Why documentation is a path to enjoyment and access to health care in USA; lessons from USA

Current U.S. public policies that deny legal immigrants equal access to public insurance programs leave lawful U.S. residents and their health care providers unnecessarily vulnerable and perpetuate needless complexity in the health care system.

Holes in the Safety Net — Legal Immigrants' Access to Health Insurance

Wendy E. Parmet, J.D.

N Engl J Med 2013; 369:596-598August 15, 2013DOI: 10.1056/NEJMp1306637

 Comments open through August 21, 2013

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While Congress debates whether publicly supported health care should be available to undocumented immigrants who may be placed on a path to citizenship under immigration reform, the health care needs of already legal immigrants continues to be overlooked. More than 12 million immigrants are lawfully present in the United States. They serve in the military, pay taxes, and contribute to the economy. Yet like undocumented immigrants, whose health care vulnerabilities are outlined in the Perspective article by Sommers, legal immigrants face substantial barriers to obtaining insurance coverage (see graphHealth Insurance, According to Citizenship Status, 2009.). As a result, some — such as Antonio Torres, an uninsured Arizona farmworker who was in a coma after a car accident — have been forcefully transferred to their native country when their treating hospitals were unable to find facilities willing to provide them with long-term care.1

Legal immigrants form a highly heterogeneous group that includes legal permanent residents (“green card holders”), refugees, asylum seekers, and many others. Because of the heterogeneity of the class and the complexity of immigration categories, information on the proportion insured is scarce. Augmenting data from the 2008 Current Population Survey, the Pew Hispanic Center reports that 24% of legal immigrants were uninsured in 2008, as compared with 59% of unauthorized immigrants and 14% of native citizens.2 In a 2005 article that was based on data from the Los Angeles Family and Neighborhood Survey, Goldman et al. reported that 32% of permanent legal residents remained uninsured for an entire 2-year period, as compared with 65% of undocumented immigrants and 18% of citizens.3Although legal immigrants, like other immigrants, spend less on health care and appear to be healthier than citizens, that appearance may be attributable in part to undiagnosed illnesses and lack of access to a regular source of care.4

There are many reasons why legal immigrants have low rates of health insurance. They are more likely to work in sectors of the economy, such as agriculture, that tend not to provide health insurance. Linguistic and cultural barriers also limit their access, as do laws barring them from public insurance programs.

There is no evidence that immigrants are excessive users of public benefits. Nevertheless, responding to the charge that immigration burdens taxpayers, Congress in 1996 enacted the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA), which barred most legal immigrants from Medicaid and other federal health programs for the first 5 years after they attain their lawful status. PRWORA also permanently prohibited undocumented immigrants and several other classes of noncitizens, such as persons with temporary administrative status, from receiving federal benefits.

Since 1996, Congress has permitted federal funds to be used to insure noncitizen children and pregnant women. PRWORA also allows states to use their own money to insure immigrants who are ineligible for federal programs. Sixteen states and the District of Columbia do so.5 However, state-funded programs for immigrants (who cannot vote) are often the first programs cut when state budgets are tight.

Although Congress has broad authority over immigration and can discriminate against legal immigrants, legal aliens are a protected class for purposes of the Equal Protection Clause of the U.S. Constitution. As a result, courts reviewing challenges to laws that are discriminatory against legal immigrants apply strict judicial scrutiny, the most stringent form of judicial review, and find the laws unconstitutional unless they are necessary to further a compelling state interest. Discriminatory state laws may also violate state constitutions.

Two recent cases demonstrate how courts look at state laws eliminating legal immigrants' access to state health programs — in different ways, depending on whether those programs insure only immigrants or citizens as well. Finch v. Commonwealth Health Insurance Connector Authority(Massachusetts Supreme Judicial Court, 2012, 2011) was a class action brought under the Massachusetts constitution by legal immigrants who challenged a 2009 state law excluding them from Commonwealth Care, a state-subsidized premium-support program established by the Massachusetts 2006 health care reform law. Initially, all legal residents with incomes under 300% of the federal poverty level who lacked access to other forms of health insurance were eligible for Commonwealth Care. After the 2008 financial crisis, the state excluded immigrants for whom it could not receive any federal support owing to PRWORA. The state simultaneously established a program with a more limited network of health care providers for immigrants who had been removed from Commonwealth Care, but that program was closed to noncitizens who first sought coverage after July 2009.

