States Weaponize Public Health Programs for Immigration Enforcement

A growing number of Republican-governed states are aligning with federal directives to bolster immigration enforcement, extending the reach of these efforts by enlisting public health agencies as conduits for identifying and deporting individuals. This trend signifies a notable shift, as these states are not only adhering to federal reporting mandates but are actively expanding them.

North Carolina Joins the Ranks

In late April, North Carolina became the most recent state to join this burgeoning coalition. Republican lawmakers in the state have mandated that its public health department flag Medicaid recipients whose legal immigration status is deemed questionable, reporting this information to the U.S. Department of Homeland Security. This directive was incorporated into a bill that also reinstated $319 million in Medicaid funding, which had been previously withheld by the legislature following a budget impasse the previous year.

Health policy experts anticipate this trend will continue to proliferate among Republican-controlled states eager to align with President Trump’s administration’s focus on combating Medicaid fraud and unauthorized immigration. To date, at least four states – Indiana, Louisiana, Montana, and Wyoming – have enacted similar legislation. Lawmakers in other states, including Oklahoma and Tennessee, are also considering such measures. In these six states, the Republican party holds a dominant political position, controlling both legislative chambers and the governor’s office.

Carmel Shachar, a health policy researcher at Harvard Law School, noted, “This is an issue that is very much on the political radar right now.”

Immigrant Access to Healthcare Under Threat

Medicaid, a vital federal and state program providing health coverage to individuals with disabilities and those of low income, along with its associated Children’s Health Insurance Program, serves over 75 million Americans. While individuals without legal immigration status are ineligible for Medicaid, a significant number of non-citizens, including green-card holders, asylees, and refugees, do qualify. It is important to note that a substantial portion of children in the U.S., the majority of whom are citizens, have at least one immigrant family member.

The implementation of these new reporting laws introduces an additional layer of apprehension for immigrants seeking essential healthcare services in the United States. This is particularly concerning given the White House’s directive to utilize Medicaid data to identify and deport individuals.

While some state laws, like North Carolina’s, specifically target health agencies, a bill advancing in Tennessee proposes a more comprehensive approach, requiring all state agencies to report individuals suspected of residing in the U.S. without legal status. These state-level measures generally exceed federal requirements, which typically involve cooperating with enforcement officers by providing recipient information upon request.

In Louisiana, families with mixed immigration statuses have reported that the state’s recently enacted law is deterring them from enrolling their U.S. citizen children in Medicaid. Yesenia Polanco-Galdamez, an immigration attorney in North Carolina, expressed concern: “I expect this law will lead to more families asking whether it is safe to seek healthcare, whether information can be shared with immigration authorities, and whether enrolling a child or seeking treatment could expose them to enforcement consequences.”

Beginning in October, North Carolina state employees will be tasked with verifying the immigration status of non-U.S. citizens receiving Medicaid and reporting those without “satisfactory” legal standing to federal authorities. Republican state Representative Donny Lambeth defended the bill during legislative debate, stating, “This bill is designed not only to fund our critical needs today, but to begin looking at fraud, abuse issues we know exist within the system.”

Data from the Cato Institute, a libertarian think tank, indicates that immigrants utilize welfare programs at a lower rate than U.S.-born citizens and are less likely to engage in welfare fraud. It is also worth noting that state health agencies already have established procedures for verifying the immigration status of Medicaid applicants.

The ramifications of these policies extend beyond the individuals directly targeted. Leonardo Cuello, a researcher at Georgetown University’s Center for Children and Families, argued that such measures, while seemingly aimed at individuals, act as an “imprecise bomb that takes out the whole household.” This can lead to U.S. citizen children foregoing necessary healthcare or hospital care due to their family’s immigration status concerns.

Broader Implications and Opposition

The strategy of utilizing public health agencies is not the sole method states are employing. Some have enacted laws compelling hospitals to collect and report similar information. A Florida law from 2023, requiring hospital staff to inquire about patients’ immigration status, has reportedly led to hesitancy in seeking care among non-citizens, family separations, and psychological distress, according to a 2024 University of South Florida study. Texas Governor Greg Abbott issued a similar executive order in 2024.

In contrast, Democratic states have actively opposed the Trump administration’s policies that leverage private medical information for immigration enforcement. Twenty-one states have joined a lawsuit initiated by California, aiming to prevent the Department of Homeland Security from using Medicaid data for deportation purposes. While a federal judge ruled that recipient identities could be shared, medical information remained protected, and litigation is ongoing.

North Carolina’s Democratic Governor Josh Stein, after signing the bill into law, issued a statement urging lawmakers to safeguard Medicaid coverage for nearly 27,000 lawfully present pregnant women and children. However, he did not address the specific provision requiring the state to report immigrants without legal status.

Polanco-Galdamez concluded that such legislative actions further erode trust in healthcare systems among vulnerable families. “At the end of the day, public health systems function best when people feel safe seeking medical care,” she stated. “Policies that blur the line between healthcare access and immigration enforcement risk pushing vulnerable families further into the shadows.”