We examined Latino populations living in the shadows within the United States, and to the extent to which they may be avoiding public life because they do not want to be discriminated against due to their citizenship status, and/or the citizenship status of their loved ones. Our analyses rely upon the groundbreaking National Latino Health and Immigration Survey, a new survey sponsored by the RWJF Center for Health Policy at the University of New Mexico and implemented by Latino Decisions. We recently showcased this dataset on a webinar for the Robert Wood Johnson Foundation's Human Capital Network blog as well as a previous post here showcasing the content more focused on the Affordable Care Act.

The survey of 1,505 Latino adults was fielded from January 29 to March 12, 2015, and provides some of the most comprehensive data on Latinos' attitudes related to health care and immigration in the ACA era. Although there is tremendous depth to this study, we focus specifically on a selection of questions that address the notion of "living in the shadows."

Are Latinos Living in the Shadows?

The question that we wanted to pursue with this line of inquiry is essentially: How many Latinos are "living in the shadows," and among Latinos, who are most likely to be reluctant to step out of the shadows and fully engage in public life? To get an answer we started by simply asking: "Have you ever avoided the following activities because you don't want to be bothered or asked about your citizenship status?" We asked specifically about daily life activities like taking public transportation, renewing or applying for a driver's license, talking with teachers and school officials, reporting crime to police and visiting a doctor or clinic.

Results from the survey indicate that the majority of Latinos, 70 percent overall, are not concerned by inquiries about their immigration status. This figure makes sense, given that the majority of Latinos in our sample are U.S. citizens, and a majority of Latinos who are not U.S. citizens are lawful permanent residents. Nevertheless, we do find evidence that a substantial percentage of Latinos do report adjusting aspects of their day-to-day life because they do not want to be bothered or asked about their citizenship status. In fact, we learned that overall, about seven percent of Latino adults shy away from contact with educators, nine percent avoid taking public transportation, nine percent steer clear of visiting health care providers, and 13 percent pass on reporting crime to police.

One of the most important sources of variation in this battery is language use. We find that Spanish-dominant Latinos (58 percent of the sample) are more likely to avoid certain aspects of life due to fears of being harassed about their immigration status. More specifically, 15 percent of Spanish dominant Latinos responded that they avoided contact with educators, 19 percent avoided taking public transportation, 16 percent avoided going to a doctor, and 19 percent avoided reporting crime to the police because they did not want to be bothered or asked about their citizenship status. These results signal a deep-rooted problem in our society and should be of concern for public servants and health care service delivery personnel interested in eliminating social and health disparities.

What does immigration mean for Latino access to health care?

Given our emphasis on the health care industry, we unpack how our findings affect the community of stakeholders in health care. Looking at the average count of self-reported visits to health care providers, we find that those living in the shadows -- measured as having avoided at least one of the activities that we ask about -- systematically report fewer health care visits. And this contrast appears sharpest for Latinos who are 30-34 years old, precisely the age demographic most needed in the risk pool to make health insurance through the ACA affordable for everyone.

Another important component of this survey is that we are able to provide perspective on an important question: Does fear of being tracked by the government for immigration reasons impact Latino take-up of health insurance through the ACA marketplaces or exchanges? We know that privacy and sharing personal information was a concern raised by Latinos during the launch of the healthcare.gov website. The administration addressed this very concern in March of 2014 in an interview on Univision, the Spanish language cable news network. In that interview, President Obama assured Latinos that the healthcare.gov website, and the CuidadoDeSalud.com version in Spanish, is not to be used to collect information for immigration enforcement agencies, such as U.S. Immigration Customs and Enforcement. To assess Latino reactions, we asked respondents which statement they agree with more:

1) "Personal information I provide to my doctor and health care providers is secure and kept private" or;

2) "Personal information I provide to my doctor and health care providers is sometimes shared and not always secure."

Approximately 24 percent of respondents stated that the personal information they provide their doctors and health care providers is sometimes shared and not always secure. However, if respondents personally knew someone that has been detained or deported (36 percent of the sample), this sentiment of feeling that your personal information is notsecure increases to 29 percent. Our interpretation of these results suggests that the externalities and consequences of immigration enforcement through mass deportations are spilling over to the health care arena and are undermining much of the hard work going into the administration's key domestic policy program.

One of the key lessons that we have gleaned from our investigation based on the 2015 National Latino Health and Immigration Survey is that Latinos may not view government as compartmentalized by policy area. Their lived experiences are much more complex. Latinos are simultaneously the targets of two of the largest bureaucracy developments in history: one charged with the provision of health care, the other for the purpose of enforcing immigration law.

There is already clear indication that health care practitioners are customizing their outreach and delivery systems to address the spill-over effects of immigration to health care provision. This is wise of physicians and nurses because the daily lives of many of their Latino clients are located at the confluence of the immigration and health policy streams. Whether policy makers and immigration enforcement officials modify their approach to take into account the collateral impact of their policies on the health of their fellow countrymen and women remains an open question.

For better or worse, the take-away from our study is that immigration policy is health policy, and health policy is immigration policy. This is directly in line with the Robert Wood Johnson Foundation's new priority of establishing a culture of health, where health and well-being is thought of comprehensively. Our findings suggests the need for public servants (teachers, police officers, school administrators) and health care providers to better understand the role social stigma plays in pushing hard to reach populations in the shadows to better engage our collective concerted effort to reduce health disparities.

Gabriel R. Sanchez is an Associate Professor of Political Science at the University of New Mexico, Executive Director of the RWJF Center for Health Policy at UNM and Director of Research for Latino Decisions. Francisco I. Pedraza is an Assistant Professor of Political Science at Texas A&M University, and is a recent alumni of theRobert Wood Johnson Scholars in Health Policy Research Program at the University of Michigan. Edward D. Vargas is a Postdoctoral scholar at the Center for Women's Health and Health Disparities Research in the School of Medicine and Public Health at the University of Wisconsin-Madison.