Looming Threats to Health Centers and Their Low-Income Patients

April 10, 2017

I recently met someone who follows my blog — one of the benefits I treasure. She’d come to the District for a meeting of the National Association of Community Health Centers. I learned a lot about this important piece of our federally-subsidized healthcare system.

I could see right off ways that they and the low-income people they serve are threatened now. But Terri told me about another that’s more than a threat.

Federally Qualified Health Centers

Terri serves as the strategist and advocate for a Southern California network of Federally Qualified Heath Centers — outpatient clinics that have met a set of requirements and receive grants from a Health and Human Services Department agency.

The FQHCs must, among other things. provide specific healthcare services — primary, preventive and emergency, plus education so that patients with diabetes and chronic kidney disease can monitor and control their conditions.

They must serve an otherwise under-served area or under-served people elsewhere. And they must use income and family size as the basis for their fees. So people with no income can get care, even if not enrolled or eligible for Medicaid.

A number of clinics provide additional services, e.g., dental care, mental health and/or substance abuse treatment. The clinic where Terri is based does all this and more.

It has social workers, for example, who link patients to sources of help, according to their individual needs, including navigating them through online enrollment in Medicaid.

The clinic goes beyond its diabetes management requirement by giving its diabetic patients cellphones that read their blood sugar levels and relay them to the clinic.

Terri, her colleagues and counterparts across the country are worried about how they will continue to operate — and what will happen to the low-income they serve if they can’t.

Her network receives some donations. But like all FQHCs, it depends largely on the HHS grants and partial cost reimbursements for patients enrolled in Medicaid.

Raid on Medicaid Still a Threat

California jumped at the chance to expand its Medicaid program when the Affordable Care Act became effective. The clinic Terri works in experienced a large influx of newly-eligible people with untreated conditions, e.g., diabetes, high blood pressure, oral diseases, mental health problems.

Congressional Republicans haven’t block-granted Medicaid or the similarly cost-shifting per capita alternative.

But the Affordable Care Act assured states that the federal government would reimburse 90% of care costs for their newly-eligible enrollees from 2020 on forward — the last phase in the incentive pay scheme.

What with Trump now trying to cut a deal with far right-wing members of the House, one might reasonably expect the product to end this level of funding like the failed repeal-replace bill. All expansion states, including California would face some tough choices then.

Federal Grants in Two-Part Jeopardy

The legislation that authorizes the federal government to award the FQHC grants will expire at the end of September. Without the grants, the health centers will collectively lose about 70% of their federal funding.

So a must-do for Congress is a straightforward extension, like the one included in the same law that kept the Children’s Health Insurance Program alive. Given the lack of hearings, other preoccupations and usual long summer break, simply kicking the expiration deadline forward is the only way to avert a for-sure funding loss.

But that would only give HHS authority to spend as much money as Congress chooses — and the President agrees to. Trump’s budget plan would cut the HHS budget by 17.9% — $15.1 billion less than it’s getting now. We don’t know the details, but we shouldn’t, I think, rule out anything.

Even if Congress won’t go along with such radical spending cuts (a likely response), the Budget Control Act’s cap on spending for non-defense programs will kick in again, after the latest two-year halt.

What this means it that Congress will have to cut spending on these programs by $2.9 billion. So the size and/or number of the FQHC grants are at risk — unless Congress decides to again defer or altogether eliminate the caps.

Immigrant Roundups and Healthcare Needs

The clinic where Terri is based is in a community where many immigrants live, including some unknown number without the documents authorizing them to live and work in this country.

Even immigrants here legally generally can’t qualify for Medicaid for the first five years, though they can receive Medicaid-financed emergency services.

California, as well as some other states provides a few others, regardless of immigration status. But as the Los Angeles Times reports, the community health care centers “treat all comers.”

We all know how federal immigration enforcement authorities have aggressively ramped up raids aimed at deportation. They’re active in the clinic’s community, where local authorities have partnered with them.

The agents have started patrolling side roads, including one leading to the clinic. Staff have witnessed a large drop off in immigrants seeking care.

