President Trump recently announced his decision to officially end the Deferred Action for Childhood Arrivals program, also known as DACA. The program has been controversial since its inception, almost as controversial as the decision to end it. What impact has DACA had on the medical community, including hospitalists, and what are the implications of ending it?
DACA is a program started in 2012 by an executive action under the Obama administration. The program currently protects approximately 800,000 undocumented immigrants in the United States from being deported. All DACA recipients were brought to this country illegally as children. When the DACA program began, in order to enroll, recipients had to prove that they had arrived to here before age 16, and that they had been living in the United States continuously since 2007. Once enrolled, the protections they receive from the program include the ability to legally work and to go to school, as well as obtain a social security number and driver’s license. These protections are then afforded for renewable 2-year periods of time.1
DACA recipients are also known as “Dreamers,” as DACA was created by the Obama administration after Congress did not pass the Development, Relief, and Education for Alien Minors (DREAM) act. If the DREAM act had passed, it would have offered these same DACA recipients the opportunity to potentially gain permanent legal residency. Although attempted many times, neither the DREAM Act nor any other legislation like it has garnered enough support to be passed by Congress.
When Trump was elected, the controversy over continuing the DACA program accelerated. Understandably, the volume of applications rose substantially, with some estimating ~8,000 renewal requests being filed each week since the election. As such, many estimate the number of illegal immigrants affected by DACA has reached almost 1 million.1
One of the reasons the Trump administration feels compelled to dismantle the program is they contend that DACA is unconstitutional, as it was established purely by executive order. In the meantime, Trump is urging Congress to replace DACA with some type of equivalent legislation. According to his staffers, the dismantling of DACA means:
- No new applications will be accepted.
- All existing permits will be honored until they expire.
- All applications in process will continue to be processed.
They contend that no current DACA recipients will be affected before March 2018. Unfortunately for the Trump administration, this has been a very unpopular move, as two-thirds of Americans support allowing the Dreamers to stay in the United States.1
Impact on health care
The concern for the medical industry is that a “dismantling” of DACA could exacerbate an already existing physician shortage in the United States. For example, the Association of American Medical Colleges estimates the physician shortage will rise as the population ages and medical access increases; they currently estimate a physician shortage of approximately 40,000-104,000 by 2030.
Along similar lines, the American Medical Association wrote in a letter to congressional leaders: “We particularly are concerned that this reversal in policy could have severe consequences for many in the health care workforce, impacting patients and our nation’s health care system. … Our nation’s health care workforce depends on the care provided by international medical graduates – one out of every four physicians practicing in the United States is an IMG. These individuals include many with DACA status who are filling gaps in care.”2
But objectively evaluating the impact of the DACA program on the medical industry is difficult. We do know that most of the DACA recipients arrived from Mexico, El Salvador, Guatemala, and Honduras, as well as from Asia (primarily South Korea and the Philippines). We also know they reside in every state, with the largest numbers in California (222,795), Texas (124,300), New York (41,970), Illinois (42,376), and Florida (32,795). Most appear to be using DACA to work and to go to school; in a recent survey, 91% were employed, and 45% were enrolled in school.1
Pertaining specifically to medical school, during the 2016-2017 school year, there were 113 DACA applicants to U.S. medical schools, 65 of which were accepted and enrolled. The AAMC expects the 2017-2018 enrollment to be even higher. Almost half of medical school enrollees attend Loyola University Chicago, Maywood, Ill.; this year alone, Loyola Stritch Medical School enrolled 32 DACA medical students. This is because, in 2013, Loyola was the first medical school nationwide to openly accept students with DACA status. They did this by creating a mechanism for DACA medical students to get student loans.
One of the biggest challenges for DACA students is paying for school, as they are not eligible for federal student loans. To remove this barrier, Loyola created a loan program through the Illinois Finance Authority, which offers interest-free loans to DACA students if they commit to paying back the principal and working after medical school for 4 years in an underserved area in Illinois. It is clear that no medical school in the country will feel the effects of the DACA dismantling more than will Loyola.3
Another unintended issue that the dismantling of DACA can have on the medical industry is the temptation for undocumented immigrants to avoid seeking medical care, for fear of being discovered and deported. Such delays in seeking care can result in these patients presenting with significant and expensive medical issues.
So what are the options for Congress and what is the likely fate of these DACA recipients whose lives have been placed in limbo? Proposals introduced to date include: