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/. ↩︎

Two months after Hurricane Maria made landfall, the Kaiser Family Foundation traveled to Puerto Rico to conduct focus groups and individual interviews with individuals affected by the storm. We spoke to 40 people from 10 different regions on the island (Appendix 1). See a companion video. Findings show:

• Hurricane Maria was a terrifying and traumatic event for participants and their children. A number of participants suffered significant damage to their homes and property with some losing everything.
• The storm had significant negative effects on physical and mental health, and many participants continue to experience depression, stress, and anxiety.
• Two months after the storm, participants were continuing to face challenges meeting basic needs, and daily life remained extremely challenging due to lack of electricity and limited work options.
• Participants felt that recovery efforts have been slow and insufficient.
• Despite these challenges, many believe Puerto Rico will recover, although they recognize recovery will likely take many years and believe that the people themselves have an important role to play in recovery.

Weathering the Storm

Weathering the storm was a terrifying and traumatic experience for participants. Some participants made preparations for the storm, while others anticipated the storm would pass by the island or not be as strong as predicted. Many stayed in their home to weather the storm and brought family and friends to stay with them. Others went to stay with family or friends who had sturdier homes. Participants described the frightening strength of the storm winds and significant rain and flooding. They said that the storm felt endless and they worried about the well-being of family members they were separated from during the storm.

Immediate Aftermath of the Storm

Participants struggled to meet basic needs immediately following the storm. Many participants suffered significant damage to their homes and properties, with some losing everything. They said that in the immediate days and weeks following the storm, it was extremely difficult to meet basic needs and that lines, for water, food, gas, and money were up to 8-10 hours long. In the weeks following the storm, there were no communications on the island and travel around the island was difficult, making it challenging to check on the well-being of family and friends. Few received any aid in the days and weeks immediately following the storm. One silver lining several participants highlighted, was that the storm contributed to increased community and stronger relationships with their neighbors as they worked together following the storm.

Effects on Physical and Mental Health

Participants said that access to health care was limited and chaotic immediately after the storm with limited staff, hospitals without power, injuries and deaths. They noted that pharmacies were unable to process insurance without power, so some had to pay out of pocket for medications. Some pharmacies provided medications on credit and /or without a prescription to help ensure continued access to medications. Participants noted that the ability to access health care has improved over time, but challenges persist, including longer waits, transportation challenges, and limited hospitals, clinics, and pharmacies, with many still running on inconsistent generator power. A number of participants had health coverage through Reforma, Puerto Rico’s Medicaid program, and said the coverage is key for accessing needed care for themselves and their children.

A number of participants said that the storm disrupted their access to medications and treatment. For example, several participants said they did not have access to insulin because they had no ability to refrigerate it, and one participant was unable to obtain dialysis treatment due to lack of power. Participants said it has been harder to manage chronic conditions like asthma, high blood pressure, and diabetes due to stress and anxiety, limited access to medication, and increased consumption of processed and canned foods and soda due to difficulties accessing fresh food.

Participants also described profound effects on their mental and emotional health. They noted that while they try to be strong for their children and others, they feel desperation in moments alone. Many said they feel stressed and anxious and are having trouble sleeping at night. They also said that many of their children are fearful and frightened ever time it rains. Several were also affected by deaths they witnessed or knew of as a result of the storm.

Life Two Months After the Storm

Daily life remains very difficult and disrupted two months after the storm. Participants said some basic needs still have not been addressed. Most are still without power, and where power has returned, it remains unpredictable. They also pointed to continued challenges accessing water and gas and noted that cell service and communication remains limited across the island. Participants described the struggles of daily life without power, noting that they are unable to keep fresh food, unable to cook inside their home, and or to use their washing machine. They emphasized that there is no relief from the heat and mosquitos and constant noise and air pollution from generators. They also said that there remain significant traffic jams and delays on the roads due to the lack of traffic lights.

Participants’ daily routines remain disrupted. Some participants are still displaced from their homes or have displaced family or friends living with them. Some children returned to school, but many schools are operating under shortened schedules. Some participants have returned to work, but a number went many days without work or lost their jobs. They noted that many jobs are not available right now because of the lack of power. Moreover, it is more difficult for parents to work given the more limited school hours.

Views on Recovery Efforts

Participants feel that recovery efforts have been slow and that major gaps in basic needs remain two months after the storm. They did not feel that President Trump has provided much help or respect for the people of Puerto Rico. They said that assistance from FEMA has been slow and not well targeted. Some felt that FEMA is acting slow because FEMA funds were misused by some individuals after previous storm. In addition, many thought that local government is complicating and slowing down recovery efforts.

Thoughts on the Future

Participants believe the island will recover, but that it will take a long time, likely many years. They feel there remains great needs across the island, but that there is not enough recognition of the continued need and suffering. Many noted that they remain committed to staying on the island and recovery, even though staying is hard. Others are leaving because they are no longer able to find employment to support them. Many have family and friends that have already left the island. Participants want more transparency and information about recovery efforts, in particular, about where funding and supplies are going. They also believe that the people of Puerto Rico have a role to play in recovery themselves, and that they can’t just sit back and wait for assistance.

Conclusion

These findings show that Hurricane Maria was a terrifying and traumatic event for many Puerto Ricans. Many suffered significant damage to their homes and property, with some losing everything, and many are struggling with mental and emotional effects of the storm and their losses. Two months after the storm, individuals were continuing to face challenges meeting basic needs, and daily life remained extremely challenging, due to lack of electricity and limited work options. Individuals feel that recovery efforts have been slow and insufficient and emphasized that the island still needs substantial help and resources to recover. Despite these challenges, many believe Puerto Rico will recover, although they recognize recovery will likely take many years and believe that the people themselves have an important role to play in recovery.

Methods

The focus groups and interviews were conducted in Spanish and English in San Juan and Ponce, Puerto Rico, on November 18 and 19, 2017. The Kaiser Family Foundation worked with PerryUndem Research/Communication to conduct the focus groups and interviews. This brief highlights participants’ experiences during and immediately after the storm as well as how they were faring two months after the storm. It also provides an overview their thoughts on recovery efforts and their reflections on the future for themselves and the island.

Donor government funding for family planning decreased in 2016 compared to the prior year, with bilateral support falling from $1.34 billion in 2015 to $1.19 billion (-12%).

