Truett C. Fortification and expansion of the DACA program: a public health mperative. HPHR. 2021; 30
The Deferred Action on Childhood Arrivals Program is the product of a 2012 executive order issued by President Barack Obama. This order was issued in the midst of the 2012 reelection under pressure from immigration activists such as Javier Hernandez and Veronica Gomez to fulfill previous campaign promises.2 Designed to shield young undocumented immigrants brought to the United States under circumstances deemed beyond their control, DACA status provides legal residency and work authorization in the United States. Currently, DACA status must be renewed biannually and is revocable.3 At this time, a formal pathway to citizenship from DACA does not exist given the failed passage of the Development, Relief, and Education for Alien Minors (DREAM) Act. However, DACA persists despite the Trump Administration’s attempt to overturn the program. Department of Homeland Security v. Regents of the University of California in a 5-4 Supreme Court Decision blocked that administration’s efforts to end the program. 4 As of December 11, 2020, the Department of Homeland Security (DHS) indicated that it was accepting renewal requests, in addition to new applications, while extending protections to those applications impacted by the restrictions made prior to the Supreme Court ruling.
In order to qualify for DACA status, a recipient must have immigrated to the United States prior to age 16 and have resided continually in the United States since 2007. In addition, they must have been present in the country since and under the age of 31 by June 15, 2012. Qualifying persons must also demonstrate they possess no other legal immigration status and are currently in school or have obtained at least a high school education or a GED. If they have not demonstrated this, then they must demonstrate honorable discharge from military service. Finally, applicants must demonstrate no felony charges or significant/multiple misdemeanor charges and that they pose no threat to national security. If approved, DACA designation must be renewed every two years.3
DACA recipients belong to a group more broadly referred to as Dreamers. This group consists of undocumented immigrants who came to the United States as children. There are an estimated 3.6 million Dreamers living in the United States currently, many of whom have never known any other home.5 According to USCIS data as of June 30, 2020, there are currently 645,610 DACA recipients, with 27,850 of those pending renewal.6 Recipients represent 150 different nationalities, though 80% of current recipients were born in Mexico. On average, recipients arrived at age 7, and have lived here more than 20 years. DACA recipients are the parents of over 250,000 U.S. citizen children.5
While DACA recipients are afforded the protection to live and work in the United States without imminent risk of deportation, they face significant obstacles with regard to healthcare coverage. Despite estimates that DACA recipients will contribute $433.3 billion to the GDP and $12.3 million in taxes to Social Security and Medicare through their employment, DACA recipients remain ineligible for programs such as Medicaid given the patchwork of state laws.5 Most notably, DACA recipients are not eligible for health insurance plans available on the Marketplace under the Affordable Care Act. Only 57% of DACA recipients received healthcare coverage through an employer while the remaining are left insured through higher education institutions, private insurance, or uninsured.7 Despite inequities, a review of the NHIS survey in Lancet Public Health found significant improvements in rates of moderate to high psychological stress for DACA eligible persons relative to ineligible non-citizen immigrants.9 Similar findings in a cross-sectional survey of Latinx DACA recipients demonstrated 76-87% reduced risk of psychological distress.10 The same survey showed no significant improvements in overall perceived health between DACA eligible and ineligible groups. Thus, while DACA affords some improvement in social determinants of health, expansion is necessary to truly ensure equitable care to this population.
The strain of the COVID-19 pandemic has revealed significant cracks in the façade of American healthcare as institutions struggle to staff inundated hospitals. Prior to the pandemic, a recent survey by the Association of American Medical Colleges estimated that by 2025, the United States will face a shortage of 60,000-95,000 physicians.11 Currently, 27,000 DACA recipients are identified as being healthcare workers. Two hundred current medical students in the United States are DACA recipients. In addition to being more likely to work in underserved areas, retention of both current and future Dreamer physicians would result in an additional 1.7 to 5.1 million patients over their careers.11 DACA recipients are a crucial part of our already overburdened healthcare system and are paramount to maintaining the pipeline of physicians and healthcare workers in the future.
United States immigration policy as it stands must be recognized as a form of structural racism with significant health and healthcare implications. The exclusionary nature of US immigration law functions to marginalize individuals based on racial and ethnic groups, subsequently decreasing immigrant access to healthcare and representation within the healthcare system.10 Though incomplete, DACA manifested as an institutional step toward a more inclusive and equitable immigration policy. DACA recipients face inordinate health consequences should the program lapse. Of the worst consequences, deportation and repatriation are associated with significantly worse mental health outcomes, including worsening anxiety disorders.9 In addition, the well-documented abuses and unlivable conditions of ICE detention centers raise human rights concerns, breeding innumerable traumas. DACA recipients’ time in the United States not only raises practical barriers in repatriation, but those deported to Mexico would likely face a delay in any social benefits, including public healthcare options due to having to revalidate their legal status.
This brief also makes the argument that protection of Dreamer healthcare workers is vital to our public health as a nation. Despite comprising 18% of the population and the majority of DACA recipients, latinx persons constitute only 5% of practicing physicians.12 A 2006 Latino Coalition task force reported one-third of latinx reported difficulty communicating with their physicians and 60% reported difficulty understanding prescription bottles.13 More recent research has supported this claim with over half of latinx participants reporting often or always having difficulty with non-Spanish speaking providers.14,15 Dreamer healthcare workers not only address the impending healthcare provider shortage, but may improve access to and quality of care to the second-fastest growing ethnic group in the US.16 Failure of this program directly results in both a humanitarian and a public health catastrophe.
The DACA program affords basic legal protection to a significant and vulnerable immigrant population in the United States. However, DACA recipients remain in an administrative limbo that places them at risk of deportation and statelessness. Despite this threat, DACA recipients make significant economic and healthcare contributions in the face of inequities in their access to the same. In addition to preserving the human rights of de facto Americans, fortification and expansion of DACA with concrete legislation that includes pathways to citizenship is imperative to the future of our healthcare infrastructure.
Dr. Cullen Truett is a fourth year psychiatry resident at the University of Virginia Health System and will be completing a Consultation Liaison fellowship at INOVA Fairfax Hospital/George Washington University. His interests include health equity, expansion of global mental health services, and migrant and refugee mental health.