As a nurse, Melissa Johnson-Camacho is trained to ensure her patients feel safe and comfortable during their hospital stay. But recently, the California nurse and her team found themselves facing an unfamiliar threat to a patient’s health.
The patient, who arrived with a critical condition, was donning a bulky ankle monitor, the kind used by Immigration and Customs Enforcement to track asylum seekers awaiting deportation hearings.
"I was really taken aback," the nurse at a California hospital told Healthcare Dive. "The first thing I thought of was, who needs a yellow star when we have modern day technology to replace that?"
Without training on how to deal with such situations, Johnson-Camacho faced a flurry of thoughts: How does she communicate to her patient that they’re safe? What if ICE agents interfere with treatment? Is it against the law to refuse them? Would she lose her job for doing so — or worse?
"This is all new territory," Johnson-Camacho said. "It was distracting to my nursing care. My focus should be completely on symptom management, lab values, emotional care as far as dealing with a new diagnosis."
Johnson-Camacho is not alone in her concern.
ICE agents detaining children needing emergency care, targeting immigrants visiting sick family members and deporting patients as they exit hospitals are putting healthcare workers in precarious positions. Some are finding their professional purpose compromised by federal immigration policies and fear patient health will suffer.
A recent survey from the advocacy group Children's Partnership found about 40% of immigrant patients in California are skipping appointments and scheduling fewer visits with their providers for fear of confrontation with ICE. One recent study of 545 Mexican women in the United States concluded that fear of deportation could be a cardiovascular risk factor for the country's ethnic minorities.
By design, fear of deportation is not only pushing legal status-holding and undocumented immigrants away from receiving treatment, but away from signing up for the public benefits they're eligible to receive.
"This is all new territory. It was distracting to my nursing care. My focus should be completely on symptom management, lab values, emotional care as far as dealing with a new diagnosis. There are a lot of other things I should be occupying my mind with. I want to be able to give my patients my best and ensure they feel safe and cared for."
"If you're in this country illegally and you committed a crime by entering this country, you should be uncomfortable," former Trump administration ICE Director Thomas Homan told the House Appropriations Committee's Homeland Security Subcommittee last year. "You should look over your shoulder, and you need to be worried."
Hospital staff, duty-bound to patient safety, aren't turning a blind eye. They have consulted lawyers about where federal agents can go and when, and trained employees about how to protect those in their charge while adhering to the letter of the law. One clinic in Los Angeles even has regular "ICE drills."
According to ICE's own "sensitive locations" policy, agents are prohibited from taking "enforcement actions" against persons of interest inside hospitals and medical facilities. The agency, however, has found ways around the policy's ambiguity in the interest of national security.
ICE spokeswoman Danielle Bennett told Healthcare Dive she is "unaware of any instance in which this policy has been violated."
Jose de Jesus Martinez, a Mexican national who was visiting his son at North Central Baptist Hospital in San Antonio last August, begged to differ. Martinez's son, suffering from a heat-induced coma after being smuggled across the border in a truck, was being relocated to another hospital room when Martinez said ICE agents entered and began interrogating the father aggressively.
Under ICE's own directive, interviews are considered an "enforcement action" not to be taken inside a sensitive location. But there are ways around the policy that make it virtually impotent.
In this case, according to Bennett, ICE agents were "attempting to talk to a potential witness to a deadly human smuggling event." Agents entered the hospital room to interview Martinez to investigate an "exigent circumstance."
There appear to be no repercussions for agents who go against the policy. Bennett said it would be "inappropriate ... to even begin to speculate on potential penalties for something that isn't even alleged to have occurred."
Lack of accountability for the agency has led Democrats in the Senate and the House to introduce the Protecting Sensitive Locations Act, which would act as an enforcement mechanism for ICE's own guidance, forcing them to exclude hospitals and medical facilities from enforcement actions. The bill has been lauded by healthcare groups that have recognized the threat ICE imposes on immigrant health, including AMA.
But chances the bill will gain steam are slim, given Republican control over Washington.
Is hospital protocol enough?
The American Hospital Association does not have a specific policy on the removal, detainment or apprehension of immigrant patients from medical facilities, so hospitals have largely been navigating their own way through murky immigration laws.
That hasn't always worked out well.
In 2013, for example, Iowa Methodist Medical Center in Des Moines put two comatose undocumented immigrants on a private jet to Mexico without the consult of any government authority.
Jeff Sconyers, a senior lecturer in the graduate program in Health Services Administration at the University of Washington, co-authored an article in AMA Journal of Ethics in 2016 arguing providers have a moral obligation to respect the confidentiality of undocumented immigrants as if they were any other patient.
