The American Immigrant Policy Portal

Human Services (Health Care)

The Human Cost of Politicizing Immigration: Migration Stigma, US Politics, and Health, Journal of the American Medical Association (JAMA), July 1, 2024 Authors: Lawrence H. Yang et al (The JAMA article is only available to subscribers. However, information about the JAMA article may be found at the link to this NYU publication) In this Viewpoint article, the authors examine the public health consequences for immigrants of the increasing “politicization of immigration” in the United States.  A new social science concept – migration stigma – is discussed which emerged from a scientific forum involving experts from the fields of stigma and international migration.  Migration stigma is defined as “a form of stigma experienced by a racial or ethnic group with a history of international migration….Being identified or labeled as belonging to a ‘migrant’ group can set off a cascade of negative consequences including stereotyping, separation, status loss, and discrimination.”  Social and political science research on anti-immigrant prejudice has not typically investigated the impact of bias and stigma on immigrants’ health and well-being or on the health inequities experienced by diverse populations.  The authors emphasize the need to develop “structural competence,” defined as “the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures.” A structurally oriented approach should have three core components:  1) Enhancing our understanding of patients’ experiences of health and illness as situated within migration-related structural factors; 2) Intervening by addressing structural factors at policy levels; and 3) Facilitating structural change by partnering with community leaders and with other disciplines. The authors recommend three areas for future research: 1) Will the migrant label elicit harmful stereotyping, separation, status loss, and discrimination at both structural and person-to-person levels, and negatively impact the physical and mental health of immigrant and other racial or ethnic groups?; 2) Will stigmatization and related restrictive laws and policies governing access to resources have long-term consequences for health?; and 3) What impact will fostering structural competence have on improving access to health care, service delivery, continuity of care, treatment engagement, and outcomes for immigrants? (Robert Like, MD, MS)

International Medical Graduates and the Physician Workforce, JAMA, July 15, 2024, 7 pp. Authors:  Oliver J. McElvaney & Graham T. McMahon This article examines the issue of physician shortages and the mal-distribution of physicians in the US and the important role played by international medical graduates (IMGs) in “bridging the domestic physician supply gap.” IMGs currently make up an estimated 25% of the medical workforce but often face significant barriers to training, clinical practice, and academic research. The authors note that IMGs are often highly competent; bring considerable research expertise, clinical skills, and diversity; fill low-preference training and practice positions; provide care to historically underserved populations; and help offset the geographic mal-distribution of general and specialist physicians.  The authors provide information about the following topics:  1) the geographic mal-distribution and shortage of US –born physicians; 2) the barriers faced by IMGs, including licensing and credentialing; 3) additional barriers for residency applicants; 4) fellowship and medical board eligibility; 5) problems faced by IMGs seeking to enter practice without US training; and 6) potential solutions for tapping into the IMG talent pool. The authors propose practical interventions for program directors, employers, training sites, policy makers, and licensing boards to help improve recruitment, career development, and integration of IMGs into the US physician workforce.  At the national level, the authors recommend streamlining the visa acquisition process, expanding eligibility for employment authorization and permanent residence, and reconsidering NIH grant eligibility criteria to include IMGs. (Robert Like, MD, MS)

How Two Immigrant-Led Organizations Are Harnessing an Opportunity to Create a More Inclusive Health Care workforce, World Education Services, April 1, 2024, 4 pp. Author: Trevor Shealy Growing health care workforce shortages have been documented in the US.  While immigrants and refugees with health care training and experience have long played significant support roles, they continue to be underutilized due to factors including non-recognition by licensing boards of relevant degrees, work experience, or occupational licensure earned abroad. The Skilled Immigrant Integration Program of World Education Services helps organizations to develop grassroots solutions that can facilitate the re-entry of internationally trained immigrants and refugees to the health care sector. This article describes two immigrant-led organizations that have developed successful pathways connecting immigrants and refugees to health care careers. The first is the African Bridge Network’s (ABN) fellowship program with local employers in Massachusetts that has trained and helped find positions for “individuals with experience from abroad in non-regulated, in-demand research administration careers in … health care and related industries.” Information is provided about ABN’s 2-year experience with candidate recruitment, research administrator training, an increasing pool of employer partners, and a positive success rate in fellows completing training and obtaining full time employment.  The second organization is The International Medical Graduates Academy (TIMGA) in Washington State that has 1) helped pass legislation creating a limited license for IMGs; 2) worked to support immigrants and refugees with obtaining this license and securing employment; 3) developed resources informing potential nominating facilities and agencies about the license and the unique challenges IMGs face; 4) helped to address a barrier requiring supervising physicians to hold malpractice insurance for any IMGs under their supervision and related financial challenges; and 5)  led efforts to educate IMGs about the license and the opportunity to practice medicine, resulting in an increase in the number of IMGs practicing and applying for the limited license. (Robert Like, MD, MS)

Lessons from COVID-19:  Managing Borders in the Next Global Public-Health Crisis, Migration Policy Institute, March 2024, 19 pp. Authors: Meghan Benton & Lawrence Huang This issue brief reports on three years of research carried out by the Migration Policy Institute’s Task Force on Mobility and Borders during and following the COVID-19 pandemic.  The authors describe the significant negative impact of closed borders, travel restrictions, entry bans and suspensions of asylum and refugee resettlement systems, as well as the massive economic, social, and psychological harms experienced by travelers and migrants globally. All forms of human mobility (e.g., international tourism, legal migration, family reunification, visa processing, short-term business travel) were affected. The results included millions of stranded migrants, unexpected relocations and repatriations, irregular migration, and migrants living in difficult quarantine, socioeconomic and public health circumstances.  Among the lessons for policy makers are the following: 1) developing evidence-based, robust risk analysis frameworks to help governments and travelers make more informed decisions about travel measures; 2) mitigating the risks and costs of travel measures including reducing their volume, inconsistency, and complexity, addressing the patchwork of exemptions, and shifting from the use of country-based to person-based rules; and 3) preparing for future public health emergencies through better international/regional coordination, integrating migrants into pandemic response planning, and incorporating mobility and travel measures into the WHO draft pandemic treaty and future revisions of the International Health Regulations.  Governments should be guided by four key principles to ensure that future mobility measures are clear (well-communicated, predictable, and based on clear metrics); equitable (not overly burdensome to vulnerable groups); streamlined (used sparingly and lifted as quickly as possible, and certainly not maintained beyond domestic measures); and prepared (based on planning and building on COVID-19 digital and institutional infrastructure). (Robert Like, MD, MS)

The Growing Demand for Healthcare Workers in New York (See below for links to Michigan and Massachusetts reports), American Immigration Council, March 2024, 5 pp. This brief report points out that there is a critical national shortage – worsened by the COVID-19 pandemic -- of healthcare workers, including physicians, surgeons, nurses, and health/clinical laboratory technicians. Using workforce statistics for the period from 2019 to 2022, the authors provide details about this shortage in New York State, as well as the important role played by immigrants in filling these positions. There were 941,608 unique healthcare worker/technical job postings, with the top five in-demand healthcare jobs being in various nursing and health/clinical laboratory technology fields. Online healthcare practitioner job postings increased by 51.5%, and average advertised annual salaries increased by 29.1%. Health care job postings that required bilingual skills increased by 65.7%. Significant physician shortages were reported for primary care and various specialties (e.g., oral and maxillofacial surgery, podiatry, cardiology, dentistry, obstetrics and gynecology, and general internal medicine) that are also projected in the future, especially in rural communities.  From 2015-2019, the average share of physicians and surgeons in New York State who were immigrants was 37.6%.  “Brain waste” with the under- or unemployment of qualified internationally trained health care workers continues to be an important problem and relates to a lack of skill recognition and recredentialing pathways. According to the authors, policies must be implemented to attract, retain, and build immigrant talent to address national and state healthcare needs. In addition to this report, the Council has also released reports on the role of immigrants in the Michigan and Massachusetts healthcare sectors. (Robert Like, MD, MS)

States Are Providing Affordable health Coverage to People Barred From Certain Health Programs Due to Immigration Status, Center on Budget and Policy Priorities, February 1, 2024, 23 pp. Authors: Claire Heyison & Shelby Gonzales This report provides an analysis of initiatives taken by a number of states to expand immigrant eligibility for various forms of health care coverage. The authors also review the restrictions imposed by the federal government on such coverage not only for undocumented immigrants, but also for legal immigrants who have not completed their required five-year waiting period for coverage, and for recipients of temporary protected status. Although they are barred from ordinary care, providers can be reimbursed for emergency services for these groups. They may also receive services from community health centers if they meet income requirements. However, many immigrants in these and other categories are fearful of accessing such services because they may violate the “public charge” restriction on permanent residency in the U.S.  The report discusses all the benefits of expanded health coverage and argues that greater federal and state investments to achieve this goal would produce greater savings in the future, including greater academic and career success for children currently excluded from coverage. The balance of the report goes into detail as to what states may do to achieve this goal, including allowing children and people who are pregnant to enroll in Medicaid or CHIP. In addition, at least five states and D.C. have created health coverage programs similar to Medicaid to cover groups excluded from federal coverage. Eleven states have created Medicaid look-alike programs for children.

State-Led Health Insurance Coverage Expansion for Noncitizens, Urban Institute, January 2024, 20 pp. Authors:  Dulce Gonzalez et al Noncitizens are much less likely to have health insurance than citizens largely due to eligibility restrictions on federally funded health insurance programs based on immigration and citizenship status. To address this issue, several states are trying to improve access to affordable health insurance by using state funding to extend public health insurance and subsidized ACA-compliant health insurance to noncitizens.  In this report, the authors provide an overview of federal restrictions on noncitizens’ eligibility for public coverage, discuss approaches states are taking to provide publicly financed coverage to noncitizens, and review emerging research on the impact of state-led expansions.  The authors carried out semi-structured interviews with stakeholders from five national organizations and five state-level organizations. The study’s scope was limited to expansions via state-funded Medicaid- or CHIP-like programs or subsidies for commercial insurance coverage for groups of noncitizens, such as children and adults of certain ages, who are excluded from federally funded Medicaid/CHIP. Among topics covered in the study were the following: (1) projections related to state-led coverage expansions, including budgets; (2) best practices for implementation of expansions; and 3) assessment of the short- and long-term impacts of expansions. Stakeholders also shared concerns that faulty research could impede state action in expanding insurance coverage and thereby harm noncitizens. (Robert Like, MD, MS

Aging Societies Rely on Immigrant Health-Care Workers, Posing Challenges for Origin Countries, Migration Policy Institute, January 26, 2024, 11 pp. Author: Heidi Bludau Shortages in the global health care workforce exist and have been exacerbated by the COVID-19 pandemic.  In high-income countries, there is a growing demand and supply gap resulting from populations getting older and living longer, combined with an aging workforce that is burning out and not being adequately replaced. This article reports on international migration trends among health-care workers, focusing on major countries of destination and origin, factors driving migration, and global efforts to regulate the movement and prevent shortages in source countries.  Leading source countries for physicians include India, China, Pakistan, and Germany; and for nurses, the Philippines, India, and Poland.  Top destination countries have been the United States, the United Kingdom, Canada, New Zealand, Australia, and Saudi Arabia.   A timeline of health worker migration trends describes how the “dynamics have … changed over time, depending on global demand, supply, and other factors.” Drivers of migration include a desire on the part of healthcare workers to improve financial conditions for themselves and their families; their search for professional development opportunities; and their need to escape harsh social, economic, or political environments. Strategies utilized by destination countries to attract foreign health workers include developing legal migration pathways and using recruitment firms to facilitate movement. Concerns have been raised about the consequences of this “brain drain.”  The report also discusses efforts to manage the situation through the 2010 Global Code of Practice on the International Recruitment of Health Personnel of the World Health Organization, along with policies of the International Council of Nurses (ICN). Remittances are the primary benefit for source countries and can help boost economies, but “they are not often reinvested into the health-care system and do not offset expenses lost in training workers for foreign employment.” According to the author, the reliance by OECD countries on foreign-trained health professionals has created a global health-care system deficit, which will only increase “unless health education is reformed to match future needs.” (Robert Like, MD, MS)

Migration Policy and the Supply of Foreign Physicians: Evidence from the Conrad 30 Waiver Program, National Bureau of Economic Research, December 2023, 25 pp. Authors: Breno Braga et al In this paper, the authors look at the impact of the Conrad 30 Waiver program—and changes to the program enacted in 2002—on the supply of international medical graduates (IMGs) and native-born U.S. doctors in medically underserved areas. Ordinarily, once IMGs complete their graduate medical education in the U.S. they must return to their home country for at least two years before applying for a temporary visa or permanent residence in the U.S. The Conrad 30 program waives the two-year foreign residency requirement for foreign physicians willing to practice in underserved areas in the U.S. Initially, each state could sponsor up to 20 IMGs per year. In 2002, the cap was increased to 30 per year per state. The authors found that states that took advantage of the increase in the cap increased the supply of medical professionals per capita in medically underserved areas. The supply of IMGs was also affected by a state’s restrictions on the waiver program. (For example, whether or not the state allowed non-primary care physicians to participate in the program.) States with fewer restrictions had more IMGs willing to participate in the program. At the same time, the authors found that there was no evidence to suggest that a greater supply of IMGs had a negative impact on the supply of U.S.-trained doctors. The authors note that by 2022, 22 states were requesting their maximum quota of 30 waivers under the Conrad waiver program, suggesting that demand for physicians to practice in underserved areas continues to exceed supply. The authors note that currently a fraction of foreign physicians who completed their medical training in the U.S. receive a waiver from the requirement to return home for two years, suggesting that raising the cap in the waiver program could alleviate the ongoing shortage of medical professionals in the U.S. (Maurice Belanger, Maurice Belanger Associates)

Addressing the Direct Care Workforce Shortage: A Bipartisan Call to Action, Bipartisan Policy Center, December 2023, 94 pp. Authors: Lisa Harootunian et al This study looks at the impacts of the direct care worker shortage in the U.S. and offers recommendations to grow and support this workforce, comprised disproportionately of immigrants (25%), people of color (68%) and women (86%). Beyond the paid workforce, unpaid family and friend caregivers are estimated at 38 million. Worker shortages strain the healthcare system, harming access to and quality of care for millions of adults and children in the U.S. and contributing to increased federal and state spending. With 5.1 million direct care workers in 2022, Health and Human Services estimates that the supply of direct care workers will fall short of the demand associated with 8.9 million projected job openings from 2022-2032. Through research, interviews with stakeholders and federal policy experts, and a private roundtable discussion, the authors identified three broad sets of bipartisan legislative and administrative federal policy solutions to address the challenges to recruiting and retaining direct care workers. These include (1) promote retention of direct care workers through reforms that encourage more supportive work environments, including assisting unpaid caregivers (2) increase the number of workers through domestic and targeted immigration policy reforms, including expanded apprenticeship programs, increased permanent and temporary employment-based visas, and legalization of qualifying unauthorized workers; and (3) improve standardized data collection and publicly available data on the direct care workforce to measure the effects of these efforts and inform evidence-based policymaking. (Jeffrey Gross, Ph.D.)

Foreign Trained Medical Professional Licensing: Report and Recommendations Michigan Task Force on Foreign Trained Medical Professional Licensing, December 5, 2023, 25 pp. A growing number of states are experiencing workforce shortages in health professions such as medicine, nursing, dentistry, pharmacy, and physical therapy. One proposed solution is addressing the underutilization of foreign trained medical professionals (FTMPs) who can provide quality health care if states can reduce licensure barriers. This report was prepared by a multi-stakeholder Task Force created by the Michigan Department of Licensing and Regulatory Affairs. Topics discussed include:  Michigan’s health care workforce crisis and projected talent shortages; health professional shortage areas by county; increasing care needs of an aging and diversifying population; how FTMPs can serve as proven and underutilized professional resources; and licensing guidelines.  Barriers experienced by FTMPs include:  financial hardship and fees associated with licensure; poor credit transfer; residency shortages; and limited licensure pathways. The report shares examples of legislative actions and case studies of initiatives taken by other states and gives eight key policy recommendations: 1) rescind English language proficiency requirements; 2) create and maintain skilled immigrant licensure guides in multiple languages; 3) establish a welcome initiative in Michigan to support FTMPs; 4) fund a grant program to assist FTMPs with licensure and credential evaluation; 5) dedicate a liaison to assist FTMPs and measure progress; 6) create a state-run initiative to provide residency slots to FTMPs; 7) develop a new transitional licensure pathway for FTMPs; and 8) expand acceptability of accredited credential evaluations from private entities. Additional federal legislation or policy suggestions are offered relating to visa utilization and processing, the Conrad 30 Waiver Program, and FTMP employment status. (Robert Like, MD, MS)

Addressing the Direct Care Workforce Shortage: A Bipartisan Call to Action Bipartisan Policy Center, December 2023, 94 pp. Authors:  Lisa Harootunian et al This report underscores the gravity of the shortage of direct care workers in the U.S. These are workers functioning as personal care aides, certified nursing assistants, home health aides, residential care aides, psychiatric aides, and other occupations. Although the number of such workers has already soared from 2.2 million in 2000 to 5.1 million in 2022, their projected numbers will likely reach 8.9 million by 2032. There is little likelihood that the domestic workforce alone will be able to satisfy the need. One problem is that compensation for direct care workers remains low and uncompetitive with comparable occupations. The report recommends a series of steps to ensure that Medicaid payments allow for adequate compensation for these workers. In addition to domestic reforms, the report recommends a series of immigration policy changes to expand the direct care workforce, including recapturing 25,000 unused employment visas for direct care workers, classifying direct care workers as Schedule A shortage occupations for at least five years; allowing J-1 Visa Exchange Visitor participants to work in caregiving professions for older adults; and creating a new four-year nonimmigrant visa classification for low-skilled health care workers.

