Association Between Anti-Immigration Rhetoric and Health Seeking Behaviors
The 2016 U.S. presidential election marked an era of deep polarization and unprecedented rhetoric — especially around immigration. With more than 11 million undocumented individuals in the country, anti-immigration messaging became a dominant political theme amplified by social media and political discourse. This environment may have shaped the health-seeking behaviors of undocumented communities, who already face barriers such as language, cost, and fear of exposure to authorities.
In the present study, the authors examined how the rise in anti-immigration rhetoric affected health care utilization. Using a difference-indifferences design, the authors analyzed data from a retrospective cohort of more than 20,200 patients within a mid-Atlantic health system, categorized as either Medicaid-eligible or Medicaid-ineligible between January 2014 and December 2018. Individuals in the Medicaid-ineligible group were participants in a charitable care or sliding-scale access program. Both adult and pediatric populations were included in the analysis. The study identified June 16, 2015—the date of Donald Trump's presidential campaign announcement—as a key inflection point marking the onset of intensified anti-immigration rhetoric.
Out of the 20,200 patients that were sampled, just over 1,500 were Medicaid-ineligible, of whom 90% were predominantly undocumented and 80% identified as Hispanic/Latino. The study found that, following Donald Trump's presidential campaign announcement, primary care visits declined significantly among Medicaid-ineligible patients: by 34.5% for adults and 43.3% for children. While adult emergency department (ED) visits remained stable, pediatric ED visits increased. Inpatient admissions from the ED among Medicaid-ineligible patients also decreased significantly after mid-2015.
These findings underscore the "chilling effect," in which individuals avoid lawful activities—such as seeking medical care—due to fear of social or legal repercussions. The heightened anxiety surrounding deportation and discrimination during the 2016 campaign likely led many undocumented patients to postpone or forgo routine health care. The authors acknowledge that, although efforts were made to minimize confounding, the results of this single-region study may not be generalizable to other geographic settings with different immigration policies. Likewise, the findings cannot be extrapolated to all undocumented populations, given the large proportion of Hispanic/ Latino patients in the sample. Additionally, undocumented status was identified indirectly to protect patient privacy, and differences in income eligibility criteria—beyond immigration status—for the charitable care and sliding-scale programs may have introduced further confounding.
Much like 2016, immigration once again dominated the 2024 election cycle. Although the political landscape has evolved, themes of anti-immigration rhetoric, social media amplification, and polarized public opinion persist. This study provides a prescient reminder of how political discourse can influence not only policy but also the health-seeking behavior of vulnerable populations.
As debates over immigration continue, understanding and mitigating the chilling effect on undocumented communities remains a pressing public health and policy challenge.
Abstract
Nwadiuko J, German J, Chapla K, et al. Changes in health care use among undocumented patients, 2014-2018. JAMA Netw Open. 2021;4(3):e210763.
Importance
The 2016 presidential campaign was marked by intensified rhetoric around the deportation of undocumented immigrants. The association of such rhetoric with primary, emergency, and inpatient care among undocumented immigrants is unclear.
Objective
To examine the association of increased anti-immigrant rhetoric during the 2016 presidential campaign with health care use among a group of Medicaid-ineligible patients largely composed of undocumented immigrants.
Design, setting, and participants
Using a difference-in-differences (DID) approach, this cohort study analyzed health care use between Jan. 1, 2014, and May 31, 2018, in a retrospective cohort of Medicaid and Medicaid-ineligible (>90% undocumented) adult and pediatric patients. The inflection point of interest was June 16, 2015, the date of Donald Trump's announcement of candidacy, which represented a documented increase in anti-immigration rhetoric during the presidential campaign. Analyses were controlled for age, self-reported sex, and baseline comorbidities. Data analysis was conducted from Aug. 28, 2018, to Sept. 1, 2020.
Main outcomes and measures
The DID of the number of completed primary care encounters before and after June 16, 2015, in Medicaid compared with Medicaid-ineligible patients. Secondary outcomes included the DID of emergency department (ED) visits and inpatient discharges over the same period.
Results
There were 20 211 patients included in the analysis: 1501 (7.4%) in the sample of predominantly undocumented Medicaid-ineligible patients (861 [57.4%] female) and 18 710 (92.6%) in the Medicaid control group (10 443 [55.8%] female). The mean (SD) age as of 2018 in the Medicaid-ineligible group was 38.2 (15.4) years compared with 22.2 (16.5) years in the control group. There was a differential decrease in completed visits among Medicaid-ineligible children compared with Medicaid children (DID estimate, 0.8; 95% CI, 0.7-0.9) and Medicaid-ineligible adults (DID estimate, 0.8; 95% CI, 0.8-0.9). There was also a significant differential increase in ED visits among Medicaid-ineligible children (DID estimate, 2.3; 95% CI, 1.1-5.0). In addition, there was a differential decrease in inpatient discharges among Medicaid-ineligible adults (DID estimate, 0.5; 95% CI, 0.4-0.7), with no significant change in ED visits or ED admission rates in this group.
Conclusions and Relevance
In this cohort study, there was a significant decrease in primary care use among undocumented patients during a period of increased anti-immigrant rhetoric associated with the 2016 presidential campaign, coincident with an increase in ED visits among children and a decrease in inpatient discharges among adults, with the latter possibly attributed to a decrease in elective admissions during this period.
EMRA + PolicyRx Health Policy Journal Club: A collaboration between Policy Prescriptions and EMRA
As emergency physicians, we care for all members of society, and as such have a unique vantage point on the state of health care. What we find frustrating in our EDs - such as inadequate social services, the dearth of primary care physicians, and the lack of mental health services - are universal problems. As EM residents and fellows, we learn the management of myocardial infarctions and traumas, and how to intubate, but we are not taught how health policy affects all aspects of our experience in the ED. Furthermore, given our unique position in the health care system, we have an incredible opportunity to advocate for our patients, for society, and for physicians. Yet, with so many competing interests vying for our conference education time, advocacy is often not included in the curricula. This is the gap this initiative aims to fill. Each month, you will see a review of a new health policy article and how it is applicable to emergency physicians.