Dos meses después que el huracán María tocara tierra, la Kaiser Family Foundation viajó a Puerto Rico para realizar grupos de discusión y entrevistas individuales con individuos afectados por la tormenta. Hablamos con 40 personas de 10 regiones diferentes de la isla (Apéndice 1, fotos de participantes seleccionados en las páginas siguientes). Haga click aquí para ver un video complementario. Los resultados muestran:

• El huracán María fue un evento aterrador y traumático para los participantes y sus niños. Varios sufrieron daños significativos en sus hogares y propiedades, y algunos lo perdieron todo.
• La tormenta tuvo efectos negativos significativos en la salud física y mental, y muchos participantes continúan experimentando depresión, estrés y ansiedad.
• Dos meses después de la tormenta, los participantes seguían enfrentando desafíos para satisfacer necesidades básicas, y la vida cotidiana seguía siendo extremadamente difícil por la falta de electricidad y las limitadas opciones de trabajo.
• Los participantes sintieron que los esfuerzos de recuperación han sido lentos e insuficientes.
• A pesar de estos desafíos, muchos creen que Puerto Rico se recuperará, aunque reconocen que la recuperación demorará muchos años, y creen que las personas mismas tienen un papel importante que desempeñar en la recuperación.

SOPORTANDO LA TORMENTA

Soportar la tormenta fue una experiencia aterradora y traumática para los participantes. Algunos hicieron preparativos para la tormenta, mientras que otros anticiparon que la tormenta pasaría por la isla o no sería tan fuerte como se había pronosticado. Muchos se quedaron en sus casas para enfrentar la tormenta y trajeron a familiares y amigos para quedarse con ellos. Otros se quedaron con familiares o amigos que tenían casas más sólidas. Los participantes describieron la fuerza aterradora de los vientos de la tormenta y la lluvia e inundaciones significativas. Dijeron que la tormenta se sentía interminable y les preocupaba el bienestar de los miembros de la familia de los que fueron separados durante la tormenta.

CONSECUENCIA INMEDIATA DE LA TORMENTA

Los participantes tuvieron problemas para satisfacer las necesidades básicas inmediatamente después de la tormenta. Muchos sufrieron daños significativos en sus hogares y propiedades, y algunos lo perdieron todo. Dijeron que, en los días y semanas posteriores a la tormenta, era extremadamente difícil satisfacer las necesidades básicas y que las filas para agua, alimentos, gasolina y dinero, eran de entre 8 y 10 horas. En las semanas posteriores a la tormenta, no hubo comunicaciones en la isla y los viajes por la isla eran difíciles, por lo que fue difícil chequear el bienestar de familiares y amigos. Pocos recibieron ayuda en los días y semanas inmediatamente posteriores a la tormenta. Un aspecto positivo que destacaron varios participantes fue que la tormenta contribuyó al aumento y el fortalecimiento de las relaciones en la comunidad con los vecinos trabajando juntos después de la tormenta.

EFECTOS EN LA SALUD FÍSICA Y MENTAL

Los participantes dijeron que el acceso a la atención médica fue limitado y caótico inmediatamente después de la tormenta con personal limitado, hospitales sin electricidad, lesiones y muertes.  Señalaron que las farmacias no podían procesar la información del seguro sin electricidad, por lo que tenían que pagar de su bolsillo. Algunas farmacias proporcionaron medicamentos a crédito y/o sin receta médica para ayudar a garantizar el acceso continuo a la medicación. Los participantes notaron que la capacidad de acceder a la atención médica ha mejorado con el tiempo, pero persisten los desafíos, que incluyen esperas más largas, desafíos de transporte, hospitales, clínicas y farmacias limitadas, con muchos de ellos todavía funcionando con generador de electricidad inconsistente. Varios de los participantes tenían cobertura de salud a través de Reforma, el programa del Medicaid en Puerto Rico, y dijeron que la cobertura es clave para acceder a la atención necesaria para ellos y sus hijos.

Varios participantes dijeron que la tormenta discontinuó su acceso a medicamentos y tratamiento. Por ejemplo, varios dijeron que no tenían acceso a la insulina porque no tenían la capacidad de refrigerarla, y un participante no pudo obtener tratamiento de diálisis debido a la falta de electricidad. Los participantes dijeron que ha sido más difícil manejar condiciones crónicas como el asma, la hipertensión y la diabetes debido al estrés y la ansiedad, el acceso limitado a medicamentos y un mayor consumo de alimentos procesados y enlatados y gaseosas debido a dificultades para obtener alimentos frescos.

Los participantes también describieron los efectos profundos en su salud mental y emocional. Señalaron que, si bien tratan de ser fuertes para sus hijos y para otros, sienten desesperación en los momentos en los que están solos. Muchos dijeron que se sienten estresados y ansiosos y tienen problemas para dormir por la noche. También dijeron que muchos de sus hijos tienen miedo cada vez que llueve. Varios también se vieron afectados por las muertes que presenciaron o conocieron como resultado de la tormenta.

LA VIDA DOS MESES DESPUÉS DE LA TORMENTA

La vida cotidiana sigue siendo muy difícil y alterada dos meses después de la tormenta. Los participantes dijeron que algunas necesidades básicas todavía no se han abordado. La mayoría sigue sin electricidad, y donde la corriente ha regresado, sigue siendo impredecible. También señalaron los continuos desafíos para acceder a agua y gasolina, y señalaron que el servicio de celulares y las comunicaciones siguen siendo limitadas en toda la isla. Los participantes describieron las luchas de la vida cotidiana sin electricidad, señalando que no pueden mantener alimentos frescos, no pueden cocinar dentro de su casa y/o usar su lavadora. Hicieron hincapié en que no hay alivio para el calor y los mosquitos, y para el constante ruido y la contaminación del aire de los generadores. También dijeron que aún hay importantes congestiones de tránsito y retrasos en las carreteras debido a que los semáforos no funcionan.

Las rutinas diarias de los participantes permanecen interrumpidas. Algunos todavía están desplazados de sus hogares o tienen a familiares o amigos desplazados viviendo con ellos. Algunos niños regresaron a la escuela, pero muchas operan con horarios más cortos. Algunos participantes han regresado al trabajo, pero algunos pasaron muchos días sin trabajar o perdieron sus trabajos. Destacaron que muchos trabajos no están disponibles en este momento debido a la falta de energía eléctrica. Además, es más difícil para los padres trabajar dado el horario escolar más limitado.

OPINIONES SOBRE LOS ESFUERZOS DE RECUPERACIÓN

Los participantes consideran que los esfuerzos de recuperación han sido lentos y que las brechas importantes en las necesidades básicas permanecen dos meses después de la tormenta. No sintieron que el presidente Trump haya brindado mucha ayuda o respeto al pueblo de Puerto Rico. Dijeron que la asistencia de FEMA ha sido lenta y no ha estado bien dirigida. Algunos sintieron que FEMA está actuando con lentitud debido a que los fondos de FEMA fueron mal utilizados por algunas personas después de una tormenta anterior. Además, muchos pensaron que el gobierno local está complicando y ralentizando los esfuerzos de recuperación.

PENSAMIENTOS SOBRE EL FUTURO

Los participantes creen que la isla se recuperará, pero que llevará mucho tiempo, probablemente muchos años. Sienten que aún hay grandes necesidades en toda la isla, pero que no hay suficiente reconocimiento de la continua necesidad y sufrimiento. Muchos señalaron que siguen comprometidos con permanecer en la isla y en la recuperación, a pesar de que quedarse es difícil. Otros se van porque ya no pueden encontrar empleo para mantenerse. Muchos tienen familiares y amigos que ya han abandonado la isla. Los participantes desean más transparencia e información sobre los esfuerzos de recuperación, en particular, sobre adónde se dirigen los fondos y los suministros. También creen que el pueblo de Puerto Rico tiene un papel que desempeñar en la recuperación, y que no pueden simplemente sentarse y esperar la asistencia.

CONCLUSIÓN

Estos hallazgos muestran que el huracán María fue un evento aterrador y traumático para muchos puertorriqueños. Muchos sufrieron daños significativos en sus hogares y propiedades, algunos lo perdieron todo y muchos luchan contra los efectos mentales y emocionales de la tormenta y sus pérdidas. Dos meses después de la tormenta, las personas seguían enfrentando desafíos para satisfacer las necesidades básicas, y la vida cotidiana seguía siendo extremadamente difícil debido a la falta de electricidad y las limitadas opciones de trabajo. Las personas sienten que los esfuerzos de recuperación han sido lentos e insuficientes y han enfatizado que la isla aún necesita ayuda y recursos sustanciales para recuperarse. A pesar de estos desafíos, muchos creen que Puerto Rico se recuperará, aunque reconocen que la recuperación demorará muchos años y creen que las mismas personas tienen un papel importante que desempeñar en la recuperación.

Apéndice 1: Métodos

Los grupos de discusión y las entrevistas se realizaron en español e inglés en San Juan y Ponce, Puerto Rico, los días 18 y 19 de noviembre de 2017. La Kaiser Family Foundation trabajó con Perry Undem Research/Communication para conducir los grupos focales y las entrevistas. Este resumen destaca las experiencias de los participantes durante e inmediatamente después de la tormenta, y cómo les está yendo dos meses después de la tormenta. También proporciona una visión general de sus pensamientos sobre los esfuerzos de recuperación y sus reflexiones sobre el futuro para ellos y para la isla.