• This marked the second year of declines in a row, following an initial increase after the London Summit on Family Planning held in 2012. These declines were largely due to currency fluctuations and the timing of donor disbursements, although even after accounting for these factors, funding in 2016 declined, returning to 2013 levels; funding from several donors decreased in real terms.
• Among the 10 donor governments profiled, four governments decreased bilateral funding (France, Norway, the U.K., and the U.S.), five increased (Australia, Denmark, Germany, the Netherlands, and Sweden), and one remained flat (Canada).
• The decline by the U.S. in 2016 (from US$638.0 million in 2015 to US$532.7 million in 2016) appears to reflect the timing of disbursements, as overall funding commitments by the U.S. have remained flat for several years.
• Despite the decline, the U.S. was still the largest bilateral donor to family planning in 2016, providing 45% of total bilateral funding. The U.K. (US$203.4 million, 17%) was the second largest donor, followed by the Netherlands (US$183.1 million, 15%), Sweden (US$92.5 million, 8%), and Canada (US$43.8 million, 4%).
• In addition to bilateral disbursements for family planning, donor governments also provided US$347.8 million in core contributions to UNFPA; this also represented a decline over the prior year period of US$44.8 million (-13%) compared to 2015 (US$392.6 million).¹  Sweden provided the largest core contribution to UNFPA in 2016 (US$59.0 million), followed by Norway (US$46.8 million), the Netherlands (US$39.1 million), and the U.S. (US$30.7).

Introduction

This report provides the latest data on donor government resources available for family planning activities in low- and middle-income countries. It is part of an effort by the Kaiser Family Foundation that began after the London Summit on Family Planning in 2012 where donors committed US$2.6 billion in additional funding to increase access to family planning by 2020 (see Appendix 1).²  This current report provides data on donor government disbursements in 2016, the most recent year available. It includes data from all members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC), as well as non-DAC members where data are available.³  Data are collected directly from donors and supplemented with data from the DAC. Ten donor governments that account for 98% of total disbursements are profiled in this analysis. Both bilateral assistance and core contributions to UNFPA are included. See methodology for more detail. For information on family planning funding from other sources (e.g. multilateral organizations, foundations, etc.) see Appendix 2.

Findings

Bilateral Assistance

In 2016, donor governments disbursed US$1,187.8 million in bilateral funding for family planning activities (see Table 1, Figure 1 & Appendix 3), a decline of more than US$150 million (-12%) compared to the 2015 level (US$1,344.0 million). This marks the second year of declines after initial increases following the London Summit in 2012. Much of the decline over the past two years can be attributed to two factors: 1) the rise in the value of the U.S. dollar compared to other currencies in 2015, which accounted for 36% of the decline; and 2) an apparent delay in the timing of disbursements by the U.S., which accounted for 42% of the decline (while U.S. funding declined by more than US$100 million in 2016, annual funding commitments appropriated by Congress have remained flat for the past several years; in addition, there have been other years where disbursements have varied from commitments; see Figure 2).⁴  However, even after accounting for currency fluctuations and the timing of disbursements, funding declined by 22% over the two-year period and returned to 2013 levels.

Among the donors profiled, five (Australia, Denmark, Germany, the Netherlands, and Sweden) increased FP funding in 2016, four decreased funding (France, Norway, the U.K., and the U.S.) and one remained flat (Canada). This was the case in current U.S. dollars as well as after adjusting for currency fluctuations.

The United States was the largest bilateral donor in 2016 accounting for US$532.7 million or 45% of total bilateral assistance (see Figure 3). The U.K. (US$203.4 million, 17%) was the second largest bilateral donor, followed by the Netherlands (US$183.1 million, 15%), Sweden (US$92.5 million, 8%), and Canada (US$43.8 million, 4%).

Donor Contributions to UNFPA

While the majority of donor government assistance for family planning is provided bilaterally, donors also provide support for family planning activities through contributions to the United Nations Population Fund (UNFPA) (see Appendix 4). Most of UNFPA’s funding is from donor governments, which provide funding in two ways: 1) donor directed or earmarked contributions for specific activities (e.g. donor contributions to the UNFPA Supplies), which are included as part of bilateral funding above; and 2) general contributions to “core” activities that are untied and meant to be used for both programmatic activities (family planning, population and development, HIV-AIDS, gender, and sexual and reproductive health and rights) and operational support as determined by UNFPA.

In 2016, donor governments provided US$347.8 million in core contributions to UNFPA, a decrease of US$44.8 million (-13%) below 2015 levels (US$392.6 million) and US$123.7 million (-26%) below 2014 levels. Despite the overall declines, the majority of donors either increased funding (Germany and Sweden) or remained flat (Canada, France, Netherlands, and U.S.); four donors declined (Australia, Denmark, Norway and the U.K.); however U.K. contributions remained flat when measured in currency of origin. Sweden provided the largest core contribution to UNFPA in 2016 (US$59.0 million), followed by Norway (US$46.8 million), the Netherlands (US$39.1 million), and Denmark (US$28.1) (see Figure 4 and Table 2). Among the ten donors profiled, one donor – Norway – provided a larger contribution to UNFPA’s core resources than their total bilateral disbursement for family planning.

Looking Ahead

As this report finds, family planning funding initially increased after the 2012 London Summit on Family Planning but more recently has begun to decline and future funding is uncertain.  While this recent decline is due to several factors, including currency fluctuations and the timing of disbursements, even after accounting for these factors, funding in 2016 had fallen to 2013 levels.  Moreover, future funding from the largest donor to family planning – the United States – is uncertain. In 2017, the Trump Administration ended funding to UNFPA and has proposed eliminating all bilateral funding in 2018. While the U.S. Congress has not yet finalized funding for the 2018 fiscal year, but is expected to continue bilateral funding at some level, this downward pressure on the family planning budget is likely to continue.

Against this uncertain backdrop, donors met in London earlier this year to renew their commitments to FP2020. In addition, following President Trump’s reinstatement and expansion of the Mexico City Policy, which requires foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” with non-U.S. funds as a condition for receiving U.S. global health assistance, the governments of Belgium, Denmark, the Netherlands, and Sweden co-organized the “SheDecides” conference in early 2017 to address potential funding losses to broader reproductive health. Whether these new and renewed commitments can increase overall FP funding levels or replace potential declines from the U.S. remains to be seen and ongoing tracking of donor government efforts will continue to be critical.

Methods

Bilateral and multilateral data on donor government assistance for family planning (FP) in low- and middle-income countries were collected from multiple sources. The research team collected the latest bilateral assistance data directly for 10 governments: Australia, Canada, Denmark, Germany, France, the Netherlands, Norway, Sweden, the United Kingdom, and the United States during the first half of 2017. Data represent the fiscal year 2016 period for all governments. Direct data collection from these donors was desirable because they represent the preponderance of donor government assistance for family planning and the latest official statistics – from the Organisation for Economic Co-operation and Development (OECD) Creditor Reporting System (CRS) (see: http://www.oecd.org/dac/stats/data) – which are from 2015 and do not include all forms of international assistance (e.g., funding to countries such as Russia and the Baltic States that are no longer included in the CRS database).  In addition, the CRS data may not include certain funding streams provided by donors, such as FP components of mixed-purpose grants to non-governmental organizations. Data for all other OECD DAC member governments – Austria, Belgium, Czech Republic, the European Union, Finland, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Spain, and Switzerland – who collectively accounted for less than 2 percent of bilateral family planning disbursements, were obtained from the OECD CRS and are from calendar year 2015.

