analyzed using constant comparison, an approach to grounded theory.^32,33 Research partnership members read and reread transcripts, identified emerging themes, and worked together to reconcile and interpret themes, noting similarities and differences across participant categories.

Participant demographic characteristics were explored using descriptive statistics, including frequencies and percentages or means and standard deviations.

Results

Participant Characteristics

Forty-nine focus group and 21 interview participants took part in this study. Focus groups ranged from 9 to 12 participants.

The mean age of focus group participants was 41.4 (range=18–86) years, over three-quarters were female, and the majority were from Mexico, the most common country of origin among Latine immigrants in NC. ³¹ On average, participants had lived in the U.S. and in NC for about 15 years. Most had at least a high school diploma or equivalent and were employed. The majority spoke more Spanish than English or only Spanish. Less than a quarter had health insurance and roughly 35% had legal permanent residency (i.e., green card), another legal immigration status (i.e., valid student or tourist visa, work permit, or deferred action), or U.S. citizenship. Select focus group participant characteristics are presented in Table 1.

Table 1.

Select Characteristics of Focus Group Participants (n=49).

Characteristic	Mean ± SD or n (%), as appropriate
Age in years	41.4 (±12.4; range 18.0–86.0)
Gender
Female	40 (81.6)
Male	9 (18.4)
Country of origin
Mexico	30 (62.5)
El Salvador	6 (12.5)
Colombia	2 (4.2)
Honduras	2 (4.2)
U.S.1	2 (4.2)
Other2	6 (12.6)
Years in U.S.	16.4 (±7.2; range 5.5–35.0)
Years in NC	14.1 (±6.7; range .3–34.0)
Educational attainment
Less than high school diploma or equivalent	19 (38.8)
High school diploma or equivalent	11 (22.4)
More than high school diploma or equivalent	19 (38.8)
Current employment status
Full-time	13 (28.3)
Part-time	12 (26.1)
Multiple jobs	7 (15.2)
Not working	14 (30.4)
Language spoken most comfortably
Only Spanish	18 (37.5)
More Spanish than English	19 (39.6)
Both equally	9 (18.8)
More English than Spanish	2 (4.2)
Currently has health insurance	11 (22.4)
Current immigration status
Legal permanent residency or green card	8 (16.7)
Valid student or tourist visa, work permit, or deferred action	4 (8.3)
U.S. citizenship	5 (10.4)

Two participants were born in the U.S. but were part of Latine immigrant families.

Other=Chile, Costa Rica, Ecuador, Guatemala, Peru, and Uruguay.

Interview participants included eight representatives from immigrant-serving organizations or groups (e.g., community organizations, grassroots groups, and Latine churches); seven from health services organizations (e.g., county health departments and community health centers); four from government organizations, including two local law enforcement representatives; and two from social services organizations (e.g., education services). Two-thirds of interview participants were female (n=13); 17 identified as Hispanic/Latine and four as non-Hispanic/Latine white.

Qualitative Themes

Twelve themes (presented in Table 2) emerged from the focus groups and interviews.

Table 2.

Qualitative Themes from Focus Groups and In-Depth Interviews.

•Municipal sanctuary laws and policies have a positive impact on health and well-being among immigrant communities

•State and federal actions limit the positive impacts of municipal sanctuary laws and policies

•Laws and policies like H.B. 318 are perceived as intentionally confusing

•Laws and policies like H.B. 318 have a chilling effect on use of needed health and other services

•Laws and policies like H.B. 318 affect children and young people in detrimental ways

•Laws and policies like H.B. 318 limit economic well-being

•H.B. 318 has made life harder for Latine persons

•Intensified federal immigration enforcement has increased fear among Latine persons, in locations with and without protective municipal laws and policies

•The election of Donald Trump and the policies of the Trump administration worsened the anti-immigrant climate

•Access to community IDs can mitigate the impact of anti-immigrant laws and policies

•Communities and municipalities have developed creative strategies to respond to detrimental state and federal laws and policies

•There is a need for dissemination of information and inter-organization coordination regarding laws and policies like H.B. 318 and responses to lessen their negative consequences

Municipal Sanctuary Laws and Policies Have a Positive Impact on Health and Well-Being Among Immigrant Communities

Focus group and interview participants emphasized that, though they did not eliminate challenges faced by immigrants, sanctuary cities and other similar municipal laws and policies reduced harms related to immigration enforcement. Participants reported that actions by municipalities to limit collaboration with Immigration and Customs Enforcement (ICE) helped immigrants feel safer leaving their homes to meet basic needs because they felt more confident that potential encounters with local law enforcement would not result in federal immigration enforcement. For example, a focus group participant described these protective laws and policies as providing “the tranquility of knowing, if I get stopped by the police, I’ll probably get a ticket and have to pay. But I’m not going to fear that I’ll be taken to Immigration and deported.”