Hurricane Maria hit on September 20^th, less than two weeks after Hurricane Irma hit on September 6, 2017, causing significant physical damage to the infrastructure (including health care infrastructure) in Puerto Rico and the US Virgin Islands (USVI).  These hurricanes left major challenges for residents and severe economic damage and health consequences in their wakes.  The problems wrought by the storms exacerbate pre-existing fiscal and health challenges faced by these territories. One of the major financing issues for the territories is how to respond given the cap on federal Medicaid financing coupled with the end of the additional funding provided through the Affordable Care Act (ACA).  This brief identifies key issues and short and long-term options for recovery in Puerto Rico and USVI drawn from research and from a November 30^th roundtable discussion held at the Kaiser Family Foundation in Washington, DC with individuals representing a variety of perspectives on Medicaid policy, health insurance and care delivery systems, and disaster recovery.  The roundtable discussion was focused on Medicaid’s role in Puerto Rico and USVI and as part of the hurricane recovery efforts.

Key challenges in Puerto Rico and USVI Pre-Hurricanes

The Territory Clause of the U.S. Constitution authorizes Congress to treat territories differently than states under federal laws and programs as long as there is a “rational basis” for the differential treatment. Federal law provides that residents of the territories are generally not required to pay federal tax; however, the territories have special rules regarding Medicaid, Medicare and SSI.¹ 

Fiscal Challenges

Prior to the hurricanes, Puerto Rico and USVI had fiscal challenges.  In Puerto Rico, 44% of the population has incomes below poverty and the unemployment rate is 14% (compared to 14% below poverty and 5% unemployment in the US).  (Appendix Table 1).  In response to the economic crisis in Puerto Rico, Congress passed the Puerto Rico Oversight, Management and Economic Stability Act (PROMESA) in June 2016 to allow Puerto Rico to restructure its debts.  PROMESA created the Financial Oversight and Management Board (FOMB) that was required to approve a fiscal plan developed by the governor.  Prior to the hurricane there was tension between the governor and the FOMB about the severity and implementation of austerity measures.² ,³   Prior to the hurricanes, Congress approved $296 million in additional Medicaid funding for Puerto Rico as part of the Consolidated Appropriation Act of 2017.  Before the hurricanes, there was an out flow of working people from Puerto Rico.  Population peaked in 2004 at 3.8 million and has decreased annually since then (by 9.2% through 2015).⁴  In USVI, 22% of the population lives in poverty and the unemployment rate is 13%. Prior to the hurricanes, the local treasury had barely enough cash to keep the government funded for three days and debt had grown so large that Wall Street stopped lending it money.⁵ 

Health Challenges

Higher shares of the population in Puerto Rico have fair / poor health or other health conditions compared to other territories and the rest of the United States.  Roughly one third of adults report fair or poor health in Puerto Rico (34%) a much higher share compared to the 50 states and DC (18%) and USVI (20%).  The population in Puerto Rico has a higher share of heart attack/heart disease, diabetes, depression, disability, low-birthweight infants and a higher infant mortality rate than the US overall (or the USVI).  (Appendix Table 1).  The HIV death rate in Puerto Rico was nearly four times higher than that of the U.S. overall, and the number of people living with HIV in Puerto Rico in 2014 was estimated at 17,072, one of the highest rates of people living with HIV per 100,000 in the U.S.⁶   Puerto Rico has also seen outbreaks of mosquito-borne viral diseases over the last several years, including dengue, chikungunya, and Zika. The majority (84%) of all U.S. Zika cases were reported in Puerto Rico.⁷  Officials declared that the Zika epidemic was over in May 2017 due to declining cases, but with the new conditions, potential for further disease outbreaks exist.  Compared to Puerto Rico, fewer adults report fair or poor health, depression and heart attack/ disease in USVI; however, the share of uninsured (30%) in USVI is much higher than in Puerto Rico (7%) and the rest of the United States (12%).

Infrastructure and Workforce Challenges

Prior to the hurricane, Puerto Rico suffered from poor health infrastructure, declining health care workforce and health indicators that lagged behind those in the rest of the United States.  In 2015 alone, approximately 500 physicians left leaving the island with less than half the emergency physicians as well as other key specialists compared to the availability of these providers on the rest of the U.S.⁸  As a result, there are long wait times to access care and individuals are less likely to receive preventive care and screenings.  The Health Resources and Services Administration (HRSA) has deemed 72 of Puerto Rico’s 78 municipalities as medically underserved areas.⁹  Prior to the hurricanes, USVI had two main hospitals—one on St. Croix and the other on St. Thomas built in the 1980s—and affiliated healthcare facilities.  Patients with needs that cannot be served are transferred to Puerto Rico, or mainland US (Florida, New York, Atlanta and Washington DC primarily).  The Department of Health (DOH) provides services on all three islands including Maternal and Child Health and Special Needs Programs, dental services, HIV/AIDS programs, long and short-term mental health and substance abuse services with funding from CDC and HRSA.  Federally qualified health center (FQHC) on St. Thomas and on St. Croix, each provide a large volume of primary care, dental services, and obstetrical care.¹⁰  Because USVI consists of three islands, St. Croix, St. Thomas, and St. John) it is difficult to share health care resources and services need to be available on each island.

Health Financing and Medicaid Challenges

Unlike the 50 states and D.C., annual federal funding for Medicaid in the territories is subject to a statutory cap. Once federal funds are exhausted under each territory’s cap, the territory no longer receives federal financial support for its Medicaid program during that fiscal year.  The territories receive a match rate that is fixed in statute, unlike the states where the statutory formula is adjusted annually based on a states’ relative per capita income. The ACA increased the traditional match rate from 50% to 55% for the territories (plus 2.2 percentage points for 2014 and 2015).¹¹  The ACA also provided the territories with the expansion state match rate for non-disabled adults without children (87% in 2017).¹²   As territories, Puerto Rico and USVI do not receive Disproportionate Share Hospital (DSH) payments that are used in other states to provide supplemental payments to hospitals that service a high share of Medicaid and uninsured patients.

Additional funds totaling $7.3 billion were made available to be divided across all the territories under the ACA. The $7.3 billion consists of a $6.3 billion allotment available between July 2011 and September 2019 and another $1 million for funds in lieu of creating its own Marketplace.¹³  Of the total $7.3 billion, $6.3 billion was directed to Puerto Rico and about $300 million was directed to the USVI¹⁴ .  In Puerto Rico, ACA funding was the largest source of Medicaid spending (beyond the Medicaid allotment ceiling and spending by Puerto Rico).  Based on projections from May 2017 (prior to the hurricanes), Puerto Rico expected to exhaust ACA funding in FY 2018 leaving a $877 million gap in funding (Figure 1).¹⁵  So, even before the hurricane, Medicaid financing was in peril.  Prior to the hurricanes, estimates showed that as the current rate of spending, it was unlikely that USVI would exhaust ACA related funds before their expiration in September and December 2019.¹⁶ 

Funding for Medicare is limited in the territories, and individuals in the territories are not eligible for SSI benefits.  Under federal law, individuals are not automatically enrolled in Medicare Part B.  As a result, many fail to enroll, and are subject to a late-enrollment penalty. There are no Medicare Savings Programs (MSP) in the territories that help low-income individuals with some of the out-of-pocket costs for Medicare, so many cannot afford Medicare Part B.  Cost-sharing assistance for Medicare enrollees in the territories is limited to individuals dually eligible for full Medicaid and Medicare benefits (not to partial duals in Medicare Savings Programs).  In Puerto Rico, nearly all dual eligible are enrolled in Medicare Platino, a Medicare Advantage special needs plan that covers Medicare Part A and B services as well as outpatient prescription drugs. Residents of the territories are not eligible for the low-income subsidies (LIS) to help pay for Medicare Part D (prescription drugs).  Instead, federal law provides a fixed amount of funding to each territory to provide Medicaid coverage of prescription drugs for low-income Medicare beneficiaries, provided under Section 1935(e) of the Social Security Act, and called the enhanced allotment program (EAP). Annual EAP funding is estimated to be significantly less than funding that would be received under the LIS.¹⁷ 

In addition, individuals in the territories are not eligible for Supplemental Security Income (SSI) benefits, but receive some aid through a grant (Aid to the Aged, Blind and Disabled, or AABD) program that requires matching funds from Puerto Rico.  According to GAO, an estimated 300,000 to 350,000 individuals would receive benefits (compared to 34,000-38,000 under AABD), and the average monthly benefit would be around $540 (compared to $74-$77 under AABD); SSI payments to beneficiaries are estimated to be between $1.5 billion and $1.8 billion per year in federal funding with no local matching fund requirement (compared to the current $24-$26 million under AABD).¹⁸ 

What was the impact of the hurricanes in Puerto Rico & USVI?

Hurricanes Maria and Irma significantly damaged key transportation, communication, and electricity infrastructure in Puerto Rico and USVI that have exacerbated fiscal and health challenges that predated the storms. More than two months after the hurricanes, power, water, and cell service are not available to many in Puerto Rico and USVI.  The ongoing power outage in Puerto Rico has been named the “largest blackout in American history”.¹⁹   Official estimates show that 64 people died as a result of the hurricane in Puerto Rico, but more recent analysis points to more than 1,000 hurricane related deaths 42 days after the storms.²⁰  The public health challenges are immense in Puerto Rico, as well as USVI, including the potential for the spread of infectious diseases due to unsafe living conditions, difficulties accessing health care services and needed medications, increasing mortality from unaddressed health care needs, and widespread mental health issues.  The hurricanes exacerbated the pre-hurricane trends in out migration of working age people and physicians.  In testimony to Congress on November 14, 2017, the Governors of Puerto Rico and USVI estimated hurricane damages of up to $95 billion in Puerto Rico and $7.5 billion in USVI.²¹ 

Health care infrastructure was badly damaged by the hurricanes.  In Puerto Rico, hospitals and other health care infrastructure suffered extensive damage from the storm. In the immediate aftermath of the hurricane Maria, most hospitals were left without electricity and with limited access to generators and the fuel needed to run them. More than two months after the storm, 4 in 10 hospitals and many dialysis centers are still running on generators rather than regular electric power. However, some at the roundtable noted that generators need maintenance and diesel and were not designed to be long-term power substitutes.  Given the high burden of diabetes in Puerto Rico, dialysis centers are an important part of the health care system. Community health centers (CHCs) have also been affected by the storm. While nearly all of the 93 health center sites on the island were open as of November 17, almost half (47%) are operating with generators or still do not have power. As a result, some have been forced to limit hours of operation and services. For USVI, Governor Kenneth Mapp testified on November 14, 2017 that Hurricanes Irma and Maria completely devastated critical health care infrastructure, destroying two main hospitals and affiliated healthcare facilities leaving many residents without access to critical care and requiring dialysis patients to be flown to the states for care.²² 

The hurricanes puts further stress on Medicaid funding limits and has quickened the pace to exhaust available ACA funding.  As noted above, before the hurricanes hit, Puerto Rico estimated that the ACA funding would be exhausted in FY 2018 leaving cliffs in federal funding when a greater response is needed.  USVI reported that the hurricanes have resulted in an increase in demand for Medicaid as well as for reimbursement from states providing services to displaced Virgin Islands residents.²³  The economic damage from the hurricanes has also made it difficult for Puerto Rico and USVI to meet the state matching requirements to draw down federal Medicaid dollars.

