Dr. Mercado, Pediatrican: Atlanta Grady Memorial Hospital

1. Dr. Mercado, Pediatrican: Atlanta Grady Memorial Hospital • “As an American citizen, I understand that you want to make sure the resources are there for the right people. Yet, how can you deny someone health access? If we don’t treat and prevent illness…our community is going to suffer.”

2. Immigrants and Health Care Lynn Christiansen, MSW New Mexico Title V CYSHCN Director Susan Chacon, MSW New Mexico Title V CYSHCN Program

3. Oklahoma Bill 1804 • The State of Oklahoma finds that illegal immigration is causing economic hardship and lawlessness in this state and that illegal immigration is encouraged when public agencies within this state provide public benefits without verifying immigration status. The State of Oklahoma further finds that when illegal immigrants have been harbored and sheltered in this state and encouraged to reside in this state through the issuance of identification cards that are issued without verifying immigration status, these practices impede and obstruct the enforcement of federal immigration law, undermine the security of our borders, and impermissibly restrict the privileges and immunities of the citizens of Oklahoma. Therefore, the people of the State of Oklahoma declare that it is a compelling public interest of this state to discourage illegal immigration by requiring all agencies within this state to fully cooperate with federal immigration authorities in the enforcement of federal immigration laws. The State of Oklahoma also finds that other measures are necessary to ensure the integrity of various governmental programs and services.

4. Penalties HB 1804 • A. It shall be unlawful for any person to transport, move, or attempt to transport in the State of Oklahoma any alien knowing or in reckless disregard of the fact that the alien has come to, entered, or remained in the United States in violation of law, in furtherance of the illegal presence of the alien in the United States.

5. Penalties HB 1804 • B. It shall be unlawful for any person to conceal, harbor, or shelter from detection any alien in any place within the State of Oklahoma, including any building or means of transportation, knowing or in reckless disregard of the fact that the alien has come to, entered, or remained in the United States in violation of law.

6. Felony Penalty • D. Any person violating the provisions of subsections A or B of this section shall, upon conviction, be guilty of a felony punishable by imprisonment in the custody of the Department of Corrections for not less than one (1) year, or by a fine of not less than One Thousand Dollars ($1,000.00), or by both such fine and imprisonment

7. Exceptions to the Law • Newborn Screening Programs • Public laboratory services • Acute and chronic disease services • HIV/STD services • Terrorism response • Child, adolescent and women’s health (MCH) • Early Intervention program • Dental health program (excluding dental loan) • Child guidance program • WIC program

8. Immigrant Health Care • Immigrants, on average, receive about half the health care services provided to native-born Americans • Immigrants received an average of $1139 worth of care, compared with $2564 for non-immigrants, according to 2005 study in AJPH. • A much higher percentage of immigrants lack a high school education, which makes it difficult for them to navigate the health care system • Immigrant children had fewer doctor visits, took less medication and made fewer trips to the ER. But their ER costs were nearly triple those for non-immigrant children. • Immigrant families are more likely to miss routine check-ups and wait until a condition was more serious before seeking treatment. They are less likely to receive standard immunizations and more likely to let chronic problems go untreated. Ceci Connolly, “Study Paints Bleak Picture of Immigrant Health Care,” 7/26/2005. Washington Post Online, accessed 9/11/2008.

9. Immigrant Health Care Cont’d • Notes contradiction in current policy: i.e. labor and delivery costs for undocumented immigrant women are covered under EMSA, but prenatal care and family planning are not • 2005 study in American Journal of public Health showed that annual per capita expenses for health care were 86% lower for uninsured immigrant children than for uninsured U.S.-born children; but emergency department expenditures were more than three times as high. • Noncitizens make up 20% of the 46 million uninsured people in the U.S. • 2005 Deficit Reduction Act requires all persons applying for or renewing Medicaid coverage to provide proof of identity and U.S. citizenship. Susan Okie, MD, “Immigrants and Health Care—At the Intersection of Two Broken Systems,” New England Journal of Medicine.