State and Federal Actions Limit the Positive Impacts of Municipal Sanctuary Laws and Policies

Participants reported that the positive impacts of municipal sanctuary laws and policies were lessened by restrictive actions at the state and federal levels, such as preemption laws like H.B. 318. A local law enforcement representative explained, “We want to establish ourselves as trustworthy. If the state does something [preemption], and we have to comply with that law, immigrants can no longer trust us.” Participants also expressed concerns that municipalities could face financial consequences if they did not cooperate with federal immigration enforcement, noting threats by then President Trump to withhold funding from sanctuary cities. Furthermore, participants cited media coverage of ICE activity in cities that had proclaimed themselves sanctuaries and worried that decisions by local law enforcement not to engage in immigration enforcement could lead to increased presence of ICE agents and more widespread immigrant detentions and deportations.

Laws and Policies Like H.B. 318 Are Perceived as Intentionally Confusing

Participants perceived H.B. 318 (and similar laws and policies) as being purposefully written in ways that could cause confusion and thus further inhibit actions to support immigrants. This ambiguity made it difficult for immigrants, local government officials, and community organization staff to be certain which types of protective actions were still permissible under H.B. 318. Participants noted that the definition of what constituted a sanctuary city was not clear; therefore, local governments seemed reluctant to take any actions to protect immigrants, including those that in actuality were not prohibited by H.B. 318, because they were unsure whether such actions would be considered violations of state law. Furthermore, participants reported that some non-governmental organizations no longer accepted consular and community IDs because of a misperception that H.B. 318 prohibited using these IDs in any setting, rather than only with certain local government officials.

Laws and Policies Like H.B. 318 Have a Chilling Effect on Use of Needed Health and Other Services

Participants shared that H.B. 318 and similar laws and policies led many immigrants to forgo needed health services because they feared denial of services and potential exposure to immigration enforcement while driving to or visiting clinics. A focus group participant reported, “The health department stopped accepting consular IDs, so there are people who don’t go [because] they don’t have a valid ID.” These laws and policies also increased mistrust in local health services among immigrant communities, including fears that healthcare providers might be required to share information about patients with the federal government. A health services organization representative noted, “If I [am an immigrant parent], my child has to have vaccines and check-ups. Yet, I'm concerned about whom I share my personal information with. It's hard for people to separate our part of the government [that provides health services] from the part of the government that doesn't want [them] here.” Participants also described the chilling effect of these laws and policies on immigrants’ use of other health-related resources, including accessing basic utilities (e.g., electricity and water), healthy foods, and public spaces for recreation and physical activity. Participants noted that more recent policy developments exacerbated these impacts of H.B. 318. For example, the 2019 federal public charge rule changes further inhibited services use.

Participants emphasized that laws and policies like H.B. 318 also eroded trust in local law enforcement and made immigrants less likely to report crimes due to concerns that they would be asked to present forms of identification that they lacked. Participants explained that this reluctance to engage with law enforcement resulted in immigrants being vulnerable to crime and reduced public safety for the entire community.

Laws and Policies Like H.B. 318 Affect Children and Young People in Detrimental Ways

H.B. 318 and other laws and policies related to immigration enforcement were perceived as acutely impacting children and young people. Public schools were identified as a particularly challenging setting for immigrant families. Participants noted that immigrant parents experienced difficulties enrolling their children in school because school staff were reluctant to accept their IDs given the perceived restrictions imposed by H.B. 318. Participants also reported that immigrant parents were impeded from engaging in their children’s education (e.g., volunteering or attending field trips) because they were unable to provide state-issued or federal identification for required background checks and were worried about the immigration enforcement consequences if identified as undocumented during the process. Furthermore, participants reported that law enforcement checkpoints were often located near schools, making immigrant families feel unsafe and inhibiting access to educational services.