Since Commonwealth Care insured both immigrants and citizens, the Massachusetts Supreme Judicial Court saw the immigrants' exclusion as discriminating against them in favor of citizens. In 2011, Justice Francis X. Spina, writing for a five-to-three majority, ruled that the discrimination was subject to strict scrutiny under the state constitution. He added that PRWORA left the decision about whether to insure immigrants with state funds up to the state and did not justify less-searching judicial review. The next year, a unanimous Court, in an opinion by Justice Robert Cordy, ruled that the immigrants had been terminated from Commonwealth Care for fiscal reasons, which did not constitute a compelling state interest. As a result, the exclusion of the immigrants from Commonwealth Care was unconstitutional.

Bruns v. Mayhew (Federal District Court, Maine, March 14, 2013), in contrast, was a class action brought in federal district court by Hans Bruns, a legal permanent resident with adenoid cystic carcinoma, and Kadra Hassan, an asylum seeker with end-stage renal disease. Both had been insured by a program that used state funds to provide immigrants with insurance comparable to Medicaid. When Maine eliminated the program, the plaintiffs sued, claiming a violation of the federal Constitution. In March, Federal Judge John A. Woodcock, Jr. denied the plaintiffs' request for a preliminary injunction. The judge found that unlike the program in Finch, the program at issue was a separate program, limited to immigrants. As a result, its termination did not put immigrants at a disadvantage as compared with citizens. An appeal is now pending.

Regardless of the appellate court's decision, once the relevant provisions of the Affordable Care Act (ACA) are implemented in 2014, legal immigrants will be eligible for tax subsidies and credits to purchase insurance through the newly established health insurance exchanges. Ironically, in states that choose not to expand their Medicaid programs — an option the Supreme Court gave states in its ACA decision last summer — legal immigrants with incomes below 100% of the federal poverty level may have greater access to insurance than will low-income citizens: the drafters of the ACA assumed that citizens with such low incomes would receive Medicaid and therefore left them, but not legal immigrants, without support for purchasing insurance on the exchanges. It remains to be seen, however, whether the insurance on the exchanges will be affordable to such low-income immigrants. Moreover, medically frail and disabled low-income legal immigrants will continue to lack access to Medicaid's coverage for long-term care. As a result, many immigrants will remain dependent on state programs that continue to be susceptible to fiscal pressures. More litigation is likely.

Public policies that deny legal immigrants equal access to public insurance programs leave lawful residents and their health care providers unnecessarily vulnerable when injuries and illness strike. By encouraging immigrant-only programs, such policies also perpetuate needless complexity in the health care system. Only by offering legal immigrants the same coverage as citizens can we ensure their health security and establish a more rational health care system.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

This article was published on July 24, 2013, at NEJM.org.

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From Northeastern University School of Law, Boston.

On Health, documentation and pursuance of quality life in USA

Despite a flurry of political activity, health care for the approximately 11 million to 12 million undocumented immigrants in the United States remains a patchwork with gaping holes, and that reality is unlikely to change much over the coming decade.

Stuck between Health and Immigration Reform — Care for Undocumented Immigrants

Benjamin D. Sommers, M.D., Ph.D.

N Engl J Med 2013; 369:593-595August 15, 2013DOI: 10.1056/NEJMp1306636

 Comments open through August 21, 2013

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Audio Interview

Interview with Dr. Benjamin Sommers and Prof. Wendy Parmet on the limited health care and insurance options for both legal and undocumented U.S. immigrants. (22:02)

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It is a time of immense change in U.S. health care and immigration policy. On the cusp of major insurance expansions under the Affordable Care Act (ACA), Congress is now debating a path to citizenship for millions of undocumented immigrants. Understanding what will (and won't) change under the ACA and immigration reform is critical to crafting sensible health policy in this realm. Despite a flurry of political activity, health care for undocumented immigrants remains a patchwork with gaping holes, and that reality is unlikely to change much over the coming decade.

Approximately 25 million noncitizens live in the United States, 11 million to 12 million of them undocumented. Though more than 75% of undocumented residents are Latin American, U.S. immigrants are more diverse than generally recognized, with substantial numbers from South and East Asia, Europe, Canada, and Africa.1 Regardless of its origins, this population's health care options remain limited.

For most undocumented immigrants, the primary sources of U.S. health insurance are unavailable. Although approximately 80% of adult undocumented immigrants are in the labor force, most are in low-income fields that rarely offer health insurance, such as farming, building maintenance, and food preparation.1 Meanwhile, undocumented immigrants are expressly excluded from Medicaid, the primary coverage option for many low-income citizens, and undocumented elderly adults are ineligible for Medicare. The only federal health program available to some undocumented immigrants is Emergency Medicaid, which covers acute care in inpatient settings and emergency departments for persons who, aside from their immigration status, meet their state's Medicaid-eligibility criteria. Given the small numbers of people who are eligible and the limited scope of services covered, Emergency Medicaid does little to facilitate meaningful access to care for most immigrants.