Navigating Recovery in Puerto Rico and US Virgin Islands

As policy makers debate legislation and implement strategies to address the short and long-term recovery needs in Puerto Rico and USVI, most of the public (63 percent) say they are closely following news about the recovery effort. An increasing share say that people in Puerto Rico are not yet getting needed help (70 percent up from 62 percent last month) although these views vary considerably by party.  On this point, most Republicans (63 percent) feel the federal government is doing enough, while majorities of independents (59 percent) and Democrats (86 percent) feel it is not.  In addition, the response to the crisis varies across Puerto Rico with more assistance and progress in urban centers compared to rural areas.

What Help Has Been Provided To Date?

To date, there has been legislative action to provide funding and administrative actions through FEMA and HHS. 

Legislative Actions:  To date, two aid packages have passed to provide hurricane relief totaling just over $50 million (this funding was for aid beyond Puerto Rico and USVI).²⁴  On November 17, 2017 the White House asked Congress for an additional $44 billion for disaster relief from recent hurricanes, but also called for spending cuts to offset disaster costs.²⁵   Puerto Rico has also requested legislation to address the cliff in Medicaid funding when the ACA related funds are exhausted.  The bill passed by the House to reauthorize CHIP included $1 billion Medicaid funding for Puerto Rico and USVI, but has not been acted on in the Senate.

FEMA Actions:  The Federal Emergency Management Agency (FEMA) along with federal and local partners, works to help prepare and respond to disasters.  In Puerto Rico, following Hurricane Maria, FEMA has primarily been working to gain stability in five critical areas: delivering meals and water to communities in need, restoring power, maintaining a sound medical support structure, and protecting property against further damage from wind and rain.²⁶   The US Army Corps of Engineers is posting daily progress reports measuring costs and personnel on the ground as well as statistics related to temporary roofing, emergency power, debris management, facilities assessment, and additional details about the power grid repair in Puerto Rico.²⁷   On November 27, 2017 FEMA announced that activities in Puerto Rico will begin to transition from the response phase to recovery.  These efforts will be led by different agencies across the federal government and will focus on housing, infrastructure systems, economic recovery, health and social services, natural and cultural resources and community planning and capacity building.²⁸ 

HHS Actions:  In October, the HHS Assistant for Preparedness and Response reported that federal partners were working with the Puerto Rico Department of Health and local hospitals to “save lives, stabilize the health care infrastructure, and restore health care services.”²⁹   Activities have included efforts to dispatch medical equipment, supplies and personnel from our National Disaster Medical System and U.S. Public Health Service; in the first 30 days, HHS, along with the Departments of Defense (DoD) and Veterans Affairs (VA) collectively cared for over 8,700 patients in Puerto Rico.³⁰   Federal teams are working with medical volunteers from New York hospitals – under an emergency medical assistance compact that is an agreement between Departments of Health in New York and Puerto Rico.³¹   In both Puerto Rico and USVI the federal government has activated the Emergency Prescription Assistance Program, which pays for prescription medications for people without health insurance who are affected by disasters.

What are the Limitations of Federal Financing?

Historically, territories have exceeded their allotted Medicaid funding ceilings each year. As noted above, the ACA funding has provided additional federal support for health coverage, but even before the hurricanes Puerto Rico and other territories were anticipating gaps in health spending as these funds are exhausted or expire.  The hurricanes have increased demand for Medicaid but also made it difficult for Puerto Rico and USVI to fund their Medicaid matching share.

Financing caps may make it difficult to use Medicaid waivers to assist Puerto Rico and USVI.  In other emergencies, the Administration has been able to grant Medicaid waivers to simplify and streamline enrollment processes, expand eligibility for coverage and provide funds for uncompensated care.  Such actions were taken following Hurricanes Katrina and Rita, and in responding to the 9/11 crisis in New York and the water crisis in Flint, Michigan. Most recently, Texas received some waivers to provide a six-month extension of eligibility for those enrolled in Medicaid and CHIP in FEMA-declared disaster counties and Texas also waived co-payments for CHIP covered services from August 25 through November 30, 2017, including pharmacy, for CHIP members with a permanent address in one of the Hurricane Harvey FEMA-declared disaster counties.³²  However, the block-grant financing structure of Medicaid in Puerto Rico does not allow for similar Medicaid response through waivers in Puerto Rico.  So, there are limited ways in which Medicaid can be used through administrative actions to provide short-term assistance.

Other federal funding for DSH, Medicare and SSI is also restricted in the territories.  Limited federal funds for hospital DSH payments, Medicare Part B and Part D financing and SSI benefits put further strain on the overall health care system.  Addressing these issues could provide additional health care resources beyond changes in Medicaid financing caps and match rates.

Options to Address health care needs:  Reflections from the RoundTable

Much of the November 30 roundtable discussion focused on identifying options to address short and longer-term health care needs in Puerto Rico and USVI.  However, there was a strong recognition that it would be necessary to both address pre-existing fiscal debt challenges as well as economic damages related to the storms to secure a sustainable economic future in Puerto Rico and USVI.  Building a strong health care system with adequate financing was identified as key for economic development on the islands.

• Provide economic and fiscal stability for Puerto Rico and USVI going forward. Short-term financing to address damages related to the storms is critical.  However, this short-term funding will not address the underlying fiscal issues tied to the debt-burden that will be needed for longer-term stability.  Improving economic stability is important to efforts to stem the flow of out migration and incentivize working people to remain or return to Puerto Rico.  Although difficult, participants at the round table underscored the importance of focusing simultaneously on short-term as well as longer term financing relief.  Strategies to address economic development are key in addressing long-term financing issues.
• Address Medicaid financing caps and matching requirements. The capped Medicaid financing structure and limit on federal matching funds contributes to broader financing problems in Puerto Rico and USVI and constrains better health care coverage and access.  In the near-term, some participants at the roundtable noted that increased Medicaid financing, without a federal matching requirement (similar to emergency relief after Katrina) could provide support to Puerto Rico and USVI, while legislation to change the cap and match rate are longer-term issues.  Overall health care funding efforts could also include support for disproportionate share payments, Medicare (Medicare Savings Programs and low-income subsidy funding) as well as funding for SSI.
• Provide support to promote health care delivery system improvements as well as improvements to health capacity (infrastructure and workforce). In the short-term, additional funding can be used to help finance community health centers and other local providers.  Some at the roundtable supported changes in emergency response that would automatically trigger increased funding for clinics in disasters.  More broadly, access to care and public health measures are lagging in both Puerto Rico and USVI.  Changes to financing can help increase resources, but other changes such as a targeted focus on capacity (in terms of infrastructure and health care work force) are interconnected; it is difficult to attract providers without facilities to support their practice.  Consideration of new models of care that may rely on electronic health records or tele-health may offer promise to improve health care systems and outcomes is important in plans to build capacity.
• Engage philanthropy and non-profits to work in conjunction with the federal and territory governments to make progress. Those experienced in disaster recovery noted the importance of a local foundation that can bring together governments, private sector, local communities and non-profits to help direct and organize relief and recovery efforts and to marshal funds from many sources.  There may be a lot of paperwork to access federal funds.  Ultimately, local leader should be working side-by-side with federal and other entities to help direct relief and recovery efforts.

Conclusion

The recent hurricanes brought light to the pre-existing economic and health issues in Puerto Rico and USVI.  Fiscal and health challenges have been exacerbated over the years by differential treatment across many federal programs; however, the capped financing and limited federal match rate for Medicaid stand out as key contributors to both the fiscal crisis and a struggling health care system.  The hurricanes resulted in widespread damage to the infrastructure (including health care infrastructure) as well as severe economic damage, health consequences and many deaths.  Research and input from a roundtable discussion point to a number of options to address the short and longer-term needs of residents in Puerto Rico in USVI.  Such options include: funding and support to provide economic and fiscal stability; options to address the Medicaid funding disparities (as well as Medicare and SSI); initiatives to support health capacity through infrastructure and workforce development efforts, and new opportunities to engage philanthropy and non-profits to work with the federal and territory governments to make progress toward recovery and stability.