For purposes of this analysis, funding was counted as family planning if it met the OECD CRS purpose code definition: “Family planning services including counselling; information, education and communication (IEC) activities; delivery of contraceptives; capacity building and training.”⁵  Where it was possible to identify funding amounts, family-planning-related activities funded in the context of other official development assistance sectors (e.g. education, civil society) are included in this analysis. Project-level data were reviewed for Canada, Denmark, France, Germany, the Netherlands, Norway, and Sweden to determine whether all or a portion of the funding could be counted as family planning. Family-planning-specific funding totals for the United States were obtained through direct data downloads and communications with government representatives. Funding attributed to Australia and the United Kingdom is based on a revised Muskoka methodology as agreed upon by donors at the London Summit on Family Planning in 2012. Funding totals presented in this analysis should be considered preliminary estimates based on data provided by representatives of the donor governments who were contacted directly.

It was difficult in some cases to disaggregate bilateral family planning funding from broader reproductive and maternal health totals, as the two are sometimes represented as integrated totals. In addition, family-planning-related activities funded in the context of other official development assistance sectors (e.g. education, civil society) have in the past remained largely unidentified.  For purposes of this analysis, we worked closely with the largest donors to family planning to identify such family-planning-specific funding where possible. In some cases (e.g. Canada), specific FP percentages were recorded for mixed-purpose projects.  In other cases, it was possible to identify FP-specific activities by project titles in languages of origin, notwithstanding less-specific financial coding. In still other cases, detailed project descriptions were analyzed. (see Appendix 3 for detailed data table).

Bilateral funding is defined as any earmarked (FP-designated) amount and includes family planning-specific contributions to multilateral organizations (e.g. non-core contributions to the Global Programme to Enhance Reproductive Health Commodity Security at UNFPA). U.S. bilateral data correspond to amounts disbursed for the 2016 fiscal year. UNFPA contributions from all governments correspond to amounts received during the 2016 calendar year, regardless of which contributor’s fiscal year such disbursements pertain to.

With some exceptions, bilateral assistance data were collected for disbursements. A disbursement is the actual release of funds to, or the purchase of goods or services for, a recipient.  Disbursements in any given year may include disbursements of funds committed in prior years and in some cases, not all funds committed during a government fiscal year are disbursed in that year. In addition, a disbursement by a government does not necessarily mean that the funds were provided to a country or other intended end-user. Enacted amounts represent budgetary decisions that funding will be provided, regardless of the time at which actual outlays, or disbursements, occur. In recent years, most governments have converted to cash accounting frameworks, and present budgets for legislative approval accordingly; in such cases, disbursements were used as a proxy for enacted amounts.

UNFPA core contributions were obtained from United Nations Executive Board documents. UNFPA estimates of total family planning funding provided from both core and non-core resources were obtained through direct communications with UNFPA representatives. Other than core contributions provided by governments to UNFPA, un-earmarked core contributions to United Nations entities, most of which are membership contributions set by treaty or other formal agreement (e.g., United Nations country membership assessments), are not identified as part of a donor government’s FP assistance even if the multilateral organization in turn directs some of these funds to FP.  Rather, these would be considered as FP funding provided by the multilateral organization, and are not considered for purposes of this report.

The fiscal year period varies by country.  The U.S. fiscal year runs from October 1-September 30. The Australian fiscal year runs from July 1-June 30.  The fiscal years for Canada and the U.K. are April 1-March 31.  Denmark, France, Germany, the Netherlands, Norway, and Sweden use the calendar year.  The OECD uses the calendar year, so data collected from the CRS for other donor governments reflect January 1-December 31. Most UN agencies use the calendar year and their budgets are biennial.

All data are expressed in US dollars (USD).  Where data were provided by governments in their currencies, they were adjusted by average daily exchange rates to obtain a USD equivalent, based on foreign exchange rate historical data available from the U.S. Federal Reserve (see: http://www.federalreserve.gov/) or in some cases from the OECD.  Data obtained from UNFPA were already adjusted by UNFPA to represent a USD equivalent based on date of receipts.

1. Includes core-contributions from members of the OECD DAC only; core contributions from non-DAC donors are not included in this total. ↩︎
2. The Kaiser Family Foundation initiated a family planning resource tracking project in 2013, adapting the methodology it has long used to track donor government spending on HIV. Since 2002, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Kaiser Family Foundation have been tracking donor government assistance for HIV in low- and middle-income countries by the donor government members of the Organization for Economic Co-operation and Development’s (OECD) Development Assistance Committee (DAC). For the methodological approach used to monitor donor government spending on HIV see: https://modern.kff.org/global-health-policy/report/financing-the-response-to-aids-in-low/. ↩︎
3. Includes funding from 29 DAC member countries and the European Union(EU). ↩︎
4. U.S. appropriations for family planning (FP) activities in a given fiscal year may be disbursed over a multi-year period. Therefore, while U.S. appropriations for FP have been relatively flat over the past several years, the actual disbursements have fluctuated over the same period. ↩︎
5. OECD, The List of CRS Purpose Codes and Voluntary Budget Identifier Codes, July 2017. ↩︎
6. UNFPA, Direct communication, September, 2017. ↩︎
7. Bill & Melinda Gates Foundation, Direct communication, November, 2017. ↩︎
8. UNFPA, “Frequently Asked Questions” (http://www.unfpa.org/frequently-asked-questions), accessed November, 2017. ↩︎
9. UNFPA, “Frequently Asked Questions” (http://www.unfpa.org/frequently-asked-questions), accessed November, 2017. ↩︎

In late August 2017, Hurricane Harvey pummeled the Texas Gulf Coast, dropping record amounts of rainfall and causing damage with estimates ranging as high as $190 million.¹  In an effort to understand the needs and circumstances of vulnerable Texans affected by the hurricane, the Kaiser Family Foundation and the Episcopal Health Foundation partnered to conduct a representative survey of adults living in 24 counties along the Texas coast that were particularly hard-hit. The survey – which was conducted between two to three months after Harvey made landfall – allows for examination of the views and experiences of residents in these counties overall, as well as in four distinct geographic regions: Harris County (the county where Houston is located and the largest in terms of population); the counties surrounding Harris that are part of the same Regional Council of Governments (“Outside Harris”); the three counties (Orange, Jefferson, and Hardin) that make up the “Golden Triangle” area east of Houston where the cities of Beaumont, Orange, and Port Arthur are located; and several counties to the southwest of Houston that make up the coastal area including Corpus Christi and Rockport (“Coastal”). In addition to the survey, the partners conducted three focus groups in Houston and two in Beaumont with low- and middle-income residents who were affected by the storm.

Key findings from the survey include:

Two-thirds of residents of the 24 hard-hit Texas counties surveyed report being affected by Hurricane Harvey in terms of damage to their homes or vehicles, employment disruption, or income loss. Four in ten sustained damage to their home, nearly half experienced an interruption or loss of employment or some other loss of income, and one in five had a vehicle that was damaged. One in nine remain displaced from their homes at the time of the survey.