The cumulative effects of these systematic limitations on insurance for undocumented immigrants, combined with low household incomes, are major disparities in health care access between this population — particularly Latino immigrants — and U.S. citizens. Whereas approximately 15% of the overall U.S. population lacks health insurance, nearly two thirds of undocumented Latino immigrants are uninsured. Less than 60% of undocumented Latinos report having a regular medical provider, and they receive recommended preventive care at far lower rates than citizens.2 When they arrive in this country, most immigrants are healthier than the U.S.-born population — the so-called immigrant paradox — but within one or two generations, they have become on average less healthy than nonimmigrants, probably because of the adoption of unhealthy American lifestyles combined with systematic access disparities that prevent appropriate care for this population's growing burden of chronic diseases.3

One underrecognized aspect of the exclusion of undocumented immigrants from the health care system is the adverse effect on millions of U.S. citizens (disproportionately children) who live in households with undocumented-immigrant relatives. Research suggests that immigration law enforcement produces a “chilling effect” on Medicaid participation by eligible citizens who live with noncitizen family members.4

What options for care do undocumented immigrants have? Some state and local governments spend resources to provide health insurance to persons in need, regardless of their immigration status. As detailed in the Perspective article by Parmet, however, state or locally funded programs — even when focused on legal immigrants — are politically precarious and typically first on the chopping block during economic downturns.

For many undocumented immigrants, Federally Qualified Health Centers (FQHCs) are one of the only options for care. Supported by federal grants from the Health Resources and Services Administration and favorable payment policies under Medicaid, FQHCs are required to provide both urgent and preventive care to all comers, regardless of immigration status or ability to pay. These centers, which include designated migrant health centers, treat approximately 20 million people in the United States and serve as an important locus of culturally competent care for immigrant communities.

But there are not enough community health centers to serve the entire population. In the gap, public health programs provide some services to immigrants (such as Title X for family planning), but these programs are narrowly targeted and administered by states and localities that are often subject to intense immigration-related politics. Thus, many undocumented immigrants — like uninsured persons born in the United States — must rely on charity care from private practitioners and safety-net hospitals, paying out of pocket for costly services, or waiting until their conditions are severe enough to warrant going to the emergency department.

The ultimate backstop — sometimes misleadingly used to assert that no one in the United States goes without needed medical care — is the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA requires hospitals to provide care to anyone with an “emergency medical condition” regardless of immigration status or ability to pay. But it contains no requirement to treat life-threatening conditions that are not “emergent” or to treat complications after patients have been stabilized, and it doesn't prohibit billing for those services. Although EMTALA prevents hospitals from literally allowing people to die on their doorsteps, it provides neither financial protection nor comprehensive access to care.

U.S. health care will change dramatically in 2014, with insurance expansions under the ACA that will make a major contribution toward coverage for millions of legal immigrants. But both Medicaid and tax credits for coverage through health insurance exchanges will remain off limits for undocumented immigrants, even for beneficiaries of the so-called Dream Act, who were brought here as children and, in 2012, given a reprieve by President Barack Obama from the threat of deportation. Most undocumented immigrants will remain uninsured, and this group will account for a growing proportion — as much as 25% — of all uninsured people in the United States after implementation of the ACA.5

Though excluded from the law's key changes, undocumented immigrants will be affected by other provisions. More will qualify for the limited benefits of Emergency Medicaid, though that change may not occur in several states with large numbers of undocumented immigrants — including Texas and Florida — if they choose not to expand Medicaid under the ACA (see mapUndocumented Immigrants as a Percentage of Each State Population and Current Medicaid Expansion Plans.). The law increases direct funding to FQHCs by $11 billion over 5 years, which will benefit many immigrants, but this increase will be traded off against cuts in disproportionate-share-hospital (DSH) payments, putting additional strain on safety-net hospitals caring for undocumented immigrants. Meanwhile, public support for local programs that treat uninsured people (who are disproportionately undocumented) may diminish, as resources are diverted into ACA-related coverage — paradoxically making access to care for this population potentially even worse than it is now.

Any long-term solution to disparities in care for undocumented immigrants will require fundamental immigration reform. More specifically, granting undocumented immigrants legal status and a path to citizenship should open the doors to programs such as Medicaid, Medicare, and tax credits for purchasing coverage through exchanges (programs for which some immigrants already pay taxes, even though they don't benefit from them). Current immigration proposals in Congress, however, wouldn't allow such immigrants to obtain citizenship for a decade or more, and health care may be one stumbling block to political compromise.