Participants stated that immigrant parents also had to weigh the benefits of accessing other services for their children against the threat of immigration enforcement. As a result, children in immigrant families often did not participate in the enrichment activities their peers did, and parents regretted being unable to facilitate those opportunities. A focus group participant shared, “I’ve been looking at summer classes for my son. But I’d have to drive him. It’s sad that [my children] are affected and … they can’t enjoy, learn, or participate.”

Participants also reported that children internalized parental anxieties about immigration enforcement, including being fearful of local law enforcement. They noted that both documented and undocumented members of immigrant families experienced high levels of fear about the threat of family separation due to detention or deportation and its potential impact on children. Additionally, participants described feelings of stress and vulnerability among immigrant families who had to place responsibilities for providing rides or registering legal documents (e.g., cars and insurance) on teenagers and young adults who were sometimes the only members of their household with driver’s licenses or other necessary identification.

Laws and Policies Like H.B. 318 Limit Economic Well-Being

Participants emphasized that laws and policies like H.B. 318 affect immigrants’ financial stability. They reported that many immigrants were reluctant to take jobs that involved driving far from home, despite needing the income, because they feared encountering local law enforcement that may be involved in federal immigration enforcement. Participants also highlighted the significant and recurring financial burden of fines and legal fees associated with law enforcement profiling immigrants as undocumented and stopping immigrants for driving without a license.

H.B. 318 has Made Life Harder for Latine Persons

Participants reported that H.B. 318 sent a message to Latine persons of all immigration statuses that they were unwelcome in NC. H.B. 318 was perceived as compounding the negative effects of existing restrictive state and federal laws and policies, particularly a 2006 state law prohibiting the NC Division of Motor Vehicles from issuing driver’s licenses to individuals without valid Social Security numbers. ³⁴ Participants explained that H.B. 318 and these other laws and policies made life increasingly difficult for immigrants. An immigrant-serving community group representative stated, “Many people are waiting to see the [border] wall, but the wall is already there. It started with driver’s licenses. Now, there are more and more complications. All that makes up this invisible wall that is being created.”

Intensified Federal Immigration Enforcement has Increased Fear Among Latine Persons, in Locations With and Without Protective Municipal Laws and Policies

Participants reported that recent increases in ICE activity (including workplace raids and large numbers of detentions) throughout NC and nationally also contributed to heightened anxieties and other mental health effects among immigrants, exacerbating the consequences of laws and policies like H.B. 318. A focus group participant stated, “You don’t wake up with joy anymore, but fear of what’s going to happen.” High-profile federal immigration enforcement actions had recently occurred in municipalities with and without protective municipal laws and policies, and news of detentions in any location caused additional worry about the threat of federal immigration enforcement in local municipalities. Because of increased fear, participants indicated that, when ICE agents were active locally or immediately following a raid, immigrants further limited their movement and use of services; for example, immigrant patients canceled medical appointments at clinics and Latine churches suspended services. Participants reported that many immigrants felt no location within their communities was “safe” from federal immigration enforcement and described a sense of exhaustion from maintaining constant hyper-vigilance for potential ICE activity.

The Election of Donald Trump and the Policies of the Trump Administration Worsened the Anti-Immigrant Climate

Participants emphasized that the effects of laws and policies like H.B. 318 were shaped by the larger national political context, including the ways that the 2016 presidential election and Trump administration had intensified existing anti-immigrant sentiment. Although they acknowledged that prior administrations had taken restrictive stances on immigration, participants perceived recent federal immigration enforcement tactics as more ruthless and noted that these actions at the federal level influenced state laws and policies and caused immigrants to feel less hopeful about their future in the U.S.

Additionally, participants observed that the Trump administration’s policies and rhetoric had created an environment that normalized and encouraged hostility toward immigrants. Therefore, immigrants worried about both immigration enforcement (by federal, state, and local officials) and increased risks of discrimination and violence from individuals encountered in their daily lives, citing the 2019 shooting targeting Latine shoppers at a Walmart in El Paso, Texas, as an example. An exchange among focus group participants illustrated such concerns:

Participant (P) 1: Now, with [Trump], people feel they have this right to insult you openly.

