Doctors hesitate to ask about patients’ immigration status despite new Florida law

Fearful of risking their jobs, jeopardizing state funding for their institutions, and further politicizing health care, Florida hospital leaders have been reluctant to speak out against a new law that requires them to ask about patients' immigration status.

While Florida joins Kansas, Texas, Mississippi, and a handful of other states in proposing crackdowns on immigrants lacking legal residency, no other state has mandated that hospitals question patients about their citizenship.

Doctors, nurses, and health policy experts say the law targets marginalized people who already have difficulty navigating the health care system and will further deter them from seeking medical help.

Olveen Carrasquillo, a practicing physician and professor at the University of Miami's Miller School of Medicine, said he's dismayed that more health care professionals aren't speaking out against the harm the law may cause.

"Imagine if all the hospitals said, 'This is wrong. We can't do it.' But they just stay silent because they may lose state funding," Carrasquillo said. "We do have political leaders who are very vindictive and who come after you."

Touted by Republican Gov. Ron DeSantis as "the most ambitious anti-illegal immigration" legislation in the country, Florida's law was enacted in July and requires, among other things, that hospitals ask on their admission forms whether a patient is a U.S. citizen and lawfully present in the country.

Hospitals are required to submit the information quarterly to the state's Agency for Health Care Administration, which will then report total admissions, emergency room visits, and the cost of care for unauthorized residents to Florida lawmakers once a year.

Bailey Smith, communications director for the agency, said in an email the information will deliver "much needed transparency on the burden of illegal immigration on Florida's health system. Collecting this data allows taxpayers to understand where their hard-earned dollars are being exploited."

But immigrants in general, particularly those without legal residency, use very little health care, said Leighton Ku, a professor of health policy and management at George Washington University and an expert in immigrant health. Ku added that some studies suggest immigrants pay taxes and premiums that help subsidize the health care of other U.S. residents — countering the narrative that they deplete health care resources.

"Immigrants do help support the system," he said.

Nearly 80 health care professionals signed a public letter in April opposing Florida's legislation. Despite this strongly felt but muted opposition to the law, some public hospitals in immigrant-rich Miami-Dade and Broward counties in South Florida are downplaying the effect on patients or their institutions.

"This element of the new law will have almost no impact on Jackson Health System or its patients," said Krysten Brenlla, a spokesperson for Miami-Dade's network of four public hospitals.

Brenlla said the hospital asks patients to voluntarily disclose their country of birth and, for those born outside the United States, their immigration status.

Yanet Obarrio-Sanchez, a spokesperson for Memorial Healthcare System, which operates six public hospitals in Broward County, said that while staffers are asking patients about their immigration status at registration using digital forms, the hospital will "continue to care for all."

But that's not the message getting through to many immigrants, said Rosa Elera, a spokesperson for the Florida Immigrant Coalition, a nonprofit network of community organizations, farmworkers, and other immigrant advocacy groups.

"It's creating fear," she said. "It's creating concern."

Besides the requirements for hospitals, the law invalidates out-of-state driver's licenses for immigrants who lack legal residency in Florida, establishes criminal penalties for transporting such immigrants into the state, and empowers state police to enforce immigration laws.

These sweeping measures have fomented distrust and fueled misinformation, said Elera.

In one instance, Elera said, a woman who went in for her regular checkup at a clinic was turned away because administrative staff members were confused about the new law. "And we've been getting questions from parents of U.S.-born children who are now afraid to take their children to pediatric offices," she said.

Elera said that in the weeks leading up to the law's effective date on July 1, the coalition launched a "Decline to Answer" campaign. There is no penalty for not answering, advocates say.

Florida's immigration law follows an executive order DeSantis issued in 2021 compelling state agencies to determine the cost of health care for immigrants lacking legal status. The following year, the state's Agency for Health Care Administration said that such immigrants had cost Florida hospitals nearly $313 million, with facilities receiving reimbursement for about one-third of the expense. In 2021, Florida hospitals with emergency rooms reported $21.7 billion in total patient care costs, according to state data.

Although the new requirement in Florida law applies only to hospitals that accept Medicaid, administrators at some free and low-cost community health centers fear they may be next. Recent Florida laws restricting abortion, prohibiting instruction of gender identity and sexual orientation in schools, and limiting gender-affirming care for youth all began with a smaller scope and later expanded, noted Laura Kallus, CEO of Caridad Center, a nonprofit clinic serving uninsured people in Palm Beach County.

Caridad Center does not ask patients about immigration status, Kallus said. But she worries the state could add conditions to a state grant the clinic receives to provide HIV testing and counseling.

"What if they said, 'You don't get this funding if you don't take this information?'" she said.

Community health centers do not wield much influence in the state Capitol, Kallus added, and many count on the Florida Legislature to increase funding for free clinics to provide dental and behavioral health, which means they won't want to risk upsetting lawmakers by criticizing the immigration law.

In his second term as governor, DeSantis has demonstrated a proclivity for punishing his perceived political opponents rather than negotiating with them.

The governor blocked state funding for a new training facility for Major League Baseball's Tampa Bay Rays when the team posted a tweet calling for gun safety laws following mass shootings in Buffalo, New York, and Uvalde, Texas. He removed an elected state attorney from office, in part, because the Hillsborough County-based prosecutor signed public statements that said prosecutors should not criminalize abortion and gender-affirming care for transgender people. And DeSantis has sought to punish Disney for opposing a Florida law that prohibited discussion of sexual orientation in certain classrooms.

Kevin Cho Tipton, a critical care nurse practitioner who works at two public hospitals in South Florida, said the irony of hospitals' muted opposition to the state's immigration law is that the governor ratified another law this year that protects health care workers' free speech.

The law was partly intended to shield physicians from disciplinary action if they advocate for alternative treatments for covid-19 or question the safety of covid vaccines, but it also protects speech about public policy, including postings on social media.

Tipton said he traveled to Tallahassee in April to urge Florida lawmakers to oppose the immigration bill, and he posted a video on Twitter of his testimony. He also conducted an informal survey of 120 co-workers at a public hospital in Broward County.

"Ninety-eight percent of nurses, doctors, pharmacists, surgeons — all across the spectrum — signed a survey on my phone that says, 'We disagree with this, its intent, and it's not what we should do,'" he said.

No one wanted to put their name out in public, though. So, Tipton posted a blurred screenshot of their signatures on Twitter to make a point.