At CommunityHealth, a free medical clinic on Chicago's West Side, nurse practitioner Margaret Bavis says her patients are usually "rock solid." That means they show up for their appointments and take their prescribed medications.
But all that has changed since President Donald Trump took office, she says.
Raids by U.S. Immigration and Customs Enforcement (ICE) agents in several cities, including Chicago, have frightened immigrant communities. Most patients who come to the free clinic are immigrants who speak Spanish or Polish — and most are uninsured. Despite surges of flu-like illnesses, many patients are staying away.
One of Bavis's patients skipped an appointment to get lab work done, but finally showed up a week later. The patient was in tears, and fearful she could be caught up in ICE raids and separated from her family.
"'Right now, I just am so afraid. I can't go anywhere,'" Bavis recalled the patient saying.
Bavis said it's been "heartbreaking to hear that kind of despair. I think we're just only at the very beginning of what's going to be a really horrible time for our patients."
Delaying care, even for a short time, can have grave medical implications, health care providers say.
"For many, many immigrants who are prioritizing a future in this country above their own health, it's a risk in their minds many people believe is worth taking," said Dr. Jose Figueroa, an associate professor of health policy at the Harvard T.H. Chan School of Public Health.
"It is one of the most difficult choices that people are making, and it is a massive problem, especially right now when it's the winter, and this is the time where we're seeing a lot of viral infection spreading in the community," Figueroa said.
He thinks of Latino immigrant communities, where it's common for multiple generations of families to live together, allowing infection to spread to elders in the household who might be more vulnerable to illness.
At CommunityHealth, many patients need help managing high blood pressure, type 2 diabetes and other chronic conditions, Bavis said. Left untreated, those illnesses can set off a cascade of health complications. Bavis witnessed this during the COVID pandemic, when people stayed away from hospitals and clinics to make space for the critically ill, but then got sicker from delaying medical care.
The health center had a huge backlog during the pandemic of patients who missed preventive cancer screenings, such as Pap smears, mammograms, and colonoscopies. When patients did return, some were diagnosed with cancer at a later stage, according to CommunityHealth's CEO Steph Willding.
Almost 30% of patients skipped or cancelled appointments
CommunityHealth treats more than 4,000 people a year, with around 50 employees and 1,000 volunteers helping take care of patients. Like a lot of hospitals and health centers, CommunityHealth doesn't ask a person's legal status.
Still, in the first two weeks after Trump took office, nearly 30% of patients didn't show up or canceled their primary care visits, specialty appointments, or lab tests without rescheduling. That translated into more than 300 missed visits, Willding said.
"It was very surreal and actually reminded me of what it felt like to be on site during the pandemic," Willding said. "Several times, I walked into the clinic and it was silent, no noise, and when I checked on the waiting room, twice we had no patients in our waiting room."
Not every clinic or hospital is having the same experience as CommunityHealth, or is keeping track of how many patients are failing to show up for appointments. Some medical facilities slide another patient into a slot when someone doesn't come.
Several clinics, including CommunityHealth, have shifted to virtual visits at the request of patients who don't want to leave their homes. But that's not a long-term solution, Willding said. Some medical needs have to be handled in person, like getting a vaccine.
Fears prompt some parents to disenroll their children from health insurance
There are other signs of a chilling effect on health care. At CommunityHealth's onsite pharmacy, two shelves were packed with small brown paper bags — all containing prescription drugs that hadn't been picked up for around 10 days. Those medications included insulin to treat diabetes, and medications to manage blood pressure, cholesterol and rheumatoid arthritis.
"Depending on how much they have at home, they definitely need these meds," said Elsa Bishop, assistant director of pharmacy at CommunityHealth.
More than half of the health center's patients have at least one chronic condition that needs consistent care, Willding said.
Social service agencies in the Chicago area that assist immigrants say their clients are also frightened of engaging in care or receiving services. For example, some people aren't renewing food assistance or medical benefits that they previously received from the state of Illinois. Some are also shying away from applying for financial aid to help pay hospital bills, advocates say.
At Mano a Mano Family Resource Center, a nonprofit in Chicago's northern suburbs, some immigrant parents are taking their kids off of health insurance, even if their children are U.S. citizens.
Mano a Mano typically helps around 12,000 mostly Latino immigrants enroll in public benefits every year. Case managers usually receive about 50 to 60 calls a day to apply, according to program manager Irma Barrientos.
That's trickled to three to five calls a day.
"The fear is so great that it's preventing people to seek life-saving treatment, preventive treatment," Barrientos said.
She points to the Illinois health insurance programs, which cover immigrant adults and seniors regardless of their immigration status. They have been lauded as a lifeline for people who don't have legal status in the state. But if people don't renew every year, they lose coverage.
"We're going to have this vicious cycle of people having to go to the ER as their last resort and having these huge medical bills that everyone in America has," Barrientos said.
During Trump's first term, the nonpartisan Migration Policy Institute analyzed the chilling effect, documenting steep declines in low-income immigrants signing up for food assistance, health insurance, and other public financial assistance that they were eligible for.
The Trump administration has said it's focusing on migrants who present a public safety threat, though some families and immigration rights advocates contend that immigrants without a criminal record are also being arrested.
Finding new ways to reach patients
With many immigrants afraid to leave home, health advocates are turning to social media to get their messages out. Mano a Mano hosts a weekly livestream to educate people about their benefits and try to ease concerns.
CommunityHealth plans to open a "micro-clinic" next month in the Back of the Yards neighborhood in Chicago. The clinic will be housed inside The Resurrection Project, a nonprofit that helps immigrants with everything from affordable housing to legal services.
This would help cut down on travel times for some patients, possibly enticing them to keep getting their regular check-ups, Willding said.
In the meantime, to help protect patients, Willding won't allow immigration officers or people who are not patients to linger in the waiting area or lobby. Immigration officers typically need to show a warrant signed by a judge or probable cause to arrest someone.
Back at the main clinic, Bavis, the nurse practitioner, reminds herself the clinic has gotten through challenges before. Like the pandemic, or when Texas sent busloads of migrants to Chicago and thousands suddenly needed food, shelter and medical care. Clinics, churches and nonprofits stepped up to help.
"In this moment, I just feel I'm looking for the hope," Bavis said. "I want to be strong for my patients and for my community, but I think right now, today, it just feels really hard."
This story comes from NPR's health reporting partnership with WBEZ and KFF Health News.
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