P2: To shoot you.

P1: The hatred is palpable.

P3: Everyone like that feels backed up by the president because this racism has been more rampant. He has instilled so much of it.

Access to Community IDs can Mitigate the Impact of Anti-immigrant Laws and Policies

Participants reported that H.B. 318's ID restrictions profoundly affected the well-being of immigrant communities. In addition to being necessary for receiving health and other services, having valid identification was seen as being linked to one’s sense of dignity and belonging in their local community. A local government representative explained, “You can’t be a full human being without a sense of identity. The IDs, and the strategies we implement in every sector to affirm that, are incredibly important.” Furthermore, participants noted that access to IDs was already limited by the 2006 NC driver’s license law, and that H.B. 318 preempted local government officials from accepting the limited forms of identification still available to immigrants.

Although participants emphasized the need for sustained efforts to increase access to driver’s licenses to provide more comprehensive benefits to immigrants (including reducing transportation barriers), they considered promoting or preserving access to alternative forms of identification as helpful in the short-term. Many participants were familiar with community IDs issued by a community organization that were used in multiple NC municipalities. H.B. 318 prohibited some local government officials from accepting these community IDs, but they were still permissible for use with local law enforcement and in other settings like health clinics, community organizations, and private businesses (e.g., banks).

Community IDs were perceived as particularly valuable given their potential use with local law enforcement. During a traffic stop, being able to show an ID that local law enforcement officers could use to verify an individual’s identity could make the difference between being cited for driving without a license and released, and being taken into local law enforcement custody where the individual’s information might be shared with ICE. Participants reported that community IDs also made some immigrants feel more comfortable calling local law enforcement to report a crime or seek help in an emergency because they had a form of identification to present to local law enforcement officers who responded to their call. Accordingly, local law enforcement participants reported that community IDs facilitated their ability to build relationships with immigrants and carry out protocols.

Participants identified additional advantages to community IDs, as well as some challenges. Some focus group participants preferred using community IDs over passports from their countries of origin, which were also a valid form of identification under H.B. 318 but could be difficult to obtain or replace if lost or stolen. Additionally, unlike these passports, the community IDs listed users’ current address in NC rather than a foreign country of origin, potentially drawing less attention to their immigrant status. At the same time, participants noted that community IDs were not accepted as broadly as driver’s licenses, and some worried that using a community ID might still signal that an individual was undocumented because they did not have a state-issued ID from NC.

Communities and Municipalities have Developed Creative Strategies to Respond to Detrimental State and Federal Laws and Policies

Participants reported that some local communities had developed creative strategies to mitigate the negative impacts of laws and policies like H.B. 318. A local government representative noted hiring additional bilingual staff to try to address the needs of immigrant community members affected by H.B. 318. In other municipalities, local law enforcement implemented changes that reduced the likelihood of interactions that could potentially lead to immigration enforcement, such as eliminating checkpoints or not authorizing them near schools and giving officers discretion about whether to detain persons stopped for driving without a license. Another municipality made services more accessible by, in lieu of a photo ID, requesting other documents containing individuals’ names and addresses such as a utility bill or child’s Medicaid card. Participants emphasized that there was a distinction between these types of strategies and more symbolic “welcoming” measures by municipalities that sent positive messages of inclusion but had fewer tangible impacts on immigrants’ lives.

There Is a Need for Dissemination of Information and Inter-Organization Coordination Regarding Laws and Policies Like H.B. 318 and Responses to Lessen Their Negative Consequences

Participants highlighted the importance of disseminating accurate, up-to-date information to promote better understanding of laws and policies like H.B. 318, as well as protective municipal laws and policies, that affect community members and organizations. Participants noted that impactful laws and policies may not be known about within communities. Furthermore, clarification around actions that were and were not allowed or prohibited by a specific law or policy was also identified as critical. Participants also suggested better coordination among local governments and organizations to share ideas and lessons learned. For example, some participants were not aware that community IDs existed, particularly in municipalities that did not participate in the program. Participants noted that municipalities were often hesitant to share information broadly about measures they were taking to protect immigrants due to concerns about potential negative repercussions (e.g., from the state), and thus immigrants living within those municipalities and organizations and local governments within other municipalities remained unaware of these supportive efforts.

