Patients, providers nervous as immigration enforcement expands to hospitals

Tucson obstetrics nurse Ashley Edgette said in recent months she’s seen more patients delaying or skipping medical care, due to fear of arrest by immigration agents.

“I see it literally all the time,” including pregnant women going without vital prenatal care, she said.

Local health-care leaders have been reluctant to discuss with the Arizona Daily Star their internal policies or guidance for staff on undocumented patients, in the wake of an April 29 Border Patrol operation in the St. Joseph’s parking lot leading to the arrest of a long-time Tucson resident from Mexico.

Some health-care programs geared toward immigrants and mixed-status families told the Star they want to avoid the spotlight, and potential targeting by immigration authorities, as the Trump administration’s deportation net widens to include patients seeking medical care.

In January, the Trump administration reversed long-standing guidance to U.S. Immigration and Customs Enforcement, or ICE, which previously limited immigration enforcement in “sensitive locations,” including hospitals, schools and churches.

Though she’d never discourage anyone from seeking medical care, Edgette said she understands the widespread fear and recommends having a safety plan, and a witness or advocate to accompany undocumented patients to medical appointments.

“I’ve had multiple friends even in the last week tell me they’re really scared to go to the hospital, and I cannot in good faith tell them that they shouldn’t be,” she said. “Nurses are concerned. We’re concerned about our patients, we’re concerned about limitations on our ability to provide care and we’re concerned about how we may end up in the middle,” between immigration agents and patients.

Public health advocates say lack of routine medical care means preventable or manageable conditions, such as diabetes, can worsen into emergencies, raising the overall cost of care and causing avoidable medical harms, disability or death.

Untreated communicable diseases, like influenza, COVID or tuberculosis, have direct impacts on the general population, health advocates say.

“Everyone in the community needs to make sure people have access to preventive care, to prevent simple problems from becoming more costly emergencies that can affect the health of everyone living, working and contributing to the community,” said Tanya Broder, senior counsel for health and economic justice policy at the National Immigration Law Center.

Reports of immigration enforcement outside St. Joseph’s have unnerved Tucson’s immigrant community, said Alba Jaramillo, a volunteer with Tucson’s Coalición de Derechos Humanos.

“The issue of health care should not be politicized,” said Jaramillo, an immigrant rights advocate. “This is about public health and keeping our entire community safe.”

New legislation could worsen fears: Arizona legislators voted Monday to require hospitals that accept Medicaid payments to inquire about patients’ legal status, though staff would inform patients that their response is optional and their information would not be shared with immigration authorities. The bill now goes to the desk of Democratic Gov. Katie Hobbs.

The bill’s sponsor, Flagstaff Republican Sen. Wendy Rogers, dismissed concerns that the bill — which she said is intended to help the state track the cost of care — would deter people from seeking medical care.

“They should stay in their own country if they want to have care,” Rogers said during a committee hearing.

Similar policies have taken effect in Florida and Texas for publicly funded hospitals, and although those laws also say responses are voluntary, that type of surveillance has a real impact, said Drishti Pillai, director of immigrant health policy at KFF, a health-policy research and news nonprofit.

“Such policies do tend to create a sense of fear among immigrants and make them hesitant to seek health care,” she said. Combined with the reversal of the “sensitive locations” guidance, the policies are likely to be even more of a deterrent, even for immigrants with legal status or U.S. citizens in mixed-status families, she said.

Six in 10 lawfully present immigrants reported fear of detention or deportation in a recent KFF survey, “because immigrant enforcement activity recently has not been limited just to undocumented immigrants,” Pillai said.

The survey also found one in three immigrants didn’t know whether enforcement could happen at hospitals or other sensitive spaces.

“Immigration-related fears, coupled with widespread confusion around shifting immigration policies, are likely to cause additional barriers to immigrants seeking health care,” she said.

While patients’ personal information, including legal status, is protected by a federal law known as HIPAA, numerous exceptions allow for law enforcement to demand access to patient records.

Jaramillo said Tucson hospitals should be vocal in explaining their commitment to protecting immigrant patients, especially in light of Trump’s reversal of the ICE “sensitive locations” memo.

“This has been the policy for three months. They’ve had plenty of time,” Jaramillo said. “I think they have moral and ethical responsibilities to ensure that (health care) facilities are safe for immigrant communities. They could issue public statements on what their written protocol is, so immigrants feel safe to access medical services, and that hasn’t happened.”

‘Under the radar’

Multiple Tucson hospitals and health-care programs provided brief, general statements in response to the Star’s questions about whether staff have been given direction or training in anticipation of heightened immigration enforcement.

Neither Carondelet’s St. Joseph’s Hospital nor its parent company Tenet Healthcare responded to the Star’s emails and calls. Tenet is also the parent of Carondelet St. Mary’s Hospital in Tucson.