Effects of the hurricane were unevenly distributed by geography and demographics. Black and Hispanic residents, those with lower incomes, and those living in the Golden Triangle and Coastal areas were more likely to be affected by property damage or income loss than other residents.

Health and mental health issues affected a smaller share of the population, but some residents report struggling to get needed health care, and focus groups suggest some may have unmet mental health needs. One in six affected residents say someone in their household has a health condition that is new or worse as a result of Harvey, and nearly two in ten feel that their own mental health is worse because of the storm. Among those with a new or worsened health condition, six in ten say they have skipped or postponed needed medical or dental care, cut back on prescriptions, or had problems getting mental health care since the storm.

About half of those who have applied for disaster assistance from FEMA or the SBA say their application is still pending or has been denied, and many of those who were denied say they were not told the reason for the denial and were not given information on how to resubmit their application. About a quarter of those whose homes were damaged say they had any flood insurance. Four in ten of those who were affected say they expect none of their financial losses to be covered by insurance or other assistance.

The financial situations of most people affected by Harvey are tenuous. About half of affected residents say they have no savings whatsoever, and another quarter say that if they lost their job or other source of income, their savings would be exhausted in less than 6 months.

Survey: Three months after Hurricane Harvey, nearly half of affected Texas residents say they are not getting the help they need to recover

Nearly half of affected residents say they are not getting the help they need to recover from the hurricane. Particular areas that stand out where residents say they need more help include applying for disaster assistance and repairing damage to their homes.

Local, county, and state governments receive high marks from residents for their response to Hurricane Harvey so far. Residents are more mixed in their views of how the U.S. Congress has responded, and responses tilt negative when it comes to President Trump’s response. Four in ten affected residents are not confident relief funds will benefit those most in need.

For the community overall, including for affected residents, the top priorities seen for the recovery focus on basic needs, including financial assistance and housing. Top priorities are getting financial assistance to those who need it, rebuilding destroyed homes, and making more affordable permanent and temporary housing available.

Hurricane Harvey made landfall as a Category 4 hurricane near Rockport, Texas on August 25, 2017. Three months later, many Texans in the affected areas continue to recover and rebuild their lives and their communities from this unprecedented natural disaster.

With a record 52 inches of rainfall and massive winds in parts of the region, the flooding caused by the storm had widespread and devastating effects. A total of 41 counties in Southeast Texas were designated as federal disaster areas. As of mid-November, 888,866 individual assistance applications had been received by the Federal Emergency Management Agency (FEMA) and $8.73 billion in federal funds had been provided to affected Texans.²  In some of the hardest hit communities, many residents remain displaced from their homes, and finding continued shelter for these individuals is a major public policy concern. The storm also affected more than 1 million students and 220 school districts across the region.

In order to provide policymakers, funders, and others working on the recovery effort with reliable information about how Texas residents were affected by Hurricane Harvey and what their needs and priorities are when it comes to recovery, the Kaiser Family Foundation and the Episcopal Health Foundation partnered to conduct a representative survey of residents in 24 counties along the Texas Gulf Coast that were heavily impacted by property damage from the storm. Both partners worked together to design the survey and analyze the results. The 24 counties were chosen based on a mapping analysis of Harvey property damage developed by FEMA (see Appendix A Figure One), in an effort to examine a contiguous area of counties that suffered the largest share of property damage. The region surveyed divides into four groupings of counties: Harris County (the county where Houston is located and the largest in terms of population); the counties surrounding Harris that are part of the same Regional Council of Governments (“Outside Harris”); the three counties that make up the “Golden Triangle” area east of Houston where the cities of Beaumont, Orange, and Port Arthur are located; and several counties to the southwest of Houston that make up the coastal area including Corpus Christi and Rockport (“Coastal”).³ 

These 24 counties are home to approximately 7.95 million people, which represents 94 percent of the total population in the 41 counties that were declared as federal disaster areas. This region is incredibly diverse in terms of race and ethnicity (40 percent White, 36 percent Hispanic, 16 percent Black, six percent Asian, and two percent others). On average about 15 percent of the people in the affected region are officially designated as living in poverty, with wide variations in poverty across the counties.⁴  These counties are also diverse in their population density; eight of the counties we surveyed were designated as rural counties and 16 as urban counties.

The survey was designed to represent the views of residents living in the region overall, and also be able to describe the views and experiences of those living in each of the four regions. In order to represent some of the most vulnerable groups affected by the storm, the survey also included oversamples of lower-income residents, Black and Hispanic residents, and those living in the areas that had the largest amount of property damage as reported by FEMA. Results for the region overall have been weighted to reflect the demographics of the overall population. The survey was fielded from late October through late November, roughly two to three months after Harvey made landfall.

In addition to the survey, the partners conducted five focus groups (three in Houston and two in Beaumont) on October 8 and 9 with lower- and middle-income residents who experienced damage to their homes and/or a loss of income as a result of Hurricane Harvey. The focus group findings highlighted in this report help provide context and add the human story behind some of the quantitative findings from the survey.

Housing, Property Damage, Employment, and Income Effects

Hurricane Harvey left a trail of physical destruction along the Texas Gulf Coast, and the survey finds that a large share of area residents felt the effects in their own lives. Overall, two-thirds of adults in the 24 Texas Gulf Coast counties surveyed say they were adversely affected by the hurricane, either because their home or vehicle was damaged or because they or a family member in their household experienced the loss of a job, decreased wages, or other lost income.

More specifically, more than four in ten residents (43 percent) report that their home was damaged, including one in five who say their home had major damage (16 percent) or was completely destroyed (3 percent). About one in five (21 percent) also say they owned a vehicle that was damaged or destroyed by Harvey. Nearly half (46 percent) say they or someone in their household experienced employment-related effects of the hurricane, including losing a job or being laid off (12 percent), having hours cut back at work (32 percent), or some other loss of income such as from a small business or unpaid missed days of work (32 percent).

For more detail on residents’ housing and transportation situation, see Section 4For more detail on residents’ employment and financial situation, see Section 5

The effects of Hurricane Harvey were felt more heavily in some communities than others. Geographically, those in the Golden Triangle (77 percent) and Coastal counties (74 percent) were more likely to report being affected than those in Harris County and the counties that surround it (65 percent and 63 percent, respectively), with differences largely driven by higher rates of property damage. Effects were also distributed unevenly across demographic groups, with Black and Hispanic residents and those with lower incomes more likely to report being affected. For Hispanics, this disparity is largely driven by higher rates of employment- related effects, while for Blacks it is driven both by employment effects and by higher rates of damage to their homes and vehicles. Not surprisingly, those with lower incomes – who are less likely to hold salaried jobs and more likely to work on an hourly or contract basis – are more likely to report adverse effects on employment and income as a result of the storm. However, the income disparity is not limited to employment effects; lower- and middle-income individuals are also more likely to report damage to their homes compared to those with higher incomes.