Discussion

Our study findings highlighted the potential of sanctuary laws and policies as a form of harm reduction against the threat of federal immigration enforcement,^35,36 and the limitations of these laws and policies given both actual intervention by state and federal governments and the fear of pushback against supportive actions taken by municipalities. The results of this study continue to be relevant to evolving state legislative contexts; for example, in 2021 a bill was introduced in NC that proposed to reinforce state preemption by allowing individuals to bring lawsuits against municipalities that do not comply with the provisions of H.B. 318. ³⁷

Findings also underscored the value of community IDs, particularly where driver’s licenses are inaccessible for many immigrants. Other studies have explored processes, benefits, and challenges associated with locally issued IDs, and continued research is needed to identify best practices for these programs.^38-40 At the same time, participants cited NC’s driver’s license restrictions as extremely detrimental, indicating that long-term strategies should include a focus on driver’s license access for immigrants as a policy-level public health intervention.^11,41,42

Additionally, this study illustrated how protective municipal laws and policies and state preemption laws are part of a larger constellation of intersecting local, state, and federal actions that affect immigrants’ physical and mental health, as well as social drivers of health, particularly economic factors.^41,43-45 Participants perceived H.B. 318 as part of an extended campaign of laws and policies against immigrants that, in combination, had a chilling effect on services use. Important factors in this greater context included the Trump administration’s policies and rhetoric and intensifying federal immigration enforcement tactics. Similar detrimental health impacts of the Trump presidency among immigrants have been documented elsewhere,^46-48 and addressing these will be a long-term endeavor. Participants described changes to the public charge rule under Trump as particularly impactful. Like H.B. 318, concerns about public charge caused immigrants to avoid accessing services and confusion about the policy’s specifics and scope led to spillover effects, including for individuals to whom the rule did not apply and programs not included in the actual rule.^27,49-51 Though the public charge changes were reversed in March 2021, ⁵² a concerted effort is needed to ensure that updated information reaches immigrant communities and to address mistrust of services stemming from public charge. Furthermore, many laws and policies identified as affecting immigrants, including H.B. 318 and the NC driver’s license law, as well as negative impacts of ICE activity on health access, ⁵³ pre-dated the 2016 presidential election. Thus, the need to advocate for policies that promote immigrant well-being will continue beyond the Trump administration and require multi-faceted approaches. ⁵⁴

Participants also emphasized the effects of immigration-related laws and policies on children and young people, and further research is needed on the long-term health consequences of fear and uncertainty in the setting of restrictive laws and policies and increased immigration enforcement for immigrant families. Although the health impacts of adverse childhood experiences (ACEs) are well established,^55,56 traditional scales that measure ACEs do not include immigration-related adversity, ⁵⁷ and longitudinal effects of the threat of immigration enforcement on child development are not well understood. ⁵⁸ Our findings demonstrate the tangible impacts of this threat, including challenges to parental engagement at school and limited enrichment opportunities.

Given that focus groups participants had lived in study municipalities for at least five years, these findings also bring particular attention to the effects of these laws and policies on the health of more established immigrant communities and on members’ ability to actively participate and access resources within municipalities where they have been living long-term.

Finally, our findings indicate the need for greater communication, dissemination, and coordination to ensure that local governments, community organizations, and immigrants understand relevant laws and policies, to raise awareness about protective laws and policies, and to promote creative strategies to mitigate the impact of more hostile laws and policies.

Limitations

Study findings were based on focus groups and interviews in a limited number of municipalities in NC and focused on the experiences of Latine immigrants. However, findings may be relevant to other immigrant populations in other states, particularly those considering state laws preempting municipal laws and policies designed to protect immigrants.

Conclusion

This study identified important findings regarding the profound impacts of protective municipal laws and policies, state preemption laws, and other immigration-related laws and policies on immigrant health and well-being. These findings provide support for applying a health equity lens to immigration policy development. Future decisions about these laws and policies should consider these impacts and ways to mitigate negative effects.

ORCID iDs

Lilli Mann-Jackson, MPH https://orcid.org/0000-0002-7088-4097

Julie M. Linton, MD https://orcid.org/0000-0003-2402-5731