Immigrant Workers’ Voices as Catalysts for Reform in the Long-Term Care Industry, Social Science Research Network, July 19, 2023, 55 pp. Authors:  Shefali Milczarek-Desai & Tara Sklar The COVID-19 pandemic exposed glaring flaws in the long-term care industry, demonstrating that older Americans and their caregivers die or suffer unnecessarily due to these shortcomings. Absent any literature on the lived experiences of these long-term care aides, a significant proportion of whom are im/migrant  women, the authors of this paper employed a novel methodology. They interviewed im/migrant women in Arizona working as home health aides and found that these workers consistently experienced violations of state and federal employment and labor laws. The article describes the use of critical race and health law theories to inform the study’s design and details the study’s methodology and findings. Through the voices of im/migrant women aides, the authors demonstrates that this subset of frontline, essential workers face significant barriers to accessing their workers’ rights, including paid sick time and protection from employer retaliation. The study’s findings show that im/migrant aides work in conditions that are unsafe not only for them but also for their patients. Together, these failures contribute to poor quality of care, chronic labor shortages, and increased potential for harm in future public health emergencies.

State Public Insurance Coverage Policies and Postpartum Care Among Immigrants, JAMA Network, July 18, 2023, 8 pp. Authors: Maria W. Steenland et al This study examines the connection between public insurance coverage and postpartum care among low-income immigrants and whether differences exist in the self-reported receipt of postpartum care among immigrants compared with nonimmigrants. Data was analyzed from the Pregnancy Risk Assessment Monitoring System for 19 states and New York City covering low-income adults with a live birth between 2012 and 2019. The study presents findings for 72,981 low-income adults, of whom 20,971 were immigrants (29%) and 52,010 were nonimmigrants (71%). States were classified as offering full, moderate, or no public insurance coverage for postpartum care to recently documented or undocumented immigrants. Receipt of postpartum care reported by immigrants was 7% lower in moderate coverage states, and 11.3% lower in no coverage states, as compared with full coverage states. Differences in the receipt of postpartum care among immigrants relative to nonimmigrants were also associated with the three coverage categories. Compared with states offering full coverage, there was a 3.3%-point larger difference in the states offering moderate coverage and a 7.7%-point larger difference in the states offering no coverage. The authors discussed the potential effects of limited access to postpartum care for immigrants including decreased diagnosis, treatment, and management of acute and chronic health conditions; increased readmission rates for medical complications; and poorer birth outcomes. The authors state that their study “makes a substantial contribution to the existing literature by documenting a significant negative association between state public insurance policies that restrict eligibility by immigration status and receipt of postpartum care in a large sample of states with large immigrant populations… restricting public insurance coverage may be an important policy-driven barrier to receipt of recommended pregnancy care and improved maternal health among immigrants.” (Robert Like, MD, MS)

Migration integration policies as social determinants of health for highly educated immigrants in the United States, BMC Public Health, 23:1358 (2023), 12 pp. Authors: Mitra Nash et al This study explores how increasingly restrictive migration policies are having an adverse affect on the health of the growing number of highly educated immigrants (HEIs) in the U.S. The authors employed qualitative study methods (phenomenology and inductive reasoning) and collected data through 31 semi-structured interviews with adult HEIs from 17 countries who were intending to remain in the U.S. Several themes emerged from the analysis: 1) a life filled with silent worries, 2) living through uncertainties and forced decisions, and 3) the complexities and challenges of living on a work visa. Narrative comments revealed high rates of stress and anxiety, negative mental and physical health outcomes, high levels of internalized vulnerabilities, and deprivations and hardship in work, school, and family life related to the complexities of different visa types, changing rules and regulations, varying country quotas, communication challenges, and frustrating bureaucratic processes. Interviewees made a number of recommendations for improving migration policies including: creating a better and more transparent communication system, replacing random review processes for applications with systematic procedures, creating expedited pathways to citizenship based on merit, and granting access to work as a basic human right.  The authors also called for more research to foster an “in-depth understanding of the history, traditions, value systems, world views, family systems, and artistic expressions of different groups of immigrants in relation to migration policies.” (Robert Like, MD, MS)

Immigrant Health Care Workers in the United States Migration Policy Institute, April 7, 2023, 9 pp. Author: Jeanne Batalova This Spotlight provides a demographic and socioeconomic profile of foreign-born health-care workers residing in the U.S. (updating an earlier Migration Policy Institute report from 2020). Primary data sources are the U.S. Census Bureau’s 2021 American Community Survey and the U.S. Bureau of Labor Statistics. The report provides data for two broad categories of workers: health-care practitioners and technical workers, and health-care support workers. Among topics covered in the report are: historical trends and projections; national and state data; gender breakdowns; region and country of birth; educational backgrounds; naturalization status; language proficiency; visa pathways; and health insurance coverage. Key findings include:  1) Immigrants account for disproportionately high shares of essential workers and were on the front lines as part of the U.S. response to the pandemic; 2) Nearly 2.8 million immigrants were employed as health-care workers in 2021, accounting for more than 18 percent of the 15.2 million people in a health care occupation; 3) Immigrants in the health-care sector hold a variety of legal statuses, including naturalized citizens, legal permanent residents, temporary workers, and recipients of TPS and DACA status; 4) The foreign-born were especially over-represented among certain health-care occupations such as physicians and surgeons as well as home health aides; 5) Compared to all immigrant workers, those employed in the health-care field were more likely to speak English fluently, be naturalized citizens, and hold health insurance coverage; and 6) Despite the need for foreign-born health care workers, the U.S. immigration system does not prioritize their recruitment.  The need for foreign-born health care workers is likely to increase as the overall U.S. population continues to age and current health-care workers continue to retire. (Robert Like, MD, MS)

Immigration Options and Professional Requirements for Foreign Health Care Workers, Congressional Research Service, April 28, 2023, 31 pp. Authors: William A. Kandel et al This report summarizes all the ways that foreign-trained health care workers (especially physicians and nurses) could qualify for admission to the U.S. as legal immigrants. At present, with but one minor exception (the J-1 program), there are no special programs prioritizing the admission of such workers. Given the severe shortages of health care workers in the U.S., efforts have been made in recent years to introduce legislation in Congress to address this problem. The authors of this report provide summaries of all these bills, only one of which has become law.  The authors also review executive actions that could be taken to address the problem, such as adding nursing to the list of STEM fields, thereby allowing international nursing students to work temporarily in the U.S. after graduation. The report also discusses efforts to harness the unutilized or under-utilized skills of foreign-trained healthcare workers already residing in the U.S. -- a problem often referred to as “brain waste.” Since states are responsible for licensing health care professionals, federal policy levers are limited, although the federal government allocates funds to the states for English language training, often a requirement for licensure. Finally, the report discusses efforts to bolster the ranks of home health care and nursing home workers. These are lesser-skilled workers in high demand to meet the needs of America’s aging population, yet few legal pathways exist for their immigration to the U.S.

A Path to Meeting the Medical and Mental Health Needs of Unaccompanied Children in U.S. Communities, American Academy of Pediatrics & Migration Policy Institute, April 2023, 38 pp. Authors:  Jonathan Beier & Karla Fredricks 2022 was a record year for the number of unaccompanied migrant children arriving in the U.S. In a report entitled “A Path to Meeting the Medical and Mental Health Needs of Unaccompanied Children in U.S. Communities,” Jonathan Beier and Karla Fredricks examine the special challenges these children face in securing healthcare. Working together with the American Academy of Pediatrics, the Migration Policy Institute sent teams to three U.S. cities: Houston, Los Angeles and New Orleans, to gauge unaccompanied children’s access to medical and mental health services. By interviewing healthcare professionals and the children themselves, they found that there were several major obstacles, including those related to official policies, the complexities of the U.S. health-care system, and individual and community factors. The report highlights promising practices that some regions have adopted to address these barriers. It also presents recommendations for governments, health systems, schools, and communities that, if implemented, the authors believe would substantially strengthen services for unaccompanied children.

The Trauma of the Family Separation Policy on Migrant Children (2017-2022), Social Science Research Network, February 8, 2023, 7 pp. Author:  Mariela Olivares During the Trump administration, nearly 4,000 migrant children were taken from their parents as a way of deterring illegal migration. In a paper entitled “The Trauma of the Family Separation Policy on Migrant Children (2017-2022),” the author delves into the government’s rationale for this policy, the Biden administration’s response, class action litigation against the policy, and the policy’s impact on separated children. The policy originated alongside the Zero Tolerance Prosecution Policy, which claimed that illegal migration with a child was a form of criminality. A lawsuit on behalf of a class of similarly situated families asserted that this policy violated the Constitution. This legal action ultimately led to the creation of a Task Force under the Biden administration, which has reunited 260 families as of May 2022, The author emphasizes the work left to be completed by the Task Force, such as defining family separation as a form of detention and torture, collaborating with nonprofits nationwide for the treatment of childhood trauma, and prioritizing the end of government-sanctioned family separation through Task Force recommendations. The alternative might be the continuation of physical and psychological harm to children, as demonstrated in the extensive overview of the medical literature on the topic.(The Immigrant Learning Center’s Public Education Institute)

Immigration, the Long-Term Care Workforce, and Elder Outcomes in the U.S., National Bureau of Economic Research, February 2023, 44 pp. Authors: David C. Grabowski et al Increased immigration to the U.S. significantly raises staffing levels and improves patient outcomes in nursing homes. David Grabowski and colleagues utilized a variety of data sets in order to reach this conclusion in their paper “Immigration, the Long-Term Care Workforce, and Elder Outcomes in the U.S.” The authors highlight that immigrants represent a disproportionate share of long-term care workers, making up 25 percent of home care and 19 percent of nursing home workers. In addition, the labor market for nursing home workers faces persistent excess demand, resulting in a lack of compliance with required staffing levels. The authors go on to analyze the effect of immigration on the quality of care in nursing homes. They found that higher levels of immigration led to reductions in the use of physical restraints, the development of urinary tract infections, and rehospitalization among short-stay rehabilitative residents. Within the long-stay population, they found reductions in the use of physical and chemical (i.e., inappropriate antipsychotic medications) restraints and the development of pressure sores. The authors conclude that inadequate staffing in nursing homes is a pressing policy issue, probably only resolved through increased levels of immigration.

Immigrants’ Experience with Medicaid Enrollment: Challenges and Recommendations Immigration Research Initiative and the Urban Institute, March 30, 2022, Four Short Reports Author: Cyierra Roldan The Medicaid enrollment process can be very challenging for people from diverse immigrant backgrounds, especially when they have limited English proficiency, lack computer access, and don’t have an understanding of the complex U.S. health insurance system.  This qualitative interview study was carried out with 20 immigrant and refugee New Yorkers “from different countries, living in different parts of the state, and with different immigration statuses” who share their negative and positive experiences with accessing the Medicaid system.  Findings are summarized in four brief reports that focus on the following topics: “Navigating Challenges of the Medicaid System”; “Impacts of the Public Charge Rule on Immigrant New Yorkers”; “Experiences of Discrimination and Unwelcoming Medicaid Personnel”; and “Lessons Learned: Community-Based Organizations Are a Key to Immigrant Medicaid Enrollment.”  In these reports, the author discusses a number of systemic, cultural, and administrative challenges including: language barriers, access to technology, anxiety created from the Trump Administration’s radical changes to the public charge rule, interacting with unwelcoming Medicaid employees, a lack of knowledge about the enrollment process, and feelings of discrimination based on race, gender, language, religion, or culture. Despite these challenges, many immigrants were grateful to the Medicaid program for providing them with access to health care that they would not have received in their birth country. A key study recommendation is that “the state should promote, advertise, and encourage immigrants to use navigators at community-based organizations and trained enrollers to ensure that immigrants have a less difficult time applying, they understand the requirements, they have access to a translator and more.” (Robert Like, MD, MS)

The Growing Demand for Healthcare Workers: A State-by-State View, American Immigration Council, February 3, 2023 (13 state reports) This series of 13 fact sheets provides information about the important role immigrants are playing in addressing critical workforce shortages in the healthcare field.  The fact sheets cover the following states: Arizona, Florida, Georgia, Iowa, Kansas, Missouri, North Carolina, Oklahoma, Tennessee, Texas, Utah, Virginia, and Wisconsin. Data from the years 2017-2021 are presented relating to: 1) the growing number of job postings for physicians of different specialties, licensed nurses, dentists, podiatrists, pharmacists, and other allied health professionals; 2) top hospital and health care system employers; 3) advertised wages; 4) healthcare job postings by rural-urban classification, especially identifying rural shortages; 5) the number of healthcare job postings that required bilingual skills; and 6) the share of healthcare workers who are immigrants. The authors note that  “immigrants routinely punch above their weight in the field,” having higher percentages of health care positions than their share of the population. The fact sheets also document the problem of “brain waste,” i.e., the underutilization and unemployment of many skilled immigrants who are unable to practice due to challenges such as re-credentialing and language proficiency. The American Immigrant Council emphasizes the need to “implement policies that not only attract and retain global talent that is complementary to the U.S.-born workforce, but that also build career pathways for immigrants who already call the state home.” (Robert Like, MD, MS)

Many Asian American and Native Hawaiian and Pacific Islander Adults May Face Health Care Access Challenges Due to Limited English Proficiency, Urban Institute, December 2022, 19 pp. Authors: Jennifer M. Haley et al This report assesses the extent of limited English proficiency (LEP) among Asian American and Native Hawaiian/Pacific Islander (AANHPI) communities and variations in LEP across AANHPI subgroups. The authors analyzed pre-pandemic data on nonelderly adults (ages 19-64) from the 2019 America Community Survey. Key findings include: 1) About 30.8% of Asian American adults and 12.1% of NHPI adults had LEP, compared with 32.9% of Hispanic adults, 3.1% of Black adults, and 1.4% of white adults; 2) AANHPI adults with LEP were more likely than those who were English proficient to be noncitizens and to have socio-economic disadvantages such as lower incomes, lower levels of education, and higher uninsurance rates; 3) Nearly all Hispanic adults with LEP reported speaking Spanish, while the languages of AANHPI adults with LEP were much more varied; and 4) Estimated LEP rates varied widely across subgroups of AANHPI adults. To advance health equity, the authors emphasize that it will be important to improve language accessibility and employ data disaggregation in order to understand the disparate needs of various AANHPI communities, especially regarding their ability to enroll in health insurance and access quality health care. The authors also briefly discuss the importance of challenging stereotypes and the “myth of the model minority” in the diverse AANHPI community. The report also describes recent federal policy efforts to strengthen the enforcement of antidiscrimination regulations and increase digital language accessibility. Targeting of local and state-level resources and additional solutions are identified for helping to meet the specific language access needs in each AANHPI community. This type of access will become particularly relevant as some pandemic-related health insurance coverage protections expire and the need for clear communication from state health insurance agencies to enrollees continues to grow. (Robert Like, MD, MS)

Changing the Playbook: Immigrants and the COVID-19 Response in two communities, Migration Policy Institute, July 2022, 39 pp. Authors: Randy Capps & Michael Fix An estimated 11 million unauthorized immigrants were barred from key forms of pandemic assistance, while many legally present immigrants had limited or no access to public benefit programs. Changing the Playbook : Immigrants and the COVID-19 Response in Two U.S. Communities examines the COVID-19 recovery and relief efforts in two contrasting U.S. communities: Worthington, Minnesota (a largely agricultural community with one of the highest infection rates in the country), and Harris County, Texas (home to Houston, the nation’s 4th largest city). Using qualitative data based on 60 interviews with public officials, community leaders and service providers, the report compares how immigrant groups, nonprofit organizations and governments in these two communities responded during the first 18 months of the pandemic. The authors highlight the critical role that state and local governments played in relief and recovery efforts, as many immigrants were barred from federal relief packages. Common elements are identified regarding these communities’ responses, as well as useful lessons in regard to the inclusion of immigrants in future recovery efforts nationwide. The report stresses the importance of building on these elements and past experiences, as well as the strengths of local stakeholders, in order to build the resilience of all U.S. communities. (Stephanie DePauw for The Immigrant Learning Center’s Public Education Institute)

COVID-19’S Effects on U.S. Immigration and Immigrant Communities, Two Years On, Migration Policy Institute, June 2022, 26 pp. Authors: Julia Gelatt & Muzaffar Chishti This report examines the impact of the COVID-19 pandemic on recent U.S. immigration policy, immigration to the country, and the nation’s immigrant communities.  Among topics covered are: changes in immigration policy in response to the pandemic; the impacts of these changes on migration trends; the role of immigrants in the fight against COVID-19; the impact of the pandemic on immigrants’ health, including infection and death rates in selected states and industries; and vaccination rates and attitudes among immigrants.  The report also looks at the impact of the economic downturn on immigrant communities. Some of the key findings are the following:  1) The pandemic led to sharp drops in immigration; 2) Foreign-born workers were employed at high rates in jobs essential to keeping the country running during lockdowns; 3) Immigrants experienced higher unemployment rates during the height of COVID-19 lockdowns, and many immigrant families have suffered economic hardship; 4) Early evidence suggests immigrants have had higher death rates from COVID-19 than the U.S. born;  5) As many immigrants were ineligible for key elements of the safety net and excluded from federal pandemic relief efforts, states, localities, and nongovernmental actors worked to fill some of the gaps. The report concludes with a discussion of selected policy adaptations, social service innovations, and relief programs that have been implemented as well as lessons learned for responding to the ongoing pandemic and future public-health crises. (Robert Like, MD, MS)

Social Determinants of Immigrants’ Health in New York City: A Study of Six Neighborhoods in Brooklyn and Queens, Center for Migration Studies of New York, June, 2022 Authors: Jacquelyn Pavilon & Vicky Virgin This report focuses on the social determinants of health experienced by immigrants living in the boroughs of Brooklyn and Queens, New York. Previous studies found that “foreign-born New Yorkers have poorer health and less access to healthcare than their US-born counterparts.” In this study, surveys were carried out with 492 immigrants from 27 countries living in six neighborhoods, as well as with 24 service providers including community health clinics and health-focused community-based organizations.  Analysis of these data, together with the US Census Bureau’s American Community Survey (ACS) and the DOHMH’s CHS, provides insight into the factors that affect immigrants’ health and well-being across these neighborhoods. Key findings contributing to the native-immigrant health gap include:  immigrants’ self-reported health, access to care, income, occupation and work conditions, education, limited English proficiency, overcrowding, neighborhood conditions, food insecurity, discrimination, and use of New York City services.  Respondents identified different barriers to accessing physical health and mental health services. Lack of health insurance, costs of insurance and health care, and inability to take time off from work were major deterrents for immigrants, more so than cultural factors. Occupational exposures and workplace hazards also placed immigrants at increased risk.  Food insecurity and the presence of “food deserts” were also significant factors in some neighborhoods. Distance to health facilities and lack of transportation were also major challenges.  Language barriers and discrimination based on race and nationality/citizenship were additional factors resulting in decreased access and service utilization.  The authors make a number of policy recommendations to improve immigrants’ health outcomes through expanding funding for various insurance, access, service delivery, and program initiatives. These include increasing the racial, ethnic, and linguistic diversity of health care providers and training about diversity, connecting immigrants to health care services and health insurance, providing healthy and fresh food, disseminating accessible outreach and informational materials, paying for interpretation and translation services, and increasing the number of community-based offices and clinics serving immigrant communities. (Robert Like, MD, MS) A recorded webinar and discussion about this report may also be found at this link.