1. Congressional Task Force on Economic Growth in Puerto Rico, Report to the House and Senate, December 20, 2016, https://www.finance.senate.gov/imo/media/doc/Bipartisan%20Congressional%20Task%20Force%20on%20 Economic%20Growth%20in%20Puerto%20Rico%20Releases%20Final%20Report.pdf. ↩︎
2. Peter Shin, Jessica Sharac, Marie Nina Luis, and Sara Rosenbaum, Puerto Rico’s Community Health Centers in a Time of Crisis, (Washington, DC: The George Washington University, Milken Institute School of Public Health, Department of Health Policy and Management, December 2015), https://publichealth.gwu.edu/sites/default/files/downloads/GGRCHN/Policy%20Research%20Brief%2043.pdf. ↩︎
3. Richard V. Reeves and Katherine Guyot, Keeping our PROMESA: What the U.S. can do about Puerto Rico’s Fiscal Crisis, (Washington, DC: The Brookings Institution, September 2017), https://www.brookings.edu/research/keeping-our-promesa-what-the-u-s-can-do-about-puerto-ricos-fiscal-crisis/. ↩︎
4. Congressional Task Force on Economic Growth in Puerto Rico, Report to the House and Senate, December 20, 2016, https://www.finance.senate.gov/imo/media/doc/Bipartisan%20Congressional%20Task%20Force%20on%20 Economic%20Growth%20in%20Puerto%20Rico%20Releases%20Final%20Report.pdf. ↩︎
5. Jeremy W. Peters, “In the Virgin Islands, Hurricane Maria Drowned What Irma Didn’t Destroy,” New York Times (September 27, 2017), https://www.nytimes.com/2017/09/27/us/hurricane-maria-virgin-islands.html. ↩︎
6. Josh Michaud and Jennifer Kates, Public Health in Puerto Rico after Hurricane Maria, (Washington, DC: Kaiser Family Foundation, November 2017), https://modern.kff.org/other/issue-brief/public-health-in-puerto-rico-after-hurricane-maria/. ↩︎
7. Ibid. ↩︎
8. “Evidence Indicates a Range of Challenges for Puerto Rico Health Care System,” U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Planning and Evaluation (ASPE), January 2017, https://gonzalez-colon.house.gov/sites/gonzalezcolon.house.gov/files/wysiwyg_uploaded/Puerto%20Rico%20Assessment–Embargoed.pdf. ↩︎
9. Ibid. ↩︎
10. “Virgin Islands Health Information Exchange Strategic & Operational Plan”, Response to Health Information Technology State Grant Program, January 15, 2011.  https://www.healthit.gov/sites/default/files/usvi-hie-sop_12-15-11.pdf ↩︎
11. “Puerto Rico Medicaid and CHIP Program Information,” Centers for Medicare and Medicaid Services (CMS), accessed November 21, 2017, https://www.medicaid.gov/medicaid/by-state/puerto-rico.html. ↩︎
12. “Medicaid and CHIP in Puerto Rico,” Medicaid and CHIP Payment and Access Commission (MACPAC), October 2017,   https://www.macpac.gov/publication/medicaid-and-chip-in-puerto-rico/. ↩︎
13. The additional Marketplace funds are also available through FY 2019 and can only be accessed after the first source of ACA funding has been depleted. ↩︎
14. “Medicaid Financing and Spending in Puerto Rico,” Medicaid and CHIP Payment and Access Commission (MACPAC), August 2017, https://www.macpac.gov/publication/medicaid-financing-and-spending-in-puerto-rico/ and “Medicaid Financing and Spending in the US Virgin Islands,” Medicaid and CHIP Payment and Access Commission (MACPAC), August 2017, https://www.macpac.gov/publication/medicaid-and-chip-in-the-u-s-virgin-islands/. ↩︎
15. “Medicaid Financing and Spending in Puerto Rico,” Medicaid and CHIP Payment and Access Commission (MACPAC), August 2017, https://www.macpac.gov/publication/medicaid-financing-and-spending-in-puerto-rico/. ↩︎
16. Medicaid Financing and Spending in the US Virgin Islands,” Medicaid and CHIP Payment and Access Commission (MACPAC), August 2017, https://www.macpac.gov/publication/medicaid-and-chip-in-the-u-s-virgin-islands/. ↩︎
17. Congressional Task Force on Economic Growth in Puerto Rico, Report to the House and Senate, December 20, 2016, https://www.finance.senate.gov/imo/media/doc/Bipartisan%20Congressional%20Task%20Force%20on%20 Economic%20Growth%20in%20Puerto%20Rico%20Releases%20Final%20Report.pdf. ↩︎
18. Congressional Task Force on Economic Growth in Puerto Rico, Report to the House and Senate, December 20, 2016, https://www.finance.senate.gov/imo/media/doc/Bipartisan%20Congressional%20Task%20Force%20on%20 Economic%20Growth%20in%20Puerto%20Rico%20Releases%20Final%20Report.pdf. ↩︎
19. Trevor Houser and Peter Marsters, America’s Biggest Blackout, (New York, NY: Rhodium Group, October 2017), http://rhg.com/notes/americas-biggest-blackout. ↩︎
20. Frances Robles, Kenan Davis, Sheri Fink, and Sara Almukhtar, “Official Toll in Puerto Rico: 64. Actual Deaths May Be 1,052,” New York Times (December 9, 2017), https://www.nytimes.com/interactive/2017/12/08/us/puerto-rico-hurricane-maria-death-toll.html?_r=0. ↩︎
21. United States Senate, Committee on Energy and National Resources Hearing, Hurricane Recovery Efforts in Puerto Rico and the U.S. Virgin Islands, November 14, 2017, statement of Hon. Ricardo Rosselló, Governor of Puerto Rico, https://www.energy.senate.gov/public/index.cfm/files/serve?File_id=EFF569D6-FA29-414D-9538-E4B9D02D6F43; United States Senate, Committee on Energy and National Resources Hearing, Hurricane Recovery Efforts in Puerto Rico and the U.S. Virgin Islands, November 14, 2017, statement of Kenneth E. Mapp, Governor of U.S. Virgin Islands, https://www.energy.senate.gov/public/index.cfm/files/serve?File_id=A2538A49-2953-4BA1-8C94-0807E62050A5. ↩︎
22. United States Senate, Committee on Energy and National Resources Hearing, Hurricane Recovery Efforts in Puerto Rico and the U.S. Virgin Islands, November 14, 2017, statement of Kenneth E. Mapp, Governor of U.S. Virgin Islands, https://www.energy.senate.gov/public/index.cfm/files/serve?File_id=A2538A49-2953-4BA1-8C94-0807E62050A5. ↩︎
23. Ibid. ↩︎
24. H.R. 569/H.R. 2266: Congress passes $36.5 billion aid package on 10/24/17. Signed by President on 10/26/17. (https://www.congress.gov/bill/115th-congress/house-bill/2266/actions) and H.R. 601: Congress passes $15 billion in hurricane relief on 9/8/2017. Signed by President on 9/8/2017. (https://www.congress.gov/bill/115th-congress/house-bill/601/actions). ↩︎
25. Thomas Kaplan, “White House Requests More Disaster Aid but Also Seeks Cuts as Deficits Rise,” New York Times (November 17, 2017), https://www.nytimes.com/2017/11/17/us/politics/trump-disaster-relief-hurricanes-wildfire-tax-cuts.html?_r=0. ↩︎
26. “Hurricane Maria Update,” Federal Emergency Management Agency (FEMA), October 19, 2017, https://www.fema.gov/news-release/2017/10/19/4339/hurricane-maria-update. ↩︎
27. “Hurricane Irma and Maria Response,” U.S. Army Corps of Engineers, November 15, 2017, http://www.usace.army.mil/Hurricane-Irma/Daily-Progress-Graphic/. ↩︎
28. “Puerto Rico Begins the Transition from Response to Recovery,” Federal Emergency Management Agency (FEMA), November 27, 2017, https://www.fema.gov/news-release/2017/11/27/4339/puerto-rico-begins-transition-response-recovery. ↩︎
29. Robert Kadlec, “Providing Care and Restoring Health Services in Puerto Rico,” U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR) Blog, October 19, 2017, https://www.phe.gov/ASPRBlog/pages/BlogArticlePage.aspx?PostID=286. ↩︎
30. Ibid. ↩︎
31. Robert Kadlec, “Providing Care and Restoring Health Services in Puerto Rico,” U.S. Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR) Blog, October 19, 2017, https://www.phe.gov/ASPRBlog/pages/BlogArticlePage.aspx?PostID=286; “HHS Activates Aid for Uninsured U.S. Islands Residents Needing Medicine,” U.S. Department of Health and Human Services (HHS), November 2, 2017, https://www.hhs.gov/about/news/2017/11/02/hhs-activates-aid-uninsured-us-virgin-islands-residents-needing-medicine.html. ↩︎
32. “Hurricane Harvey Medicaid and Children’s Health Insurance Program (CHIP) Frequently Asked Questions,” Texas Health and Human Services Commission, November 22, 2017, https://apps.hhs.texas.gov/documents/hurricane-harvey-faq.pdf. ↩︎
33. The World Factbook, 2017. Washington, DC: Central Intelligence Agency, Accessed November 2017, https://www.cia.gov/library/publications/the-world-factbook/index.html. ↩︎
34. 50 States and DC and Puerto Rico Estimates: U.S. Census Bureau; 2016 American Community Survey 1-Year Estimates, Table S0501; using American FactFinder, http://factfinder.census.gov. U.S. Virgin Islands Estimates: U.S. Census Bureau; 2010 Census of the Island Areas, Table DP-2; using American FactFinder, http://factfinder.census.gov. ↩︎
35. The World Factbook, 2017. Washington, DC: Central Intelligence Agency, Accessed November 2017, https://www.cia.gov/library/publications/the-world-factbook/index.html. ↩︎
36. 50 States and DC and Puerto Rico Estimates: U.S. Census Bureau; 2016 American Community Survey 1-Year Estimates, Table B03002; using American FactFinder, http://factfinder.census.gov. U.S. Virgin Island Estimates: U.S. Census Bureau; 2010 Census of the Island Areas, Table DP-1; using American FactFinder, http://factfinder.census.gov. ↩︎
37. The World Factbook, 2017. Washington, DC: Central Intelligence Agency, Accessed November 2017, https://www.cia.gov/library/publications/the-world-factbook/index.html. ↩︎
38. 50 States and DC and Puerto Rico Estimates: U.S. Census Bureau; 2016 American Community Survey 1-Year Estimates, Table DP03; using American FactFinder, http://factfinder.census.gov. U.S. Virgin Island Estimates: U.S. Census Bureau; 2010 Census of the Island Areas, Table DP-3; using American FactFinder, http://factfinder.census.gov. ↩︎
39. Reported for adults 18 and older. Kaiser Family Foundation analysis of the 2016 Behavioral Risk Factor Surveillance System. ↩︎
40. Birth Rate and Life Expectancy Estimates: The World Factbook, 2017. Washington, DC: Central Intelligence Agency, Accessed November 2017, https://www.cia.gov/library/publications/the-world-factbook/index.html. Other Health Status Estimates: Reported for adults 18 and older. Kaiser Family Foundation analysis of the 2016 Behavioral Risk Factor Surveillance System. ↩︎

