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Thousands of medical staff leading America’s pandemic response are subject to ever-shifting immigration policy.
Each day 21-year-old Karla Santiago arrives at the Arizona hospital where she works, gets her temperature checked, dons protective equipment, and starts sterilizing scalpels, clamps, and other surgical instruments. It’s a routine she’s become accustomed to in the time of Covid-19, but sometimes she gets anxious about contracting the virus and spreading it to her family.
Along with several other states, Arizona experienced a significant spike in new Covid-19 cases over the summer, which meant Santiago was having to work as many as 60 hours per week during the peak of the outbreak. Although it can be stressful at times, she likes working at a place that can heal people. It’s a job she doesn’t take for granted.
And, after months of anguish, another source of stress in her life has just eased.
Santiago was 3 years old when her mother brought her from Puebla, Mexico, to live in the U.S. without proper government documents. As a teenager, she was enrolled in the controversial Deferred Action for Childhood Arrivals program, or DACA, an Obama-era policy that shields from deportation individuals who have lived in the country without legal status since childhood.
The administration of President Donald J. Trump ended DACA in 2017, threatening around 700,000 people with deportation, but the U.S. Supreme Court struck down that decision in June, so, at least for now, Santiago won’t be losing her protected status. The relief may only be temporary — it’s possible the president may try again to end the program — but according to Santiago, “it’s taken some weight off the shoulders.”
And DACA recipients — often called “Dreamers” — aren’t the only beneficiaries of the extension. Had these immigrants lost their protected status, the U.S. health system would have lost an estimated 29,000 frontline workers in the midst of the pandemic: physicians, nurses, lab technicians, and home help aides, spread all across the country. With the pandemic showing few signs of abating, many DACA recipients, like Santiago, are putting their lives on the line caring for America’s sick.
“Even more now, they’re critically important,” says Marc L. Boom, president and CEO of Houston Methodist, an eight-hospital system in Texas. Susan Bailey, president of the American Medical Association, described DACA recipients’ contributions as “vital” in a statement issued shortly after the court’s verdict.
Yet even without the pandemic, removing this population from the workforce would have a substantial impact on American health care. DACA recipients often occupy hard-to-fill positions, and they can be well-placed to care for other immigrants. And with the U.S. health system having a disproportionately aged workforce, with many staff set to retire in the next decade, losing additional workers would compound an already looming staff shortage.
“Upholding a rollback of the DACA program would have reduced our nation’s health care capacity at a time when we can ill afford it,” Bailey said. The question now is what happens next.
The U.S. is home to approximately 10.5 million undocumented residents, and DACA was born after years of failed congressional attempts to reform immigration laws concerning their status. In 2001, the Development, Relief, and Education for Alien Minors (DREAM) Act — from which DACA recipients get their nickname — was introduced to provide a gradual pathway to citizenship for law-abiding immigrants who had come to the country as children. But, year after year, it stalled in Congress. So the Obama administration created DACA via an executive order in June 2012 to offer such immigrants legal protections that could be renewed every two years.
“They are Americans in their heart, in their minds, in every single way but one: on paper,” President Obama said of DACA candidates when he announced the policy.
Even though the program offered no guarantee of citizenship or a path to permanent residency, it changed the course of Santiago’s life. Unlike many of her high school peers, she was unable to attend college after graduation. Her family couldn’t afford the tuition and her lack of legal status made her ineligible for state or federal financial aid. She had to forgo plans to become a teacher. But DACA enabled her to get a job and obtain a driver’s license, despite Arizona’s legal fight to keep people like her from driving legally.
“It gave me the opportunity to apply for certain job positions that required a Social Security number,” she says. “It helped me find a new path.”
The legal argument wasn’t that the Trump administration lacked the power to revoke DACA, but rather that it had failed to adhere to the Administrative Procedure Act (APA), which governs the rulemaking process for federal agencies — in this case, the Department of Homeland Security. This 1946 law requires that agencies put forth reasonable justifications for their courses of action, after having first published proposals of those actions in the Federal Register at least 30 days before the change takes effect and considered public comments submitted within that period. When government departments explain their actions, they must “give honest reasons so that the public can find them accountable, and that didn’t happen here,” says Ethan Dettmer, a lawyer in the San Francisco office of the firm Gibson, Dunn & Crutcher’s, which represents DACA plaintiffs.
