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AIMEE ALLISON HEIN, PhD

Considering Health Care Access for Undocumented Immigrants

For many, the vaccination sites that have popped up across the country have provided a reason for hope, an indication that the COVID-19 pandemic may be nearing its end. For some immigrant families, however, vaccine distribution has been a source of stress and fear. People without legal immigration status hoping to get vaccinated face a number of potential hurdles. In part, these barriers stem from systematic exclusion predating the pandemic.

Under the Affordable Care Act, undocumented immigrants are not eligible to purchase insurance in the exchange or for subsidies to purchase health insurance. In addition, they are largely excluded from other federal health programs such as Medicaid. Moreover, while the federal government has insisted that everyone, regardless of immigration status, has the right to be vaccinated, the reality is not that simple.¹ Some sites require documentation to facilitate reimbursement from the government for the cost of the vaccine.² There are also reports of employees at pharmacies and campus distribution sites asking for proof of residency or insurance to be vaccinated.^3,4 While such cases appear to be isolated failures to follow established policies, these stories do nothing to bolster undocumented immigrants' trust in health care systems and their fears of discrimination.⁵ Given the highly contagious and indiscriminate nature of the coronavirus, these barriers that keep undocumented immigrants unvaccinated put not only their individual health at risk, but also the health of their families and the broader public.

From the perspective of Christian ethics, these practices and their consequences are at odds with the belief in our deep interconnectedness and all the ways we are in relationship with one another. For Catholic theologian Charles Curran, relationships are a central theme in scripture and the Catholic tradition. His "relationality-responsibility model" of ethics aims to similarly center relationships, viewing the concrete details of specific relationships as important data for guiding moral action.⁶ People, he argues, live and make decisions within networks of relationality. Acting rightly involves responding well to the demands of these relationships.⁷ Such a framework proves consistent with the values of Catholic social teaching by seeking to balance concern for the individual with attention to the demands of the common good. Responsibility ethics, then, is a framework in which acting ethically requires a consideration of our relationships and how we respond fittingly or unfittingly to those relationships. Applied to immigration, a responsibility ethics approach considers how we have been and currently are in relationship with each other, as citizens and migrants, and how those relationships come with responsibilities and obligations that might guide our moral decision-making.

In health care, a responsibility ethics framework directs us to four crucial considerations. First, the coronavirus pandemic makes clear that everyone needs access to quality health care. Now more than ever, we see that health care cannot be tied to income or documentation status alone. Health care is an important element of the common good in that it contributes to the conditions that allow people to flourish. On a pragmatic note, our health is directly dependent on the health of the people around us. We have a responsibility to contribute to the common good and to be in just relationships with our communities by doing all we can to avoid contracting or spreading the virus. Because our ability to stay healthy is so deeply interconnected, as a society we each have a responsibility to ensure that all people have access to health care that can allow them to limit the virus' spread. Responsibility to the specific relationships in which we find ourselves, wherein each of us depends on others to maintain good health, demands that we provide each other access to the means to maintain good health.

Second, according to the Center for Migration Studies, 74% of undocumented workers are considered "essential infrastructure workers," which is nearly 10% more than the native-born labor force.⁸ In other words, undocumented workers make up a disproportionate percentage of the essential workforce that has been on the front lines of this pandemic, providing sanitation, food and the delivery of goods. Despite this, the barriers that limit access to health care, including vaccines, persist for undocumented immigrants. By failing to adequately address these barriers while continuing to rely on undocumented labor, we fail to be in a relationship grounded in mutuality. It is unjust to continue to rely on them to put themselves at risk while denying them access to vital health care services, even if the denial of access is unintentional. We have built a society that depends on the labor of undocumented immigrants. They have a right to expect access to basic needs, such as health care, in return. To deny them access is a failure to respond justly to them as community members with whom we are in relationship and on whom we depend.

Third, given that undocumented immigrants are so embedded in our communities and the ways that we rely on them, we must also consider reasons they might be hesitant to access health care services. For example, staffing vaccine distribution sites with uniformed members of the National Guard, while efficient, might dissuade immigrant families from getting vaccinated.⁹ One of the most difficult hurdles to overcome in providing health care to undocumented immigrants is the distrust many immigrants have for U.S. systems. Undocumented immigrants who fear being reported and deported are less likely to seek out medical care when they need it. Taking responsibility, therefore, includes considering how to repair this situation and establish trust so that people who are undocumented aren't afraid to access health care and other vital social services. Along with new policies to expand access to health care and health insurance, this will require dismantling policies that discourage people who are undocumented from accessing essential services. Further, building trust requires tangible efforts to establish accountability.¹⁰ Undocumented immigrants need real reasons to believe they will be treated differently than they have been in the past.