Immigration policy has been and continues to be a controversial topic in the U.S. Over the course of the election and since taking office, President Trump has intensified national debate about immigration as he has implemented policies to enhance immigration enforcement and restrict the entry of immigrants from selected countries the Administration believes may pose a threat to the country. The climate surrounding these policies and this debate potentially affect 23 million noncitizens in the U.S., including both lawfully present and undocumented immigrants, many of whom came to the U.S. seeking safety and improved opportunities for their families.¹  They also have implications for the over 12 million children who live with a noncitizen parent who are predominantly U.S-born citizen children.²  We conducted focus groups with 100 parents from 15 countries and 13 interviews with pediatricians to gain insight into how the current environment is affecting the daily lives, well-being, and health of immigrant families, including their children. Key findings include:

For #immigrant families, increased fears are having significant negative effects on the health and well-being of #children.

Immigrant families, including those with lawful status, are experiencing resounding levels of fear and uncertainty. Fears affected participants across backgrounds and locations, with particularly pronounced effects for Latinos and Muslims. Undocumented parents fear being deported and separated from their children while many of those with lawful status feel uncertain about their status and worry they may lose their status or permission to remain in the U.S. These feelings of uncertainty escalated after rescission of the Deferred Action for Child Arrivals (DACA) program in September 2017. Parents said that although they try to shield their children from these issues, many children are hearing about them at school and fear potentially losing their parents to deportation or having to leave the U.S., the only home many have ever known.

Parents and pediatricians said that racism and discrimination, including bullying of children, have significantly increased since the election. Many felt that Latinos and Muslims have been the primary targets of increased racism and discrimination. They also noted that the increased bullying of children in schools extends beyond immigrants to children of color, regardless of their immigration status.

Daily life has become more difficult for immigrant families due to increased fear and uncertainty. Some parents said that it is harder to find employment in the current environment, further increasing financial strains on families. Increased fears also are affecting some families’ daily routines. Some parents, particularly those who are undocumented or who have an undocumented family member, said they are only leaving the house when necessary, such as for work; limiting driving; and no longer participating in recreational activities, like visiting their local park. As a result, they and their children are spending long hours in the house behind locked doors. Parents also indicated that they and their children are increasingly fearful of interacting with police or authorities.

Most parents said they are continuing to access health care for their children and maintaining their children’s Medicaid and CHIP coverage, but there were some reports of changes in health care use and decreased participation in programs. Parents note that they highly prioritize their children’s health and generally view hospitals and doctors’ offices as safe spaces. However, there were some reports of changes in health care use, including decreased use of some care, and decreased participation in Medicaid and CHIP and other programs due to increased fears.

Increased fears are having significant negative effects on the health and well-being of children that have lifelong consequences. Parents and pediatricians reported that children are manifesting fears in many ways. They described behavioral changes, such as problems sleeping and eating; psychosomatic symptoms, such as headaches and stomachaches; and mental health issues, such as depression and anxiety. Parents and pediatricians also felt that fears are negatively affecting children’s behavior and performance in school. Pediatricians uniformly expressed significant concerns about the long-term health consequences of the current environment for children. They pointed to longstanding research on the damaging effects of toxic stress on physical and mental health over the lifespan. They also expressed concerns about negative effects on children’s growth and development, and felt that the current environment is compounding social and environmental challenges that have negative impacts on health.

Together these findings show that immigrant families across different backgrounds and locations are feeling increased levels of fear and uncertainty amid the current climate, and that these feelings extend to those with lawful status. The findings show that these fears are having broad effects on the daily lives and routines of some immigrant families. In addition, they point to long-term consequences for children in immigrant families, including poorer health outcomes over the lifespan, compromised growth and development, and increased challenges across social and environmental factors that influence health.

Introduction

Immigration policy has been and continues to be a controversial topic in the U.S. Over the course of the election and since taking office, President Trump has intensified national debate about immigration as he has implemented policies to enhance immigration enforcement and restrict the entry of immigrants from selected countries the Administration believes may pose a threat to the country (Appendix 1). The climate surrounding these policies and this debate potentially affect 23 million noncitizens in the U.S., including both lawfully present and undocumented immigrants, many of whom came to the U.S. seeking safety and improved opportunities for their families.³  They also have implications for the over 12 million children who live with a noncitizen parent, who are predominantly U.S-born citizen children.⁴  This brief provides insight into how the current environment is affecting the daily lives, well-being, and health of immigrant families, including their children. The findings are based on focus groups with 100 parents in immigrant families from 15 countries and telephone interviews with 13 pediatricians who serve immigrant communities.

Methods

During Fall 2017, the Kaiser Family Foundation worked with PerryUndem Research/Communication to conduct focus groups with 100 parents in immigrant families. Focus group participants were selected to represent a range of races/ethnicities, countries of origin, and immigration statuses and to provide for geographic diversity of experiences. A total of 10 focus groups were conducted in 8 cities in 4 states (Chicago, Illinois; Boston, Massachusetts; Bethesda, Maryland; and Anaheim, Fresno, Los Angeles, Oakland, and San Diego, California). In addition, 13 telephone interviews were conducted with pediatricians and clinics serving immigrant families. With assistance from the American Academy of Pediatrics, pediatricians were identified who serve different immigrant populations across a range of states (Arkansas, California, District of Columbia, Illinois, Minnesota, North Carolina, Pennsylvania, Texas, and Vermont). The Blue Shield of California Foundation supported the focus groups and interviews conducted in California.

Focus groups were conducted in 5 languages with parents from 15 countries of origin. There were six Spanish-speaking focus groups with parents from Mexico, the Caribbean, and Central and South America; one group with Korean parents; one group with Portuguese-speaking parents from Brazil and Cape Verde; one group with Farsi-speaking parents from Afghanistan; and one group with Arabic-speaking parents from Iraq, Egypt, and Syria. Participants included individuals with a range of immigration statuses, including undocumented individuals, refugees/asylees, and lawful permanent residents (“green card” holders). (See Appendix 2 for an overview of selected immigration statuses.) Four of the groups were held in focus group facilities; the remaining six groups were organized and held in community-based organizations serving the community. Since participants in the groups hosted by community-based organizations were often receiving services through the organization, they generally were connected to more resources and more knowledgeable about their rights compared to the general community.

One-on-one telephone interviews were conducted with pediatricians. Interviewed pediatricians serve a variety of immigrant families, including Latino immigrants from Mexico and Central and South America as well as immigrants from an array of other countries and regions, including Bhutan, Burma, China, India, Korea, Myanmar, Mongolia, Vietnam, Yemen, the Democratic Republic of the Congo, Somalia, Ethiopia, Eritrea, Eastern Europe, and the Middle East.

Key Findings

Overview of Participating Parents and Their Families

Participating parents immigrated to the U.S. to escape war or gang activity in their native countries, for job and educational opportunities, and/or to reunite with family. Some parents told stories of losing loved ones to war or gang violence in their native countries and said they immigrated to the U.S. to find safety. Similarly, refugees and asylees immigrated to escape war or persecution in their native countries. Many parents also noted that their native countries have high rates of poverty, inadequate education systems, and poor job prospects, and that coming to the U.S. provides their families better educational and employment opportunities. Some participants also came to the U.S. to join other family members who had previously immigrated. Participants varied widely in their length of time in the U.S. Some have been in the U.S. for many years, while others arrived more recently. Some came to the U.S. as children and have no experience in their native countries. A number of participants, particularly refugees and asylees escaping war, expressed how grateful they were for the opportunity to be in the U.S.

Children of participating parents are mostly U.S.-born citizens. Similarly, pediatricians noted that in many families that they serve, the children are U.S. born citizens while one or both parents may be undocumented. Some parents also have older children that they brought with them to the U.S. who either have obtained status under the Deferred Action for Childhood Arrivals (DACA) program or are undocumented, and a few have children who are still in their native country. Parents noted that many of their children have never visited their native countries and that the U.S. is the only home they have known. Children of refugees and asylees include a mix of those that fled to the U.S. with their parents and younger children born in the U.S.

Finances and language barriers are a major concern for many participants. Participants generally have at least one worker in the family, often in service, construction, or landscaping jobs. Many noted that they are trying to find as much work as possible, but still are living paycheck to paycheck. They noted that the costs of rent and groceries continue to increase, making it difficult to make ends meet. Participants who arrived to the U.S. more recently, particularly those from Middle Eastern countries, described challenges assimilating to life in the U.S., noting the pressure to find employment quickly and the difficulty they face finding a job due to language and cultural barriers. Some noted that they had professional careers in their native countries and have had to work in less-skilled service jobs here in the U.S. as they become established.

Fears and Concerns Among Families

Parents and pediatricians said that fears of deportation and overall feelings of uncertainty have increased since the presidential election. Parents who are undocumented or who have an undocumented family member expressed growing fears that they will be separated from their children and/or spouse. Some also fear returning to their native country because of the violence and gang activity there. A number of participants have friends and/or family members who were recently detained or deported. They also described recent immigration raids and enforcement activity in their neighborhoods, along roadsides, and in their workplaces. One pediatrician noted that, although these fears among undocumented immigrants often are perceived to primarily affect Latinos, there are growing numbers of undocumented Asians who also are feeling increased fear.

