PRCH Comment on Exclusion of Some Immigrants from Affordable Care Act
Author: PRCH Board President Douglas Laube, MD, MEd
VIA ELECTRONIC SUBMISSION October 29, 2012 Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-9995-IFC2 P.O. Box 8016 Baltimore, MD 21244-8016 RE: CMS-9995-IFC2 Comments on CMS’ Interim Final Rule Changes to Definition of “Lawfully Present” in the Pre-Existing Condition Insurance Plan Program of the Affordable Care Act of 2010
Dear Sir/Madam: Physicians for Reproductive Choice and Health (PRCH) is a doctor-led national advocacy organization that relies upon evidence-based medicine to promote sound reproductive health policies. PRCH opposes the decision to exclude those granted deferred action under the new Deferred Action for Childhood Arrivals (DACA) policy from eligibility for expanded coverage options under the Patient Protection and Affordable Care Act (ACA), Medicaid, and the Children’s Health Insurance Program. All women, including immigrant women, need access to reproductive and sexual health care services. DACA individuals deserve access to the important preventive and pregnancy-related programs of the ACA. The Interim Final Rule excludes immigrant women from important advancements like access to health insurance that provides quality and affordable pregnancy-related care. Under the reforms, all new private plans will cover important preventive health services, including pregnancy-related care, at no additional cost-share to patients. These services include prenatal visits, sexually transmitted infection screenings, folic acid supplements, breast feeding support, alcohol cessation support, iron deficiency anemia screenings, and gestational diabetes screenings. The decision to exclude DACA individuals from the ACA programs threatens the health of lawfully present DACA individuals and their families. Under the ACA, maternity and newborn health care are one of the ten health services considered “essential health benefits” that must be included in all plans offered on the exchanges, as well as individual and small group plans offered outside the exchanges. Additionally, the ACA’s prohibitions on certain insurance company practices, including imposing caps on care, gender rating, and denying health insurance because of a preexisting condition, will expand coverage to health insurance for women before
pregnancy.1 Yet immigrant women granted DACA will largely be left out of these tremendous gains, to the detriment of their health and the health of their families. We urge the Centers for Medicare and Medicaid Services (CMS) to reverse the Interim Final Rule. Immigrant women granted deferred action through DACA should be considered “lawfully present,” and, meeting other criteria, eligible for expanded coverage options under the ACA. Additionally, pregnant women and those under 21 years of age with an income at or below a relevant level should be eligible for expanded coverage under Medicaid and the Children’s Health Insurance Program (CHIP) under the Children’s Health Insurance Program Reauthorization Act. Many DACA-eligible individuals are women of childbearing age. It is counterintuitive to deny these lawfully present individuals opportunities to access preventive sexual and reproductive health services. Expanding access to health coverage helps all women, including immigrant women, prevent health conditions like cervical cancer, sexually transmitted infections, and unplanned pregnancy. As physicians, we know that immigrant women do not have the same access to health care compared to U.S.-born women. This is due to a number of cultural, linguistic, financial and other barriers. Lack of access to health insurance impacts the ability to access care, which leads to poor health outcomes. I. Access to Coverage Affects Timely Access to Health Care PRCH physician Dr. Rebecca Mercier of North Carolina recalls caring for undocumented immigrants in New York. In New York, there is a special Medicaid program for pregnant women that does not require proof of citizenship. Because of this program, and the promotion of it by NY agencies and hospitals, immigrant women register for prenatal care early in their pregnancy and receive care that is appropriate and equivalent to that of women with private insurance with no extra cost burden. This results in good health outcomes for mothers and their babies. Now Dr. Mercier practices in North Carolina where undocumented women are not eligible for Medicaid. Instead, pregnant undocumented immigrants receive prenatal care through county health departments or hospitals, but often must pay for visits and procedures. Dr. Mercier had a patient decline first-trimester screening for anomalies only to find out later in her pregnancy that her fetus was afflicted with Trisomy 18, a lethal fetal anomaly. Immigrant women need more access to health insurance, not less. Lack of health insurance can lead to delay of diagnoses and ultimately increase medical costs when care is delayed. This is a terrible burden to place on DACA women and their families. While many states rely upon the “unborn child” option in the Children’s Health Insurance Program and Emergency Medicaid to provide vital maternity services to immigrant women, the coverage is specifically for a woman’s pregnancy, not for the
Arons J. Women and Obamacare: What’s at Stake for Women if the Supreme Court Strikes Down the Affordable Care Act. Center for American Progress. May 2012. Available at http://www.americanprogress.org/wpcontent/uploads/issues/2012/05/pdf/women_obamacare.pdf. Accessed on October 29, 2012.