Establishing trust and accountability can include a number of different concrete actions. Because public health intersects with a network of other social, political and economic concerns, successful vaccine distribution must work with other policy efforts.¹¹ While the Department of Homeland Security has promised not to "conduct enforcement operations at or near vaccine distribution sites or clinics,"¹² there is little in terms of tangible law or policy holding the agency accountable, and immigration agents have a documented history of staking out health care facilities.¹³ Ideally, public health efforts of vaccine distribution would be paired with new policies that prevent undocumented immigrants from being detained or deported. Health care systems ought to consider how they might ensure immigrants' safety. In states like California, Illinois and Maryland, partnerships with churches and other trusted community organizations provide immigrants with information and hold vaccination events. Doing so diminishes the fear some might feel by allowing them to access care at a more comfortable location.¹⁴

Structural sin refers to the ways in which our social structures and institutions create an unjust distribution of resources and power, contributing to a situation of sinfulness that goes beyond any one person's choices or actions. The barriers that keep undocumented immigrants from accessing health care are an example of structural sin. As such, the proper response is conversion — not conversion to a particular religious worldview, but rather conversion to a more just way of living together in society. Mark Kuczewski, a philosopher and bioethicist at Loyola University, highlights the importance of conversion "away from a status quo that settles for unjust immigration policies," and toward a full recognition of people who are undocumented as members of our communities.¹⁵ While he is specifically responding to institutional barriers that prevent undocumented young people from access to education and jobs, his call to a conversion of our existing relationships with undocumented immigrants is more broadly applicable, and fits well into the responsibility framework of health care. The disproportionate number of undocumented workers who take on the essential jobs that Americans have relied upon during this pandemic brings into sharp focus the ways we depend on undocumented immigrants and how they are already deeply embedded in our communities. Responsibility ethics calls us to consider how we can make this relationship more just. Forming more just relationships with the undocumented immigrants so often excluded from equitable access to health care requires the creation of structures of solidarity and tangible support.

Churches and other community groups that build relationships with undocumented immigrants can help assuage immigrant's fears and protect their safety. (See sidebar.) These actions could include accompanying undocumented immigrants to vaccine appointments, locating "safe" health care professionals they can direct immigrants to, establishing safe sites for vaccine distribution, or offering supports when someone is reported or detained after receiving the vaccine. They can secure legal aid, participate in protests, or provide sanctuary in appropriate church or community buildings. Not only will this improve the health of undocumented immigrants and contribute to overall public health, but it can lead to more widespread societal conversion away from structures of sin and toward the values of the common good. Kuczewski reports that creating structures of solidarity has led other organizations to hear the "prophetic cry for justice" and begin their own efforts to create a more just situation.¹⁶ Churches and other Christian organizations can show the world what is possible and call publicly for the reshaping of the United States into a more just society.

Finally, we need to consider migrants held in detention centers. These facilities are known for keeping people in close quarters, inadequate mask distribution, failure to report infections, expecting employees to work when sick and frequent transfer of detainees between facilities that adds to the possibility of contagion and infection.¹⁷ They are hotbeds for the virus, with more than 10,000 cases reported,¹⁸ a significantly higher rate of infection than is seen within the broader U.S. population. Detainees have also reportedly received inconsistent access to health care when sick. In short, some U.S. policy has directly threatened undocumented migrants and public health.¹⁹ Moreover, Immigration and Customs Enforcement (ICE) has no vaccination program of its own, unlike its counterpart, the Federal Bureau of Prisons. ICE instead chooses to deflect responsibility to the health departments of state and local governments.²⁰ Yet some state health departments have stated that they won't vaccinate people in ICE custody because ICE is a federal program. Adding to the confusion, many states have reported they were unaware that some of their federally allocated doses of the vaccine were meant for detainees.²¹ Little data exists on how many detainees have been vaccinated, but the number appears to be small.

A responsibility ethics framework necessitates we pay attention to how unjust relationships can be repaired by creating accountability and taking concrete responsibility for past injustices.²² In light of the way ICE detention centers have failed to keep detainees as well as employees safe and healthy, we have a responsibility to repair the relationship and, at the very least, provide more sufficient health care and safer policies in detention centers, including prioritizing vaccines for detainees. A responsibility ethics framework holds that ICE does, in fact, have a moral responsibility to ensure those in its detention centers have access to vaccines. Moreover, the federal government and state health departments have responsibilities to be clear in their communications to ensure that detainees do not fall through the cracks. As long as we, as a society, continue to use detention as a centerpiece of our immigration policy, we must take more responsibility for the health and safety of those we detain and the impact detention has on public health.

Responsibility ethics offers a helpful framework not only for diagnosing the problems facing undocumented immigrants as they navigate the U.S. health care system, but also provides a path forward for those of us invested in creating a more just future. Justice will require better relationships, and better relationships start on the ground, person to person and community to community. In conclusion, I offer a set of questions churches, community groups and Catholic health care services can ask themselves as they consider what steps they might take to address health care inequity.

• Who do we serve/who is already in our communities? Some churches and health care systems already have large immigrant populations among the people they serve and are therefore naturally plugged in to these communities. Others will have to consider how to go about building relationships with immigrant communities.
• What needs exist in your town, city or community? Not every community will have the same needs. It's important to know your own concrete context.
• Who is already doing the work? What organizations or groups are working to provide services to immigrants or protect and promote immigrant rights?
• How can we build relationships with these groups? How can we respect, support and bolster the work already being done?
• What resources exist in our community or broader social network? Is there an immigration lawyer in our congregation who might be willing/able to provide legal advice or help people understand how laws impact them? A medical professional who might know the local health care landscape and help people navigate it safely and comfortably? Does our building have space and amenities that might be able to house someone?