Chief Justice John Roberts, writing for the high court’s 5-4 majority, noted that the government had offered no reasoned explanation for the program’s shutdown. On top of this, the Trump administration, Roberts wrote, had not dealt with the fact that hundreds of young people had relied on DACA to pursue college degrees, embark on careers, start businesses, buy homes, and marry and have children. The court found that the shutting down of the program was “arbitrary and capricious, in violation of the APA.”
However, the Supreme Court did not rule on whether the Trump administration had the right to end DACA, although the court’s opinion noted that all parties agreed that it did. This has left the door open for the program to still be revoked, and President Trump has sent mixed messages since the ruling was handed down. He has promised to craft an immigration reform plan that will benefit DACA recipients, while also vowing to keep up efforts to rescind the program.
Indeed, for DACA recipients there’s a definite sense that they are still in the firing line. On July 28, the Department of Homeland Security released a memo stating that, effective immediately, it would deny any pending and future first-time DACA applications, as well as shorten any renewals and accompanying work authorization from two years to one.
And the June decision has also served to revive another attempt to end the program — a 2018 multistate lawsuit filed in Texas. In its ruling, the Supreme Court defined DACA as “a program for conferring affirmative immigration relief” — that is, as more than a simple nonenforcement of immigration policy. This has rekindled an argument that the Obama administration overstepped its executive authority when setting the program up — executive orders are allowed to direct how laws are applied, but not change or create them.
Speaking shortly after the ruling, Tom Goldstein, a Washington lawyer who has argued cases before the Supreme Court, told NBC News that the Texas case poses a big, possibly fatal, threat to DACA. “Ironically, Thursday’s Supreme Court decision sparing DACA also likely paved the way for its eventual doom,” he said.
"While this pandemic highlights the contributions of DACA recipients to the health care industry, we don’t need a pandemic to convince us how important this program is,” says Ramis Wadood, a law student at Yale University and member of the school's Worker and Immigrant Rights Advocacy Clinic, which was among the group of legal organizations to file the first challenge to the Trump administration’s move. Nevertheless, he adds, the extraordinary circumstances brought on by Covid-19 have made it appropriate to emphasize the role that DACA recipients play in society.
Various polls have shown that most Americans empathize with DACA recipients, who are now in their 20s and 30s. (To be eligible, applicants had to have arrived in the U.S. as children before June 2012 but have been born after 1981.) They come from various countries — though the majority are from Mexico.
Indeed, this gives these people skills that can benefit the nation’s health care system long after the pandemic is over, says Guadalupe Martinez, who works in human resources for Phoenix-based Banner Health, which operates a system of hospitals in six states.
“A lot of the people that we serve come from underserved populations,” says Martinez, a DACA recipient herself. “And in that aspect, I can relate, I can understand what these communities need, what these communities are asking for, what health disparities they’re facing.” When DACA recipients on the frontlines “see Hispanic families, they can understand where they’re coming from, how we like to be taken care of,” she adds. Many DACA recipients are bilingual, which is useful in communicating with patients who speak little or no English.
In July, a group of more than 140 prominent businesses and trade groups — including Google, Target, and Apple — wrote a letter urging President Trump to keep DACA intact. The work of DACA recipients and their “commitment to our companies, their families, and their communities are critical to our nation’s strength, especially since there are tens of thousands of DACA recipients working as frontline doctors and nurses and in other critical industries fighting Covid-19,” the letter stated.
Not everyone, though, agrees that DACA recipients are truly indispensable and couldn’t be replaced by U.S.-born workers. “There’s no evidence that they’re essential workers,” says Ira Mehlman, a spokesman for the Federation for American Immigration Reform (FAIR), which promotes restrictions on immigration.
And even if DACA recipients were to lose their protected status and get pulled out of the system, the process could take several years, he says: “This idea that we’re going to wake up one morning and everybody’s going to be gone is simply ludicrous.”