Since race and income are correlated, it can be difficult to determine whether the disparities in storm-related effects are driven more by one factor or the other. Our analysis indicates that both race/ethnicity and income play a role, but that some racial and ethnic differences persist regardless of income. For example, Hispanic residents at both higher and lower income levels are more likely than their white counterparts to say someone in their household experienced employment-related disruptions as a result of the storm – specifically having hours cut back at work. Nearly six in ten (58 percent) Hispanics who report incomes below 200 percent of the federal poverty level (FPL) say this happened, compared with three in ten lower-income Blacks (31 percent) and two in ten lower-income whites (19 percent). And for those with self-reported incomes above 200 percent of poverty, Hispanics are almost twice as likely as whites to say a family member had their hours cut back (37 percent versus 20 percent).⁵ 

Effects on Physical and Mental Health

In addition to the reported effects on people’s finances and living situations, some residents also report problems with their physical and mental health as a result of Hurricane Harvey. Overall, 13 percent of residents in the 24-county area (including 17 percent of those who suffered property damage or income losses and 4 percent of those who did not) say someone in their household has a health condition that is new or has gotten worse as a result of Harvey. Similarly, 13 percent of all residents (including 18 percent of those who suffered property or income losses and 3 percent of those who did not) feel that their own mental health has gotten worse as a result of the hurricane.

For more detail on residents’ health care challenges, see Section 6

Residents’ General Level of Recovery

Three months after the storm, residents’ self-reported level of recovery from Hurricane Harvey is somewhat mixed. Among those who were affected by property damage or income loss from the storm, just over half say their lives are largely (25 percent) or almost back to normal (31 percent), while about four in ten say their lives are still somewhat (28 percent) or very disrupted (16 percent). Once again, those living in the Golden Triangle area appear to be the hardest hit, with roughly six in ten affected residents saying their lives are still somewhat (29 percent) or very disrupted (33 percent).

When asked to name in their own words the biggest challenge facing their family in recovering from Hurricane Harvey, affected residents focus on basic needs like housing and financial stability. One-third (33 percent) say their biggest challenges are financial, including general financial problems (11 percent), making up lost wages (8 percent), and problems keeping up with bills (6 percent). Another third (32 percent) mention housing-related challenges, including 16 percent who mention home repairs and 5 percent who mention trying to find a new living situation. Eight percent mention transportation issues including the need to repair or replace a vehicle, five percent mention health challenges, including mental health or stress, and four percent name family-related issues.

The survey shows there is room for progress in getting needed help to affected residents. Nearly half (45 percent) of those who were affected in terms of property damage or income loss say they are getting the help they need to recover from Hurricane Harvey, while an equal share (45 percent) say they are not. Here, too, progress is uneven, with Black residents and those with lower incomes more likely to say they’re not getting the help they need.

Experiences with Disaster Assistance

One major source of help for people affected by natural disasters in the U.S. is disaster assistance provided by the Federal Emergency Management Agency (FEMA) and low-interest loans provided by the U.S. Small Business Administration (SBA). Overall, about four in ten (44 percent) residents who were affected by Hurricane Harvey, including 59 percent of those whose homes were damaged, say they have applied for assistance from FEMA or the SBA. Among those who applied, one quarter (26 percent) say their application has been approved and one-third (33 percent) say it was denied. Another 19 percent say their application is still pending, and 16 percent are not sure of the status.

Among those who applied for assistance from FEMA or the SBA, those who report incomes at least four times FPL (45 percent) and those whose home had major damage or was destroyed (36 percent) are more likely to say their application was approved. In addition, white and Hispanic residents who applied for assistance are more likely than Black residents who applied to say their application was approved (34 percent, 28 percent, and 13 percent, respectively).

Among the 30 percent of those who applied for FEMA or SBA assistance who say their application was denied, four in ten (38 percent) say they were not told why their application was denied, and six in ten (59 percent) say they were not given information on how to revise and resubmit their application.

When those who did not apply for FEMA assistance were asked why they did not apply, most (63 percent) said they had only minor damage or did not feel they needed the help. However, some said they lacked information about how to apply (12 percent), they didn’t think they would qualify (8 percent), or they thought it would be too much hassle or too difficult to go through the process (5 percent).

Areas where Additional Help is Needed

Related to this confusion around accessing FEMA benefits, the most common area in which residents say they need more help is applying for disaster assistance, with 34 percent of affected residents saying they need help in this area. A close second is repairing damaged homes, an area in which 29 percent of affected residents say they need assistance. Some also say they need help finding affordable permanent or temporary housing, finding a job, getting transportation, and accessing medical care and mental health care. For most of these areas, Black residents, those with lower incomes, and those in the Golden Triangle area are more likely than others to say they need more help.

When asked about the different types of help they may have received from government agencies, local charities, or other organizations, about a third of affected residents (35 percent) say they’ve gotten help paying for food, including half (51 percent) of those living in the Coastal region and 41 percent living in the Golden Triangle area. Much smaller shares of affected residents say they’ve gotten help paying for housing or utilities (9 percent), paying for health care (7 percent), finding employment (5 percent), or accessing mental health services (5 percent).

When asked about priorities for rebuilding and recovery in their area, Texas Gulf Coast residents – including those who were affected by the hurricane and those who weren’t – identify many areas where more resources are needed, with the largest focus being on financial help and housing for those in need. The highest-ranking priority overall is getting financial help to people who need it; 64 percent say more resources are necessary in this area and when forced to choose, 19 percent pick it as the top priority. A close second is rebuilding destroyed homes (63 percent say more resources are necessary and 17 percent choose it as the top priority). Ranking third and fourth are making more affordable permanent and temporary housing available, with nearly six in ten saying more resources are necessary and 12 percent choosing each as the top priority. About half also say more resources are needed in cleaning up pollutants released by the flooding (49 percent), removing trash and debris (49 percent), and helping small businesses affected by the storm (48 percent), while about four in ten say the same about repairing damaged schools (42 percent), getting mental health services to those who need them (42 percent), and repairing roads and highways (40 percent). Ranking of priorities is similar when looking at responses only among those who were directly affected by the storm.

Looking at residents overall – including those who were affected by the storm and those who weren’t – most give their local, county, and state governments positive marks for the job they’re doing responding to Hurricane Harvey, with about seven in ten saying each is doing an excellent, very good, or good job. Ratings are more divided when it comes to the U.S. Congress, with 46 percent saying they’re doing at least a good job and 43 percent saying they’re doing a fair or poor job. Ratings are more negative for President Trump, with half (49 percent) saying the president is doing a fair or poor job responding to the hurricane and about four in ten (43 percent) giving him positive ratings.