One day an agent showed up in the building, with a warrant for something (not somebody). He opened the door to the waiting room. Patients fled, dragging children by the hands. What’s going to happen to them and their kids now that fear will keep them away?

These aren’t the only threats to the health of low-income people. The unremitting efforts to defund Planned Parenthood clinics put them at high-risk too, notwithstanding the anti-choice Congress members’ and supporters claim that clinics like Terri’s can fill the gap.

May have more to say about this than I already have.


What Would June Think of the Hostilities Toward Immigrants?

July 5, 2016

Many years ago, when I was a graduate student, I inherited June when a fellow graduate student left the Berkeley area. She was a precious gift in more ways than I expected.

June cleaned my house as I never did and no one has since. While she cleaned, I edited the very long novel she’d written — essentially converting words and phrases into colloquial American English.

She needed the edit — and it was the only compensation she wanted — because she’d come to this country from China, with only the English she’d learned at school and had to become more fluent just be listening and figuring out what people meant.

The novel was her effort to tell English speakers about what she’d witnessed during the Second World War and the Communist takeover afterwards. Parts of it were truly brilliant. So reading it was part of the gift.

Talking with June was another part. We’d sit at the kitchen table for brief conversations before tackling our separate tasks. We generally talked about word changes I’d made, but not always. June was a sharp observer and intellectually curious.

I recall her asking me one day what she could read about “brothers fighting brothers.” I understood she meant our Civil War — much on her mind, given her post-war time on the mainland before she fled to Taiwan.

Fled alone, with her young son because the air force pilot she’d married, over her parents’ objections, wanted to have concubines when he returned home.

She’d lose face, she said, if she went back to her parents. Instead, she bravely moved here, where she knew no one — or anything about working for a living. Yet she found enough work that paid enough to support herself and “the boy.”

She managed somehow to find time for the novel, while still paying for rent, food and the like, but only after she’d also paid for at least some of her son’s college costs.

I think of June now because I wonder what she’d think about our country today. We surely do have a version of “brother against brother” — several versions actually.

June, I know, would disapprove of in-your-face actions and shoving at political rallies. She had very strong feelings about decorum. She’d remark on the shouting and shoving among kids passing by on their way home from the nearby public school. Their parents didn’t bring them up properly, she’d say.

I’m more curious about how June would view the blatant hostility to immigrants that Trump has surfaced and fostered.

She’d understand, I think, that the hostility isn’t directed toward people like her. We do see hostility against Asians in some quarters, but it’s mainly focused on high-achievers, in the conventional sense — college students, for example, and graduates with high-tech jobs.

Might June nevertheless feel unwanted — anxious even? All that talk of deportation. I’m quite sure she had the paperwork authorizing her residency. But she’d never become a citizen. She stubbornly insisted — my urgings notwithstanding — that she’d need to know more about our country first.

This had nothing to do with whether she could pass the test. She’d completed night school courses to prepare for that. But she believed she had to know more than most native-born Americans do before becoming an American herself.

And what, I wonder, would June think about the administration’s rounding up and deporting immigrants who, like her, had come to this country for safety and better lives for their children.

She was a devout Christian. I’m inclined to think she’d have based her view on what the Bible says about caring for strangers and loving neighbors as ourselves. But the Bible also speaks of honoring laws. And for whatever reason, June showed no tolerance for law-breakers.

She and I lost touch some time after I left Berkeley. That was back in the days when keeping in touch meant sending letters through the postal system or making long-distance calls.

June had little spare time, what with the still-unfinished novel — and very little money. I was short on both too, but basically just didn’t try to sustain the connection. I couldn’t help her. She wouldn’t let me. And I got none of the rewards of our weekly conversations.

I’m quite sure June is dead now. I couldn’t possibly find her anyway. But I do wish I could hear her thoughts on the immigration debate — if we can call it that. And I think of how she enriched not only my life, but the country she loved perhaps more than she should have.


What Does the Supreme Court Immigration Case Have to Do With Poverty in America?

