The hidden stakes of the birthright citizenship case: healthcare for babies

By Jen Christensen, CNN

(CNN) — The birthright citizenship case in front of the US Supreme Court is about much more than just citizenship. It’s also about an issue that was little discussed in court arguments: babies’ immediate access to safety net programs and medical tests that need to be done within the first couple days of life.

For newborns, there’s typically a test for jaundice, pulse oximetry for heart defects and a heel prick that checks for rare but serious conditions that all can result in permanent brain damage if not addressed right away. Even during the high court arguments in April, advocates for children worried that these impacts were being overlooked.

“It was unbelievable, listening to the arguments,” said Bruce Lesley, president of First Focus on Children, a bipartisan children’s public policy organization. “I was screaming at the television.

“Kids are sort of the afterthought with all of this. They kept sitting around talking about allegiance and all this BS, but the people this affects are babies. The harm is to babies,” he added.

Since 1868, the 14th Amendment has granted virtually all people born in the United States automatic citizenship. On the first day of his second term in office, President Donald Trump signed an executive order to limit that birthright citizenship. The lower courts paused the order, and the case will soon be decided by the US Supreme Court.

If the high court strikes down birthright citizenship, experts say, it has the potential to hurt the health of all babies born in the United States, not just the hundreds of thousands — 320,000 in 2023, the last year for which data is available — born to unauthorized or temporary legal immigrants. It could also create what Lesley and others described as “serious chaos” in the health system.

Currently, when a baby is born in the US, they are automatically a citizen, and that gives them immediate access to a range of support and services. Parents don’t have to gather any proof of citizenship documents or mail any records to get a child a Social Security number, which is required for a baby to officially be enrolled in food benefits, health insurance and other support services. It also means babies are given near-universal access to tests that help determine what early treatment and care they may need.

“With the act of being born, [hospital or birth center] staff come in, they gather crucial information about the baby, and they are automatically enrolled. Essentially, they send in all your data for your birth certificate, your Social Security number. You really don’t have to do anything,” Lesley said.

Without automatic birthright citizenship, a hospital would essentially have to verify every baby’s citizenship in order to get a Social Security number, and that could delay care for millions of children, Lesley said.

More than 21 million Americans lack ready access to documents that prove citizenship, according to the amicus brief that First Focus on Children filed with the Supreme Court in this case. And even if parents are ultimately able to prove citizenship, it may not be done immediately, and that could delay care.

“Any administrative burden that could destabilize that system or slow it down would really put children’s health at risk,” said Dr. Kim Avila, a pediatrician based in Texas who also serves as a member of the American Academy of Pediatrics Committee on Federal Government Affairs. “In the newborn period, there is such a need for immediate and continuous access to healthcare.”

About half of all children born in the US are enrolled in Medicaid or the Children’s Health Insurance Program, according to government data. Children without health coverage are much less likely to get medical care, studies show.

Newborns also spend a lot of time at the pediatrician’s office, Avila said. They receive multiple screenings for conditions like cardiac abnormalities. Pediatricians provide weight checks, help with feeding support and urgent follow-ups for serious conditions.

Avila points to jaundice as a good example of why newborns need continuous care, timely re-evaluation and repeated testing to prevent potentially lifelong conditions. This yellow coloring to the skin and eyes is common in infants. Up to 60% of full-term babies develop jaundice during the first week of life, and 80% of premature babies do, according to the Cleveland Clinic.

Jaundice is caused by a buildup of bilirubin, a substance the body makes when red blood cells break down. In the womb, the mother’s body clears it, but then the newborn’s liver must take over this duty. Sometimes, the liver isn’t developed enough to clear out the bilirubin quickly. Too much of it can cause brain damage, and pediatricians must regularly check for bilirubin in newborns to measure the severity of the jaundice and determine whether the child needs treatment.

Before an infant leaves the hospital, screening will include a crucial pulse oximetry test to look for critical congenital heart disease. Some heart defects can cause an infant to seem healthy at birth, but they can go into sudden cardiac arrest when their oxygen supply drops. Staff will also do a blood spot test, a heel prick when the baby is a day or two old, to screen for 35 serious conditions like cystic fibrosis or congenital hypothyroidism that, though rare, can cause significant developmental delays or brain damage.

They’ll also test a newborn’s hearing, since a baby’s brain develops speech and language skills quickly in the first month and untreated hearing loss can cause permanent cognitive delays.

“Delay in checking for many medical conditions in that first week or days of life could really have devastating and potentially lifelong consequences for that child,” Avila said.

And if a child has complex health problems, losing coverage could be a financial disaster for the family.

During the first year of life, pediatricians track vital growth milestones and conduct routine exams for eye problems, ear problems, heart issues and breathing trouble. They give preventive vaccines and screen for developmental delays.

Additionally, pediatricians screen moms for postpartum depression and provide counseling and support for caretakers at a time when “things can be a little chaotic and overwhelming for a parent,” Avila said. “And these visits can provide important anticipatory guidance to really help families understand what to expect next and how to keep their healthy babies healthy and safe before time problems arise.”

Studies and experience, Avila said, have shown her that if Medicaid eligibility becomes more complex, children will lose coverage — not necessarily because they’re ineligible for citizenship but because of the administrative hurdles.

“When systems become more complex and harder to navigate, especially in the case of babies, babies are really going to be the ones that pay the price,” Avila said.

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