Leveraging the Skills of Immigrant Health-Care Professionals in Illinois and Chicago, Migration Policy Institute, April 2022, 20 pp. Authors: Jeanne Batalova & Michael Fix This MPI issue brief explores the scope of skill underutilization among highly skilled immigrant health-care professionals in Illinois and Chicago, drawing on U.S. census data and discussions with national and local health care workforce experts, immigrant advocates, and educational leaders. The authors pay special attention to the pressures the pandemic has imposed on the health care workforce, and the plight of the 270,000 underemployed immigrant healthcare professionals in the United States who have remained on the sidelines of the emergency. Paradoxically, the authors find that immigrants, while only 14 percent of state’s population, play a vital role at all levels in Illinois’ health care workforce, making up 37 percent of physicians and 19 percent of nurses. Yet an estimated 12,000 immigrants with health or medical degrees in the state remain underemployed or out of work. The effects of the pandemic have only exacerbated existing shortages of physicians and nurses, even as the state’s demand for primary care services is predicted to grow sharply in the coming decade, with an aging as well as an increasingly diverse patient population. This population, the authors note, would be well served by the diverse backgrounds of the state’s underemployed immigrant health professionals. Looking at models in other states, including New York, Washington State, Minnesota, and Colorado, the brief points to a variety of institutional and legislative opportunities to address the challenges these immigrants face. These include programs that boost immigrants’ work skills and professional English proficiency, expanding options for internationally trained health professionals to work with restricted licenses, and providing counseling for alternative careers in adjacent fields such as clinical research. Alongside state and local data, the MPI web page for this report includes a data file with estimates of skill underutilization among immigrant and U.S.-born adults with undergraduate degrees in health care and health science fields in 25 states and nationwide. The analysis also includes details on their race/ethnicity, gender, legal status, origin countries, and languages spoken other than English. (Jeffrey Vega, Ph.D.)

Vaccine Requirements Predate the COVID-19 Pandemic by More than a Century Migration Policy Institute, April 6, 2022, 9 pp. Authors:  Chi Chi Huang & Alison Bashford The COVID-19 pandemic has created significant challenges for international travel resulting in government-issued vaccine mandates to reduce the global spread of COVID. The authors review the history of vaccine mandates and the linkages between border control and infectious disease management.  “Vaccine certification has been an internationally recommended approach to manage the spread of infectious diseases.”  “Vaccine passports” can include “paper cards, smartphone apps, and historically even physical scars.”  The British Empire’s experiences during the 1800s with implementing early vaccine requirements for smallpox are discussed. Initially bodily scars (whether from previous smallpox infection or vaccination) were used as evidence for immunity and determined whether travelers could leave or enter different countries.  Paper vaccine certificates, which include an individual’s vaccine history, were increasingly adopted in the 1900s, and their use expanded to additional communicable diseases including polio, yellow fever, cholera, and meningococcal meningitis. Inconsistencies existed, however, in the vaccine certification system with a “mosaic of rules and regulations” for specific vaccine preventable diseases. This included variations in required timeframes for receiving a vaccination, number of required shots, and issuing authorities. Episodic outbreaks of disease also led to intermittent requirements being applied at different destinations such as airports and seaports, and to certain classes of passengers and migrant workers.  Examples of fraudulent and criminal vaccine certifications and the differential burden of proof applied to travelers of lower socioeconomic status are discussed. Two major international conferences in 1926 and 1933 led to the development of a “multilateral protocol that recommended using vaccines as a condition of cross-border movement” and the standardization of international certificates of vaccination.  These processes were further streamlined by the WHO in the 1950s resulting in the issuing of the “Carte Jaune (or Yellow Card) which became the standard vaccination certification worldwide.” The authors conclude by reminding readers that “migration and the management of infectious disease – including the certification of vaccination – have been intertwined for more than a century” and that “recent requirements for certifications around COVID-19 vaccination are anything but exceptional.” (Robert Like, MD, MS)

Assessing Meaningful Community Engagement: A Conceptual Model to Advance Health Equity through Transformed Systems of Health, National Academy of Medicine, February 14, 2022, 12 pp. The importance of meaningful community engagement is increasingly being recognized by a host of key stakeholders and constituency groups. Community engagement is an important strategy for “bringing about environmental and behavioral changes that will improve the health of the community and its members.” This National Academy of Medicine project was designed to:  1) identify concepts and metrics that can best assess the extent, process, and impact of community engagement; and 2) provide community-engaged, effective, and evidence-based tools to those who want to measure engagement to ensure that it is meaningful and impactful, emphasizing equity as a critical input and outcome.  A diverse Organizing Committee consisting of experts in community engagement—community leaders, researchers, and policy advisors – conducted an analysis of the peer-reviewed literature and organizational websites for frameworks and conceptual models of engagement. The authors describe the methodology and participatory process used to develop the new Assessing Community Engagement (ACE) Conceptual Model and propose eight foundational standards for assessing meaningful and effective community engagement:  1) Define what should be measured in meaningful community engagement, not what is currently measured; 2) Be sufficiently flexible to measure engagement in any community; 3) Define health holistically; 4) Allow the community to see itself in or identify with the language, definitions, and context; 5) Embed equity throughout the model; 6) Emphasize outcomes of meaningful community engagement;  7) Present a range of outcome options for various stakeholders; and 8) Communicate the dynamic and transformative nature of engagement. A series of core principles are identified as being essential for community engagement:  trust, bidirectionality, inclusivity, culturally centered, equitable financing, multi-knowledge, shared governance, ongoing relationships, co-created, and coequal participants. (Robert Like, MD, MS)

Health Care Sanctuaries, Yale Journal of Health Policy, Law, and Ethics, November 11, 2021, 67 pp. Author:  Medha D. Makhlouf This five-part article argues that immigration surveillance resources should be focused on efforts that produce the greatest benefit and the least collateral damage to the U.S. health care system. Part I presents data showing that “noncitizens and their family members avoid health clinics, hospitals, and enrollment in publicly funded health coverage because of immigration-related fears.” Part II describes the legal framework of immigration surveillance in health care, e.g. the mass collection and analysis of personal data by public and private actors, and how the “expansion and normalization of interior immigration enforcement motivates system avoidance behaviors.”  The authors emphasize the chilling effects of this system on the ordinary tasks of life, e.g. accessing health care, seeking COVID testing, participating in publicly funded health care programs, and enrolling in Medicaid.  Additionally, they call attention to the perceived (but not necessarily real) risks of being interrogated or arrested at or near health care sites because of “gaps, uncertainties, and exceptions” in existing laws and policies.  Part III examines how surveillance in health care can create “tradeoffs between immigration and health policy.” Among the serious collateral consequences are:  delay or avoidance in seeking vaccines or treatment for infectious disease resulting in increased community disease transmission, and poorer clinical outcomes and less cost-effective care leading to higher morbidity and mortality from all kinds of medical conditions. The current system also poses ethical dilemmas for health care providers, who often have to disregard their professional duties to patients, watch people dying or suffering from treatable and preventable conditions, and violate health equity norms, including commitments to reduce racial health disparities.  Part IV of the report discusses how “the state also compromises its legitimacy through surveillance in health care.” This can occur when the laws regulating immigration surveillance in health care impose nearly insurmountable barriers for noncitizens to understand how and when they may access health care without triggering immigration-related consequences. Part V proposes the creation of “health care sanctuaries” as a means for providing “durable legal protections against immigration surveillance in health care.” When sanctuaries are politically not feasible to create, “health care institutions can still take steps to limit information sharing with immigration agencies, provide physical refuge from immigration enforcement, link noncitizens with legal services, and promote norms of justice and empathy in immigration policy.”  (Robert Like, MD, MS)

Human Mobility and Human Rights in the COVID-19 Pandemic: Revisiting the 14 Principles of Protection for Migrants, Refugees, and Other Displaced Persons, Cornell International Law Journal, October 27, 2021, 28 pp. Authors: T. Alexander Aleinikoff et al In this collection of symposium papers, the authors revisit some of the 14 Principles* developed by a group of legal and migration scholars in 2020.  The first paper focuses on Principle 2 – the Right to Health (RTH) - and discusses its relevance for all migrants, barriers to its full realization, and COVID-19’s dramatic impact on migrants’ ability to enjoy RTH.  The second paper examines the legal framework vs. the reality of implementing Principle 2. Topics addressed include: the impact of repression and neglect, including the worsening of the socio-economic determinants of poor health, inequitable access to vaccines, and the neglected issue of mental health; and what nation-states should be doing now, including effectively helping migrating people to access services, and the ramping up of international cooperation and assistance. The third paper focuses on the following question: “How should international refugee law grapple with COVID-19 vaccine hesitancy, mistrust, and refusal?” Topics explored include:  vaccine hesitancy in highly fragile systems of trust, individual choice and mandatory vaccinations, and requirements for mandatory COVID-19 vaccination schemes. In the conclusion of the first paper, three significant emerging rights challenges are described:  how governments have used COVID-19 to exert greater control over migrant and refugee populations, how “derogations in fact” from human rights treaties have occurred, and how controls over both internal and external movement have increased in many states. The authors offer potential resistance and advocacy strategies for addressing these problems. In the concluding recommendations of the second paper, the authors describe three avenues for re/asserting the rights of all migrants through civil society activism. These include “building [globally] the political will to support a formal articulation of the rights of all migrants …. as a binding mandate governing the actions of IOM,”  “engaging with regional human rights bodies to support their active engagement on migrants’ rights within the relevant political bodies,” and amplifying “coordinated, strategic litigation campaigns to promote the rights of people in the context of human mobility” both nationally and through transnational partnerships. (Robert Like, MD, MS) *For detailed information on the 14 principles, go to the following site: https://academic.oup.com/ijrl/article/32/3/549/5954392

A Virus Without Papers: Understanding COVID-19 and the Impact on Immigrant Communities, Journal on Migration and Human Security 2021 (92:2), 14 pp. Authors: Elizabeth Kiester & Jennifer Vasquez-Merino This paper provides a comprehensive review of the cross-disciplinary literature regarding the significant impact of the COVID-19 pandemic on immigrant communities. These communities “face an intersection of … three major vulnerabilities”: preexisting economic precarity, health care barriers, and greater risk of infection as essential workers. The authors carried out Zoom interviews with 26 immigrant service providers in Pennsylvania and New York, including lawyers, case workers, religious leaders, advocates, doctors, and educators. Three key themes emerged from these interviews: “the consequences of being an essential worker, the absence of social safety nets, and the insufficient actions of ICE [Immigration and Customs Enforcement] pertaining to immigrant health and safety in detention centers and continuing deportation of immigrants in the face of COVID-19.” The authors make the following policy recommendations:  1) Congress and states should pass legislation to provide COVID-19 relief payments to all essential workers, regardless of their status, as compensation for putting their lives on the line to keep the economy running; 2) Federal and state governments should expand coverage of Medicaid and Children’s Health Insurance Programs (CHIP) to include immigrant essential workers and their children, regardless of their status; and 3) DHS should not refer essential workers to removal proceedings, and immigration courts should terminate all removal proceedings for essential workers without criminal records. Additionally, the authors urge the expansion of the Affordable Healthcare Act for those who do not qualify for Medicaid but earn too little to afford insurance on their own. They also encourage rigorous enforcement of workplace health and safety standards, particularly when it comes to farming, meatpacking, food production, and food service industries. (Robert Like, MD, MS)

COVID-19 and the State of Global Mobility in 2020, International Organization for Migration and Migration Policy Institute, April 2021, 57 pp. Authors: Meghan Benton et al There may never have been a year like 2020 —almost every country shut down borders, grounded flights and halted immigration and resettlement programs. Meghan Benton and her colleagues explore the effects of this disruption on human migration in the article “COVID-19 and the State of Global Mobility in 2020,” published jointly by the International Organization for Migration and the Migration Policy Institute. The COVID-19 pandemic affected the regions and countries of the world in different ways, creating multiple effects on migrants, including increasing the gap between “movers and non-movers,” increasing socioeconomic precarity, and strengthening the dependence-exploitation dynamic many migrants face when forced to deal with smugglers and traffickers. The authors also attempt to predict the future of public health responses to the ongoing pandemic, suggesting that vaccination and routine testing certificates may be the most effective public health strategy moving forward. This policy, however, has the potential to exacerbate gaps between the rich and poor, as access to vaccines and to quality testing has proven challenging to lower income countries. To improve outcomes, the report suggests that international bodies and governments explore lower-cost mitigation efforts (like multistage or combined testing and quarantine measures), enhance cooperation, emphasize transparency and take an inclusive approach. Overall, governments and international organizations must work to build a system that brings us out of this pandemic, prevents the next one, and eases the burden on migrants, “who have borne the brunt of the current pandemic,” even when there is little evidence that mobility controls played a significant role in stopping the spread of the pandemic. (Katelin Reger for The Immigrant Learning Center’s Public Education Institute)

Home Health Care Workers: Immigrants Can Help Care for an Aging U.S. Population, National Immigration Forum, May 28, 2021, 19 pp. Author: Dan Kosten This report discusses the dramatic growth of the older adult population in the U.S., and the need for addressing significant labor shortages in the home health care industry. The author emphasizes the important role immigrants can play as essential home health care workers, but notes the many challenges they face in doing so.  The report reviews the changing demographics of the elderly population, pointing out that “by 2035, older adults, 65 and over, will replace children, under 18, as the largest population in the U.S.” Long-term care needs and institutional costs are increasing, and life expectancy is longer. Preferences exist for home-based care, but “the ratio of native-born workers to retirees is declining leading to labor shortages in low- and middle-skilled occupations,” such as direct care workers, and these disparities are especially true in rural areas. “Immigrants, who already work in large numbers in the sector, could mitigate workforce shortages and be a major contributor to the long-term care of the elderly.” Barriers to filling home health care demand include:  inadequate training and professional development, financial barriers to obtaining training, limited English language proficiency, and lack of digital and health information technology skills.  The report makes the following recommendations:  1) Provide Expanded and More Flexible Home Health Care Training and Education; 2) Pass the Gateway to Careers Act, S. 52; 3) Expand Pell Grants to Include Short-Term 75-Hour Credential Programs; 4) Develop Federal Training Standards for Personal Care Aides; 5) Expand Contextualized English Language Programs; and 6) Provide Digital Skills Training. The author also offers a number of recommendation in the area of immigration policy:  1) Create a Low-Skilled Non-immigrant Employment-based Visa; 2) Designate Home Health Care Aides as a “Schedule A” Shortage Occupation; and 3) Create New Immigrant Status Opportunities for Home Health Care Workers. (Robert Like, MD, MS)

The Impact of COVID-19 on Immigration Detention, Frontiers in Human Dynamics, April 8, 2021, 10 pp. Author:  Fatma E. Marouf COVID-19 has spread quickly through immigration detention facilities in the United States. As of December 2, 2020, there have been over 7,500 confirmed COVID-19 cases among detained noncitizens. This Article examines why COVID-19 spread rapidly in immigration detention facilities, how it has transformed detention and deportation proceedings, and what can be done to improve the situation for detained noncitizens. Part I identifies key factors that contributed to the rapid spread of COVID-19 in immigration detention. While these factors are not an exhaustive list, they highlight important weaknesses in the immigration detention system. Part II then examines how the pandemic changed the size of the population in detention, the length of detention, and the nature of removal proceedings. In Part III, the Article offers recommendations for mitigating the impact of COVID-19 on detained noncitizens. These recommendations include using more alternatives to detention, curtailing transfers between detention facilities, establishing a better tracking system for medically vulnerable detainees, prioritizing bond hearings and habeas petitions, and including immigration detainees among the groups to be offered COVID-19 vaccine in the initial phase of the vaccination program.