Banner Health, Northwest Healthcare and El Rio Health said in their statements that they comply with laws and regulations that protect patient privacy, while sharing patient information when required by law. All encouraged patients, regardless of status, to seek out needed medical care.

Tucson Medical Center’s response was more detailed, saying, “It is not our role or responsibility to collect or share information about immigration status.”

“TMC is privately owned, so no persons (including law enforcement) are allowed to be on our property absent an invitation, in conjunction with care for a person in police custody, or taking action pursuant to an appropriately documented warrant,” spokesman Tim Bentley said in an email. “We will comply with lawful orders or warrants, but our property (since it is private) will not be used for random sweeps or other general investigative purposes.”

One Arizona-based health-care executive told the Star — speaking on the condition of anonymity, for fear of retaliation by the Trump administration — that providers want to avoid drawing the attention of the federal government, especially providers running programs that do outreach to immigrant communities and mixed-status families, and those that receive federal funding.

“Hospitals are scared right now. We’re all trying to stay under the radar,” the executive said. “This administration is different than any administration we’ve ever dealt with in health care. We’ve never had such large threats to funding.”

The Trump administration has been openly retaliating against perceived adversaries, including lawyers, sanctuary cities and universities, critics say.

Edgette said insufficient transparency from hospital leadership regarding ICE enforcement has been stressful for front-line health workers.

Nurses such as herself are concerned about a lack of guidance on undocumented patients’ rights and the extent to which existing privacy laws protect both patients and hospital staff, she said.

At her hospital, “there’s been silence,” she said. “In obstetric care there was not a single memo from our management in terms of, know your rights or what to do” if confronted by immigration agents.

She said that leaves hospital staff on their own in the face of big questions like, “What does it mean to say no to an ICE officer?”

The lack of public response from St. Joseph’s, a Catholic hospital, is “a disappointment for faith communities,” Jaramillo said.

“The Catholic Church is very outspoken about their support of immigrants, and we should expect even more so from a medical facility that is funded by the church and by Catholic donors,” she said.

Moment ‘calls for courage’

Privacy experts say hospitals and other health-care facilities can take steps to improve protections for patients and to empower staff to resist law enforcement overreach, without interfering with legitimate law enforcement activity.

Medical providers should avoid asking about legal status unless necessary, and should also avoid recording legal status in patients’ medical records, said Broder, of the National Immigration Law Center.

Information in medical records, including immigration status, is generally protected by the federal privacy law known as HIPAA. But the law carves out exceptions that allow law enforcement access to medical records, said Jacqueline Seitz, deputy director of health privacy for the Legal Action Center, a New York group that advocates for people with stigmatized health conditions, such as substance-use disorders and HIV.

Today’s heightened immigration enforcement “really puts pressure on some of the weak spots in HIPAA,” she said. Another weakness is that HIPAA enforcement authority is concentrated in the federal government, meaning in most cases, one can’t sue for a HIPAA violation but must make a complaint to the government, she said.

“With the current landscape, it just leaves people without sort of baseline privacy protections,” she said. “We don’t want to live in a world where our family, friends and neighbors aren’t getting health care. ... Blurring the lines between health care and law enforcement is so harmful.”

Health-care facilities should delineate between public and private spaces using signs, and move vulnerable patients as quickly as possible into private patient areas, rather than public-facing waiting rooms, Broder said.

Immigration agents must have a court order or judicial warrant, signed by a judge based on probable cause, in order to enter a private space, she said.

ICE agents often have an administrative warrant that does not allow them to enter without permission, so hospital staff should be trained to know the difference and push back when appropriate, Seitz said. That includes if agents try to enter spaces, or search records, that are included in the warrant, she said.

“There needs to be someone on staff with the courage to say, ‘I’m so sorry, you’re not allowed to enter this space,’” she said. “That really puts a lot of pressure on nurses and doctors and administrators in health care, but it’s also their legal and ethical duty.”

Health-care staff can also provide patients with “red cards” that list immigrants’ rights in English and Spanish, such as the right to remain silent when asked about immigration status, and the right to ask for an attorney. Staff might advise patients not to run from immigration officers, which can constitute probable cause to detain someone, Broder said.

Jaramillo said she hopes local health-care facilities will take proactive steps to protect immigrant patients, such as increasing security in parking lots, where they should have the authority to ask immigration agents to leave, and clearly marking public and private spaces.

Seitz said she understands health-care personnel are in a tough spot, and might fear being detained themselves, particularly as the Trump administration’s law enforcement arms have disregarded due process requirements in high-profile cases.

“It really puts staff in a precarious position,” she said. “This is a moment that calls for a lot of courage.”