Among those who were directly affected by the storm, views of the government’s response are similar, but tend to lean more negative than among the public overall. In particular, affected residents living in the Golden Triangle area, the counties surrounding Harris County, are more likely than those living in Harris and the Coastal counties to say each level of government is doing a fair or poor job responding to the hurricane. For example, about four in ten residents of the Golden Triangle and the counties surrounding Harris say that government officials in their county are doing a fair or poor job responding to Harvey, compared with about a quarter in Harris County and the Coastal counties. The exception to this pattern is in ratings of President Trump, whom Harris County residents rate more negatively than others.

Overall, about six in ten residents – including majorities in each of the four geographic areas – say they are very or somewhat confident that the money being spent on hurricane relief in Texas will benefit the people who need it most, while 38 percent say they are not too or not at all confident. However, those who were directly affected by the storm are more likely than those who were not affected to say they are not confident that money spent on relief will reach those who need it most (42 percent versus 30 percent, rising to nearly half – 46 percent – among those whose homes had major damage or were destroyed). Those who remain displaced from their homes (52 percent), those who say their FEMA application was denied (56 percent), those who say they or a family member have a health condition that is new or worse as a result of the storm (58 percent), and those who feel their own mental health is worse (59 percent) are particularly likely to lack confidence that funds will reach the people who need them most.

HOUSING DAMAGE AND DISPLACEMENT

The most visible and catastrophic harm wrought by Hurricane Harvey was the damage – sometimes irreparable – to residents’ homes and living spaces. As noted in Section 1, more than four in ten residents (43 percent) of the 24 counties surveyed say their home was damaged as a result of the hurricane, including 3 percent who say it was completely destroyed, 16 percent who say it suffered major damage requiring more than a month to repair, and 23 percent who say there was minor damage that could be repaired within a month. The numbers are starkest in the Golden Triangle, where 62 percent reported damage, including 35 percent who say their home either had major damage or was destroyed. Reported home damage was also common, but less severe, in the Coastal counties; 64 percent in that area say their home was damaged, with the major portion (40 percent) saying the damage was minor and could be repaired within a month.

In addition to these geographic disparities, Black residents and those with lower incomes were also somewhat more likely than their white and higher-income counterparts to report damage to their homes.

More than half (55 percent) of those whose homes were damaged by Harvey are homeowners, but 42 percent (including 60 percent of those with self-reported incomes below the federal poverty level) are renters. Renters are more likely than owners to report that the damage to their home was minor (62 percent versus 48 percent), while owners whose homes were damaged are more likely to say the damage was major or that their home was destroyed (50 percent versus 37 percent).

Among those whose homes were damaged, half (48 percent) say they had homeowners’ or renters’ insurance and 23 percent had flood insurance; combined, 51 percent report having at least one type of insurance. Lower-income residents are much less likely to report having insurance; three in ten (30 percent) of those with self-reported incomes below 100 percent FPL whose homes were damaged say they had any. Similarly, Black and Hispanic residents are less likely than whites to report having insurance; among those whose homes were damaged, two-thirds of whites, half of Blacks, and one-third of Hispanics say they had any insurance.

Overall, 37 percent of those living in the 24 Texas counties surveyed, rising to 54 percent in the Golden Triangle area and 68 percent in the Coastal counties, say they evacuated or left their home for some amount of time as a result of Hurricane Harvey. About one in nine residents overall (11 percent), including 24 percent in the Golden Triangle area, were still displaced from their homes at the time of the survey. Among those who have not returned to their pre-Harvey home, half say their housing costs have increased, including 28 percent who say they’ve increased a lot.

Most residents who evacuated temporarily say they feel safe after returning to their homes, however some report that they are living in unsafe conditions. Among those who evacuated and have returned to their homes, 32 percent say they moved back in before they felt it was safe, including 13 percent (rising to 24 percent in the Golden Triangle area) who still felt their home was unsafe at the time of the survey.

Vehicle Damage and Transportation Issues

Beyond damage to their homes, many residents report having damage to a vehicle as a result of the hurricane. Overall, 21 percent of residents say they had a vehicle such as a car or truck that was damaged by Harvey, including somewhat larger shares of those living in the Golden Triangle and Harris County compared with other areas, and a larger share of Black residents compared with whites.

Among those whose vehicle was damaged, about half (51 percent) say they have been able to repair or replace their vehicle, while the other half (47 percent) say they have not. Lower-income adults who experienced vehicle damage are less likely than those with higher incomes to say they’ve been able to repair or replace their vehicle. Among those who have not been able to repair or replace their vehicle, about half (51 percent) say there is convenient public transportation in their area that allows them to get to work or other places they need to go, while the other half (48 percent) say there is not.

Employment Disruption and Loss of Income

While damage to homes and other property was surely the most visible impact of Hurricane Harvey, interruptions in employment were a common occurrence and caused financial disruptions for many residents, particularly when combined with the cost of repairing damage to their home or repairing or replacing a damaged vehicle. Overall, nearly half (46 percent) of residents say they experienced some type of job or income loss as a result of Harvey, including 12 percent who say they or a family member was laid off or lost a job, 32 percent who say someone in their household had their hours cut back at work, and 32 percent who say they experienced another loss of income, such as from a small business or unpaid missed days of work.

Job and income effects were evenly distributed geographically for the most part, but were much more commonly reported among Hispanic (65 percent) and Black residents (46 percent) compared with whites (31 percent), and among those with lower incomes compared to those with higher incomes.

On the other hand, some residents report taking on extra work since the hurricane; three in ten residents affected by the storm say that since Harvey, they or another family member in their household has taken on an extra job or worked more hours to make ends meet.

Financial Circumstances of Affected Individuals

While insurance payments and FEMA assistance may be a financial help for some, many residents either don’t have access to these benefits or don’t expect them to cover a major portion of their financial losses. Among all those who were affected by the storm, just one in five (22 percent) expect that insurance and other financial assistance they receive will cover most of the financial losses they experienced. Three in ten (29 percent) say they expect it to cover just some of their losses, and 42 percent say they expect none of their losses to be covered.

Similarly, among those who had a vehicle damaged, half say they expect insurance to cover none of the cost of repairing or replacing their vehicle, while 27 percent expect insurance to cover most of the cost and one in five say it will cover just some. Lower-income adults are much less likely than those with higher incomes to say insurance will cover most of the cost of repairing or replacing a vehicle (19 percent of those who report incomes below 200 percent FPL versus 4o percent of those with higher incomes).

The financial impacts of Hurricane Harvey have led to serious consequences for some residents who were affected by the storm, particularly among Black and Hispanic residents and those with lower incomes. For example, three in ten (29 percent) affected residents – rising to 36 percent of Hispanics and 40 percent of those who report incomes below the poverty level – say that since Harvey, they have fallen behind in paying their rent or mortgage. One quarter of affected residents, including 37 percent of Black residents, say they have had problems paying for food since the storm. In addition, about four in ten affected residents say that since the hurricane, they have borrowed money from friends or relatives (39 percent), and one in eight (13 percent) say they have borrowed from a payday lender to make ends meet.