Behavioral Health Implementation Guide for the National Standards for Culturally and linguistically Appropriate Services in Health and Health Care, Office of Minority Health, U.S. Department of Health and Human Services, 2021, 24 pp. The Office of Minority Health’s (OMH) National CLAS Standards are “designed to improve the quality of care, help eliminate health care disparities, and advance health equity by establishing a blueprint for health and healthcare organizations to implement culturally and linguistically appropriate services.” Originally released in 2000 and subsequently enhanced in 2013, they were operationalized with the publication of a Blueprint for Advancing and Sustaining CLAS Policy and Practice, along with various implementation tools and assessment resources.  Due to the growing recognition that “there was less participation in and engagement with the standards among behavioral health providers,” the Substance Abuse and Mental Health Services Administration (SAMHSA) worked with the OMH to develop this Guide.  Organized around the overarching themes of the 15 standards, the Guide reviews:  the Principal Standard (Standard 1); Governance, Leadership and Workforce (Standards 2-4); Communication and Language Assistance (Standards 5-8); and Engagement, Continuous Improvement, and Accountability (Standards 9-15).  Each section (except for the Principal Standard) includes the following content:  the purpose of the standard, a hypothetical behavioral health scenario relevant to the standard; implementation strategies related to the scenario; and examples of ‘real-life’ programs showing the standards ‘in action.’ The report is intended to reach the following key audiences:  accreditation and credentialing agencies, advocacy organizations, behavioral health care staff and administrators, governance and policy leadership, patients/consumers and their families, professional training institutions and faculty, public health workforce, and purchasers of behavioral health services. (Robert Like, MD, MS)

The Integration of Immigrant Health Professionals: Looking Beyond the COVID-19 Crisis, Migration Policy Institute, April 2021, 12 pp. Authors: Jeanne Batalova et al In this publication, the authors address the following two issues:  first, the extent to which pre-pandemic and COVID-19-related trends will influence the demand for and availability of healthcare workers in the United States; and second, how 270,000 immigrant and refugee health workers whose skills are underutilized might help the country meet that demand. In reaching their conclusions, the authors conducted interviews with more than 50 medical and public-health professionals, hospital administrators, labor market and health policy experts, and representatives of organizations that promote the integration of immigrant professionals. The authors believe that the professional, language, and cultural skills of internationally trained health professionals, many of whom are unemployed or working in low skilled jobs, represent a critical resource for the nation. Their potential contribution is all the more important considering the high numbers of frontline health workers who are burned out and leaving the field, the aging of the U.S. population, and the country’s growing cultural and linguistic diversity. The paper discusses lessons learned during the pandemic by states that used their governors’ executive authority to temporarily suspend or adjust licensing requirements to boost the ranks of available immigrant workers in health services. Although efforts to address licensing, placement, training, and educational barriers facing internationally trained healthcare professionals are primarily the responsibility of state government, the authors argue that the federal government should provide leadership and funding for reforms in this area. (Robert Like, MD, MS)

Reversing Immigration Law’s Adverse Impact on Health, (Chapter 35 in S. Burris et al, COVID-19 Policy Playbook: Legal Recommendations for a Safer, More Equitable Future), February 15, 2021, 6 pp. Author: Wendy Parmet Wendy E. Parmet of Northeastern University School of Law argues that the Trump administration’s policies were especially punitive during the COVID-19 pandemic, rendering some 46 million immigrants in the United States vulnerable to public health hazards. With an accelerated rate of immigrant detentions during the Trump administration, camps and prisons turned into “tinder boxes” for infection, and science-based public health policies were largely overlooked. The author suggests that it is critical to understand how immigration laws can heighten vulnerability to pandemics in order to prevent another failed response to a future public health crisis. Millions of immigrants living without basic health care benefits could become vectors of infectious diseases. Simply repealing Trump era policies, however, is not enough; immigration reform must be considered a vital policy tool. Such reform would include offering paths to legalization for undocumented immigrants, increasing healthcare coverage among non-citizens, and reducing reliance on enforcement and detaining immigrants who do not pose a risk to public safety. The author gives recommendations at both the federal level, such as repeal of the public charge provision in the Immigration and Naturalization Act, and state level, such as providing Medicaid and CHIP to all otherwise eligible noncitizens. (Samah Rizvi for The Immigrant Learning Center’s Public Education Institute)

Mapping Key Determinents of Immigrants’ Health in Brooklyn and Queens Center for Migration Studies, February 2021, 36 pp. Authors: Vicky Virgin and Robert Warren This report examined the determinants of immigrant health, focusing primarily on noncitizens and undocumented individuals living in Brooklyn and Queens, New York. The goal of the study was to enable healthcare providers, government agencies, and non-profit migrant-serving entities to identify gaps in their services to immigrant populations, and to help meet the needs of subgroups with heightened risk of adverse health outcomes. Using American Community Survey and other data for the years 2014-2018, the authors generated “detailed population profiles … for native-born citizens, naturalized citizens, legal noncitizens, and undocumented immigrants” in relationship to selected determinants of health in 32 community districts (CDs) in Brooklyn and Queens. The researchers found that poverty, overcrowding, undocumented residency status, limited English proficiency, lack of a high school education, and percent uninsured were associated with poorer health outcomes. However, significant variations existed among immigrant sub-groups. Naturalized citizens, for example, had health profiles more like the native-born population than noncitizens. Noncitizens also had relatively larger percentages of essential workers than the native-born or naturalized populations and thus were more likely to have been adversely affected by the COVID-19 crisis. Lack of health insurance – an important health determinant – affected the undocumented population more than it did residents with legal status. The authors concluded with a series of recommendations relating to improving health care access and insurance coverage, eliminating the public charge rule, addressing job and housing insecurity, increasing outreach and disseminating information, facilitating citizenship and naturalization services, and attaining legal status. Understanding that “immigrants are a heterogeneous group with many different legal statuses” is an important contribution of this study. A holistic and tailored approach to service delivery in specific neighborhoods will be needed to address the determinants of immigrant health and improve health outcomes. (Robert Like, MD, MS)

Community-Level Factors Associated with Racial And Ethnic Disparities In COVID-19 Rates in Massachusetts, Health Affairs, 39:11 (2020), 8 pp. Authors: Jose F. Figueroa et al This report by researchers at the Harvard T. H. Chan School of Public Health and Harvard Medical School looks at racial and ethnic disparities in COVID-19 infection rates in Massachusetts, focusing on demographic, occupational, and economic factors contributing to higher risk for COVID-19.  Massachusetts has had one of the highest case and death rates in the country, with disproportionate impacts on Black and Latino populations, a trend repeated in states nationwide. Using data from the Massachusetts Department of Public Health and the 2013–18 American Community Survey, a cross-sectional analysis of 351 Massachusetts cities and towns from January 1 to May 6, 2020 found that several factors (foreign-born noncitizen status, household size, and job type, especially work in food services occupations) are associated with the higher COVID-19 rates among Latinos. However, these same factors do not appear to explain higher case rates in Black communities. Other systemic inequities not included in the study may contribute to the rate of spread of COVID-19 among Black populations, including high incarceration rates, residence in areas with more multiunit dwellings, and neighborhood segregation leading to disparities in health care access and greater exposure to environmental hazards. The study concludes that further research into the social and economic factors underlying COVID-19-related health disparities and new policies to address risk factors and institutional racism will be critical to controlling the epidemic and improving health equity. These policies include public health and policy efforts that improve access to health care, address crowded housing and environmental hazards, and protect essential workers in public-facing roles. (Jeffrey Gross, Ph.D.)

Entry Denied: COVID-19, Race, Migration, and Global Health, University of Maryland School of Law Research Paper, December 22, 2020, 8 pp. Author: Matiangai V.S. Dirleaf This essay examines “how the racialization of diseases is reflected in historical and ongoing United States’ migration law and policy as well as the global health law regime.” The author argues that there has been “a long history of othering and denigrating Black, Indigenous and other people of color as infection-prone, afflicted with exotic sicknesses and generally unhealthy.” She provides a brief history of the “othering” of selected populations in the US, using as examples, syphilis (Blacks), cholera and smallpox (Chinese), HIV/AIDS (Haitians), and COVID-19 (Latinx migrant workers). These groups often have experienced invasive and humiliating medical inspections, migration shutdowns, detention, and stigmatization. The author reviews how “containing racialized threats of disease contagion from colonized peoples” led to “the creation of an international system of quarantine regulations.” The International Sanitary Conventions of 1892, 1897, 1903, 1912, 1926, and 1944, and related treaties required notification for cases of cholera, plague, yellow fever, smallpox, and typhus, and were shaped primarily by the fear of imported disease by people in Western countries. After reviewing the principles that guided the establishment of the World Health Organization (WHO), the author discusses WHO’s power to declare a Public Health Emergency of International Concern (PHEIC), including the ways in which the US and other countries racialized PHEIC responses to the Ebola outbreak in 2014-2015 and the ongoing COVID-19 pandemic. The author acknowledges that while it’s important to understand “how the history of diseases and responses to diseases is linked to colonial and ongoing politics of racial exclusion,” there are many other factors along with race that influence migration and global public health law and policy. (Robert Like, MD, MS)

Report of the Foreign Trained Health Professional Licensing Pilot Project, New Mainers Resources Center, Portland Adult Education, October 2020, 31 pp. Authors: Sally Sutton & Vanessa Sylvester This report is an overview of results of a pilot project in Maine to increase the diversity and cultural competence of the healthcare workforce by reducing the barriers to training, licensing, and employment faced by foreign trained health professionals. Many immigrants and minority group members face barriers themselves to accessing health services, as seen in the disparate effects of the Coronavirus across population groups. The premise behind this project is that greater workforce diversity would make the entire system more culturally competent. The recommendations in this report take into account the fact that the majority of foreign-trained health professionals in Maine are refugees. The authors recommend a series of modifications to state programs, licensing requirements, higher education, and employer practices in order to put more doctors, nurses, pharmacists, and others working at or close to their former training fulfilling diversity and staffing deficiencies. Health employers, for example, can help their entry-level employees develop a career plan and gain the experience necessary to qualify for licensure. The report asserts that the problems faced by foreign-trained health professionals are “deep-seated systemic issues that require a concerted and collaborative effort for change at a number of different levels by a wide range of stakeholders.” The report also gives recommendations for specific health care professions. (Julianne P. Weis, Ph.D.)

A systematic Review of Medical-Legal Partnerships Serving Immigrant Communities in the United States, Journal of Immigrant and Minority Health, September 25, 2020, 12 pp. Authors: Avery League et al Medical-Legal Partnerships are increasingly being embraced as a service delivery model for addressing the social, environmental, and political determinants of health experienced by low-income and vulnerable populations. The authors of this article carried out a systematic literature review to examine “existing forms of medical-legal partnerships that demonstrate how medical and legal professionals work together to meet the unique needs of immigrants.”  Five online databases were searched, and 222 English language articles (published between 2010-2019) were selected for initial screening.  After applying inclusion and exclusion criteria, the authors retained 18 articles for further analysis.  Forty-two questions were developed relating to 10 different themes. Cross-referrals of clients for legal and medical services (especially asylum evaluations) occurred between lawyers, physicians, and their clinics “Partnerships often engaged in advocacy work, provided translation services, and referred clients to non-medical providers and legal services.” Co-location of services was less often seen.  The articles generally lacked information about “follow up from the partnerships about the duration of collaborations,” “long-term legal and patient outcomes,” “duration of services through the partnership,” “success/failure rates of clinical care,” and “systems in place to support people’s legal and medical needs.” An essential component identified was demonstrating cultural and structural competence. This included understanding diversity within and across immigrant, refugee, and asylee populations as well as the impacts of trauma, persecution, and stigma. Addressing institutional barriers (e.g., “translation services, financial assistance, affordability, access to psychiatric care”) and integrating medical, mental health, and legal services was also of critical importance.  The authors conclude that “[m]edical-legal partnerships are crucial for investing in the mental and physical health of immigrant communities.”  They also note, however, that “… despite the increasing salience of such partnership, few have written up their lessons learned and best practices.”  Further ethnographic studies and dissemination of real-world findings are needed. General information about medical-legal partnerships may be found on the website of the National Center for Medical-Legal Partnership at George Washington University. (Robert Like, MD, MS)

Immigration Enforcement and the Mental Health of Latino High School Students, Migration Policy Institute, September 2020, 67 pp. Authors: Randy Capps et al This study examines the mental health toll on Latino teenagers arising from the deportation activities of the Trump administration. The authors also present the findings of a survey of Latino students at five high schools in Harris County, Texas, and six high schools in four Rhode Island cities, conducted during the 2018–19 school year. While actual deportation numbers under President Trump never reached the peak of the Bush and Obama years, ICE arrests have remained very high over the last years, increasing levels of anxiety and fear among Latino teenagers. The authors found that the majority of respondents (59 percent) feared someone close to them would be arrested and deported, one-third feared that they themselves would be deported, and 56 percent personally knew someone who had been deported. These fears of deportation were lower but still high in jurisdictions which have tried to limit ICE activities, like the state of Rhode Island, where 30 percent of Latino teenagers reported changing their behavior, e.g. avoiding driving or going to the doctor, as a result of deportation fears. Findings from both the Texas and Rhode Island surveys also show downstream health effects of deportation fears and the anxiety caused by Trump administration policies restricting immigration. Most troubling, reports of discrimination, traumatic life events, and averse mental health conditions such as PTSD, depression or anxiety were experienced in an alarming number of teenager respondents. Teens compensated for these averse health indicators with high levels of reported personal goals, spiritual and school engagement, and family support. Many schools have tried to mitigate the deportation anxieties with safe haven measures, but school funding and staffing resources are highly limited to meet the enormous needs. Shifting the current political environment would help ease much of the deportation fears and anxieties in Latino teenagers, as well as bolstering support networks within the schools and communities to assist in providing more robust mental health services. (Julianne P. Weis, Ph.D.)

COVID-19 and the Remaking of U.S. Immigration Policy? Empirically Evaluating the Myth of Immigration and Disease, UC San Diego, US Immigration Policy Center, April 22, 2020, 11 pp. Author: Tom K. Wong Concerned that the Trump administration is using a centuries-old bias, i.e. blaming immigrants for importing disease into the United States -- a myth unsupported in the academic literature – the author of this study conducted an analysis of immigration rates since 2000 to see if they correlated with upswings in swine flu infections. He looked at immigration indicators specific to the southern border, such as the number of people entering over the southern border, the number of people requesting and granted asylum, as well as general admission numbers for the country as a whole. Covering a 20-year period that included the H1N1 pandemic in 2009, the author found no relationship between these numbers and fluctuations in flu rates. He concludes that “The results presented here bolster the argument that the Trump administration may, indeed, be using the global COVID-19 pandemic as a guise to further change U.S. immigration policies, which in this case means effectively choking off access to our asylum system, as well as suspending immigration into the U.S. more generally.”

Combatting COVID-19: Why Community-based Investigation and Contact Tracing is Crucial, WKF Giving Fund, May 8, 2020, 24 pp. Authors: Ed Kissam & Jo Ann Intili California currently plans to recruit, train, and mobilize a workforce of 10,000-20,000 case investigation and contact-tracing workers. This report makes recommendations as to how to recruit and deploy this workforce. As the state gradually opens up, and people weary of observing social distancing guidelines, the ability of this workforce to contain local flare-ups of the virus is crucial to protecting the general population until a vaccine becomes readily available. Anticipating that low-income working poor households, through the kinds of jobs they hold and their living conditions, will have greater exposure to the virus, the authors of the report believe that it is crucial to target this population in the contact-tracing program. The authors argue “that the most critical organization and individual competencies (for case investigators) are not health-specific knowledge but, rather, experience and efficacy in reach and communicating well with hard-to-reach households.”  They further suggest that immigrant-serving organizations should play an active part in the program, not only because immigrants remain especially vulnerable to infection, but also because millions of Californians live in mixed-status families.

The Hidden Curve: Estimating the Spread of COVID-19 among People in ICE Detention, Vera Institute of Justice, June 2020, 14 pp. Authors:  Dennis Kuo et al Little is known about the prevalence of COVID-19 in immigration detention facilities run by ICE. Although ICE regularly updates some basic statistics on its COVID-19 webpage, its reporting, according to the authors of this report, is inconsistent and inadequate, making it impossible to answer basic questions about the risks detained people face. To remedy this deficiency, the Vera Institute of Justice has built an epidemiological model to estimate the prevalence of COVID-19 in detention. Using the most recent publicly available ICE data, the model specifically explores how new book-ins to—and frequent transfers between—detention centers may be contributing to COVID-19’s spread among people in immigration detention. The model makes clear that ICE is severely underreporting the prevalence of COVID-19 in detention. As Vera’s model demonstrates, the true scale of the spread of COVID-19 in ICE detention is likely to be “shockingly high.”