10. Overview of Federal Regulations and Funding • Immigrant Reform and Control Act/ IRCA-1986 • Personal Responsibility and Work Opportunity Reconciliation Act/PROWRA-1996 • Examination and treatment for emergency medical conditions and women in labor/EMTALA-1985 • Emergency Services for Undocumented Aliens/EMSA-1999 • Federal Payments to Hospitals for Emergency Room Care-2005

11. Immigrant Reform and Control Act • Restricts Medicaid and other Federal programs to newly legalized immigrants • U. S. Attorney General Ruling allowed: • Exceptions-”don’t ask, don’t tell” also considered not a provider, a contractor for services • Emergency Services • Services to pregnant women • National School Lunches • Vocational Education Act • Headstart Programs • Job Training • Public Health Programs as set forth in The Public Health Service Act. “20 USC 1070” • Federally Qualified Health Centers

12. RPHCA and FQHC • RPHCA and FQHC clinics are the safety net for immigrants • RPHCA – Rural Primary Health Care Act provides state funding that is supplemental – intent is to help keep their doors open for people who are unable to pay – should maximize resources with Medicaid and other insurance billing NM puts $13 mill into clinics - rare • FQHC – receive federal funds to operate primary care clinics – determines payment mechanisms • Consumer boards oversee compliance and establish regulations. Board determines sliding scale fees based on their understanding of their individual communities. Sliding scale goes to 0 in some cases. Fee not always collected • Provider shortages – limited resources • All are 501c3 • 93 clinics in NM: some don’t get federal funding

13. Personal Responsibility and Work Opportunity Reconciliation Act • Welfare reform that restricted immigrant access to all programs receiving state and/or federal funding such as Medicaid • Required immigrants wait 5 years after obtaining green card before applying for benefits • Shifted responsibility to the states

14. Title V PROWRA Opinion • Many HHS programs are targeted to meet the needs of certain populations such as children or pregnant women. But unless the authorizing statutes require that the characteristics of these groups form the basis for denial of services or benefits, these are not benefits that go to “eligibility units.” The authorizing statutes of these programs identify populations with specific characteristics to clarify the types of services that should be provided; they do not contemplate that providers use variations in individual characteristics as a basis for determining eligibility, on a case by case basis. • Therefore a benefit targeted to certain populations based on their characteristics, such as a benefit provided under the Maternal and Child Health program, which provides health services to women and children, is not a “Federal public benefit.”

15. Response to PROWRA • Illinois, NY, D.C., and some CA counties used own funds to expand health insurance coverage for undocumented immigrant children and pregnant women with low income • AZ, CO, GA, VA and OK passed laws making it more difficult for noncitizens to obtain health care • AZ and OK criminalized provision of services to immigrants

16. Examination and treatment for emergency medical conditions and women in labor (EMTALA-1985) • Medical screenings for those who come to the ER with a complaint and a request to have their condition evaluated • Necessary stabilizing treatment for emergency medical conditions and labor • Restricts transferring of patients until patient is stabilized

17. Emergency Services for Undocumented Aliens (EMSA) • Provides Medicaid payments to hospital emergency rooms on behalf of undocumented immigrants

18. 2005 Federal Appropriation • Provided funding to Emergency Rooms and doctors for services to undocumented immigrants/others who do not have pay source • Largest allocations went to: CA: $70.8; TX $46; AZ $45; NY $12.3; ILL: $10.3; FL$ 8.7 and NM $5.1 million the first year

19. “Dumping?”: Efforts to coerce undocumented immigrants to leave U.S. • Under federal law, hospitals receiving Medicare funds must transfer or refer patients to “appropriate” post-hospital care (NY Times) • Some hospitals choose to return immigrants to their home countries • Advocates view practice as international “dumping”

20. Immigrant Health Care Services in New Mexico • Title V CYSHCN Program – comprehensive care for those with medical and fiscal eligibility • New Mexico Medical Insurance Pool • Service to immigrant families often begins with ER visit, then referred to clinics and CMS for CYSHCN • FQHC and RPHCA funded community health care clinics provide comprehensive primary care with sliding scale fees • Healthier Kids Fund provides primary care • Family Infant Toddler Program provides early intervention • Some counties provide county indigent coverage • Family Planning • Project ACCESS and Healthy Tomorrows Van in Santa Fe – primary care – and some surgeries doctor donated

21. New Mexico Issues in Immigrant Care • Families being divided by (ICE)  Immigration and Customs Enforcement Agency is deporting some family members, leaving others.  Primary income provider may be deported; separation from parents • Since 9/11, CYSHCN program no longer able to use Angel Fight • Families fear deportation when flying or traveling for care in other states • Immigration check points in NM bar access to Albuquerque specialists • CYSHCN who are immigrants face funding and citizen barriers when coordinating care for kidney, liver transplants and cardiac surgery

