Tennessee has become the first state to condition life-saving healthcare for critically ill immigrant children on their willingness to be identified to immigration authorities.
Earlier this month, parents of approximately 400 children statewide with cancer, cerebral palsy, congenital heart disease and epilepsy — about 100 of them in Nashville — received notice that to keep their children enrolled in the Children’s Special Services (CSS) program, they would need to disclose their immigration status by July 1; this disclosure would trigger a report to Immigration and Customs Enforcement (ICE).
The letters and phone calls came in the wake of a law passed by the state’s Republican legislature last April requiring all state and local agencies to report the immigration status of people applying for and receiving public benefits to Tennessee’s new Centralized Immigration Enforcement Division.
Many of these families had already been excluded from TennCare, Tennessee’s Medicaid program, because of their immigration status, and had turned to CSS, a publicly funded safety-net program that helps low-income families afford costly treatments, including surgery, medications and rehabilitation services, for children with severe or terminal illnesses.
CSS receives a portion of its funding through a federal block grant — a fixed federal allocation given to states for broadly defined health programs, with fewer federal restrictions than matching-fund programs — a distinction that initially led advocates to believe it might be insulated from immigration status-based enrollment restrictions.
Approximately 4,640 total children were enrolled in CSS as of 2024, according to federal data.
Advocates, health professionals and faith leaders who gathered on a June 23 briefing convened by America’s Voice described the directive as unprecedented in the United States, and warned that it will cost some children their lives.
“Innocent and vulnerable children are at risk of death,” said Lisa Sherman Luna, executive director of the Tennessee Immigrant and Refugee Rights Coalition.
The legislation passed last April was drafted in direct coordination with White House Deputy Chief of Staff Stephen Miller, chief architect of the Trump administration’s immigration crackdown, after Tennessee House Speaker Cameron Sexton returned from meetings with Miller in Washington and announced the state would lead the nation in discouraging immigration.
‘There isn’t another option’
“Here we are with children, really vulnerable sick children, paying the price for politics,” said Luna.
She described a recent call from a mother of a “very sick” child covered by CSS with an upcoming renal surgery, who received one of the state’s letters and is now “torn between two excruciating decisions: What’s going to happen to her child if they do not get the medically necessary care and surgery that they need, and who will care for her child if she is detained or deported?”
“This is an impossible choice that no family who is facing this kind of situation should have to face. We are a country that can provide health care. We have the resources to do so,” Luna added.
Tennessee is currently the only state in the country applying such a restriction to children with critical or terminal illnesses.
The path to this directive began even before the letters, said Michele Johnson, executive director of the Tennessee Justice Center.
Last September, the Trump administration sent guidance telling states they needed to verify immigration status for applicants of certain public programs. Though that guidance excluded block grant programs — which includes CSS — Johnson said it put state health departments on alert for immigration-based federal funding cuts and opened the door for the Republican legislative push that followed.
With this push, the state may have overstepped even its own law, Johnson said, noting that the bill’s operative language applies to individuals 18 and older, and that the legislation’s own Senate sponsor has since said he “hopes to come back next session and clarify anything in the bill that is misinterpreted, because he understood it not to be impacting children.”
“We have referred kids who are barred from our public program, TennCare, because of their immigration status, to the only safety net that can enable them to get the care they need to ease their suffering and lengthen their lives, and that’s been Children’s Special Services,” she explained. “There isn’t another option for these families.”
Well before the July 1 deadline, many families were already pulling back voluntarily.
However, a legal challenge is in the works: Three Nashville physicians treating CSS-enrolled children filed a lawsuit June 24 arguing the directive misinterprets state law by including the reporting of immigrants under 18; the claimants are asking for an immediate restraining order temporarily barring state health officials from sharing children’s information with immigration enforcement authorities while the case moves forward.
That afternoon, within hours of filing, a Davidson County judge issued the temporary order to block the law from taking effect next week, finding that plaintiffs would “suffer immediate and irreparable injury” without the block. A hearing is scheduled for July 2.
“We’ve been talking to families for the last two-and-a-half weeks where they are already having to cancel services, already having watched their child suffer, not because of the lack of science, but because of lack of moral leadership,” Johnson said.
“What is at risk is not just the lives and the thriving of these 400 families,” she added. “What’s at risk is the soul of the state.”
“If this policy remains unchanged, there will be interruptions in care,” said Dr. Jill Obremskey, a pediatrician and former Tennessee Department of Health official. “Those interruptions will lead to worsening health, more emergency room visits, more hospitalizations, more suffering, and for some children, death.”
“How can we claim to be a state that values children and values life, while denying essential healthcare to children based solely on their place of birth?” she continued.
The number at risk, Obremskey said, extends far beyond the 400 enrolled: “The community suffers around that child — the family, their friends. So 400 children, yes, but we’re talking 400 families plus 400 more connections. Everybody feels the pain.”
‘Who is going to shape our values?’
Among those affected is Brenda, a single mother from Honduras who spoke through a translator at the briefing and asked that only her first name be used. Her 12-year-old daughter has cerebral palsy and epilepsy; the family came to the United States because the care her daughter needed was unavailable in their home country.
CSS has covered her daughter’s daily seizure medications as well as a heart surgery that saved her life.
“As a single mother, it is impossible for me to afford the specialists my daughter requires, including cardiologists, neurologists and ENT specialists,” Brenda said. “Thanks to the assistance provided by the CSS program, my daughter remains stable.”
“The lives and the health of our children are not a game,” she added.
The Rev. Jeff Brown, pastor of Woodmont Hills Church in Nashville, said the policy illustrated a contradiction at the heart of Tennessee’s political culture, where the Republican supermajority campaigns heavily on Christian faith.
“I can see how these policies might pander to the preferences of the sitting president. I can see how they might even garner some favor among a particular part of a political base in an election year,” he said. “But they do nothing to embody the weight of Jesus in the world.”
“Literally, what in God’s name are we doing?” Brown continued. “Jesus explicitly connects …. the measure of a person, a city, a state, a society not to how we engage with those who are labeled most important, but how we interact with those who are most vulnerable. These are the most vulnerable families. We’re talking about things like feeding tubes and ventilators.”
“When my wife and I were foster parents, there was a well-established practice of judges being required to actually interact with kids that they would be making decisions about,” he explained. “I think we would do well to have elected officials actually interact with those people who are most affected.”
He added: “This is a moment to ask ‘Who are we going to be?’ Who is going to shape our values?’”