As a law enforcement body, ICE must go through a subpoena process to get a patient's information. But what happens when ICE agents camp on hospital property while a person of interest is being treated, as was the case with a critically ill woman from El Salvador who last year was bound in her wheelchair by federal agents who moved her from the Texas hospital where she was awaiting emergency brain tumor surgery and into a detention center?
Can a hospital ask ICE agents to leave? According to Sconyers, yes. But, he added, hospitals have a need to maintain a good working relationship with law enforcement.
"Most organizations would take a pretty lax view of somebody just camping out. Most emergency rooms are really busy. If you don't present yourself to the nurse, if you're not wearing an ICE jacket, they might very well assume you're just a family member waiting for someone to come out," Sconyers said.
Altaf Saadi, a UCLA National Clinician Scholars Fellow, told Healthcare Dive that one direct method for protecting immigrant patients is expanding existing policy on dealing with law enforcement to include immigration enforcement.
"There are already some guidelines and policies for hospitals about working with law enforcement," Saadi said, adding that hospitals don't have to proactively give immigration enforcement information about immigrant patients in the same way they don't need to give other law enforcement agencies information on patient drug use. "People just haven't made that connection ... There's no need to report undocumented immigrants to officials."
"The problem is, in public spaces, it's hard to know what to do about letting people stay there or not. You'd have to know it's an ICE agent, and if they're smart, they won't identify themselves."
Senior lecturer, University of Washington Health Services Administration
In a JAMA paper published earlier this year, Saadi advocated making hospitals sanctuaries where ICE agents must present verified identification. Above that, the authors wrote, "no hospital employee should provide information about any patient to the agents or provide them access to any patient's room without a court-ordered warrant or subpoena," except in the case of an emergency that poses immediate harm.
The role of healthcare workers
Employees at St. John's Well Child & Family Center in Los Angeles instituted similar protocols to ensure the protection of their immigrant patients.
Since spring, employees at the Los Angeles clinic have participated in voluntary "ICE drills" to train them in protecting immigrant patients from ICE agents. Mario Chavez, director of government affairs at St. John's, told Healthcare Dive he developed the training after hearing reports of anxiety among the clinic's immigrant patient population.
"Rather than just wait and react, we figured we would equip our staff," Chavez said. "We had to have a game plan, given all the fear in the community. We couldn't be reactionary."
St. John's makes sure its front desk staff and clinicians are "made clear" on the rights granted to them and their patients by the Fourth Amendment protection against unreasonable search and seizure. Front desk employees are given a script to prepare them for questions may be asked by ICE agents. Managers are trained in how to read warrants.
Staff who have participated have learned how to form a human shield to prevent apprehension, much like North Central Baptist employees did in the case of Martinez last year. Worst comes to worse, St. John's staff have a protocol for keeping ICE agents in place while patients are locked in their rooms.
"We shouldn't have to compromise our constitutional rights as citizens or residents in this country in the name of national security when there's clearly a due process," Chavez said.
Chavez's program has caught the interest of other facilities as more healthcare workers express the need to prepare for a possible ICE raid. A training seminar set for later this month has already reached max registration.
"The likelihood of something like that happening is very low," Saadi said. "It's good to prepare for it, but there are so many other aspects that are important for caring for this population. That could include training providers on local legal or community resources to provide to patients experiencing immigration-related legal concerns."
The Emergency Department of LAC + USC in Los Angeles, a medical-legal partnership funded by the Robert Wood Johnson Foundation is going a step further by helping legalize incoming patients' immigration status — insuring those patients and making sure they know their rights in the process.
Rebecca Trotzky-Sirr, a family doctor with the hospital, is one of the founders of that medical-legal partnership.
"We have data from the past year that shows many people who come through our doors are able to legalize their status," Trotzky-Sirr told Healthcare Dive.
The cost of fear
Chavez told Healthcare Dive that St. John's has experienced a 10% drop in visits among undocumented patients and a 30% no-show rate since the Trump administration ramped up deportations.
That's not uncommon in geographies with immigrant-heavy populations. A body of evidence for this predates the current administration, Saadi said, but fear of deportation and its health impacts have "certainly increased" over the past two years.
Aubrey Hill, director of health systems change at the Center for Health Progress in Colorado, told Healthcare Dive state providers see increases in appointment cancellations and no-shows by immigrants and refugees, decreases in appointments made by those populations and an "uptick" in patients sharing with their providers a fear or concern over sharing their private information.
A report released by Hill's organization last year found an increase in immigrant children coming into ERs with emergency conditions that could have been prevented had they visited a primary care physician.
"People who show up to hospitals, court houses and schools, they're trying to be a part of society. We want to make sure our institutions are working for them," Hill said. "These are the most essential functions of our society. When they break down, we've lost a society that can function properly."