May 16, 2016

CLASP has partly answered a question that’s been on my mind: Why should we who focus on poverty in America care how the Supreme Court rules on the immigration case it’s considering? Turns out we should care a lot and for a variety of reasons.

Simple Synopsis of the Case

As you may know, the case involves an “action” the President took in late 2014. Two parts, issued as directions through his head of Homeland Security in effect exempt certain undocumented immigrants from deportation for some indefinite time, unless they commit “serious crimes” or seem a threat to national security.

One expands the eligibility of people brought to this country when young — a group originally protected by the Deferred Action for Childhood Arrivals guidelines.

The other, commonly referred to as DAPA, covers the parents of children born here — and therefore, American citizens — and those who’ve become lawful permanent residents, provided the parents have lived here continuously for at least five years.

Both deferrals, like the original DACA, enable the immigrants covered to apply for legal authority to work. Arguably, nothing new. A regulation issued during the Reagan administration allows any “lawfully present” immigrant to get a work permit.

Texas, joined by 25 other states filed a lawsuit, alleging that the President had exceeded his legal authority — and in a way that would cost them money.

The judge who heard the case at the district level ruled for the states. And he issued an order covering all states, not only those within his court’s jurisdiction. The appeals court majority upheld the order.

So the Justice Department appealed to the Supreme Court, saying basically that the President had merely exercised his authority to set enforcement priorities and that the alleged costs were either speculative or irrelevant.

The Supreme Court thus has to decide whether the order can stand — or decide it can’t, now that it’s shy a member.

Effects on Deferred Action Families

A ruling for the administration would mean that roughly 4.7 million people in this country will no longer live in constant fear of deportation. Most are parents who fear losing their children and vice versa.

Many of the families live in poverty, as CLASP says, because, as it doesn’t say, the parents often have jobs that don’t pay even the legal minimum — or sometimes anything — since undocumented immigrants will hardly file claims of wage theft.

The parents can’t get any federal safety net benefits to compensate — and still couldn’t, unless their status changed. In some cases, their children can because they’re citizens. But the parents are unlikely to claim those benefits because that too would alert the authorities to their presence.

So the children are likely to suffer from hunger, insufficient (or no) health care and other harms those benefits help prevent — for example, by providing affordable, high-quality early education.

A friend-of-the-court brief filed by CLASP and 75 other organizations engaged in children’s advocacy and/or education argues that children with parents at risk of deportation also suffer psychological harms — toxic levels of stress, for example, because both they and their parents fear separation.

These multiple harms, it says, “undermine their long-term prospects for self-actualization and educational and economic success.”

Even worse harms if a working parent is deported, including loss of most or all family income and the consequences thereof, e.g. homelessness, the instabilities of life in foster care.

Potential Effects on Other Poor and Near-Poor People

No administration — not even one headed by the candidate I need not name — is going to deport the millions of immigrants the contested action covers.

That would take an enormous investment of federal resources, while doing nothing to protect our country — and us, as we go about our everyday lives — from genuine threats. It would instead pose something more certain than threats to major sectors of our economy.

So we’ll have DAPA parents and DACA young adults — some now parents — either still living in the shadows or free to live as openly as thee or me. Many work, though how many remains unclear — for obvious reasons.

As I’ve already suggested, they’re highly vulnerable to exploitation. What this means, among other things, is that employers can pay minimal wages to other workers and deny them basic safety protections and benefits.

If the workers don’t like it, well, they’re readily replaceable by others who’ll just hunker down. So it’s not only the undocumented immigrants who’d have a better shot at a living wage – and lives with their lungs and limbs intact — if the Court upholds the action.

Giving DAPA children the security they lack could also benefit other poor and near-poor children because state and local governments would have to spend less on efforts to remedy preventable harms — remedial education, for example, and child welfare services.

Less need for such efforts too because the children who are citizens would be more likely to receive safety net benefits that help prevent the many well-known, lasting harms of hunger, untreated illnesses and the like.

And there’d be more tax revenues, of course — from both the workers and the businesses they buy from. Which could lead the latter to create more jobs — a potential opportunity for workers now legally-authorized, but under-employed.