Barriers to COVID-19 Testing and Treatment:  Immigrants without Health Coverage in the United States, Migration Policy Institute, May 2020, 17 pp. Authors: Randy Capps & Julia Gelatt This MPI fact sheet estimates the number of uninsured noncitizens nationwide and by state, and how many are ineligible for Medicaid coverage due to immigration status. Immigrants, many of whom live in urban and rural communities with high infection rates and work in frontline industries such as health care and food production with a high risk of transmission, are among the most vulnerable U.S. residents during the COVID-19 pandemic. Rapid job loss—rising faster among immigrants than U.S. residents as a whole—also means loss of employer-based health insurance and more dependence on publicly-funded healthcare, primarily Medicaid, for screening and treatment. Yet eligibility restrictions based on immigration status mean that many low-income noncitizen immigrants do not qualify for Medicaid or other publicly funded services. Fears of immigration enforcement or public charge impacts discourage even many who are eligible from seeking testing and treatment. While recent congressional aid packages expanded funding for COVID-19 testing and treatment for the uninsured, many noncitizens including both legal immigrants and the unauthorized remain excluded from coverage. In a pre-COVID-19 scenario of 4 percent unemployment, MPI estimated 7.7 million noncitizens did not have public or private health insurance coverage, including 2.1 million low-income unauthorized immigrants and 500,000 low-income LPRs and nonimmigrants excluded from Medicaid. In a scenario of 17.5 percent unemployment (the rate at the end of April 2020), 9.3 million noncitizens would be uninsured, with 2.5 million unauthorized immigrants and 700,000 LPRs and nonimmigrants excluded from Medicaid. In a high-employment scenario of 25 percent unemployment, 10.8 million noncitizens would be uninsured, with 2.9 million unauthorized immigrants and 800,000 LPRs and nonimmigrants excluded from Medicaid. In all three scenarios 55 percent of uninsured were unauthorized immigrants and 45 percent LPRs or nonimmigrants. Without substantial federal assistance, the study concludes, serving uninsured patients will strain state and local budgets. Moreover, leaving millions of noncitizens uninsured or afraid to seek COVID-19 testing and treatment also risks spreading the virus and undermining public health for all Americans. (Jeffrey Gross, Ph.D.)

Crisis within a Crisis:  Immigration in the United States in a Time of COVID-19, Migration Policy Institute, March 26, 2020, 7 pp. Muzaffar Chishti & Sarah Pierce This article in MPI’s Policy Beat reviews the various immigration policy changes implemented by the Trump administration ostensibly in response to the coronavirus pandemic. These changes include greatly restricted entry at U.S. land borders with Mexico and Canada (for example, by barring the entry of asylum seekers); suspension of hearings in immigration courts for non-detained individuals; the suspension of in-person processing services by USCIS, and of routine visa services by U.S. embassies and consulates abroad. The article also highlights the public health consequences of the detention of immigrants in ICE facilities where they are at risk of an outbreak of COVID-19. The authors also discuss the fear many immigrants have of accessing health care with the administration’s new public charge rule going into effect in February just as the pandemic was taking hold in the U.S. (even though USCIS has said that treatment related to COVID-19 will not be included in a public charge analysis). There is also some discussion of the exclusion of immigrants from the financial relief legislation passed thus far by Congress in response to the economic fallout from the pandemic. At the end of the article is a bibliography of links to Trump administration policies and other resources related to immigration and COVID-19. (Maurice Belanger, Maurice Belanger Consulting)

“You Will Never See Your Child Again:” The Persistent Psychological Effects of Family Separation, Physicians for Human Rights, February 2020, 38 pp. Authors: Hajar Habbach et al This is a study of the psychological and physiological effects of family separation on 17 adults and nine children who had been separated for an average of 60-69 days under the Trump administration's "Zero Tolerance" Policy. All participants in the study had fled traumatic experiences in their home countries before arriving at the United States. Believing their children would be safe when arriving in the US, parents were instead separated forcibly, and often secretly, from their children with no explanation from immigration authorities. PHR described symptoms and behaviors consistent with trauma and its effects in every study participant. Past traumas compounded those experienced during family separation, and every study participant met diagnostic criteria for at least one mental health condition, e.g. PTSD, depression, or anxiety. The cruel, inhuman, and degrading treatment towards these families rises to the level of torture according to the PHR experts. Because of the "significant distress" and ongoing functional impairment caused by these traumas, the physicians recommend further intervention and ongoing therapeutic support. PHR also recommends: providing redress to the victims of torture, reuniting those families that were separated, including in cases where the parents have been deported, and prosecution of US officials who broke the law throughout this process. (Julianne P. Weis, Ph.D.)

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition, International Journal for Equity in Health, 18: 174 (2019), 17 pp. Authors: Elana Curtis et al In this paper, the authors seek to clarify the current understanding of “cultural safety” and “cultural competency,” and to argue that health practitioners and health care systems must move beyond the notion of “competency” if they want to gain insight into the systems and power dynamics that are often the main drivers of health inequities. Through an international literature review, examination of New Zealand’s cultural competency legislation, and consultation with Maori healthcare providers, the authors determine that ethnic and indigenous inequities in health outcomes have traditionally been explained through the lens of physiological, genetic or cultural difference. However, the authors posit that inequity is actually caused primarily by socio-economic deprivation, unequal access to care, and intentional or unintentional bias from healthcare providers. The authors suggest that health care organizations and professionals organize their work around the principle of cultural safety, which not only encourages the examination of difference in cultural practices but also calls for a critical analysis of inter-group power dynamics. (Clare Maxwell for The Immigrant Learning Center’s Public Education Institute)

Public Health Insurance Expansion for Immigrant Children and Interstate Migration of Low-Income Immigrants (Key Points), Journal of the American Medical Association – Pediatrics, November 18, 2019 Authors: Vasil Yasenov et al The extension of state-funded health insurance to legal permanent resident children and pregnant women with less than five years of residency in the United States does not lead to greater in-migration of immigrant adults from other states. This study utilizes data on 208,060 immigrants from the American Community Survey from 2000 through 2016 to compare migration rates for eligible and ineligible immigrants before and after the health insurance expansions. The data analysis shows that there is no association between in-migration and expansion of public health insurance. For example, the change in the rate of in-migration following coverage expansion was not higher than 1.78 percentage points for immigrant children and 1.38 percentage points for pregnant immigrant women, lower than the average move rate of 3 percent across the entire sample. In the light of these results, the authors conclude that states considering coverage expansion need not be concerned with in-migration and can instead focus on the cost-effectiveness of preventive pediatric and pre-natal health care. (Jasmina Popaja for The Immigrant Learning Center’s Public Education Institute)

Care for America’s Elderly And Disabled People Relies on Immigrant Labor, Health Affairs, 38:6 (2019), 8 pp. Authors:  Leah Zallman et al As the elderly population in the United States is expected to double in size by 2050, health care workforce shortages are expected to increase. Three-and-a-half million additional workers will be needed in the next decade alone. Although several studies have examined the role that immigrants play in the formal health care sector, “Care for America’s Elderly and Disabled People Relies on Immigrant Labor” focuses on the immigrant role in nonformal settings such as private housing and nonmedical facilities.  The study used the Annual Social and Economic Supplement of the 2018 Current Population Survey (CPS), a nationally representative survey conducted by the Census Bureau and the Bureau of Labor Statistics, which collected data on 180,084 people in March 2017.  The researchers found that immigrants constituted 18.2 percent of health care workers, 27.5 percent of direct care workers, and 30.3 percent of nursing home housekeeping and maintenance workers. The category of direct care workers includes home health and personal care aides. The authors observe that these workers allow hundreds of thousands of Americans to live at home or in other nonmedical settings such as senior housing-- thereby reducing the need for expensive institutional care. “Curtailing immigration,” the authors conclude, “will almost certainly move us in the wrong direction…” in ensuring quality health care for all Americans

The Worst of Health: Law and Policy at the Intersection of Health and Immigration, Symposium Paper, Indiana Health Law Review, 16: 2 (2019), 22 pp. Author: Wendy E. Parmet Due to the influence of nativist forces, the United States has had a long history of misguided health policy and law. This essay reflects on past and present immigration, healthcare and public health policies and shows how they are connected to and impact each other. Parmet cites various cases of immigration policy that had a harmful effect on public health, from the quarantine of Chinese-Americans in San Francisco during a 1900 epidemic to the recent Trump administration family separation policies. Parmet utilizes these historical case examples to illustrate the damaging conflation of immigration and health policy and the extent to which these federal policies are fueled by anti-immigrant and racist sentiment. She stresses that these policies are not only exclusionist, they are ineffective, costly and dangerous to public health. The author also strongly opposes the Trump administration’s regulation to expand the meaning of “public charge,” which, she points out, was used to turn away Jewish refugees during the Holocaust. The article recommends that policymakers rethink the ethical foundations at the intersection of immigration and public health law. (Olivia Pickard for The Immigrant Learning Center’s Public Education Institute)

Summary of State Law Requirements Addressing Language Needs in Health Care,  National Health Law Program, April 2019, 137 pp. Author: Mara Youdelman This report summarizes legislation on language access in all 50 states. The report is the latest update to earlier versions. A short introduction identifies major trends and noteworthy initiatives.

Approaches to Protect Children’s Access to Health and Human Services in an Era of Harsh Immigration Policy, Institute of Human Development and Social Change, New York University, March 18, 2019, 26 pp. Authors:  Hirokazu Yoshikawa et al This report examines the barriers low-income immigrant children and their families encounter when trying to access social services in a climate of heightened immigration enforcement and hostility towards immigrants. The paper also outlines a wide range of strategies that can partly overcome these barriers. In the U.S., one in four children lives with at least one immigrant parent, and more than one-quarter of children of immigrants have an undocumented parent or are undocumented themselves. Recent policy changes and proposals have severely disrupted the lives and well-being of many immigrant families. Citing examples of best practices from across the country, the authors make 12 recommendations to mitigate the adverse affects that these policies have on the nearly 18 million at-risk immigrant children. Among the solutions are ensuring the confidentiality of public benefit records, expanding program eligibility through state action, easing enrollment challenges, increasing access to immigrant legal services, expanding family educational programming, providing identity documents and allowing child-only applications. In order to benefit from any of these recommendations, the authors suggest improved collaboration between community stakeholders, policymakers and immigrant individuals, as well as more robust government infrastructure, such as offices of immigrant affairs, to coordinate policy responses. (Patrick Bloniasz for the Immigrant Learning Center's Public Education Institute)

Health Justice for Immigrants, Journal of Law and Public Policy (University of Pennsylvania), 4:2 (January 2019), 78 pp. Author:Medha D. Makhlouf Should universal health coverage include immigrants in the definition of “universal?” Should federal taxpayers subsidize health insurance coverage for immigrants, even those who are undocumented? Should all immigrants be required to purchase health insurance? The author of this paper answers all these questions in the affirmative and in so doing, challenges both the cost-savings and “deservedness” arguments of restrictionists. She cites, for example, a number of studies that suggest that cost increases, such as spikes in the cost of uncompensated emergency room care, may partly or completely offset any gains to the system through the denial of benefits. She also fears that the ethos of deservedness reinforces the individualistic notion that some people, whether immigrant or not, are entitled to health care and others are not. This ethos also imposes a seemingly gratuitous punishment for lack of immigration status, above and beyond removal from the country.  The author then goes on to explicate a “health justice” framework for understanding coverage priorities -- a philosophical orientation quite different from the “individualistic” focus that seemed to dominate until the passage of the Affordable Care Act. Under this new framework, the starting point is not the health needs of the individual, however important in final outcome, but the needs of the community as a whole. “The Health Justice approach highlights evidence that disparities in access to health care do not merely affect the individuals or populations with restricted access; they can also have negative spillover effects in the general community,” such as increasing the threat of infectious disease, building antibiotic resistance, reducing worker productivity, and increasing wasteful spending and transaction costs for the entire healthcare system.

Immigrants and Public Benefits: What Does the Research Say Bipartisan Policy Center, November 2018, 18 pp. Authors: Tim O’Shea & Cristobal Ramón This review of studies on the use of public benefits by immigrants takes a look at research that has been done to examine whether immigrants use public benefits at greater rates than other groups; which groups of immigrants use public benefits; immigrants’ fiscal impacts on public benefits programs; the impact of federal and state benefits legislation on immigrants’ use of public benefits; and the impact of immigration enforcement and the complexity of benefits laws on the use of public benefits. The report concludes that whether or not immigrants are found to have a negative or positive fiscal impact often depends on who has conducted the research. For example, most studies find that individual immigrants use public benefits at lower rates and at lower levels that native-born Americans. However, other studies show that immigrant-headed households — which may include U.S.-citizen children — use public benefits at a higher rate than households headed by the native-born. The household method tends to be favored by immigrant restrictionist groups. In another example, studies come to different conclusions about the costs and benefits of immigrants depending on whether they measure costs and benefits in a moment in time or over the course of many years. An immigrant household with children in local schools might be viewed as a net cost on the one hand, but if the higher productivity, earnings, and tax payments of that educated child are factored in over the long term, there is a net benefit to the system. The report also points out some areas where additional research would be useful — including whether extending Medicaid and state health benefits to undocumented immigrants would save local governments money by lowering costs associated with the provision of emergency medical care by hospitals. (Maurice Belanger, Maurice Belanger Consulting)

Immigration as a Social Determinant of Health: Proceedings of a Workshop, National Academies of Sciences, Engineering and Medicine, 2018, 64 pp. Rapporteurs:  Steve Olson & Karen M. Anderson These proceedings summarize discussions held at a workshop on “Immigration and the Social Determinants of Health” held by the Roundtable on the Promotion of Health Equity of the National Academies in October of 2017.  The National Academies does not expect this type of workshop to reach a consensus, or to produce a set of recommendations, but rather to engage in a preliminary exploration of the issue.  Citing a meta-analysis on immigration and health that was published in 2015, one conference participant noted that research on immigrant health has largely focused on cultural practices and individual behaviors, rather than “on glaring patterns of inequality and pathogenic conditions produced by structures of poverty, immigration policy, and heavy-handed enforcement tactics.” Another participant suggested that pursuing comprehensive immigration reform should be considered a public health strategy because of the high rates of depression and post-traumatic stress caused by lack of legal status and intensified deportations. The workshop included a “world café” session featuring the work of six California organizations active in reducing health inequities:  The Alameda Health Consortium, Asian Pacific Islander Legal Outreach, the Center for Empowering Immigrants and Refugees, Centro Legal de la Raza, Culturally Responsible Care groups at Kaiser Permanente, and Filipino Advocates for Justice.

Proposed Public Charge Rule Would Significantly Reduce Legal Admissions and Adjustment to Lawful Permanent Resident Status of Working Class Persons, Center for Migration Studies, November 2018, 11 pp. Authors: Donald Kerwin et al  A proposed rule issued by the Department of Homeland Security in October 2018 would broaden the ability of U.S. Citizenship and Immigration Services officers to determine that a beneficiary is inadmissible to be granted a visa, adjust status or apply for Lawful Permanent Residence (LPR) based upon the perceived risk that the individual could become a “public charge,” i.e. financially dependent upon the federal or state government for assistance. This report analyzes the implications this proposed rule could have on the immigration system and discusses the impact on two populations of immigrants that would be most affected by the change in adjudication procedure: undocumented immigrants and otherwise LPR-eligible nonimmigrants. Under the proposed guidelines, the government would consider “all the factors bearing on the intending immigrant’s ability or potential ability to be self-sufficient” -- a much broader standard than the one currently in use. The new factors would include lack of current employment or history of unemployment, lack of access to private health care, and receipt of one or more public benefits. The authors argue that the proposed DHS rule would place an undue burden on lower-income immigrants, restrict the entry of individuals within family-based categories, and have negative ripple effects on millions of other people both in the U.S. and in sending countries. The article concludes by estimating the number of individuals who could be affected by the proposed rule and providing educational, economic and employment profiles of those individuals. (Mia Fasano for The Immigrant Learning Center's Public Education Institute)

Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid, Henry K Kaiser Family Foundation, October 2018, 15 pp. Authors: Samantha Artiga et al This brief provides an analysis of the potential impact of the Trump Administration’s proposed rule changes regarding what types of support can be included in determinations of how likely it is for someone applying for Legal Permanent Residency (LPR) to become a public charge at some point. Previously, housing, nutrition and health programs (including Medicaid) had been excluded from the analysis of the applicant’s economic vulnerability. Including those programs under the proposed rule would mean that 94 percent of non-citizens looking for LPR status would have at least one characteristic that could lead to their application being denied. The authors suggest that in order to maintain eligibility for LPR, non-citizen immigrants will avoid getting any support from fear of being considered a public charge. For example, they estimate that between 2.1 to 4.9 million Medicaid enrollees would disenroll, even when there may be US born children in the household that are eligible for services. This massive loss of healthcare will lead to worse health outcomes not only for those who are disenrolling, but also for their families and communities. The authors also stress that this will in turn affect housing security, educational attainment and economic productivity. In this way, perceptions of the new regulations will be just as consequential as the rule changes themselves, and the negative impacts will not be limited to members of the immigrant community that are the target of the law (Erik Jacobson, Montclair State University).

