Just beyond the reception desks at the two Clinica Romero health center sites in Los Angeles are signs in English and Spanish that say: “All Are Welcome,” as do buttons worn by staff members.

That message at the two clinics, which welcome patients regardless of whether they can pay, aims to counter fears that health facilities such as clinics are prime arrest sites for undocumented immigrants.

“We are seeing stressed and worried patients as well as conversations about what could happen to patients among clinic staff,” said Nicole Lamoureux, CEO of the National Association of Free and Charitable Clinics (NAFCC), which has clinics in Fresno, Visalia and Tularc.

Constant news reports of potential changes to immigration laws, community rumors and, occasionally, some strategically parked cars manned by Immigration and Customs Enforcement (ICE) agents are keeping some immigrants—lawfully present and undocumented—and their family members away from their health providers.

A December 2017 survey by the Kaiser Family Foundation of 100 immigrant families in eight cities—five in California—found that some families cut back on well-child visits as well as appointments with providers they didn’t already know. The survey also found that fear is keeping some undocumented immigrant women expecting babies from seeking prenatal care.

No California health facilities have reported raids to the California Primary Care Association which represents 1,300 community health clinics and centers serving over six million patients in California.

Undocumented immigrants have been questioned at health clinics in Vermont and North Carolina, according to the NAFCC and “a few clinics in California have reported seeing ICE agents parked across the street or near health centers,” said Carmella Castellano-Garcia, the association’s president and CEO.

Clinic directors across the state are adding the welcome signs and buttons as well as posters listing immigrant rights on clinic walls. They are also training for staff in case ICE officials enter the buildings.

Nicole Lamoureux said interest among NAFCC member clinic directors for webinars and other information on protecting undocumented immigrants “has been astronomical.”

Health care facilities such as clinics are “sensitive locations” according to guidelines from the U.S. Department of Homeland Security (DHS) which runs ICE. Other sensitive locations include schools, day care centers and houses of worship.

ICE policy states that “enforcement actions at sensitive locations should generally be avoided.” In a DHS FAQ updated at the end of January, the department confirmed the list of sites, as well as exceptions, including a perceived security threat, and an order from a supervising officer.

While there are no known documented cases of arrests specifically at sensitive locations, the fear is enough to keep many immigrant families at home as much as possible, according to the Kaiser Family Foundation report and clinic directors interviewed by the California Health Report.

“We haven’t had agents at our clinics, but we know how fearful our patients are and we’ve seen a small drop-off in the last few months in patient visits,” said Marty Lynch, CEO of Lifelong Medical Care, a Federally Qualified Health Center which has fourteen health clinic sites and other health services in Alameda, Contra Costa and Marin counties.

“We used to get a good mix of patients from our ads and flyers, but most of that has dropped off in the last year,” said David Wallace, director of Clinic by the Bay, a free clinic in San Francisco. “Now our patients come almost purely through word of mouth because people they know tell them it’s safe.”

A survey conducted earlier this year by the CPCA together with The Children’s Partnerships and funded by the California Program on Access to Care with 151 clinic directors, but not yet published, found changes in clinic visit patterns among immigrant families:

• Close to 40 percent said that immigrant families increasingly were not scheduling routine prevention or primary care appointments for their children.
• Almost thirty percent said immigrant families have increasingly changed how they access care for their children such as switching to walk-in visits (rather than have their name on clinic lists), phone visits and scheduling all health care visits in a single day, to limit visits to the clinic.
• Nearly half of those responding said immigrant children are increasingly being diagnosed with mental health conditions such as anxiety and depression, and almost a quarter said that parents are increasingly seeking mental health care for their children.

Immigrants’ fear of accessing health care could get worse if other types of immigration enforcement is strengthened, such as deporting immigrants known as “dreamers,” who came here as children with their parents, according to Gabrielle Lessard, senior policy attorney for the National Immigration Law Center in Washington, DC.

“It’s hard to give people credible assurances in a situation where everything is changing so fast,” Lessard said.

In order to stay current, most clinics have regular staff meetings and the clinic associations offer assistance, webinars and materials to inform the clinics about the legal rights of their immigrant patients. “We have board and staff meetings to reinforce previous trainings,” said Wallace of Clinic by the Bay.

The two Clinica Romero sites also have monthly staff trainings, according to the clinic’s operation manager, Karissa Moreno.

The National Immigration Law Center also provides assistance to clinics for the staff training and last year created a webinar on the rights of clinic patients as well as an issue brief called “Know Your Rights, Know Your Patients’ Rights.”

Among the reminders and recommendations:

• ICE officers are generally barred from private areas of a health facility. (Clinica Romero has a sign near the reception desk pointing toward the exam rooms that says “patient access only.” It won’t definitively keep the agents out, said Gabrielle Lessard, but it can allay patient fears. )
• Be cautious of information in open view of the public, such as files visible from the visitors’ side of the reception desk.
• Avoid collecting immigration status information.
• Provide posters and educational materials advising patients that they have the right to refuse to answer questions from immigration agents and other law enforcement as well as insist that their lawyer be present if they are questioned.
• Advise patients never to run from immigration officers, because this can give an officer probable cause to arrest them.
• Establish a relationship with a local immigration lawyer who can be available if an enforcement officer comes to the clinic.
• Designate an authorized staffer to engage with law enforcement officers.
• Check any warrants to see if they are valid including correct date and name of person
• Have staff role play their responses to an immigration raid on the health care facility so they are prepared to respond confidently in a stressful situation.
• Educate and reassure patients that their health care information is protected by federal and state laws.

Staff at National Immigration Law Center are encouraged by the number of clinics seeking assistance to better protect their patients, but clinic directors shrug that off as their mission and duty.

“That’s our primary function,” said Karissa Moreno of Clinica Romero: “To create a safe space for our patients regardless of their immigrant status.”