Feelings of increased fear and uncertainty extend to those with lawful status. For example, Korean parents in Chicago and Afghan parents in Oakland said they feel having a green card is no longer sufficient and that they need to obtain citizenship to secure their status. Some said that, even with a green card, they no longer feel safe traveling out of the country because they worry that they will have problems reentering the U.S. Some parents also said that it has become more difficult to obtain citizenship since the election, and that the length of time to obtain a green card or citizenship has increased. Arabic-speaking parents and a number of pediatricians reported that refugees and asylees feel unstable and worry about whether they will be able to remain in the country. Pediatricians emphasized that refugees and asylees come from histories of government persecution and that it is difficult for them to trust that they will remain protected. In addition, some parents expressed concerns that the government might eliminate Temporary Protected Status (TPS) for people from Nicaragua, El Salvador, and Honduras.⁵  Some parents said that, although current policies have not affected them, they are worried that rules may change, causing them to lose status or permission to remain in the U.S.

Parents and pediatricians noted particular concerns among individuals that have obtained DACA. In the focus groups that were conducted prior to the rescission of DACA, parents expressed concerns about the security of DACA, fearing that it would be eliminated. In the groups conducted after the rescission of DACA, parents reported that fear and uncertainty among individuals with DACA had intensified, with many worrying about their current situation and losing hope for the future.

Parents varied in the levels of fear they felt. A variety of factors influenced the level of fear felt by parents, including their and their family members’ immigration statuses; experiences in their native countries; reasons for immigrating to the U.S.; length of time in the U.S.; the extent of diversity, support, and leadership in their local communities; and exposure to deportations and immigration raids. For example, some participants in California who were from Mexico noted a willingness to reestablish their lives in Mexico if they or a family member was deported, particularly those in San Diego who are close to the border. In contrast, participants from other countries who came to the U.S. to escape war and/or persecution said that returning to their native country is not an option. Parents who have been living in the U.S. for many years generally felt more secure than those who had arrived more recently. Parents connected to local community organizations felt they are more informed about their rights compared to others in the community and that rumors spread through social media or word of mouth often lead to increased fears and panic based on misinformation. One pediatrician noted that, among Asian communities, there is reluctance to talk about immigration status, which limits sharing of information and may contribute to increased fears stemming from rumors or misinformation.

Children are also feeling increased fear and uncertainty about potentially losing their parents to deportation or having to return to their parents’ native countries. Parents across the groups, including those with lawful status, recounted stories of their children and children in their community coming home in tears immediately after the presidential election and worrying about what would happen to them and if they would have to leave the country. Parents said that, although they try to shield their children from these issues, many children are hearing about them at school. Parents also said that some children have expressed fears and concerns about their parents’ home countries, noting that the U.S. is the only home they know.

Participants and pediatricians said that racism and discrimination, including bullying of children of color in schools, have significantly increased since the election. A number of parents said their personal experiences with racism and discrimination have increased since the election and described recent incidents affecting themselves, friends, and/or family members. Many felt that Latinos, particularly Mexicans, and Muslims have been the primary targets of increased racism and discrimination. They also noted that bullying has increased for children in schools and that it extends beyond immigrants to children of color, regardless of their immigration status.

Effects on Daily Lives

Some families, particularly those with an undocumented family member, are making changes in their daily lives and routines in response to fear of deportation. Some said that they only leave the house when necessary, for example, to work; that they limit their driving or only have people with legal status drive; and/or that they limit time out in their neighborhood. For example, parents in Boston said that families used to fill their local park with picnics and barbeques on the weekends but that it now sits empty. A number of parents and pediatricians indicated that families now spend long hours inside their homes behind locked doors, fearful whenever anyone comes to the door. Some parents and pediatricians also noted that school attendance declined immediately after the election and that it dips after an immigration raid or if there is a rumor of a raid in the community. Parents in Maryland and California said that some of the schools sent letters to reassure families of their safety in school, which they believe helped relieve fears. Families also are increasingly fearful of police and authorities, and some parents and pediatricians expressed concerns that individuals may be less likely to report assault, abuse, or other crimes. Other participants, particularly those who have lived in the U.S. for many years and who live in diverse communities with strong support, said that they are carrying on with their daily lives and regular routines despite increased fears.

Many participants said it is more difficult to find employment in the current environment, exacerbating financial challenges. A number felt that employment options had become more limited since the presidential election. They noted that fewer work permits are available and permits are not being renewed. Some also said that increased verification procedures by employers are causing some people to lose jobs, sometimes jobs they have held for many years. Given these challenges, participants said they now often have to go outside of their neighborhoods or community and/or travel long distances to find work, which increases commuting time and costs and makes child care more difficult. In some cases, individuals are no longer seeking work because they fear exposing themselves to authorities. Similarly, some parents in Maryland said they are fearful of volunteering in their children’s schools because the schools have documentation and background checks for parent volunteers.

Some parents have arranged for their children’s care in case they are detained or deported, while others are uncertain and fearful about what would happen to their children. Some parents have acquired power of attorney letters to authorize family members or friends to become their children’s guardians in case of detention or deportation. Some also reported receiving requests from neighbors, family members, and/or friends to become guardians for their children. However, other parents said they do not know who would care for their children if they were detained or deported and/or that they do not have friends or family here in the U.S. that they could turn to for help. One pediatrician noted that some parents were asking if they could designate the children’s hospital as a guardian for children with complex needs because they had no one else who could provide the level of care their children need.

Effects on Children’s Health and Well-Being

Increased fear among children is manifesting in many ways, including behavioral issues, psychosomatic symptoms, and mental health issues. Parents and pediatricians reported that fears are contributing to behavioral issues among children, including problems sleeping and eating, regression, increased restlessness and agitation, and withdrawal from family and friends. Children also are experiencing psychosomatic symptoms, including headaches, stomachaches, nausea, and vomiting. In addition, parents and pediatricians indicated that some children are experiencing anxiety, having panic attacks, displaying symptoms of depression, and/or expressing an overall loss of hope for the future. For example, one pediatrician recounted how a child whose father had been deported starting having panic attacks because she was afraid she would also lose her mother and be placed into foster care. Another pediatrician noted that, after the election, “fear of Trump” emerged as a chief complaint in her daily schedule.

Parents and pediatricians expressed concerns that increased fear and stress is negatively affecting some children’s performance in school. Parents and pediatricians said some children are having increased difficulty paying attention in school because of their stress and worries about potentially losing their parents. A couple of pediatricians noted an increase in school reports of attention-deficit/ hyperactivity disorder (ADHD), which they believe may be attention problems stemming from fear or anxiety. Others noted that some children are having increased behavioral problems that are interfering with their performance in school. For example, one parent noted that his son recently had issues at school resulting from standing up to other students that were bullying other Spanish-speaking students.

Increased fears have also affected the well-being of parents and made it more difficult for them to focus on caregiving. A number of parents reported that they also are suffering increased anxiety and/or depression due to their fears. Some reported problems sleeping and eating as well as headaches and nausea due to stress and worry. Some pediatricians indicated that, in some cases, these fears have served as triggers for parents who have histories of trauma or persecution leading to depression and/or anxiety. Pediatricians also noted that, as parents experience increased stress and anxiety, they might have more difficulty focusing on caregiving and/or become more withdrawn from their children. A few pediatricians reported concerns about strains on family relationships, particularly when family members have different immigration statuses. For example, a younger sibling in the family may be a U.S.-born citizen while an older sibling may be undocumented or have DACA status.

Effects on Health Care Use

Most parents indicated that they have not made any changes in how they seek health care for their children in response to increased fears; however, some parents and pediatricians described changes in health care use. Most parents noted they are continuing to obtain health care for their children and that they trust their existing doctors and view their doctors’ offices and hospitals as safe spaces. They also noted that they prioritize obtaining care for their children over their fears. Pediatricians also reported that, in general, patients are continuing to get care. However, some parents and pediatricians reported declines in visits and/or changes in the timing of visits. For example, some pediatricians have observed decreases in well-child visits, in follow-ups on referrals with providers that families do not have an existing relationship with, and in expectant mothers seeking prenatal care. One pediatrician also reported that some parents are no longer opening their doors or answering phones for home health visits. Another pediatrician felt that parents had shifted from using scheduled visits to walk-in visits because they may be hesitant about providing information to schedule the visit. In Boston, some parents said that they try to schedule their children’s appointments in the morning because they feel like that is the safest time to be outside. In addition, one pediatrician reported that parents are bundling visits together to minimize the frequency of visits and limit their time outside the home. In Fresno, some parents said that they prefer to utilize Latino providers in the current environment.

Pediatricians described some actions they are taking to help families feel safe. Pediatricians reported posting signage in their practices to communicate to families that their children are welcome and safe. One noted that the practice has placed bilingual staff outside the entrance to welcome families and ensure they do not encounter any difficulties when entering the clinic. Some indicated that they are taking steps to reassure families that they will keep their information confidential, so that families feel comfortable discussing immigration-related issues during health care visits. A number said that they have undertaken staff training to highlight the importance of confidentiality and best practices for discussing sensitive topics like immigration status. Two pediatricians also indicated that their practices had developed operational protocols so staff know what steps to take if immigration officials enter the practice. Some pediatricians noted that they have hosted events or provided referrals to help families understand their rights and assist families in planning in case they are detained or deported. Many pediatricians also reported writing letters to assist families involved in deportation proceedings.

Some pediatricians expressed concerns about the ambiguity of the borders around safe spaces and uncertainty about how to advise families amid the current environment. For example, one pediatrician indicated that while the hospital itself may be safe, it is unclear how far that border extends and whether protection extends to the parking lot. A pediatrician noted that practices near the U.S.-Mexico border are reporting increased presence of border patrol in parking lots of clinics and said that their presence is dissuading parents from bringing their children to clinics. In addition, a few pediatricians highlighted the challenges developing policies and protocols for staff on immigration related issues because the environment is constantly shifting.