Although there are valid perspectives on multiple sides of the immigration debate, there are stark public health implications of continuing to permit the existence of a medical underclass comprising more than 10 million people. Neither the recent national health reform law nor the immigration bill currently being considered solves these vexing problems; indeed, these policies may increase the barriers for some undocumented immigrants. For the foreseeable future, undocumented immigrants will remain on the outskirts of our public programs and safety net, a controversial reminder of ongoing inequities in our health care system.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

This article was published on July 24, 2013, at NEJM.org.

SOURCE INFORMATION

From the Department of Health Policy and Management, Harvard School of Public Health, Boston.

Extremes faced by categories of marginalized population groups; lessons shared by RWJF

RWJF News Digest: Vulnerable Populations

This frequently updated news digest on the subject of Vulnerable Populations showcases select articles from major journals, news publications and blogs. Articles within this digest highlight the integral relationship between our health and how and where we live, work, learn and play. The digest is a free service of the Robert Wood Johnson Foundation.

Status and Stress
The New York Times, Moises Velasquez-Manoff, 07/27/2013
Although professionals may bemoan their long work hours and high-pressure careers, really, there’s stress, and then there’s Stress with a capital “S.” The former can be considered a manageable if unpleasant part of life; in the right amount, it may even strengthen one’s mettle. The latter kills. What’s the difference? Scientists have settled on an oddly subjective explanation: the more helpless one feels when facing a given stressor, they argue, the more toxic that stressor’s effects. Perhaps most devastating, the stress of poverty early in life can have consequences that last into adulthood. The British epidemiologist Michael Marmot calls the phenomenon “status syndrome.” He’s studied British civil servants who work in a rigid hierarchy for decades, and found that accounting for the usual suspects — smoking, diet and access to health care — won’t completely abolish the effect. There’s a direct relationship among health, well-being and one’s place in the greater scheme. “The higher you are in the social hierarchy,” he says, “the better your health.”

Q: What If We Treat Violence Like An Epidemic Disease? A: We Could Put Violence Into The Past!
TEDMED, Gary Slutkin, M.D., 07/30/2013
Dr. Slutkin writes: What if we, as public health professionals, approached violence as a public health problem in a serious way? What if we, as public health professionals, approached violence as a problem that we can treat with health interventions and prevent using science based solutions? I asked myself those questions when we launched the Cure Violence model of violence reduction 15 years ago. Following more than 10 years of fighting health epidemics in Africa and Asia, I returned to the United States and began to notice parallels between the trajectory of violence plaguing U.S. cities and the trajectory of diseases plaguing the communities in which I previously worked abroad.

Editor's Note: Cure Violence is a RWJF grantee.

Kids’ Lawyer Puts Out Shingle—At The Hospital
New Haven Independent, Brianne Bowen, 07/30/2013
The child came to the hospital to see a doctor to treat muscular dystrophy. It turned out the child needed to see a lawyer too—and found one without leaving the building. That was able to happen because of a new in-house law office at Yale-New Haven Hospital dedicated solely to remedying poverty-related legal problems for pediatric patients—problems that can sometimes contribute to medical problems as well. Since the law office – called a medical legal partnership – opened in June, Yale-New Haven has sought to tackle both kinds of problems in tandem.

Editor's Note: The National Center for Medical-Legal Partnership (referred to in the article) is a RWJF grantee.

Can Ex-Offenders Stop The Spread Of Gun Violence?
WYPR.org (Baltimore), Mary Rose Madden, 07/29/2013
James Timpson of Safe Streets has been working on the issue of gun violence for years. Contrary to what some may assume, he says, it isn’t all gang related, but could be “a simple argument over a can of soda or you owe me a dollar.” But what to do about it? Timpson looks at gun violence through a different lens. Rather than focusing on illegal guns or getting the police involved, he’s part of a team, Safe Streets, that focuses on the abnormal behavior behind picking up a gun to solve a dispute. Gary Slutkin, the founder and executive director of Cure Violence – the Chicago model for Safe Streets and other programs like it, says the health department is the logical place for the program.

Editor’s Note: Cure Violence is a RWJF grantee.

Childhood Economic Status Affects Substance Use Among Young Adults
HealthCanal.com, 07/30/2013
Children who grow up in poverty are more likely than wealthier children to smoke cigarettes, but they are less likely to binge drink and are no more prone to use marijuana, according to researchers at Duke Medicine. The researchers also found that economic strains in early life – including family worries about paying bills or needing to sell possessions for cash – independently erode a child’s self-control, regardless of strong parenting in adolescence. Lack of self-control often leads to substance use. The findings, appearing July 30, 2013, in the Journal of Pediatric Psychology, debunk common assumptions about who abuses substances, and provide a basis for better approaches to prevent young people from falling into drug and alcohol addiction.