AIMEE ALLISON HEIN earned her PhD in Theological Ethics from Boston College in February 2021. She currently teaches at Boston College.

1. Joey Peters, "Fearing Retaliation, Some Immigrants Stay Away from Public Aid," NPR, December 9, 2019, https://www.mprnews.org/story/2019/12/09/fearing-retaliation-some-immigrants-stay-away-from-public-aid.
2. Caroline Chen and Maryam Jameel, "False Barriers: These Things Should Not Prevent You From Getting a COVID Vaccine," ProPublica, April 1, 2021, https://www.propublica.org/article/false-barriers-these-things-should-not-prevent-you-from-getting-a-covid-vaccine.
3. Bill Hutchinson, "Rite Aid Apologizes after Undocumented Immigrants Denied COVID-19 Vaccine," ABC News, March 21, 2021, https:/ abcnews.go.com/US/rite-aid-apologizes-undocumented-immigrants-enied-covid-19/story?id=76590963.
4. "A Message to the UTRGV Community Regarding Vaccine Distribution," University Updates/Resources Related to COVID-19, The University of Texas Rio Grande Valley, February 25, 2021, https://www.utrgv.edu/coronavirus/vaccine-updates/2021-02-24/index.htm.
5. Akilah Johnson, "For Immigrants, IDs Prove to be a Barrier to a Dose of Protection," The Washington Post, April 10, 2021, https://www.washingtonpost.com/health/2021/04/10/covid-vaccine-immigrants-id/.
6. Charles E. Curran, The Catholic Moral Tradition Today: A Synthesis (Washington, D.C.: Georgetown University Press, 1999), 77.
7. Charles E. Curran, "Responsibility in Moral Theology: Centrality, Foundations, and Implications for Ecclesiology," The Jurist 31, no. 1 (1971): 115.
8. Donald Kerwin et al., "US Foreign-Born Essential Workers by Status and State and the Global Pandemic," Center for Migration Studies, May 2020, https://cmsny.org/wp-content/uploads/2020/05/US-Essential-Workers-Printable.pdf.
9. Sarah Varney, "Anti-Immigrant Vitriol Complicates Vaccine Rollout in Southern States," Kaiser Health News, February 16, 2021, https://khn.org/news/article/anti-immigrant-vitriol-complicates-vaccine-rollout-in-southern-states/.
10. Margaret Urban Walker, "Making Reparations Possible: Theorizing Reparative Justice," in Theorizing Transitional Justice, eds. Claudio Corradetti, Nir Eisikovits and J. V. Rotondi (London: Ashgate, 2015), 215-19.
11. Joseph H. Wu, Stephen D. John, and Eli Y. Adashi, "Allocating Vaccines in a Pandemic: The Ethical Dimension," The American Journal of Medicine 133, no. 11, (2020): 1242.
12. "DHS Statement on Equal Access to COVID-19 Vaccines and Vaccine Distribution Sites," Department of Homeland Security, released February 1, 2020, https://www.dhs.gov/news/2021/02/01/dhs-statement-equal-access-covid-19-vaccines-and-vaccine-distribution-sites.
13. Varney, "Anti-Immigrant Vitriol."
14. Tim Henderson, "Churches, Community Groups Help States Vaccinate Immigrants," Stateline, March 9, 2021, https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2021/03/09/churches-community-groups-help-states-vaccinate-immigrants.
15. Mark Kuczewski, "DACA and Institutional Solidarity," in Catholic Bioethics and Social Justice: The Praxis of US Health Care in a Globalized World, eds. M. Therese Lysaught and Michael McCarthy (Collegeville, MN: Liturgical Press, 2018), 190.
16. Kuczewski, "DACA and Institutional Solidarity," 194.
17. Kuczewski, "DACA and Institutional Solidarity," 195.
18. John Washington, "ICE Mismanagement Created Coronavirus 'Hotbeds of Infection' in and Around Detention Centers," The Intercept, December 9, 2020, https://theintercept.com/2020/12/09/ice-covid-detention-centers/.
19. Maria Sacchetti, "ICE has No Clear Plan for Vaccinating Thousands of Detained Immigrants Fighting Deportation," The Washington Post, March 12, 2021, https://www.washingtonpost.com/immigration/ice-detainees-covid-vaccine/2021/03/12/0936ee18-81f5-11eb-81db-b02f0398f49a_story.html.
20. Washington, "Coronavirus `Hotbeds of Infection'."
21. Nicole Einbinder, Angela Wang and Daniel A. Gross, "After an Insider Investigation, ICE Reverses its Claim that It Asked States to Vaccinate Detained Immigrants," Business Insider, February 23, 2021, https://www.businessinsider.com/ice-walks-back-covid-vaccine-claim-deflects-responsibility-2021-2.
22. Walker, "Making Reparations Possible," 215-19.