Effects on Participation in Medicaid/CHIP and Other Programs

Parents generally reported that they are maintaining Medicaid and CHIP coverage for their children, but there were some reports of decreased participation in Medicaid and CHIP and other programs. Most participants have their children enrolled in Medicaid and CHIP and said that they intend to keep their children enrolled. Parents said they highly value Medicaid and CHIP coverage and that the coverage enables them to access needed care for their children. However, some parents and pediatricians reported that some families with eligible children are less interested in enrolling in Medicaid and CHIP. In addition, one clinic noted that some patients have asked to be disenrolled because they fear they may be putting undocumented family members at risk or jeopardizing family members’ lawful status. Pediatricians noted that they have observed sharper declines in participation in the Women, Infants, and Children (WIC) nutrition program and the Supplemental Nutrition Assistance Program (SNAP). They believe parents are more likely to view WIC and SNAP as federal programs that could expose their information to authorities. Parents and pediatricians also noted ongoing concerns in the community that use of Medicaid, CHIP, and other programs will negatively affect immigration status among those with lawful status or seeking residency or citizenship. Participants felt it would be helpful if official sources made more information available about how use of benefits could affect families’ immigration status. A few pediatricians indicated that they are uncertain about how to advise families on the use of benefits and enrollment in programs since policies could change. For example, one pediatrician indicated that she is more cautious about encouraging families to enroll in SNAP because doing so could potentially have negative consequences if policies change.

Most participating parents are uninsured and said they delay or go without care due to cost. Those who are undocumented are not eligible for Medicaid and generally do not have access to private coverage. They primarily rely on clinics, but often avoid seeking care because of cost. Those parents with lawful status were more likely to have coverage, often through Medicaid, and were better able to access needed care.

Long-Term Implications for Children

Pediatricians uniformly expressed significant concerns about the long-term consequences of the current environment for children. They pointed to longstanding research on the damaging effects of toxic stress on physical and mental health over the lifespan (Box 1). They believe that the current environment is creating toxic stress for children and that this stress will result in physiological changes that contribute to increased rates of chronic disease and mental health disorders through adulthood. One pediatrician that serves families near the Mexico border noted that the stress for children in that environment is extreme, particularly because of the constant visual presence of border patrol and militarization of the area, which she says has increased since the presidential election. Pediatricians expressed concerns that declines in participation in WIC and SNAP will negatively affect healthy development of children. Similarly, they cautioned that reductions in health care use could result in more serious and costly conditions. Some pediatricians expressed concerns that the increased amount of time families are spending inside behind locked doors will compromise children’s development and reduce their enrichment opportunities and physical activity. Pediatricians also emphasized that the loss of a parent due to deportation negatively affects health and development of children in multiple ways, including the loss of economic and social support and disruption to the parent-child bond.

Pediatricians and parents described how deportation and the rescission of DACA compound challenges for families and increase the risk of cyclical poverty. Pediatricians and parents both noted that losing a family member to deportation often results in loss of family income, leading to financial strains and sometimes food and housing insecurity. One pediatrician noted an increase in homelessness among children due to the loss of family members and income. Pediatricians said that these income losses will increase the likelihood of cyclical poverty among families. They also noted that many individuals with DACA were pursuing education and careers that could potentially move their families out of poverty and that this opportunity is lost with the DACA rescission. They have observed that some adolescents, particularly those who are undocumented or who have DACA, have lost hope for the future and are reconsidering plans to attend college or pursue certain job opportunities. They said this loss of hope and negative future outlook could affect their life choices and limit their potential achievements and economic gains. Parents and pediatricians also expressed concerns that immigrant families may become increasingly alienated from their broader communities as a result of the current environment. Pediatricians worried that this situation may lead families to feel more isolated and that children may face challenges formulating their identities.

Conclusion

Together, these findings show that immigrant families across different backgrounds and locations are feeling increased levels of fear and uncertainty amid the current climate. Parents and children in families with an undocumented family member fear being separated from each other, and those with lawful status worry about the security and stability of their status and whether they may be affected by policy changes in the future. The findings show that these fears are having broad effects on the daily lives and routines of some immigrant families who are fearful to leave their home, limiting their participation in activities, and facing increased employment challenges. In addition, they point to long-term consequences for children in immigrant families, including poorer health outcomes over the lifespan, compromised growth and development, and increased challenges across a range of social and environmental factors that influence health.

 

 

Appendix 1: Recent Changes in Immigration Policy, 2017

Executive Order: “Protecting the Nation from Foreign Terrorist Entry into the U.S.,” January 2017: Suspends entry of nationals from seven Muslim-majority countries — Iraq, Iran, Libya, Somalia, Sudan, Syria, and Yemen—into the U.S. for 90 days as well as all refugees for 120 days (and an indefinite ban on Syrian refugees), with an exception for religious minorities. States and other groups challenged the order, resulting in a temporary restraining order against enforcement of the ban. In March 2017, the Administration revised the order, removing the ban on nationals from Iraq, the indefinite ban on Syrian refugees, and the exception for religious minorities. In June 2017, the Supreme Court permitted a limited version of the revised ban to take effect, but ultimately dismissed legal challenges to the ban before ruling on its merits in October 2017, after the ban expired. In September 2017, the Administration released a new ban targeting primarily Muslim-majority countries—keeping Iran, Libya, Somalia, Syria and Yemen on the list, removing Sudan, and adding Chad as well North Korea and Venezuela. This version of the ban suspended entry of most nationals from these countries indefinitely (except Venezuela, where it is limited to government officials and their family) and enhanced screening and vetting requirements. On December 4, 2017 the Supreme Court, while not ruling on the merits, allowed this ban to go fully into effect while it continues to be challenged in the Fourth and Ninth Circuits and makes its way before the Supreme Court. A fourth ban was issued on October 24, 2017, requiring refugees from 11 Muslim-majority countries—Egypt, Iran, Iraq, Libya, Mali, North Korea, Somalia, Sudan, South Sudan, Syria, and Yemen—to undergo extreme vetting before entering the U.S. and preventing family members of refugees from joining them in the U.S. This ban is also being challenged in federal courts.

Executive Order: “Enhancing Public Safety in the Interior of the US,” January 2017: Expands the category of individuals classified as “priorities for removal,” prioritizing undocumented immigrants who have committed, been charged, or been convicted of a criminal offense, as well as those who have “committed acts that constitute a chargeable offense,” even if they are never convicted of an offense. Also disqualifies “sanctuary cities,” or jurisdictions that limit their role in civil immigration enforcement, from receiving federal grants. Cities are challenging the restriction of federal grants, including law enforcement funding, to “sanctuary cities” in the courts. The U.S. District Court permanently blocked the “sanctuary cities” provision. The Administration later narrowed the scope of the provision, but cities continue to challenge the new conditions on federal grants.

Executive Order: “Buy American Hire American,” April 2017: Encourages employers to verify all new hires through e-verify and calls for reforms to the H1B visa program that allows employers to find workers with highly specialized knowledge outside of the US.

Executive Order to Rescind Deferred Action for Childhood Arrivals (DACA) Program, September 2017: Rescinds DACA, which allowed for certain undocumented youth who came to the U.S. as children to be granted permission to stay in the U.S. and work for temporary renewable periods. DACA has protected nearly 800,000⁹  undocumented children over the past five years and currently protects nearly 690,000 immigrants.¹⁰  The Administration rescinded DACA in September 2017, and is no longer accepting applications for or renewals of DACA.¹¹  Individuals’ DACA and work permits (employment authorization documents) remain valid until their expiration date.

Termination of Temporary Protected Status (TPS) Designation for Sudan, September 2017: Terminates TPS designation for Sudan effective November 2, 2018. Individuals currently residing in the U.S. under this TPS status must obtain an alternative lawful immigration status to remain in the U.S.¹² 

Termination of TPS Designation for Nicaragua, November 2017: Terminates TPS designation for Nicaragua effective January 5, 2019. Individuals currently residing in the U.S. under this TPS status must obtain an alternative lawful immigration status to remain in the U.S.¹³ 

Termination of Central American Minors (CAM) refugee program, November 2017: Applications for CAM stopped being accepted November 9, 2017, and interviews for CAM cases will end January 31, 2018.¹⁴ 

Termination of TPS Designation for Haiti, November 2017: Terminates TPS designation for Haiti effective July 22, 2019. Individuals currently residing in the U.S. under this TPS status must obtain an alternative lawful immigration status to remain in the U.S. Haitians with TPS will be required to reapply for Employment Authorization Documents to legally work in the U.S. until the termination date.¹⁵ 

Appendix 2: Immigration Statuses and Eligibility for Health Coverage

Immigration Statuses

Lawfully present immigrants are non-citizens who are lawfully residing in the U.S. This group includes:

• Lawful permanent residents (LPRs or “green card” holders): Individuals who have been granted permission to permanently reside and work in the U.S. Individuals may be granted lawful permanent residence while overseas or adjust to permanent status within the U.S.¹⁶ 
• Refugees: Individuals who are at risk of or have been subject to persecution in their home countries and are unable to return because they fear serious harm.¹⁷  Individuals may be granted refugee status from outside the U.S.; those who flee to the US may seek asylum or withholding of removal once in the U.S.
• Asylees: Individuals who meet the same definition of refugees but are already in the U.S. or are seeking admission at a port of entry.¹⁸ 
• Other individuals who are authorized to live in the U.S. temporarily or permanently.

Undocumented immigrants are foreign-born individuals residing in the U.S. without authorization. This group includes individuals who entered the country without authorization as well as individuals who entered the country lawfully and stayed after their visa or status expired.