Detained and Denied: Healthcare Access in Immigration Detention, New York Lawyers for the Public Interest, 2017, 20 pp. Authors: Sola Stamm et al As the Trump administration threatens to deport an increasing number of immigrants, immigration advocates have expressed concern over the state of health care treatment within detention centers. The New York Lawyers for Public Interest (NYLPI) provides legal representation and advocacy work for undocumented immigrants in ICE custody. NYPLI reports in Detained and Denied: Healthcare Access in Immigration Detention that immigrant detention facilities often provide sub-par health care to detained individuals and fail to provide timely and adequate medical care to accommodate the medical needs of the incarcerated population. Under the 14th Amendment of the U.S. constitution, detained immigrants have a right to adequate healthcare. ICE itself also has issued official "performance-based standards" for medical care.  NYPLI collected information on the state of medical care at detention facilities through a review of complaint records and interviews with 47 individuals with serious medical conditions who were held in immigration detention in the New York metropolitan area. The researchers found recurring deficiencies in medical care, including incomplete intake assessments, lack of interpreters for patient-doctor communication, denied or severely delayed medical care, and inadequate departure planning for continuing medical care. These deficiencies, the authors argue, have endangered the lives of detainees and undermined their basic human dignity. The report concludes with a recommendation that ICE detention facilities be mandated to comply with performance standards regarding comprehensive health care and be held legally accountable for the care of detained individuals.   (Mia Fasano for The Immigrant Learning Center) Living in an Immigrant Family in America: How Fear and Toxic Stress are affecting Daily Life, Well-Being, & Health The Henry J. Kaiser Family Foundation, December, 2017, 24 pp. Authors: Samantha Artiga & Petry Ubri According to this report, immigrant families from various backgrounds are living with increased fear and uncertainty due to the current political climate. The election of Donald Trump has led to policies that increase immigration enforcement and restrict the entry of immigrants from selected countries. These policies can potentially impact 23 million non-citizens who live in the United States, as well as 12 million children who are predominantly U.S.-born. This Kaiser Family Foundation brief uses focus groups with 100 immigrant parents from 15 countries as well as 13 telephone interviews with pediatricians who serve immigrant families to understand how the political climate and enforcement policies since the 2016 presidential election impact the daily lives and health of immigrant families.  The report finds that the heightened stress many immigrant families are experiencing can have broad effects on the life and daily routine of these families. Many immigrant parents report difficulty in finding employment. Adults also feel insecure about their ability to stay in the U.S., and they limit their time outside the home to reduce risk of deportation or interaction with law enforcement. Said one Latino parent, "Before, there were many kids in the parks... but now... the kids spend more time inside these days because we are afraid of being deported." In addition, children appear to be exposed to elevated levels of toxic stress. Parents report that their children are experiencing more bullying at school, causing physiological, behavioral and mental health changes in children that can lead to compromised development and poorer mental and physical health outcomes. In response to witnessing increased racism and bullying since the 2016 election as well as changes in health care use, some pediatricians have taken steps to help immigrant families feel safe including increasing communication to reassure confidentiality, having bilingual staff welcome families, and writing letters to assist families facing deportation. (The Immigrant Learning Center's Public Education Institute) Facilitating Health Communication with Immigrant, Refugee, and Migrant Populations Through the Use of Health Literacy and Community Engagement Strategies: Proceedings of a Workshop The National Academies of Sciences, Engineering, and Medicine, 2017, unpaginated Rapporteur:  Joe Alper The goal of this workshop was to identify approaches that will enable health care organizations to serve immigrant and refugee populations "in a manner that allows all members of these communities to obtain, process, and understand basic health information and the services needed to make appropriate health and personal decisions." This publication summarizes the workshop's presentations and discussions, and highlights important lessons, practical strategies, and opportunities for using the principles of health literacy to facilitate communication with newcomer populations. In accordance with the policies of the National Academies, the workshop did not attempt to reach any conclusions or make any recommendations about needs and future directions. Rather, it simply highlights the issues identified by speakers and workshop participants and calls attention to programs and initiatives that show some promise of success.  One important concern of participants was to earn the trust of immigrant communities by responding to the climate of fear that surrounds immigrants today and to ensure that personal information, if collected at all, is safeguarded. One model program is the "You are safe here" campaign of the San Francisco Department of Public Health. Another approach is to probe more deeply into the experience of migrants, many of whom have been tortured or have suffered other forms of trauma. As one participant said, "perhaps the most important thing a clinician can do is to be curious and ask people about their experiences." The workshop gave examples of efforts to address the social determinants of health, such as the work of the California Healthy Nail Salon Collaborative.  Workshop participants also learned about efforts on the part of health care organizations to partner with community-based organizations, such as the Casa de Salud in the St. Louis metropolitan area. Finally, innovative programs to improve communication with newcomer populations, such as the Let's Talk About Medicines project of Wisconsin Health Literacy, were described. Pre-Migration Trauma Exposure and Mental Health Functioning among Central American Migrants Arriving at the US Border, PLoS One 12(1), January 10, 2017, 8 pp. Authors:  Allen Keller, Amy Joscelyne, Megan Granski, Barry Rosenfeld In recent years, the influx of families and children from Central America arriving at the U.S. border has been deemed an "urgent humanitarian situation." Examining how the experiences of migrants correspond with the requirements for asylum status can powerfully inform public discourse and policy.  This report focuses on migrants from the Northern Triangle region, formed by El Salvador, Guatemala and Honduras, and considers their pre-migration trauma, current mental health functioning, reasons for leaving the region, and rate at which they appeared to satisfy the legal criteria for asylum. Researchers interviewed 234 adults seeking assistance at the Church of the Sacred Heart in McAllen, Texas and found that 83 percent of participants cited violence as a reason for fleeing their country, 69 percent did not report violent events to the police for fear of police corruption and gang-related retribution, and 90 percent are afraid to return to their native country. Based on self-report symptom checklists, 32 percent of participants met the criteria for post-traumatic stress disorder, 24 percent for depression, and 17 percent for both disorders. When considering the data against the criteria for asylum in the U.S., researchers found that 70 percent of the overall sample met the criteria for asylum. The findings indicate that with the high degrees of trauma and psychological distress present in the population, the use of detention for these asylum-seekers may be cruel and retraumatizing. (Grace Chen for The ILC Public Education Institute) Organisational systems' approaches to improving cultural competence in healthcare: a systematic scoping review of the literature, International Journal for Equity in Health, 16:78 (2017), 19 pp. Authors: Janya McCalman, Crystal Jongen, & Roxanne Bainbridge Noting that the scope of cultural competence has expanded beyond the interpersonal domain to address system-level factors, the authors of this study set about to determine the evidence base for a systems approach to eliminating inequities in health care. A systems approach "requires an amalgamation of attitudes, practices, policies and structures to enable healthcare organizations and professionals to work effectively in culturally diverse situations." A review of the literature from 2002 to 2015, examining health care interventions in Australia, Canada, New Zealand, and the United States, produced nearly 3,000 studies touching on cultural competence in healthcare settings. However, only 141 studies appeared to focus on systems-level approaches, and of those studies, only 15 studies included evaluation measures and were deemed worthy of inclusion in the study.  Three approaches that seemed particularly efficacious were: user engagement in the development or implementation of strategies, organizational readiness, and delivery across multiple sites. However, there is a clear need for additional studies in order to bolster the case for systemic approaches to cultural competence. "...There is little guidance for healthcare organisations about how to identify what mix of cultural competence strategies works in practice, when and how to implement them properly, or whether their investment in cultural competence interventions will have the intended effects on client experiences or health outcomes." Building an Organizational Response to Health Disparities: A Practical Guide to Implementing the National CLAS Standards, National Committee for Quality Assurance, December, 2016, 59 pp. In 2013, the federal Office of Minority Health (OMH) issued the "enhanced" National CLAS Standards  (Culturally and Linguistically Appropriate Services) to guide health and health care organizations in their efforts to ensure health equity. This Toolkit, produced under OMH contract with the National Center for Quality Assurance (NCQA), provides examples of resources available to support organizations committed to the implementation of the CLAS standards. The toolkit is divided into four chapters that follow the organization of the National CLAS Standards:  Principal Standard; Governance, Leadership and Workforce; Communication and Language Assistance; Engagement, Continuous Improvement and Accountability.  Resources are categorized by the five groups that are likely to experience disparities in care:  people with disabilities, people with limited English proficiency, people with low health literacy, racial/ethnic minorities, sexual and gender minorities. The LEP section of the Toolkit provides descriptions and links to a variety of resources, including training materials and assessment tools. A panel of experts reviewed the content of the Toolkit to ensure the quality and relevance of all materials. Practicing Cultural Humility American Counseling Association, Counseling Today, December 27, 2016, 6 pp. Author: Sidney Shaw This paper endorses a revision to the Multicultural Counseling Competencies (MCCs) model, which has been a foundational document in the counseling profession for several decades. The chief flaw in the model, according to Shaw, is the "self-assessment bias" of the counselor, who typically overrates his/her abilities in relating to clients from diverse cultural backgrounds. Although the insights of MCC remain valid, they need to be supplemented with what the author calls Multicultural Orientation (MCO). This approach "privilege(s) the voice of clients and make(s) the counselor's own invisible privilege a little more visible."  It requires the counselor to practice "cultural humility," which involves "engag(ing) in collaborative, open exploration with clients regarding their cultural identity as a salient factor in treatment." It also enables counselors to practice "dynamic sizing," i.e. knowing under what circumstances to generalize cultural knowledge to specific individuals. In addition, the approach helps to reduce the number of "microagressions" (reported by more than 50 percent of racial and ethnic minority clients). The paper concludes with a number of in-session recommendations for counselors interested in embracing this new approach. Ethnic Attrition and the Observed Health of Later-Generation Mexican Americans, Institute for the Discussion of Labor, Discussion Paper No. 10062, August 8, 2016, 13 pp. Authors: Francisca Antman, Brian Duncan, & Stephen J. Trejo This study suggests that there is a bias built into many studies of the health condition of second and later generations of Mexican immigrants. These studies often show a pattern of worsening health outcomes with each successive generation. The authors point out that there is a major flaw in these studies, in that they rely on the reported ethnic self-identification of survey respondents. "Ethnic attrition" occurs whenever a U.S.-born descendent of a Mexican immigrant fails to self-identify as Mexican.  Such individuals "are generally more likely to display health outcomes closer to those of non-Hispanic whites compared with individuals who identify as Mexican Americans."  The data used in this study came from the 2000-2014 waves of the National Health Interview Survey, the major source of detailed data on a broad range of health outcomes and related characteristics of the U.S. population.  Ethnic attrition rates are greatest for children of intermarried parents. Pursuing Health Equity through Welcoming Work Welcoming America, 2016, 10 pp. Authors: M. Mayor & Jennifer Drive Pursuing Health Equity through Welcoming Work describes replicable strategies to promote health equity as part of efforts to integrate immigrants into community life. The report draws on key points from a Welcoming America panel discussion and uses data from governmental agencies and scholarly research to highlight promising practices in Georgia, Pennsylvania, Virginia and New Hampshire. The authors emphasize three key requirements for achieving health equity: involving immigrants in planning and research, overcoming social and cultural barriers, and examining the effects of social and economic policies on health outcomes. Attention to these requirements has led to successful initiatives at both local and state levels. In Atlanta, for instance, a health center worked with immigrant community leaders to implement the "promotores de salud" model. Used in Latin America to raise awareness among Latinas about reproductive health, this model has reached 11,000 community members in Atlanta. As an example of the "Health in All Policies" approach from the American Public Health Association, New Hampshire's health equity plan promotes broader agency partnerships to address the social determinants of health and provides periodic report cards to help identify issues that require follow-up action. The authors advise that immigrant and refugee voices should be at the center of local and national discussions on community health. (Jasmina Popaja for The Immigrant Learning Center Public Education Institute) Racial and Ethnic Disparities in Mental Health Care for Children and Young Adults: A National Study International Journal of Health Services, August 12, 2016, 15 pp. Authors: Lyndonna Marrast, David U. Himmelstein, & Steffie Woolhandler This study finds that black and Latino children and young adults receive substantially less outpatient mental health and substance abuse care than their non-minority counterparts, even when controlling for income and health insurance status. About 5.7 percent of white children and young adults saw a mental health specialist in a single year, compared with about 2.3 percent for black or Hispanic young people. The authors note that the prevalence of most psychiatric conditions is similar for all three groups. Among reasons suggested by the authors for these treatment disparities are:  the stigmas associated with mental illness in some groups and the shortage of behavioral health specialists in minority communities. The authors also suggest that the disparities in mental health treatment for blacks and Latinos lead to high rates of school discipline, such as suspensions and expulsions, and higher incarceration rates. For example, blacks and Hispanics account for 63 percent of children detained in juvenile facilities. "Prisons and jails," the authors argue, "have become de facto mental institutions," and the consequences for families and communities have been devastating. Integrating Health Literacy, Cultural Competence, and Language Access Services: Workshop Summary National Academies, Health and Medicine Division, July 18, 2016, 96 pp. Rapporteur:  Joe Alper This "roundtable" discussion focused on important lessons, practical strategies, and opportunities for creating greater integration of health literacy, cultural competence, and language access services in the healthcare system. Held on October 19, 2015, the workshop brought together a select group of leaders in these three fields, including academics, health care administrators, and advocates. Sponsors of the event included various agencies with the U.S. Department of Health and Human Services, as well as non-governmental organizations such as the Aetna Foundation and Eli Lilly and Company. In accordance with the policies of the National Academies of Sciences, Engineering, and Medicine, the workshop did not attempt to reach conclusions or make recommendations, but instead focused on the issues identified by the speakers and workshop participants. An initial presentation by Dennis Andrulis, senior research scientist at the Texas Health Institute, was followed by a panel discussion addressing two key questions:  what are the key concepts in this area, and what three things have changed over time to facilitate integration? Another panel featured presentations from four organizations that have made progress in achieving this kind of integration:  the National Committee for Quality Assurance, the California Pan-Ethnic Health Network, the Robert Wood Johnson Foundation, and Hofstra North Shore - LIJ School of Medicine. Upon conclusion of these sessions, three breakout groups in the areas of research, policy, and services/care were formed to discuss developments and needs in these areas. Improving Cultural Competence to Reduce Health Disparities Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services, March, 2016, 91 pp + appendices Prepared by: Minnesota Evidence-based Practice Center In furthering its mission to improve the quality, safety, efficiency and effectiveness of health care in the U.S., AHRQ conducts systematic reviews of health care research to determine its strengths, limitations, and usefulness to practitioners.  This review analyzed over 37,000 English-language citations dealing with the provision of "culturally appropriate health care" for racial/ethnic minority populations, people with disabilities, and LGBT populations. Fewer than 100 studies met the rigorous standards for inclusion in the final report. However, none of the included studies measured the effect of cultural competence interventions on health care disparities. Most of the training interventions measured changes in professional attitudes toward the population of interest but did not measure the downstream effect of changing provider beliefs on the care delivered to patients." The report concludes by suggesting a new model for research that substitutes a "relational" for an "attributional" model, i.e. instead of focusing on the internal characteristics of groups (or "culture"), which may not apply to all members of a particular group, practitioners are urged to examine "the devaluation and exclusion of these groups within the broader society." Another possible term for this approach, according to the authors, might be "diversity competence." A ‘Healthy Immigrant Effect' or a ‘Sick Immigrant Effect'? Selection and Policies Matter, Institute for the Study of Labor, September 22, 2015, 25 pp. Authors:  Amelie F. Constant et al The "healthy immigrant effect" refers to research showing that immigrants to the U.S. and other countries tend to be healthier than comparable native-born populations. In this study, the researchers attempt to tease out the reasons for this phenomenon.  Using data from the Survey of Health Aging and Retirement Europe (SHARE), the researchers compare the health status of immigrants in 16 European countries with that of immigrants in Israel. Israel provides an intriguing and "unique" case study, as it is the only country that does not screen Jewish immigrants by education level or health status. The study shows that immigrants to Israel have only a "fair" health status, compared to their counterparts in Europe who are rated as "good."  Compared to native Israelis, immigrants to Israel "have also been diagnosed with major diseases, have more medical symptoms and more mobility limitations, use more prescriptions drugs, have a higher number of hospitalizations, have lower cognitive skills, and suffer more from eyesight problems."  The researchers provide evidence that "self-selection alone does not explain the healthy immigrant effect."  Rather, the migration policy of the immigrant-receiving country may have a powerful impact on the health status of arriving immigrants. Creating Conditions to Support Healthy People: State Policies that Affect the Health of Undocumented Immigrants and their Families, UC Global Health Institute, UCLA Blum center on Poverty and Health in Latin America, UCLA Center for Health Policy Research, 2015, 22 pp. Authors: Michael A. Rodríguez, Maria-Elena Young, & Steven P. Wallace This study attempts to rank states according to their record in promoting the health of undocumented immigrants. The authors consider five areas to be important "social determinants of health," which they define as "the circumstances in which people are born, grow up, live, work, and age - and that impact immigrants' ability to live healthy lives. " The five policy areas are:  the availability of public health and welfare benefits, such as children's health insurance, prenatal care, and eligibility for SNAP; access to higher education; labor and employment practices, such as the inclusion of undocumented workers in workers' compensation laws; the availability of driver's licenses; and state legislation limiting participation in the federal Secure Communities enforcement program. The states with the highest scores were California (9), Illinois (7), Washington (4), Colorado (2), and Texas (2). The states with the lowest scores were Ohio (-7), West Virginia (-6), Mississippi (-6), Indiana (-6), Arizona, (-6) and Alabama (-6). Improving Cultural Competence: A Treatment Improvement Protocol Substance Abuse and Mental Health Services Administration (SAMHSA), 2014, 329 pp. With a mission to reduce the impact of substance abuse and mental illness, SAMSHA produces Treatment Improvement Protocols (TIPs) to provide evidence-based and best practice guidance to clinicians, program administrators, and payers. A panel of non-federal clinical researchers, clinicians, program administrators, and patient advocates debates their particular area of expertise until they reach a consensus on best practices. This particular TIP explores the importance of cultural competency in treating substance abuse and mental illness. The first chapter defines cultural competence and the rationale for pursuing it. The second chapter covers behaviors and skills for cultivating cultural competence as well as attitudes conducive to working effectively with diverse client populations. The third chapter discusses interviewing skills, assessment practices, and treatment planning. The fourth chapter discusses "top-down" organizational strategies for achieving cultural competency. The fifth chapter reviews cultural knowledge specific to individual racial and ethnic groups; and the final chapter explores the concept of "drug culture." Implementing CLAS Standards and Improving Cultural Competency and Language Access: A Practical Toolkit, Arizona Health Disparities Center, 2014, 15 pp. This publication is designed to promote use of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS Standards) developed by the Office of Minority Health. Originally published in 2000, the CLAS standards were revised in 2013. The Toolkit includes a short history of the CLAS standards movement, the rationale for their use, as well as a side-by-side comparison of the original and revised versions of the standards. The publication also provides links to resources useful in implementing each of the 15 standards. Responding to Culture: Beyond Cultural Competence Training, Robert Wood Johnson Foundation, March, 2014, 14 pp. While cultural competence training for health care professionals may increase awareness of cultural differences and of the need to address disparities in health outcomes, it is not enough to produce real results. This is one conclusion of a national program of the Robert Wood Johnson Foundation that funded 33 organizations to examine intervention to reduce health disparities with particular focus on diabetes, cardiovascular disease, and depression.  