22. New Mexico Issues in Immigrant Care • Need for culturally competent response when immigrants seek health care services • Lack of prenatal care – immigrant Moms covered at birth – not pre or post-natal • Spontaneous and intermittent raids in certain areas of NM create a culture of fear • Language – limited number of interpreters - often rely on children to translate for health care • Difficulties in compliance with Federal Civil Rights Law • NM is a bilingual language and requires translation for all written communication – still not always available

23. New Mexico Issues in Immigrant Care • Fear of ability to meet health care sliding scale fee • Education re:  health and social service resources is limited • Limited knowledge of immigrants rights re:  human rights issues  i.e., housing, etc. • Transportation – no car for transport to work or health care • Lack of resources – can’t apply for health insurance No sick leave to go to doctor and/or take children to doctor • Immigrants are not eligible for many social programs

24. New Mexico Issues in Immigrant Care • Response of health care system providers • Poverty – lower socioeconomic status • Little or no support system – family not present • Significant oral health problems – young adults no oral health care and often lose teeth. Parents less likely to go for preventive health care – will take care of children instead • Elderly cannot apply for social security • Families share housing – often 2 or 3 in 1 house or apartment

25. Comparing States: Arizona • Title V services do have a citizenship requirement • State law passed that restricts all public services to immigrants

26. Comparing States: California • Title V services do not have a citizenship requirement • Low/no-cost non-profit or private clinics provide health care

27. CA request for SCHIP for Immigrants • Gov. Schwarzenegger’s health reform proposal seeks health insurance through Medicaid and SCHIP for all children at or below 300% FPL • Republican legislators response: “…do not believe that state general fund revenues should be invested in people who are here illegally and that extends to children.”

28. Comparing States: Florida • Title 19 (Medicaid), Title 21 (SCHIP), are ineligible unless they are qualified individuals • No state law or statute forbids utilization of funds, however Title V CYSHCN follows operational policy of not providing care to unqualified individuals • Title V may use Federal funds for care of unqualified individuals, but MAY NOT use general fund match for unqualified individuals • Federal laws were extended to apply to state laws even though, it may not be legally binding. • Some counties are” turning the other cheek” to operational policy (not to serve unqualified individuals) • Political refuges are not seeking qualified individual status for fear of deportation (kids go to public school, graduate and people never become documented

29. Comparing States: Georgia • Law required immigrants to show proof of legal residency resulted in fewer kids going to the doctor • Per Dr. Mercado, a Pediatrician: Many clients are leaving and going to other states, some back to their country • Hispanics stopped offering health fairs fearing police and immigration raids • Media regularly blames illegal immigrants for decline in health care system

30. Comparing States: Iowa • No citizenship requirement for Title V program; Title V services are direct health care services • Health and other assistance from the refugee health program • Private health clinics as available

31. Comparing States: Illinois • Medicaid available to all children with no citizenship requirement • Title V programs require that the parent or the child be a citizen or a legal resident of the US

32. Comparing States: Minnesota • Title V programs do not have a citizenship requirement • Community Health and Rural Health Centers provide services without a citizenship requirement • CSHCN program provides a “health care flow chart” for non-citizens that helps identify avenues for treatment • CSHCN program has compiled, with community partners, a comprehensive list of low/no-cost clinics statewide

33. Comparing States: Texas • Title V programs do not have a citizenship requirement • Community Health and Rural Health Centers provide services without a citizenship requirement • Some cities have low/no-cost clinics available

34. Sources • Directors of State Title V CSHCN Programs • Minnesota Department of Health: http://www.health.state.mn.us/mcshn • Iowa Department of Public Health: http://www.idph.state.ia.us • EMTALA Online: http://www.medlaw.com/statute.htm • “Payments to Help Hospitals Care for Illegal Immigrants,”New York Times, May 10, 2005. Accessed online 9/18/2008 • Kaiser Commission on Key Facts: Medicaid and the Uninsured: Health Coverage for Immigrants http://www.kff.org/uninsured/upload/Health-Coverage-for-Immigrants-Fact-Sheet.pdf • Susan Okie, MD, “Immigrants and Health Care—At the Intersection of Two Broken Systems,” New England Journal of Medicine. 8/9/2007, 357:525-529. • Ceci Connolly, “Study Paints Bleak Picture of Immigrant Health Care,” 7/26/2005. Washington Post Online, accessed 9/11/2008.