RWJF Invests $1.2M In BCT Partners And Frontline Solutions To Improve The Health And Success Of Young Men Of Color
Barber Shop Magazine, Dallas Xavier Evans, 07/24/2013
BCT Partners and Frontline Solutions announced today that they have been awarded $1.2 million to provide advisory services and national technical assistance on behalf of the Robert Wood Johnson Foundation’s $9.5 million Forward Promise initiative. Forward Promise aims to vastly expand the potential for boys and young men of color to grow up healthy, obtain a good education, and find meaningful employment.

Wow Of The Week: Could Rethinking Traditional Nursing Home Model Improve Senior Health?
MedCity News, Stephanie Baum, 07/27/2013
In an effort to move away from the traditional model of a nursing home, a nonprofit organization has developed an alternative — smaller scale housing for elderly residents. They’re referred to as Green Houses. The idea is that small homes of roughly 10 residents can improve social interaction and the quality of life and health of its residents. And that could reduce healthcare costs.

Editor’s Note: The Green House Project is a RWJF grantee.

Immigrant and looking for work in USA

Solving the Hiring Disconnect: Focus on Skills

ANGELA COBB

August 02, 2013

We first met Alexandra when she graduated from high school in Santa Fe, New Mexico, in 2012. Raised by a single mother who speaks little English, Alexandra was determined to fulfill her dream of becoming a doctor. In her senior year, she participated in a program sponsored by CHRISTUS St. Vincent's Hospital and New Options Project partnerInnovate+Educate that helps young adults in New Mexico to enter the healthcare sector. The program required Alexandra to take a skills-based assessment, or a test that measures her work-ready skills. As a result of taking the assessment, she was able to get a job working for St. Vincent’s as a medical assistant while she attends community college.

Next fall, she will enroll at the University of New Mexico and become the first person in her family to attend a four-year college.

 Skills-based hiring is five times more predictive of success on the job than hiring by degree alone.

Had the hospital not valued Alexandra’s skills—and had Alexandra not been able to prove that she had them—it’s likely that she would have been overlooked as a qualified job candidate.

Fortunately, there is growing excitement for skills-based hiring. It is increasingly seen as a more reliable alternative to traditional hiring practices that focus on a candidate’s degree, resume and experience to predict his or her potential to succeed on the job. More than a welcome expansion of the applicant pool, this new approach addresses a widespread disconnect in the hiring landscape: Despite the high unemployment rate, many employers still struggle to fill open positions—more than 3 million jobs across the U.S. go unfulfilled. Employers simply can’t find enough candidates with the necessary skills for the job. Many others find the employees they’ve hired are unable to do the work for the position. 

That’s why the New Options Project and our partner Innovate+Educate are working to change the way employers think about talent. In particular, we view out-of-school, job-seeking young adults who are typically overlooked by traditional hiring methods as economic assets, not social liabilities. Some of the leading voices in educationand business—including Bill Gates, the Aspen Institute, The National Skills Coalition and the White House— agree with this view, and have implemented similar programs bolstering skill-building and skills-based hiring.

The results speak for themselves. Research by Innovate+Educate shows that employers who have incorporated skills-based hiring into their practices have seen a 25-75% reduction in turnover, 50-70% reduction in time to hire, 70% reduction in cost-to-hire and a 50% reduction in time to train.  In short, skills-based hiring is five times more predictive of success on the job than hiring by degree alone. A win-win for youth and employers!

Ultimately, our hope is that this method will help to level the playing field and give everyone a shot at having a fulfilling career regardless of past education or work experience.

Innovate+Educate’s strategy has been to work directly with communities and regions to develop a skills-based credentialing system for youth and employers, which allows for greater transparency for both the employer and the candidate. Innovate+Educate also trains HR staff to advertise job openings by skill score and match applicants’ submitted scores to available positions. And for applicants who don’t score as high as they’d like, Innovate+Educate works with local partners to offer Skill Up Centers.  In the coming weeks, the City of Albuquerque will formally launch Talent Albuquerque, its partnership with Innovate+Educate, to implement skills-based hiring, including free skills assessments for job-seekers.

Have you had experience with skills training programs or skills-based hiring?  Tell us about it over Twitter@NewOptions4Work.

SOURCE: http://www.impatientoptimists.org/Posts/2013/08/Solving-the-Hiring-Disconnect-Focus-on-Skills