Entitled "finding Answers: Disparities Research for Change," the program evaluated strategies used in a variety of health care settings to determine what works - and what does not - to improve prevention and care.  This report summarizes the main conclusions of this research and urges four broad "strategies for considering culture" as an integral aspect of quality improvement in health care. First, gather as much information about patients' culture through patient and community input; second, build interventions based on patients' culturally-based values, preferences, and perceptions; third, create patient educational materials  with images and language that resonate with the target population; and fourth, ensure sustainability of the overall effort especially during periods of staff turnover or changes in the patient population.  The report includes many practical examples of these strategies in action.  The website of Finding Answers has descriptions of the funded projects, as well as summaries of the published research produced by them. Hispanic Community Health Study Data Book: A Report to the Communities U.S. Dept. of Health and Human Services, National Institutes of Health, National Heart, Lung, and Blood Institute, September, 2013, 58 pp. Described as "the largest health study of Hispanic/Latino populations in the United States,"  this publication presents data from 16,415 Hispanic adults recruited from a random sample of households in the Bronx, Chicago, Miami, and San Diego between 2008 and 2011. Participants were given the opportunity to self-identify as Cuban, Dominican, Puerto Rican, Mexican, Central American, or South American and health measures were reported accordingly. Participants were selected to be representative of the local population rather than the broader U.S. population.  Although almost 80 percent of participants were born in other countries or Puerto Rico, the data does not differentiate between native-born and foreign-born Hispanics. The primary purpose of the study was to identify the factors "that may have a protective or harmful role in the development of cardiovascular disease..." The study found that prediabetes, diabetes, and obesity were "very common" among Hispanics, with one out of three participants with diabetes unaware of having the disease.  The study also examined the prevalence of hypertension, smoking, depression and anxiety, sleep problems, and hearing problems.  Lifestyle factors such as diet and physical activity were also examined. The Affordable Care Act & Mixed-Status Families: Frequently Asked Questions (FAQs), National Immigration Law Center (NILC), October, 2013, 7 pp NILC answers sixteen FAQs about how the Affordable Care Act (ACA) affects mixed-status families in the U.S. The report defines a mixed-status family as "a household made up of individuals with different citizenship or immigration statuses."  Many of these families are unsure if and/or how they can access health insurance through the ACA without putting their undocumented family members at risk. Under the ACA "only U.S. citizens and people who are ‘lawfully present'" are eligible for health insurance. However, ineligible (i.e. undocumented) family members may complete an application on behalf of an eligible family member without being required to reveal their immigration status and risk apprehension. "The ACA codifies longstanding federal guidance, known as the Tri-Agency Guidance, which...ensure[s] that applications do not require unnecessary information from nonapplicants, because these inquiries deter eligible people from securing benefits for which they may be eligible." Therefore, any information provided on ACA applications, NILC advises,  "will not be used by U.S. Immigration and Customs Enforcement (ICE)." NILC also encourages family members to apply for Medicaid or CHIP on behalf of eligible family members.(Jade Flora-Holmquist) Is the United States Bad for Children's Health? Risk and Resilience among Young Children of Immigrants, Migration Policy Institute (MPI), July, 2013, 28 pp. Authors: Jennifer Van Hook, Nancy Landale, & Marianne Hillemeier The authors wrote this paper for a health policy symposium convened by MPI in January of 2013. The goal of the symposium was to "frame the major policy and practice issues affecting children (birth through age 10) with immigrant parents." As childhood health disparities are associated with delays in cognitive development and poor integration outcomes later in life, an examination of the health status of these children may have important public policy implications. This paper reviews the available research on health outcomes for immigrant children, with particular focus on the children of Mexican immigrants, who experience greater health risks than most other children.  Although the so-called "epidemiological paradox," i.e. the lower prevalence of several health conditions, such as allergies, asthma and learning disabilities, among the children of immigrants, is well-documented, new data is "paint(ing) a considerably more nuanced picture," especially when you dig down to the level of national origin groups. Like other children with immigrant parents, children of Mexican parents, particularly those from lower socio-economic backgrounds, show a lower incidence of asthma; however, Mexican children with the disease are "highly disadvantaged in access to high-quality care for chronic health conditions." Mexican children also have the highest prevalence of obesity among all racial/ethnic groups in the U.S. The authors review four factors that help to explain the poor health outcomes of children of Mexican immigrants: limited English proficiency of many parents, low socioeconomic status of many families, parental legal status, and the dispersion of Mexican immigrants to new destinations where they may be viewed with resentment and suspicion. The authors conclude that the fate of these children may "stand at a crossroads." As children of immigrants now make up almost one-quarter of all children, "promoting the health of children in immigrant families will maximize the long-term well-being and productivity of tomorrow's adults." Health Care for Immigrant Families: Current Policies and Issues Migration Policy Institute, June, 2013, 19 pp. Authors:  Leighton Ku & Mariellen Jewers This report assesses how the current health care system in the U.S. addresses the health care needs of immigrants. Debunking the myth that immigrants abuse health care services, the report finds that immigrants, even when covered by public or private insurance, see doctors less frequently and use emergency rooms at a lower rate than the native-born. Low-income, immigrant children with private insurance, for instance, were significantly less likely to visit a doctor's office in 2010 than low-income, native-born children at 44 percent versus 69 percent. Similarly, only 17 percent of publicly insured (Medicaid or Medicare), low-income, immigrant adults overall visited an emergency room versus 25 percent of low-income, native-born adults. Among uninsured adults, the rate was six percent for immigrants and 14 percent of the native-born. Although low levels of insurance coverage (both public and private) does in part account for low utilization of health care by immigrants, there are other reasons as well, including language barriers, cultural differences, and worries over whether utilization will lead to deportation or revocation of legal status. The authors recommend that federal and state governments expand Medicaid access to legal permanent residents; support non-profit, community health centers; and increase access to interpreters. (Denzil Mohammed) Cultural Competence in Health Literacy Primer, Maryland Office of Minority Health and Health Disparities & University of Maryland School of Public Health, March, 2013, 237 pp. Authors: Monica McCann, Olivia Carter-Pokras, Bonnie Braun, & Carlessia A. Hussein In 2012, Maryland enacted a law requiring attention to cultural competency and health literacy in the curricula of health profession degree programs.  This primer is intended to help health educators, students, and practicing health professionals learn how to reduce health disparities and improve health outcomes through culturally-sensitive and effective communication with patients across the various health disciplines. The primer is unique in merging the fields of health literacy and cultural competence, which are usually treated separately and often compete for time in already tight curricula. The primer consists of six modules of instruction: health disparities, community strategies, bias and stereotyping, effective communication skills, use of interpreters, and self-reflection and culture of health professions. Within each module, learning objectives are listed by type of competency (K = knowledge; S = skill; and A = attitude), as well as by learning stage (novice, intermediate, and advanced). The primer is a work in progress. Revisions will be made as new resources are identified for specific learning objectives and as existing resources undergo standardized review. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice, Office of Minority Health (OMH), U.S. Department of Health and Human Services, April, 2013, 191 pp. First developed by OMH in 2000, the national CLAS Standards have been widely circulated and implemented. In 2010, OMH launched a project to update the Standards to reflect growth in the field of cultural competency and increasing diversity in the nation.  The new Standards emerged out of an extensive consultation process with stakeholders and experts, many of whom recommended clarification as to the Standards' intention, terminology, and implementation strategies. The Standards now reflect a broader and more inclusive definition of culture, encompassing racial/ethnic, linguistic, religious/spiritual, sociological, and biological markers of difference. The Standards are also directed toward a broader audience than the original Standards, including policy makers and legislators, accrediting and credentialing agencies, educators, and community-based organizations. The 15 standards are grouped into three categories:  (1) Governance, Leadership, and Workforce; (2) Communication and Language Assistance; and (3) Engagement, Continuous Quality Improvement, and Accountability.  This publication contains both the standards and a "blueprint" for the implementation of each standard.  The Blueprint explains the purpose and components of each standard, along with model implementation practices and useful resources. The Standards themselves are also available in a separate file. Information on Small Populations with Significant Health Disparities: A Report on Data Collected on the Health of Asian Americans in Massachusetts, Institute for Asian American Studies, University of Massachusetts (Boston), November, 2012, 48 pp. Authors: Carolyn Wong, Hannah Hosotani, & John Her How can data collection procedures be improved to capture information on Asian populations with significant health disparities? Hoping that the State of Massachusetts might become a model for the country, the authors offer a number of recommendations to public authorities and private health care organizations. One is to conduct health surveys in local communities where many Asian Americans live. Another is to use categories that reflect "sensitivity to ordinary people's understandings" of their primary identity, which may not be "Asian." Another is to use interviewers speaking the languages of Asian populations, so that findings are not biased towards fluent English-speakers. And finally, academic researchers should partner with community-based organizations, especially those working in low-wage Asian communities, to gain access to hard-to-reach populations. Maximizing Health Care Reform for New York's Immigrants, New York Immigration Coalition, Empire Justice Center, & NYS Health Foundation, February, 2013, 41 pp. This paper contains a set of recommendations on how New York can maximize the inclusion of immigrants in health care reform. The authors also devote special attention to immigrants left out of federal reform. The paper is divided into five major sections: eligibility of non-citizens to participate in New York's Health Benefit Exchange; documentation and verification requirements; marketing and outreach to immigrant communities; community input and monitoring; and maintaining safety net services for the residual uninsured population. In developing these recommendations, researchers undertook a review of the literature; conducted in-depth interviews with stakeholders and experts; and analyzed the experience of three early-adopter states: Massachusetts, California, and Maryland. The authors hope that the report will serve as a "blueprint" for advocates in working with state and local government partners on health care reform, and that "New York can pave the way nationally as a model of immigrant inclusion." Promoting appropriate use of physicians' non-English language skills in clinical care: Recommendations for policymakers, organizations and clinicians, American Medical Association, 2013, 18 pp. Authors:  Marsha Regenstein, Ellie Andres, & Matthew Wynia Produced by the Commission to End Health Care Disparities, an umbrella group consisting of more than 70 state and specialty medical societies, this report seeks to improve the quality of communication and care given by bilingual physicians, who may have varying levels of ability in one or more non-English languages.  While nearly nine out of ten hospitals report using bilingual providers to treat limited English proficient (LEP) patients, very few evaluate their competence in non-English languages in any careful and systematic way.  As there are a number of groups in the process of development assessment tools for this purpose, the Commission seeks to encourage these efforts and to capture the consensus of stakeholders on effective strategies for reducing disparities in treatment and health outcome due to language barriers. The report provides separate recommendations for clinicians, healthcare organizations, and policy makers.  Among the recommendations for policy makers are: creating tools to assess and improve use of clinicians' non-English language skills, developing payment models to cover the cost of interpreter services, and collecting and recording patients' language needs at initial point of service.  Health care organizations are urged to provide training to staff on how to work with interpreters and to bring interpreters into clinical care teams.  Finally, the Commission encourages physicians to use their bilingual skills with patients "whenever doing so is safe and effective."  In order to make this determination, physicians may wish to ask a trained interpreter "to audit a handful of patient encounters and provide feedback on the quality of the communication." Finally, the Commission proposes a research agenda to clarify outstanding issues, including developing and testing "affordable and accessible (language) assessment tools for bilingual physicians and other health professionals providing care to patients with LEP." (Lorin Mordecai) Discharge, Deportation, and Dangerous Journeys: A Study on the Practice of Medical Repatriation, Center for Social Justice (Seton Hall Law School) & New York Lawyers for the Public Interest, December, 2012, 55 pp. Authors:  Pyo lee, Erica Sibley, Todd Tolin, & Sarah Vader Woud This study reviews almost 1,000 cases of forced or coerced medical repatriation, defined as the decision of a hospital to return a critically injured or ill immigrant patient back to his/her native country without consent.  Often the quality of care available to these patients is inferior, family members and support networks are missing, and patients suffer and die. According to the authors, the frequency of such cases will likely increase under the Affordable Care Act by reducing the pool of Medicaid Disproportionate Share Hospital (DSH) payments and by excluding an estimated 4.3 million undocumented immigrants from coverage. By tolerating coerced repatriation, the United States is violating its obligations under international human rights agreements. Moreover, hospitals are, in effect, preempting the authority of the federal government to deport individuals and denying them due process. In addition, hospitals often fail to inform immigrant patients of the immigration consequences of repatriation, which may include a 10-year bar on reentry to the United States. The report includes many case histories and provides a series of recommendations to the U.S. Congress, HHS, the Department of State, hospitals, states, state courts, and community groups and advocates, designed to prevent the proliferation of this practice. Black and Immigrant: Exploring the Effects of Ethnicity and Foreign-Born Status on Infant Health, Migration Policy Institute, September, 2012, 21 pp. This study challenges earlier research suggesting "superior" birth outcomes among immigrant mothers when compared to their native born counterparts. Most immigrant birth-outcome studies were based on data derived primarily from Mexican immigrant mothers.  Using 2000-2003 data from the National Center for Health Statistics, this study compares the prenatal behaviors and birth outcomes (preterm birth, low birth weight, and small for gestational age) of non-Hispanic Black immigrant mothers to those of non-Black immigrants and both Black and non-Black US-born mothers. The findings indicate that Black foreign-born mothers show a slight health advantage over Black US-born mothers, and the author suggests that lifestyle choices among Black immigrant mothers, such as lower rates of smoking, may play a role in better birth outcomes when compared to their US-born counterparts. However, the author notes a lower likelihood among foreign-born Black mothers of beginning prenatal care during the first trimester when compared across all groups.  The study also finds that the health advantages of Black immigrant mothers disappear when compared to most non-black foreign-born mothers, mirroring the "infant-health gap observed among US-born Black and non-Hispanic white mothers." The author suggests that these disparities have a wider implication for the health of the overall Black population residing within the US, and calls for further research to investigate the "socioeconomic mechanisms" behind these inequities. (Dan McNulty) Enhancing the Delivery of Health Care: Eliminating Health Disparities through a Culturally & Linguistically Centered Integrated Health Care Approach: Consensus Statements and Recommendations , Office of Minority Health (OMH) & Hogg Foundation for Mental health, June, 2012, 28 pp. This is the fourth in a series of OMH-sponsored reports addressing the mental health needs of underserved populations.  This report grew out of a two-day expert panel meeting in 2011 looking at "the integration of behavioral health and primary care services for racial and ethnic minority populations and those with limited English proficiency."  A companion technical report reviewing the literature on integrated approaches was also prepared.  Among the key elements of such an integrated approach are: the deployment of an integrated care team, consisting of multi-disciplinary and cross-trained practitioners in both physical health and behavioral health; use of a single patient health and behavioral health history; and development of unified treatment plan. The report recommends specific strategies to enhance cultural and linguistic competence at the individual, community, practice, system, and workforce levels.These strategies are illustrated with examples of how specific organizations have utilized these strategies in real world settings. Community-Defined Solutions for Latino Mental Health Care Disparities, UC Davis Center for Reducing Health Disparities, 2012, 79 pp. In order to reduce mental health disparities in minority populations, the California Department of Mental Health (Office of Multicultural Services) launched the California Reducing Disparities Project, which established five Strategic Planning Workgroups (SPWs) to study the following populations: African Americans, Asian/Pacific Islanders, Latinos, LGBTQ, and Native Americans. Funding for the project was provided by Proposition 63, better known as the Mental Health Services Act, passed by the California voters in 2004. With staff support provided by the UC Davis Center, the 15-member Latino SPW got off the ground in 2009, quickly followed by the creation of a stakeholder group called the California Latino Mental Health Concilio. The goal of the project was to identify "community-defined, strength-based promising practices, models, resources, and approaches that may be used as strategies to reduce disparities in mental health."  The report's conclusions were shaped by input from more than 550 Latinos who participated in community forums conducted in 13 cities and two high schools throughout the state. According to the authors, this study is "the first of its kind to use a community-based, grassroots approach to identify barriers and seek solutions to mental health care needs in historically unserved or underserved Latino communities."  Stressors associated with immigration, undocumented status, and poverty receive considerable attention in the study. Based on evidence gathered from community informants and a literature review, the study recommends six "core strategies" and seven "strategic directions" for adoption by stakeholders. The study concludes with capsule summaries of 16 programs in California that satisfy its seven-point criteria for being listed as promising in nature. Health Care and the Illegal Immigrant, Georgetown University Law Center, March, 2012, 60 pp. Seeking to "steer a middle course between the rhetorical extremes of the health care and immigration debates," the author of this article, Patrick J. Glen,  examines two questions in depth: first, whether unauthorized immigrants have a legal  or constitutional claim to health benefits when they lack status in a country; and second, whether there are compelling economic and public health reasons for providing such benefits. The first section of the article discusses constitutional precedents relevant to the legal question both in the Canadian and U.S. contexts, including a lengthy discussion of the 2010 Toussaintdecision by the Canadian Federal Court barring an unauthorized immigrant from accessing the Canadian health care system. The author concludes that deference to the authority of legislatures to set limits on alien access to benefits is a precedent that will be hard to overturn. However, "under the U.S. Constitution and Canadian Charter no provision mandates that public coverage be extended to illegal immigrants, but nothing forbids that choice as a matter of policy."  