It’s worth noting that the financial circumstances of many of those who were affected by Harvey were tenuous even before the hurricane, and few report having many financial resources to fall back on. About half (48 percent) of affected residents say they have no savings whatsoever, and another quarter (24 percent) say that if they lost their job or other source of income, their savings would be exhausted in less than 6 months. This level of financial instability is much more common among Black and Hispanic residents compared with whites, and among those with lower incomes compared with higher-income individuals.

Health Conditions and Access to Care

Below the surface, and often related to the housing and financial problems they are facing, some residents report problems with their physical and/or mental health as a result of their experiences with Hurricane Harvey. Overall, one in eight residents (13 percent) say they or another family member in their household has a health condition that is new or has gotten worse as a result of the storm. Those who were affected by home damage or income loss are more likely to report a new or worsened health condition (17 percent), but still a small share of those who were not affected (4 percent) report such a condition. Among those who were affected, Black and residents and those living in the Golden Triangle are somewhat more likely to report a decline in the health of someone in their household (25 percent each).

Among those who report that someone in their household has a new or worsened health condition, 38 percent mention a respiratory condition such as asthma, allergies, or cough, and 20 percent mention mental health issues including anxiety, depression, and general stress.

While Hurricane Harvey may have led to new or worsened health problems for some residents, it’s worth noting that many affected residents lacked consistent access to health insurance and health care providers even before the storm. Four in ten (39 percent) of those who were affected by Harvey say that they do not have health insurance. Reported lack of coverage is highest among Hispanic (53 percent) and Black residents (39 percent) affected by the storm, as well as those who report incomes below 200 percent of the poverty level (53 percent).

In addition, three in ten Harvey-affected residents (31 percent) say they have no usual place they go for care when they are sick or need advice about their health, or that their usual source of care is a hospital emergency room. This is highest among affected Black (39 percent) Hispanic residents (38 percent) and those with self-reported incomes below 200 percent of poverty (40 percent).

Since Hurricane Harvey, some residents report skipping or postponing medical care or having problems paying medical bills, with much higher rates among those who have someone in their household with a new or worse health condition resulting from the storm. For example, 36 percent of those who say someone in their household has a new or worse health condition due to Harvey say that they or another family member has put off or postponed getting needed health care since the storm, 32 percent say a family member has skipped dental care or check-ups, and 31 percent say they have not filled a prescription, cut pills in half, or skipped doses of a medicine. In addition, 10 percent of residents overall, including 26 percent of those with a health problem due to Harvey, say they’ve had problems paying medical bills since the storm.

Stress and Mental Health Issues

The trauma associated with living through a disaster like Harvey and its aftermath can lead to increased stress and declines in mental health for some people. While most residents of the Texas counties surveyed (64 percent) say their mental health is excellent or very good, those who were affected by Harvey are less likely than those who were not affected to rate their mental health as excellent (35 percent versus 48 percent) and more likely to rate it as fair or poor (17 percent versus 7 percent).

Overall, 13 percent of residents – including 18 percent of those who were affected by property damage or income loss and 3 percent of those who were not affected – feel that their mental health has gotten worse as a result of the storm. Among those who were affected, some also say they have had a harder time controlling their temper or felt they had a shorter fuse since Harvey (22 percent), that they’ve increased their alcohol use (7 percent), or that they’ve started a new medication for mental health problems since Harvey (6 percent).

Mental health needs may be most acute in the Golden Triangle area. Among affected residents, those living in the Golden Triangle are more likely to say their mental health has gotten worse (33 percent) and that they’ve had a harder time controlling their temper since the storm (36 percent).

Access to care is also a problem for some with mental health needs. Fifteen percent of those who say their mental health is worse as a result of the hurricane say they or a family member have had problems getting mental health care since the storm.

In addition to formal mental health services, informal support networks can be a key source of help for individuals coping with the stress of living through a disaster like Hurricane Harvey. The survey finds that few affected residents report having a robust support network of relatives and friends living nearby. Just one in five affected residents (19 percent) say they have “a lot” of people nearby who they can rely on for help or support, with another 17 percent saying they have “a fair amount.” Six in ten say they have “just a few” (47 percent) or no people living nearby who they can rely on (17 percent). Black and Hispanic residents and those with lower incomes are also more likely than others to say they lack a robust support network.

Immigrants, particularly those who do not speak English well or do not have legal resident status in the U.S., can be particularly vulnerable to the effects of natural disasters and their aftermath for many reasons, including that they may lack the literacy necessary to navigate the systems in place to help people affected, they may be ineligible for benefits, or they may be hesitant to seek help for fear of exposing their own or a family member’s legal status.

The survey used questions to determine the likely immigration status of respondents by asking those who were born outside the U.S. whether they were a permanent resident (i.e. had a green card) when they came to the U.S. or if their status had been changed to permanent resident since arriving. Overall, 12 percent of residents in the 24-county area, including 27 percent of Hispanics, say they have not been granted permanent resident status, indicating that they are likely to be undocumented immigrants. Of this group, seven in ten (73 percent) were directly affected by Harvey, including two-thirds (68 percent) who experienced a disruption in their employment and three in ten who say their home was damaged.

Among those who are likely to be undocumented immigrants, a majority says they are very worried (39 percent) or somewhat worried (17 percent) that if they try to get help in recovering from the hurricane, they will draw attention to their own immigration status or that of a family member. Even among immigrants who are legal residents, about one in five (21 percent) worry about drawing attention to someone else’s status.

Language issues also presented a barrier for some individuals, regardless of immigration status. Among Hispanics who completed the survey in Spanish (42 percent of all Hispanics), three in ten say it was very or somewhat difficult to find the information they needed in Spanish when trying to get recovery help, while four in ten say it was easy and another quarter say they did not seek help.

Overall, the survey and focus group results provide an early snapshot of the biggest challenges facing vulnerable Texas Gulf Coast residents three months after Hurricane Harvey cut its wide swath across the region. With about half of affected individuals saying they are not getting the help they need to recover from the storm, residents prioritize basic needs like repairing damaged homes, help finding temporary and permanent shelter, and financial assistance to help affected individuals get back on their feet. The results also suggest that there is ongoing confusion about the different ways to get financial assistance, and that many affected residents could benefit from navigators or other resources to help with the application process. Finally, these results demonstrate that lower-income individuals, Black and Hispanic residents, and those living in the Golden Triangle area were particularly hard-hit by the effects of Harvey and continue to lag in the recovery, suggesting that organizations focused on recovery should keep a focus on these communities as they move forward from short-term to long-term recovery efforts.