Some business leaders, though, aren’t just thinking in the short term. Even before the global pandemic reached the U.S. earlier this year, Boom, the CEO of Houston Methodist, had written to Congress to encourage them to find a permanent solution to the DACA quandary, noting these immigrants’ essential role in the nation’s health system. “If DACA is repealed and we were to lose these employees, it would be very detrimental to us and really so wrong for them,” he says.
At the end of the day, “patients don’t care what the immigration status of their caregivers is,” Boom adds. “They want to see the doctors, nurses, and clinical workers that they interact with to be well-trained, compassionate caregivers.”
Houston Methodist employs 113 DACA recipients as nurses, physical therapists, medical assistants, and in other positions — some of them hard to fill, according to Boom. One of those nurses is Susana Dickson, a DACA recipient who works in a hospital emergency department that has overflowed with patients during the pandemic.
“All of the patients that are Covid come through the emergency department, therefore we’re exposed to a lot of patients on a daily basis,” says Dickson, 34. But Covid-19 symptoms are not always clear cut: “Sometimes a lot of our elderly come because they fall, and then you come to find out that they fall because they’re fatigued and have a cough.”
Earlier in the pandemic, Dickson and her colleagues, wearing only surgical masks due to the nationwide shortage of personal protective equipment, cared for patients who, initially unbeknownst to them, were infected with the coronavirus. “At some point, I must’ve inhaled some droplets from a patient that was positive — and then I got ill.”
She was quarantined at home with moderate symptoms for a month, but by mid-May was back at a job she still relishes. DACA has smoothed the road toward her career goals, but for years she has struggled to overcome obstacles that come with being undocumented. She has lived in the U.S. since she was 5 years old, when her family came to the country from the Mexican state of Nuevo León.
Dickson faces less uncertainty about her future than other DACA recipients, as she recently married a citizen and can obtain legal status through her husband. But for Santiago, the program is her only option to live and work in the country legally. Without DACA, she can’t count on keeping her job. “I would lose my car as well, because I wouldn’t be able to pay for it anymore.” And, she says, her plans to get a college degree would be put off again. Worse yet, deportation would mean separation from her three U.S.-born siblings.
Advocates say that ending DACA would not only affect the current public health crisis, but also exacerbate a looming shortage of medical professionals. The industry has not kept pace with an aging population that’s living longer.
Fifteen percent of the nation’s physicians are aged 65 or older, while 27 percent are between the ages of 55 and 64, according to the American Medical Association. That means that more than four in 10 U.S. physicians will be at the traditional retirement age in the coming decade. “Our country relies on the skills and experiences of the hundreds of active physicians, plus medical students and residents who depend on DACA for their eligibility to study, practice medicine, and fill crucial gaps in patient care,” AMA president Bailey declared.
Becoming a doctor is a cherished goal for DACA recipient Jorge Contreras, a college student and medical assistant who was born in San Luis Potosí, Mexico, and has lived in the U.S. since he was 2 years old. In May, he earned a bachelor’s degree in biology from the University of Texas Rio Grande Valley. He paid for school with private funds from an organization that helps DACA recipients, as well as with state financial aid. (Texas is among the few states that grant it to DACA recipients.) Contreras wants to work on a master’s degree in sociology next and then go on to medical school.
Working at a clinic during the pandemic in the town of La Feria, Texas, near the U.S.-Mexico border, has given Contreras a chance to screen and help patients in a time of crisis — something that has strengthened his resolve to become a doctor. “It gives me a boost because I can see how health care workers, DACA recipients, are essential for times like this, even though there’s a presidency that despises us,” he says. “So there’s something that shows that we’re here for the good and not for the bad.”
Contreras, 22, says he’s thrilled that the Supreme Court has offered relief and he’s trying to stay positive about the case, because dwelling on the demise of DACA is unsettling. If the program eventually disappears, Contreras says, he would no longer be protected from deportation when he encounters Border Patrol agents at area checkpoints or at airports if he were to travel out of state to visit medical schools. “Even though my life is up and down, I’m hoping for the best and going from there,” he says.
Santiago says she also chooses to believe that the Supreme Court’s decision can bring attention to the good that DACA recipients can do — in health care and elsewhere. “We all deserve an opportunity in order to make our impact in this world, and we all deserve chances.”
Lourdes Medrano is a reporter based in Southern Arizona.