IMMIGRATION AS A SOCIAL DETERMINANT OF HEALTH Disclosures

IMMIGRATION AS A SOCIAL DETERMINANT OF HEALTH

Disclosures

Outline

Traditional Medical Model • Focused on the individual behavioral choices and health practices as the cause of outcome disparities • This can be alienating if we do not explore the context in which they happen

Social Determinants of Health • Medical care alone cannot improve overall health w/o addressing where and how patients live • Economic and social conditions that shape the health of individuals and communities • Housing, food insecurity, employment, transportation, education, immigration status

Social determinants of health • Complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities including: • Social environment, physical environment, health services, and other structural and societal factors • Shaped by the distribution of money, power, and resources

Role of Social Determinants of Health An approach to health that aims to: 1. Tackle the inequitable distribution of power, money and resources that drive health outcome disparities 2. Raise awareness of these determinants of health and expand knowledge base of the public and work force 3. Measure existing problems, take appropriate actions and evaluate outcomes of intervention * Adapted from goals of the commission on the social determinants of Health from IOM

Immigration status as a social determinant of health - Healthy immigrant effect - However, immigrant status can also be associated with poorer health: - decreased access to services, employment, and resources due to exclusionary policies; - racism and discrimination; - behaviors to avoid deportation - Growing fears due to increasing social exclusion wbur. org June 5, 2017

How does immigration status impact our patients? • Immigration status is an independent predictor of health outcomes. • Immigrants have reduced access to: • Social programs and insurance • Job opportunities • Education • In the migrant patient, problems are compounded by: • differential access to social programs & insurance • discrimination • poor labor systems • exploitation

System wide response • Include aspects of migration into social, health and economic policy changes • Education of health care providers, other educators and policy makers on issues around migrant health • Changes in attitudes towards immigration to combat xenophobia, discrimination, stigmatization and exploitation as well as social exclusion • Build health service delivery systems that promote migrant friendly and equitable comprehensive care

Access to Benefits National Immigration Law Center webinar: Protecting Your Immigrant Patients’ Access to Health Care, April 24, 2017

Who is eligible for health services in the US? Undocumented Immigrants Lawful Permanent Residents Refugees ACA Subsidies No Yes Medicaid No No Yes CHIP No State option Yes Workers’ Compensation Yes Yes (emergencies only) (often not enforced) (state options for children, pregnancy, > 5 yrs residency)

How does Massachusetts provide health services to otherwise ineligible immigrants? Health Safety Net • For people up to 300% Fed Poverty Level • All usual Mass. Health benefits, only in community health centers or acute care hospitals • Does not reimburse other doctors - say you have an ED visit at MGH- Health Safety Net covers hospital portion of the bill, not the ED doc, radiologist, etc. Mass. Health Limited • Emergency coverage, including hospitalization, insulin, dialysis, L&D Children’s Medical Security Plan • Primary and preventive care only • Low caps on coverage, e. g. $200/yr cap for meds 14

• Health Safety Net is for immigrants (and non- immigrants) with low incomes. 1. Deductible was introduced for very low income people. 2. Used to be a 60 day retroactive period. Allowed people to apply after they got a bill. This was reduced to 10 days. 3. Reduced eligibility from 400% of federal poverty level, to 300% of FPL • This is not insurance. It is a provider reimbursement mechanism. Does not reimburse doctors, unless they work at hospitals or health centers.

SERVICES NOT COVERED BY HEALTH SAFETY NET: • Physicians, labs, radiology from non-contracted locations • Ambulance services • DME • Non medically necessary services • Experimental or unproven services

10 day HSN window

• Mass Health Limited is emergency Medicaid. Up to 138% of FLP. You apply prospectively, give people a card. • Only covers emergency services. ED visits, the subsequent hospitalization, and the ambulance, but only what is considered an “emergency. ” Works best as a combo with Health safety net. • Children’s medical security program: Only covers primary and preventive care. Low caps on coverage.

Role of immigration status on health: Differential Healthcare access Undocumented Immigrants

Role of immigration status on health: Fear of using Social services • 352, 882 intakes to detention in FY 16 • 600, 000 pending deportation cases

• Can ICE obtain info about a patient from a health care provider? • Protected health info is protected by HIPPA, regardless of immigration status. • Do the executive orders prevent immigrants from getting health care? • No, neither health care nor health insurance that they are eligible for. • Are health providers required to verify immigration status of patients? • No.

• May health care providers educate their patients about their rights with regard to immigration enforcement activities? • Yes. Only consider funding limitations, if they exist. • Will applying for health coverage get me deported? • Per federal law, this information cannot be shared with ICE. • Is immigration status affected by whether an immigrant receives govt-subsidized health care services, or applies for government insurance (such as Mass. Health)? • No, but…

Health Service Threats Per Cambridge Health Alliance Financial Services: • We have been getting these calls from people who were in legal status and have gone to their embassy before leaving the country towards the end of their visa. They are being told they can’t reenter the US because they have accepted government money or received federal services for which they are not eligible. Eventually they find out this was because they took Mass Health, but they were not a legal permanent resident. They even call from out of the country asking if they can pay, because they are told they owe money and for this reason, cannot get another visa. Sometimes this is on the order of $10000 or more. If they are having a baby it’s more like $20000. When they pay, the financial assistance office can help them with the Mass Health retraction paperwork. • This is a new phenomenon. It seems patients are getting scared because it’s being enforced. I don’t know who is alerting them, but we are seeing this calls now, and haven't seen them so much in the past.

Acknowledgements • Health and Law Immigrant Solidarity Network • Sarah Kimball, MD • Nicolette Oleng, MD • Aura Obando, MD • Laura Janneck, MD, MPH • Lenore Azaroff, MD

References • IOM. Disparities in Health Care: Methods for Studying the Effects of Race, Ethnicity, and • • • SES on Access, Use, and Quality of Health Care, 2002 NCHHSTP Social Determinants of Health Definitions. March 21, 2014. https: //www. cdc. gov/nchhstp/socialdeterminants/definitions. html National Immigration Law Center webinar: Protecting Your Immigrant Patients’ Access to Health Care, April 24, 2017 Understanding the Affordable Care Act: Non-citizens’ eligibility for Mass. Health & other subsidized health benefits. Massachusetts Law Reform Institute. March 2018. https: //www. masslegalservices. org/system/files/library/Understanding%20 eligibility%20 of%20 non-citizens_0. pdf Schoenberg, S. Baker administration changes eligibility for health coverage for the poor in Massachusetts. March 29, 2016. https: //www. masslive. com/politics/index. ssf/2016/03/baker_administration_changes_e. html Cunningham, PW. The Health 202: Immigrants' health-care problems are about to get worse. Sept. 6, 2017. https: //www. washingtonpost. com/news/powerpost/paloma/thehealth-202/2017/09/06/the-health-202 -immigrants-health-care-problems-are-about-toget-worse/59 aeffdf 30 fb 04264 c 2 a 1 ceb/? utm_term=. 629 d 4 c 89686 e Healy M. Attorney General Guidance: Information for Massachusetts Health Care Providers regarding Immigration Enforcement. The Commonwealth of Massachusetts Office of the Attorney General. May 16, 2017.