woman herself. Access to safety net programs and other state-based health care options for immigrants vary widely from state to state, and safety net programs have been greatly strained due to budgetary cuts and increased demand. For example, the Title X program has seen a loss of $24 million or 7.4% to its budget in two fiscal years, while the patient population has increased by 5% since 2007.2 Immigrant women have health care needs that are not being met. Amending the DACA policy would help alleviate that burden for those women by allowing them access to more health care programs. II. DACA Women Deserve Access to ACA Advancements Such as Contraceptive Coverage The ACA’s advancements will improve health outcomes for women. DACA women should not be left behind. PRCH Board Chair-Elect Dr. Nancy Stanwood of Connecticut remembers her patient Luz. Luz was 25 years old and had delivered her baby two months before meeting Dr. Stanwood. She and her husband came from Central America a few years before and were excited to start their family. As part of her hospital’s mission, she was able to receive free prenatal care but did not have coverage for postpartum contraception. As a couple they knew they wanted to wait several years before they had another baby, so they could focus on their newborn and continue to work hard to rise out of poverty. Fortunately, Dr. Stanwood’s program had the ability to provide Luz with a free intrauterine device for postpartum contraception. Had the hospital not had this program, she would have had to pay up to $1,000 for this contraceptive care, an amount they could not afford. Luz and her husband probably would have gone without, relying on less effective methods of contraception, like condoms, and have had a much higher chance of getting pregnant before they felt ready for a second child. Contraception is an example of preventive care that is essential to the health and wellbeing of our patients. Regular use of contraception prevents unintended pregnancy and reduces the need for abortion.3 Contraception also allows women to determine the timing and spacing of pregnancies, protecting their health and improving the well-being of their children.4 Contraceptive use saves money by avoiding the costs of unintended pregnancy and by making pregnancies healthier, saving millions in health care expenses.5 Several contraceptives also have non-contraceptive health benefits, such as decreasing the risk of certain cancers and treating debilitating menstrual problems.6 The ACA makes contraceptives more affordable for women through better health insurance coverage, a significant step forward for the health of women and their families. Excluding DACA women from ACA programs, such as the insurance exchanges, means
2 National Family Planning & Reproductive Health Association. The Impact of Budget Cuts on the Title X Family Planning Network. March 2012. Available at http://www.nationalfamilyplanning.org/document.doc?id=500. Accessed on October 29, 2012. 3 Deschner A, Cohen SA. Contraceptive Use Is Key to Reducing Abortion Worldwide. 2003. The Guttmacher Report on Public Policy. 6(4): 7-10. 4 Testimony of the Guttmacher Institute, submitted to the Committee on Preventive Services for Women, Institute of Medicine. 2011. Available at http://www.guttmacher.org/pubs/CPSW-testimony. pdf. Accessed on October 29, 2012. 5 Gold RB. Wise Investment: Reducing the Steep Cost to Medicaid of Unintended Pregnancy in the United States. 2011. Guttmacher Policy Review. 14(3): 6-10. 6 Burkman R, Schlesselman JJ, Zieman M. Safety Concerns and Health Benefits Associated with Oral Contraception.” American Journal of Obstetrics and Gynecology. 190(4): S5-22.
that immigrant women will not have increased access to affordable contraceptive coverage. This makes no sense as a public health policy. III. Denying Access to Coverage Leads to Adverse Outcomes It is also demeaning and cruel to deny access to insurance coverage that could make people healthier. Dr. Kathleen Morrell in New York remembers caring for an immigrant mother of two teenagers who was not eligible for the Medicaid program because she wasn’t pregnant. She was having problems with incontinence and the resulting odors and smells. She was so embarrassed by her situation that she spent most of her days in the bathroom. She needed to see a specialist and likely needed to have surgery. Dr. Morrell sent her to a New York City hospital for care because they provided care to the uninsured at a reduced cost and could put her on a payment plan. If this patient had had access to regular health care, her problem might not have escalated to such an extent. As physicians we know that when individuals do not have access to regular health care, their only option becomes expensive visits to the emergency room. A PRCH physician in Florida, Dr. Karla Maguire, remembers caring for uninsured, undocumented immigrants with end-stage renal disease during her residency in Texas. Her patients had no access to scheduled dialysis. Instead they had to resort to coming to the emergency room once a week, in the middle of the night when there were hardly any patients. If their potassium levels were life-threatening, they could then receive emergency dialysis. If those patients and their counterparts across the nation were able to purchase health insurance, doctors could treat them more effectively and save money in expensive emergency room visits. Dr. Maguire also recalls seeing a 30-year-old immigrant woman in Texas. A mother of two young children, she came into the emergency room because she was having heavier than usual bleeding during her menstrual period. The bleeding was due to a large cervical cancer tumor. As an undocumented immigrant, she did not have health insurance or access to routine health screenings. Because her cancer went undetected and escalated, she faced a long road of chemotherapy and radiation to recover. Dr. Maguire does not know if she survived. Even before the issuance of the Interim Final Rule and the CMS Guidance, the existing barriers to public and private health insurance mean that immigrant women are significantly more likely than their U.S.-born peers to lack insurance for health care. These barriers take a toll on the health of immigrant women and widen health disparities. For example, while cervical cancer has been on the decline for U.S.-born women, research indicates that the disease, which can be prevented through routine gynecological care and is highly treatable when caught early, has been on the rise for immigrant women.7 And studies point to lack of health insurance as a significant barrier
American Congress of Obstetricians and Gynecologists. Health Care for Undocumented Women. January 2009. Available at http://www.acog.org/Resources_And_Publications/Committee_Opinions/Committee_on_Health_Care_for_Underserved_Wome n/Health_Care_for_Undocumented_Immigrants. Accessed on October 29, 2012.
for immigrant women in accessing the routine gynecological care necessary to prevent cervical cancer.8 IV. Conclusion The Interim Final Rule undermines the goals of expanding access to affordable health coverage, eliminating racial and ethnic health disparities, prioritizing prevention, and lowering health care costs. The rule’s barriers have real and lasting consequences on the health of immigrant women and entire immigrant communities. PRCH physicians believe that DACA individuals should be considered “lawfully present” for purposes of health coverage eligibility. PRCH urges CMS to change the definition of “lawfully present” in the Pre-Existing Condition Insurance Plan program as well as the use of this definition in other provisions of the ACA. The rule represents poor public health policy and undermines the important goals of the ACA. Sincerely,
Douglas Laube, MD, MEd Board Chair Physicians for Reproductive Choice and Health
Rodriguez MA, Ward LM, Perez-Stable EJ. Breast and Cervical Cancer Screening: Impact Of Health Insurance Status, Ethnicity, And Nativity of Latinas. 2005. Annals of Family Medicine. 3:235-241.
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