Altogether then, more funds to spend on low-income families, regardless of immigration status.

A Stop-Gap Measure

The President’s action is no substitute for immigration reform, as he made clear. We have an estimated 11.3 million undocumented immigrants in the country — thus more who’d still be insecure and vulnerable than reprieved.

And a future President could rescind the action, using only the same power of the pen Obama used to create it. So the security it provides is tentative.

As everyone knows, we’ve long needed comprehensive reform of our immigration system — one that recognizes the realities of our population and our economy. We can hope it would also reflect the values most, though not all of us espouse — and that we would see it soon.

Not highly likely, but better to hope for that than contemplate what might happen after November.


New Hope for Refugee Families in Detention Camps

July 9, 2015

Perhaps you recall my post on the detention centers that the immigration authorities are warehousing immigrant families in. Or perhaps you’ve read about them elsewhere.

They gotten some good media coverage. So the families — mostly mothers with young children who’ve fled violence in their countries — are out of the shadows now. But not out of the detention camps.

A letter national organizations recently sent to the President says that his administration has nearly 3,700 beds in the camps — a 4,300% increase (not a typo) from only a year ago. Highly doubtful the Department of Homeland Security would pay for so many beds if it thought most would be empty.

Some of the incarcerated families soon could have a chance to live with relatives, friends or in housing provided by faith-based groups while they await a final decision on their requests for asylum.

In late April, a federal judge issued a tentative ruling in favor of plaintiffs, who claimed that wholesale family detention violates a settlement the government agreed to long ago.

It obliges DHS to place minors in “the least restrictive setting possible.” The judge reportedly has interpreted this to mean that children — and their parents — can’t be held in detention camps unless they’re likely to flee or pose a risk to public safety.

DHS apparently read the handwriting on the wall. The Secretary recently announced “substantial changes” in the department’s practices. These include reviews of cases where families have been detained for more than 90 days to decide whether further detention is warranted.

Another change provides for the release of families who’ve persuaded the authorities they have a “credible fear” of persecution in their home countries, i.e. are over the threshold to a decision on whether they can remain here indefinitely.

Families may, however, have to post bonds — much as people charged with crimes must post bonds to ensure they’ll show up for trial (or remain in jail or prison).

DHS has offered some detained families the bond option for awhile, but the amounts have been more than most could come up with — as high as $15,000. DHS will now supposedly take account of ability to pay.

But recall bonds are only for families who’ve passed the first major screening test. And advocates have said they’re unnecessary because virtually all families who’ve been released — as most used to be — show up for their hearings regardless.

So steps in the right direction. But still families held in those camps. And children damaged, perhaps irreparably.

How our government treats families who’ve fled from imminent dangers is ultimately the President’s call because what DHS does — and doesn’t — reflects his strategy on broader immigration issues.

Basically, I think, he will have to decide whether to continue trying to persuade recalcitrant Republicans to work with him on immigration reform. Perhaps he already has.

One notes, for example, his in-your-face expansion of reprieves from deportation for some undocumented immigrants who were brought to this country as children, as well as somewhat similar reprieves for undocumented parents whose children were born here or have since gained legal status.

Perhaps the recently reported (though not new) targeting of deportation actions belongs in this category too.

But if the President’s really given up, then it’s hard to see why the administration persists in stressing and re-stressing vigilance at our borders — at least insofar as penned-up refugee families are offered up as proof.

More broadly, it’s hard to see why the administration seems so bound and determined to prove that House Republicans are wrong when they claim they can’t trust him to enforce a new immigration law — the latest in a litany of excuses for their refusal to tackle a difficult and divisive issue.

Not saying the administration should just roll out the welcome mat to all tired, hungry and poor people seeking a better life here. Our country decided against that in the late 19th century.

But people who’ve every reason to fear death, rape and other violence shouldn’t suffer more because our leaders want to deliver a message to others who might also throw themselves on our tender mercies, rather than dutifully line up at a consulate back home.

Nor should they be made pawns in a political game that looks for all the world like a no-win till at least some time after the next election.