Appendix A: Survey and Focus Group Methodology

Survey Methodology

The Kaiser Family Foundation/Episcopal Health Foundation Post-Harvey Survey was conducted by telephone October 17 – November 20, 2017 among a random representative sample of 1,635 adults age 18 and older living in 24 counties along the Texas Gulf Coast. The counties were chosen based on a mapping analysis of Harvey property damage developed by FEMA, in an effort to examine a contiguous area of counties that suffered the largest share of property damage (see Figure 1). The region was further divided into four groupings of counties: 1) Harris County; 2) Counties surrounding Harris (Liberty, Chambers, Galveston, Brazoria, Matagorda, Wharton, Colorado, Austin, Waller, Fort Bend, Montgomery, and Walker counties); 3) Golden Triangle (Jefferson, Hardin, and Orange counties); and 4) Coastal counties (Nueces, San Patricio, Refugio, Aransas, Calhoun, Victoria, Jackson, and Lavaca counties).

Interviews were administered in English and Spanish, combining random samples of both cellular and landline telephones (note: persons without a telephone could not be included in the random selection process). Sampling, data collection, weighting and tabulation were managed by SSRS in close collaboration with Kaiser Family Foundation and Episcopal Health Foundation researchers. Episcopal Health Foundation paid for the costs of the survey fieldwork, and Kaiser Family Foundation contributed the time of its research staff. Both partners worked together to design the survey and analyze the results.

The sampling procedures were designed to reach set numbers of respondents in each of the four county-groups and to oversample particular vulnerable subpopulations who were likely to require assistance in the aftermath of the hurricane, namely: people who experienced property damage as a result of the hurricane, those with household incomes near or under poverty level, Hispanic residents (in particular, non-native Hispanics), and Black residents. Some respondents were reached by oversampling cellular and landline numbers matching directory-listings in areas where data from the Federal Emergency Management Agency (FEMA) indicated large amounts of property damage due to Harvey. The sampling and screening procedures included an oversample component designed to increase the number of low-income respondents, specifically low-income Hispanic and Black respondents. This included 104 respondents who were reached by calling back respondents in the affected areas who had previously completed an interview on the SSRS Omnibus poll and indicated they fit one of the oversample criteria (based on income and race).

The dual frame cellular and landline phone sample was generated by Survey Sampling International (SSI) using random digit dial (RDD) procedures. All respondents were screened to verify that they resided in one of the 24 counties covered by this study at the time Harvey hit Texas. For the landline sample, respondents were selected by asking for the youngest adult male or female currently at home based on a random rotation. If no one of that gender was available, interviewers asked to speak with the youngest adult of the opposite gender. For the cell phone sample, interviews were conducted with the adult who answered the phone.

A multi-stage weighting design was applied to ensure an accurate representation of the population of each county-group. The first stage of weighting involved corrections for sample design, including accounting for oversampling of the most-affected areas, as well as non-response for the callback sample. In the second weighting stage, demographic adjustments were applied to account for systematic non-response along known population parameters, within each county-group. Population parameters included gender, age, race, Hispanic origin (broken down by nativity), educational attainment, and phone status (cell phone only or reachable by landline). This stage excluded the low-income oversample component. Based on this second stage of weighting, estimates were derived for the share of low-income respondents (Black, Hispanic and other) in the population. The third stage of weighting included all respondents in each county-group and included income-status (low or high) by race/ethnicity based on the previous stage’s outcomes. In the last stage each county-group was weighted to accurately represent its adult-population share within the 24-county region. Weighting parameters were provided by SSI based on estimates from the U.S. Census Bureau’s 2016 American Community Survey (ACS) for Harris County and 5-year (2011-2015) cumulative data from the ACS for other county groups.

The margin of sampling error, including the design effect for the full sample, is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available by request. Note that sampling error is only one of many potential sources of error in this or any other public opinion poll. Kaiser Family Foundation public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

Focus Group Methodology

As part of this project, the Kaiser Family Foundation and the Episcopal Health Foundation conducted focus groups to gather qualitative data from vulnerable populations affected by Hurricane Harvey. Topics covered in the focus groups were similar to those covered in the survey. The groups were held in Houston on November 8-9, 2017 and Beaumont on November 9, 2017. In total, five two-hour groups were conducted with eight participants each.

To qualify for each group, individuals must have said: 1) that their total family income from all sources in 2016, before taxes, was less than $60,000; and 2) that they experienced damage to their home or vehicle or lost job-related income as a result of Hurricane Harvey, and that the loss was at least a minor problem for them and their family. In addition, participants in each session were recruited with several additional aims: That at least half said their loss of income or property was a major problem for them and their family, and at least half said they their home had major damage or was destroyed. Recruitment also aimed to target a mix of owners and renters.

In Houston, two groups were conducted with Hispanics in Spanish – one of which consisted of participants who self-identified as undocumented immigrants. A third Houston group, consisting of mixed races/ethnicities, was conducted in English. In Beaumont, two groups were conducted in English, one with Black residents and the other with participants of mixed races/ethnicities. Participants in four of the groups were given an incentive of $100, and participants in one Houston group were given $125 since the group was conducted in the morning, a more difficult time to recruit for.

ConneXion Research recruited and provided moderator services for each group. The Houston groups were held at ConneXion’s research facility, and the Beaumont groups were held at a health service organization. The screener questionnaire and discussion guide was developed by researchers at the Kaiser Family Foundation and the Episcopal Health Foundation. Groups were audio and video recorded with participants’ permission. Focus group costs were paid for by the Episcopal Health Foundation.

Appendix B: Additional Resources

In Episcopal Health Foundation’s (EHF) initial effort to study the scope of property damage caused by Harvey, staff created a user-friendly, interactive map by using a geographic information system (GIS) mapping file from the FEMA website. The analysis was conducted using parcel data on buildings and homes, as well as flood inundation data showing the depth of water levels in different areas. EHF staff also overlaid the CDC-developed social vulnerability index data on these maps, identifying communities in need of additional support to prepare or recover from a disaster. Staff further identified and analyzed FEMA application data at the zip code level across the 41 counties, showing tremendous diversity of needs in the region.

1. Vox News, “The stunning price tags for Hurricanes Harvey and Irma, Explained,” September 18, 2017. https://www.vox.com/explainers/2017/9/18/16314440/disasters-are-getting-more-expensive-harvey-irma-insurance-climate ↩︎
2. Office of the Texas Governor, Commission to Rebuild Texas Update: Issue 10, November 2017. https://gov.texas.gov/news/post/commission-to-rebuild-texas-update-issue-10 ↩︎
3. The counties included in each cluster are: Cluster One: Harris County; Cluster Two (Surrounding Harris): Liberty, Chambers, Galveston, Brazoria, Matagorda, Wharton, Colorado, Austin, Waller, Fort Bend, Montgomery, and Walker counties; Cluster Three (Golden Triangle): Orange, Jefferson and Hardin; and Cluster Four (Coastal): Nueces, San Patricio, Refugio, Aransas, Calhoun, Victoria, Jackson, and Lavaca counties. ↩︎
4. Analysis of U.S. Census Bureau American Community Survey data. ↩︎
5. There were not enough higher-income Black residents in the sample to analyze. ↩︎