The Deferred Action for Childhood Arrivals (DACA) program, which was established in 2012, allowed for certain undocumented youth who came to the U.S. as children to be granted permission to stay in the U.S. for temporary renewable periods. The Administration rescinded DACA in September 2017 and is no longer accepting applications for or renewals of DACA.¹⁹ 

Eligibility for Health Coverage Programs

Lawfully present immigrants may qualify for Medicaid and CHIP subject to certain restrictions. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP and many, including most LPRs or green card holders, must wait five years after obtaining qualified status before they may enroll. Some immigrants, such as those with temporary protected status, are lawfully present but do not have a qualified status and are not eligible. Some immigrants, such as refugees and asylees, do not have to wait five years before enrolling. For children and pregnant women, states can opt to eliminate the five-year wait and extend coverage to lawfully present immigrants without a qualified status.

Lawfully present immigrants can purchase coverage through the Affordable Care Act (ACA) Marketplaces and may receive subsidies for this coverage. These subsidies are available to people with incomes from 100% to 400% FPL who are not eligible for other coverage. In addition, lawfully present immigrants with incomes below 100% FPL may receive subsidies if they are ineligible for Medicaid based on immigration status. This group includes lawfully present immigrants who are not eligible for Medicaid or CHIP because they are in the five year waiting period or because they do not have a “qualified” status.

Undocumented immigrants and individuals granted DACA are not eligible to enroll in Medicaid or CHIP or to purchase coverage through the ACA Marketplaces.

1. Kaiser Family Foundation, Health Coverage and Care for Immigrants, (Washington, DC: Kaiser Family Foundation, December 2017), https://modern.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants. ↩︎
2. Ibid. ↩︎
3. Kaiser Family Foundation, Health Coverage and Care for Immigrants, (Washington, DC: Kaiser Family Foundation, December 2017), https://modern.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants/. ↩︎
4. Ibid. ↩︎
5. Since these groups were conducted, the Department of Homeland Security announced that TPS will be eliminated for people from Nicaragua effective January 5, 2019. Department of Homeland Security, Acting Secretary Elaine Duke Announcement on Temporary Protected Status for Nicaragua and Honduras, (Washington, DC: Department of Homeland Security, November 6, 2017), https://www.dhs.gov/news/2017/11/06/acting-secretary-elaine-duke-announcement-temporary-protected-status-nicaragua-and. ↩︎
6. Lisa M Edwards and Jacki Black, Stress Related to Immigration Status in Students: A Brief Guide for Schools, (Milwaukee, WI: Marquette University: February 2017), http://www.marquette.edu/education/news/documents/Immigration-RelatedStress-AGuideforSchools.pdf; Omar Martinez, Elwin Wu, Theo Sandfort, et. al., “Evaluating the Impact of Immigration Policies on Health Status Among Undocumented Immigrants: A Systematic Review,” Journal of Immigrant and Minority Health 17, 3 (June 2015):947-970; Human Impact Partners, Family Unity, Family Health: How Family-Focused Immigration Reform Will Mean Better Health for Children and Families, (Oakland, CA: Human Impact Partners, June 2013), http://www.familyunityfamilyhealth.org/uploads/images/FamilyUnityFamilyHealth.pdf; Jorge Delva, Pilar Horner, Ramiro Martinez, et. al., “Mental Health Problems of Children of Undocumented Parents in the United States: A Hidden Crisis,” Journal of Community Positive Practices XIII, 3 (2013):25-35; Karen Hacker, Jocelyn Chu, Carolyn Leung, et. al., “The Impact of Immigration and Customs Enforcement on Immigrant Health: Perceptions of Immigrants in Everett, Massachusetts, USA,” Social Science & Medicine 73, 4 (August 2011):586-594; David K Androff, Cecilia Ayon, David Becerra, et. al., “U.S. Immigration Policy and Immigrant Children’s Well-being: The Impact of Policy Shifts,” The Journal of Sociology & Social Welfare 38, 1 (March 2011):77-98; Ajay Chaudry, Randy Capps, Juan Manuel Pedroza, et. al., Facing Our Future: Children in the Aftermath of Immigration Enforcement, (Washington, DC: Urban Institute, February 2010), https://www.urban.org/sites/default/files/publication/28331/412020-Facing-Our-Future.PDF; Randy Capps, Rosa Maria Castañeda, Ajay Chaudry, and Robert Santos, Paying the Price: The Impact of Immigration Raids on America’s Children, Prepared for the National Council of La Raza, (Washington, DC: Urban Institute, 2007): https://www.urban.org/sites/default/files/publication/46811/411566-Paying-the-Price-The-Impact-of-Immigration-Raids-on-America-s-Children.PDF. ↩︎
7. American Academy of Pediatrics (AAP), “AAP Statement on Protection Immigrant Children,” [Website], January 25, 2017, Accessed September 18, 2017, https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAPStatementonProtectingImmigrantChildren.aspx. ↩︎
8. Center on the Developing Child, NGA Center for Best Practices, and National Conference on State Legislatures, In Brief: The Impact of Early Adversity on Children’s Development, (Cambridge, MA: Center on the Developing Child, Harvard University, 2015), https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2015/05/inbrief-adversity-1.pdf; Hillary A Franke, “Toxic Stress: Effects, Prevention and Treatment,” Children 1 (2014):390-402; Sara B Johnson, Anne W Riley, Douglas A Granger, and Jenna Riis, “The Science of Early Life Toxic Stress for Pediatric Practice and Advocacy,” Pediatrics 131, 2 (February 2013):319-327; Jack P Shonkoff, Andrew S Garner, et. al., “The Lifelong Effects of Early Childhood Adversity and Toxic Stress,” Pediatrics 129, 1 (2012):e232-e246; Committee on Psychosocial Aspects of Child and Family Health, et. al., “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health,” Pediatrics 129, 1(2012):e224-e231; National Scientific Council on the Developing, Child Persistent Fear and Anxiety Can Affect Young Children’s Learning and Development: Working Paper No. 9, (Cambridge, MA: National Scientific Council on the Developing Child, 2010), http://www.developingchild.net; Jack P Shonkoff, W Thomas Boyce and Bruce S McEwen, “Neuroscience, Molecular Biology, and the Childhood Roots of Health Disparities: Building a New Framework for Health Promotion and Disease Prevention,” Journal of the American Medical Association 301, 201 (2009):2252-2259; Jennifer S Middlebrooks and Natalie C Audage, The Effects of Childhood Stress on Health Across the Lifespan, (Atlanta, GA: Centers for Disease Control and Prevention (CDC), 2008), http://health-equity.lib.umd.edu/932/1/Childhood_Stress.pdf; Stanley D Rosenberg, Weili Lu, Kim T Mueser, et. al., “Correlates of Adverse Childhood Events Among Adults with Schizophrenia Spectrum Disorders,” Psychiatric Services 58, 2 (2007): 245-253; Shanta R Dube, Robert F Anda, Vicent J Felitti, et. al., “Childhood Abuse, Household Dysfunction, and the Rise of Attempted Suicide Throughout the Life Span: Findings from the Adverse Childhood Experiences Study,” JAMA 286, 24 (December 2001): 3089-3096; Vincent J Felitti, Robert F Anda, Dale Nordenberg, et. al., “Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Casues of Death in Adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 14, 4 (1998):245-258. ↩︎
9. U.S. Citizenship and Immigration Services, Data Set: Form I-821D Deferred Action for Childhood Arrivals as of June 30, 2017, (Washington, DC: U.S. Citizenship and Immigration Services, September 20, 2017), https://www.uscis.gov/sites/default/files/USCIS/Resources/Reports%20and%20Studies/Immigration%20Forms%20Data/. ↩︎
10. U.S. Citizenship and Immigration Services, Approximate Active DACA Recipients: Country of Birth As of September 4, 2017, (Washington, DC: U.S. Citizenship and Immigration Services, September 4, 2017), https://www.uscis.gov/sites/default/files/USCIS/Resources/Reports%20and%20Studies/Immigration%20Forms%20Data/. ↩︎
11. National Immigration Law Center, “DACA,” [Website], Accessed December 1, 2017, https://www.nilc.org/issues/daca/. ↩︎
12. U.S. Citizenship and Immigration Services, “Temporary Protected Status for Sudan to Terminate in November 2018,” [Press Release], September 18, 2017, Accessed December 7, 2017, https://www.uscis.gov/news/news-releases/temporary-protected-status-sudan-terminate-november-2018 ↩︎
13. U.S. Department of Homeland Security, “Acting Secretary Elaine Duke Announcement on Temporary Protected Status for Nicaragua and Honduras,” [Press Release], November 6, 2017, Accessed December 1, 2017, https://www.dhs.gov/news/2017/11/06/acting-secretary-elaine-duke-announcement-temporary-protected-status-nicaragua-and. ↩︎
14. U.S. Citizenship and Immigration Services, “In-Country Refugee/Parole Processing for Minors in Honduras, El Salvador and Guatemala (Central American Minors – CAM),” [Website], November 15, 2017, Accessed December 1, 2017, https://www.uscis.gov/CAM. ↩︎
15. U.S. Department of Homeland Security, “Acting Secretary Elaine Duke Announcement on Temporary Protected Status for Haiti,” [Press Release], November 20, 2017, Accessed December 1, 2017, https://www.dhs.gov/news/2017/11/20/acting-secretary-elaine-duke-announcement-temporary-protected-status-haiti. ↩︎
16. U.S. Citizenship and Immigration Services, “Permanent Resident Alien,” [Website], Accessed December 1, 2017, https://www.uscis.gov/tools/glossary/permanent-resident-alien. ↩︎
17. U.S. Citizenship and Immigration Services, “Refugees & Asylum,” [Website], Accessed December 1, 2017, https://www.uscis.gov/humanitarian/refugees-asylum. ↩︎
18. Ibid. ↩︎
19. National Immigration Law Center, “DACA,” [Website], Accessed December 1, 2017, https://www.nilc.org/issues/daca/. ↩︎