And here the author feels there are persuasive arguments for providing coverage, including the counterintuitive idea that such coverage would actually lower costs to the overall healthcare system. Unauthorized immigrants, who are relatively healthier and younger than the general population, would increase the risk pool for insurance, thereby helping to subsidize the sick. Moreover, by using more preventive services, unauthorized immigrants would drive down the cost of more expensive emergency room and acute care services. Finally, the author suggests that extending health care benefits to this population would contribute to public health generally by allowing all people to have access to primary care, thereby reducing the threat of infection and contagious disease. Language Proficiency and Health Status: Are Bilingual Immigrants Healthier? (Article available by subscription only), Stanford University and Rice University, March, 2012, 36 pp. Increases in English fluency are often associated with progress in acculturation and improved health for immigrant populations in the United States.  However, as English fluency increases, native language fluency may decrease, producing possible negative effects on both physical and mental health.  This article seeks to examine the effect of both English and native language fluency, or simultaneously maintaining native language fluency while increasing English language fluency, on self-rated physical and mental health for immigrant populations.  The authors examine the effect of language proficiency while controlling for mediating variables such as socioeconomic status, family and social supports, stress, discrimination, age at migration, and country of origin.  Findings indicate that those who are bilingual, or proficient in both their native and English languages, report better health on both physical and mental health self-rated scales, as compared to those who are native language dominant or English language dominant.  These findings are consistent with other studies on biculturalism, that indicate that those who simultaneously maintain strong ethnic identities while also acculturating into their host society show improved psychosocial well-being. (Patricia Lundgren)  Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status, U.S. Department of Health and Human Services (HHS), Office of Minority Health, October, 2011, 10 pp. After a careful review, with more than 400 public comments on draft standards, HHS adopted final data standards for race, ethnicity, sex, primary language and disability status. The new standards permit the collection and analysis of data about ethnic groups within the broader Hispanic, Asian, and Pacific Islander populations. The standards are designed to reveal disparities in health status among people in specific groups, whose conditions are often masked in current data collection practices, and to facilitate the development of targeted interventions to reduce these disparities.  The new standards were required under Section 4302 of the Affordable Care Act. Addressing Health Disparities and Health Literacy Challenges in the South Asian Community: Conference (October 9, 2010) Summary Report and Recommendations South Asian Total Health Initiative, UMDNJ, and other sponsors, June, 2011, 28 pp. This report provides detailed summaries of all conference plenary and workshop sessions. The conference drew 126 participants, including 28 faculty members.  Plenary sessions dealt with the meaning and significance of health literacy in multicultural communities, the state of current research on the subject of health disparities in South Asian communities, and innovative models for reaching these communities. Three workshops focused on health disparities in diabetes, cancer, and tuberculosis. Another three workshops discussed innovative strategies to address health disparities, including complementary and alternative medicine, chronic disease management, and the development of multimedia solutions for health promotion. The report concludes with a series of recommendations relating to policy planning and resource development, data collection and research, community education and professional training, and networking and partnerships. Assuring Health Equity for Minority Persons with Disabilities: A Statement of Principles and Recommendations, U.S. Dept. of Health and Human Services Advisory Committee on Minority Health (ACMH), July, 2011, 17 pp This is the third in a series of reports by ACMH designed to ensure that health care reform responds to the needs of vulnerable populations.  While people with disabilities experience worse health outcomes than the general population, the report finds that "minorities with disabilities are doubly burdened by their minority status." The report makes five recommendations: first, raise awareness about the health inequities experiences by persons with disabilities, especially minorities;  second, improve care and treatment by devoting attention  to "the culturally specific differences among people with disabilities, and among subgroups of that population;"  third, require cultural competency for all health care providers and professionals; fourth,  improve research and practice on disabilities in minority populations; and fifth, strengthen the health care workforce to ensure high quality care for people with disabilities.   Educating Clinicians About Cultural Competence and Disparities in Health and Health Care (Abstract Only), Journal of Continuing Education in the Health Professions, 2011, 12 pp. Authored by Robert C. Like, Professor and Director of the Center for Healthy Families and Cultural Diversity, UMDNJ, this paper outlines the role that the continuing medical education (CME) profession can play in reducing disparities in service access and health outcomes. The paper reviews CME initiatives in cultural competency around the country, discusses the reaction of medical professionals to them, and makes a series of thoughtful recommendations to improve their effectiveness. Among these recommendations are the development of "a new type of ‘participatory CME' through active engagement and collaboration with patients, consumers, and advocates as the ‘faculty experts'..." and greater use of social media to facilitate on-going communication on cultural competency among medical professionals. National Standards for Healthcare Interpreter Training Programs, National Council on Interpreting in Health Care, April, 2011, 38 pp. The publication of these standards culminates a two-year process, involving a review of existing training curricula, consultation with an expert advisory committee, the convening of ten focus groups, and online surveys seeking feedback on draft standards.  The standards are intended to apply to all preparatory training programs regardless of their duration or sponsorship. They cover core content to be mastered before an aspiring interpreter begins professional work in the field.  More demanding areas of healthcare interpreting, such as proficiency in simultaneous interpreting, are omitted from the standards because they may be addressed in advanced training.  In addition to content standards in such areas as modes of interpreting, message conversation, and interpreting ethics, the document also outlines a set of recommended instructional strategies, as well  as guidelines for program design and operation.  The Council recommends some flexibility in implementing the standards for speakers of "languages of lesser diffusion." National Immigration Policy and Access to Health Care: A Position Paper, American College of Physicians (ACP), 2011, 18 pp. Honoring medical ethics and mindful of legal requirements under EMTALA (Emergency Treatment and Active Labor Act), the ACP -- the nation's largest medical specialty society representing 130,000 internists -- developed this position paper to voice concerns over "unsustainable" policies limiting immigrant access to health care. The College, for example, opposes provisions of the Affordable Care Act barring undocumented immigrants from paying out-of-pocket for health insurance coverage. The College also opposes any effort to require physicians to report on the legal status of their patients. The College also laments the low levels of insurance coverage for the U.S. born children of immigrants, many of whose parents refrain from seeking coverage for their children out of fear of possible deportation. Another issue of concern to ACP is the absence of testing for communicable diseases, and low levels of vaccinations, among undocumented immigrants - gaps in the health care system that threaten the health status of all Americans.  Finally, ACP urges the federal government to strengthen the network of safety-net health care facilities around the country that provide primary care for the poor and uninsured. The Health of the Newest New Jerseyans:  A Resource Guide, Center for Health Statistics, Office of Policy & Strategic Planning, NJ Dept. of Health and Senior Services, February, 2011, 72 pp. This report provides detailed information on the health status of foreign-born residents of New Jersey. With the exception of infectious disease and HIV/AIDS, where nativity data is lacking, the report covers a wide array of illnesses, such as heart disease, stroke, diabetes, and cancer, and provides incidence data both by race/ethnicity and by nativity.  Most comparisons are between native-born and foreign-born in broad racial/ethnic categories, i.e. Black, White, Hispanic, and Asian. Health outcomes for specific national groups are not given, even though the report notes that "each foreign-born group comes to the U.S. with its own health advantages and health disadvantages." In general, "overall health outcomes for the foreign-born for many leading causes of mortality and morbidity are quite favorable."  However, the longer the period of residence in the United States, the more the foreign-born appear to resemble the native-born. "As time spent in the United States increases, nativity differences in health diminish." Culturally Effective Care Toolkit American Academy of Pediatrics, 2011, 22 pp. The Academy describes this publication as a "practical, hands-on resource to help practicing pediatricians and their office staff provide culturally effective care to their patients and families."  The toolkit provides short summaries of key issues, such as health beliefs and practices, nutritional questions, child development and mental health norms, interpretive services, and health literacy. The toolkit includes a selected listing of supplemental tools and resources in each area. Advancing Effective Communication, Cultural Competence, and Patient-and Family-Centered Care: A Roadmap for Hospitals, The Joint Commission, August, 2010, 93 pp This report culminates a multi-year project of The Joint Commission to develop new accreditation standards for hospitals for addressing the language and communication needs of diverse patient populations. This publication provides guidance to hospitals in complying with the new standards. Each of six chapters covers a separate component on the continuum of care:  admission, assessment, treatment, end-of-life care, discharge and transfer, and organizational readiness. The report urges hospitals to "embed effective communication, cultural competence, and patient- and family-centered care practices into (their) core activities," rather than viewing them as stand-alone initiatives. Copies of the old and new standards are included in the appendices to the publication, along with explanations as to why particular standards were revised. The new standards were approved in December 2009 and released to the field in January 2010. They will be published in the 2011 hospital accreditation manual, initiating a pilot implementation phase. Full implementation is expected to occur in 2012.  A System of Care Team Guide to Implementing Cultural and Linguistic Competence(CLC), Technical Assistance Partnership for Child and Family Mental Health, July, 2010, 14 pp. This Guide offers practical suggestions as to how local communities can organize to deliver culturally and linguistically competent mental health care.  It discusses the role and compensation of the CLC Coordinator;  budgeting suggestions for CLC; the role of the CLC committee;  the importance of the CLC plan; and examples of how all staff members and community partners can contribute to the goal of CLC. The Guide provides links to many tools and templates, including  a sample CLC coordinator position description, suggested hiring tips, and a CLC budget spreadsheet. The Partnership operates under contract with the federal Child, Adolescent and Family Branch, Center for Mental Health Services (SAMHSA),  U.S. Dept. of Health and Human Services. The High Costs of Language Barriers in Medical Malpractice, National Health Law Program & School of Public Health, University of California, Berkeley, 2010, 21 pp. This study analyzed 35 closed claims of medical malpractice based on inadequate language assistance. The claims were against a single insurer operating in four states in the West.  All claims were adjudicated between 2005 and 2009. Major themes in the cases included the following: "failure to provide competent oral interpretation; failure to provide written translations of important documents, e.g. informed consent forms and discharge instructions; inadequate documentation; and allegations of discrimination."  The insurance carrier paid out over $5 million in damages, settlements, and legal fees on the 35 cases. What's in a Word? A Guide to Understanding Interpreting and Translation in Health Care, National Health Law Program in cooperation with NCIHC and ATA, April, 2010, 27 pp. This guide is designed to clarify the differences and commonalities between interpreting and translation, to identify the skill sets required for each, to identify standards of practice, to review progress towards national certification, to define the role and functions of the interpreter and translator, and to summarize the modes and methods of interpreting and translation. A final section of the guide discusses procedures for hiring interpreters and translators. Confronting Inequities in Latino Health Care, Special Issue of the Journal of General Internal Medicine, Abstracts and links to in-depth news releases on each article, October, 2009, 4 pp. An important theme of this series of articles is that the country of birth and immigration status of Latinos affect the quality of health care they receive in the U.S. The nine studies examine topics such as rates of hypertension, diabetes, health insurance coverage, discrimination, quality of care, and spiritual beliefs. Predictably, lack of insurance and undocumented status are associated with poor health outcomes. The authors argue for attention to the needs of the Latino population in the current health care reform debate. Moving to the Land of Milk and Cookies:  Obesity among the Children of Immigrants, Migration Policy Institute, Sept., 2009, 8 pp Based on a federal longitudinal study of 21,000 children from kindergarten to 8th grade, 25% of whom were children of immigrants, this study concludes that children of immigrants are a high-risk group for obesity, and that poverty doesn’t fully explain their vulnerability. Obesity cuts across all socio-economic levels, but tends to be higher among boys, Hispanics, and non-Hispanic whites. By 8th grade, 49% of immigrant boys were obese or overweight, compared to 33% of native-born. The authors speculate as to causes, e.g. "many immigrants originate from countries in which food insecurity and stunting pose significant health risks to children, so they may be unaccustomed to protecting children from the opposite problem that comes from overeating." The Health and Cognitive Growth of Latino Toddlers:  At Risk or Immigrant Paradox? Bruce Fuller et al, Maternal and Child Health Journal, June 25, 2009, 14 pp. Looking primarily at Mexican immigrant mothers, most living in households earning $25,000 or less annually and with limited educational backgrounds, the authors of this study explore the causes and consequences of "the immigrant paradox," i.e. the fact that Mexican and other Latino immigrant newborns display robust birth weight and low mortality compared to whites and African-Americans.  The study finds that these early advantages do not persist over time. Instead, these children at 24 months of age display higher rates of obesity and asthma and lagging cognitive development.  These results have important implications for federal policy makers interested in designing effective intervention strategies. State Practices in Health Coverage for Immigrants: A Report for New Jersey, Rutgers Center for State Health Policy, June, 2009, 29 pp. This report surveys the landscape of health coverage for immigrants in New Jersey. Although New Jersey provides more public coverage and safety net programs for immigrants than most other states, New Jersey appears to lag behind other states with large immigrant populations in its outreach and enrollment success. The report contains descriptions of outreach strategies employed in California, Illinois, Massachusetts, and New York, and concludes that "culturally-attuned outreach efforts and improved enrollment processes" will be "critical factors in the success of any public program to cover immigrants and their children." An earlier CSHP reportprovided esimates of children and parents without health insurance in New Jersey, including non-citizens. NJ FamilyCare Outreach, Enrollment and Retention Report, Submitted by the Outreach, Enrollment and Retention Working Group in Response to the New Jersey Health Care Reform Act of 2008, NJ Office of the Child Advocate, May, 2009, 32 pp + appendices Created under a provision of the NJ Health Care Reform Act of 2008, this Working Group was charged with developing a plan to improve outreach to low and moderate income families eligible to participate in NJ FamilyCare. One of the subcommittees of the Working Group examined the challenge of  "Overcoming Barriers to Immigrant and Minority Access" (OBIMA).  The report contains numerous recommendations, either building on existing initiatives or employing new approaches based on successful outreach strategies used in other states. The report also emphasizes collaboration among various departments of state government, such as the Department of Education which tracks the location of limited English proficient students in local school districts, and urges expanded use of incentives to community-based organizations to enroll uninsured individuals. Improving Access to Language Services in Health Care: A Look at National and State Efforts, Policy Brief, Mathematica Policy Research, Inc., April, 2009, 10 pp. This policy brief focuses on the three states that have been most active in legislating access to language services in health care:  California, Minnesota, and New York. The authors discuss the history and scope of various legislative initiatives in those states. They also identify key challenges facing states and stakeholders seeking to develop language services, including setting up information technology systems to support the collection and management of data on primary language, promoting appropriate use of language services by clinical staff, ensuring the quality of language services, and developing payment mechanisms for language services. The State of Asian American, Native Hawaiian and Pacific Islander Health in California Report, A report from the California Asian Pacific Islander Joint Legislative Caucus, Prepared by the University of California Asian American Pacific Islander Policy Multi-Campus Research Program, Health Work Group, April, 2009, 67 pp. By disaggregating California's Asian American Pacific Islander group, comprising over 14% of the state's population, into some of its many ethnic sub-groups, and investigating the health characteristics of each group, this report sheds important light on the health needs of particular communities and appropriate policy responses to those needs. Koreans and Vietnamese, for example, have uninsured rates higher than the state average. Filipinos have high obesity and smoking rates. Childhood asthma rates are highest among South Asians. Vietnamese experience mental distress at higher rates than other groups. The authors urge further efforts to disaggregate other communities, particularly the South Asian category, into Indian, Pakistani, Bangladeshi and Sri Lankan sub-groups. More than Words Toolkit Series, Hablamos Juntos, April 2009 This series of 7 short publications outline the requirements for effective document translation, a process often approached haphazardly and without full understanding of its complexity. Tool One (Getting Started with Translations in Health Care) lays out the basic steps in the process, cautions against use of unqualified bilingual staff as translators, and emphasizes the importance of document meaning, context and purpose, as opposed to "word-for-word replacement operations." Tool Three (Developing the Translation Brief: Why and How) describes how to provide formal instructions for the translator, based in part on an analysis of potential "source culture bias" in the original document. Tool Six (Assessing Translation - A Manual for Requesters) outlines a tested procedure for evaluating the quality of translations. A Comprehensive Framework and Preferred Practices for Measuring and Reporting Cultural Competency, National Quality Forum, April, 2009, Public Version, 11 pp. In an attempt to "bring the cultural competency movement to the next level," the National Quality Forum (NQF), a broad-based coalition of stakeholders in the healthcare industry dedicated to the definition and measurement of quality care, has produced this "comprehensive framework – a road map – for measuring and reporting cultural competency." The framework consists of four guiding principles, and 45 endorsed practices within seven domains: leadership, integration into management systems and operations, patient-provider communication, care delivery and supporting mechanisms, workforce diversity and training, community engagement, and data collection. The framework is intended for all healthcare organizations, but has applicability to the broader human service field. The significance of this document is that NQF standards become the primary standards used to measure the quality of healthcare in the United States. Full report is available by purchase only. Webinars on Language Access in Health Care, Polyglot Systems, 2008-2009. A for-profit language technology provider for health care organizations, Polyglot Systems has produced a series of five free webinars on the subject of language access for hospital patients. Each webinar features national experts in the field. Among the topics covered are:  language and cultural barriers in health care: a growing crisis (September 18, 2008), leveraging data to improve the quality and availability of language services (November 18, 2008), using technology to improve language access (December 9, 2008), the Prolingua platform for hospital admissions and patient instructions (January 9, 2009), and funding sources for language services (April 1, 2009). Undocumented Immigrants in New Jersey's State and County Psychiatric Hospitals, New Jersey Department of the Public Advocate, February, 2009, 11 pp. This report examines the plight of 55 undocumented immigrants in state psychiatric hospitals, deemed medically ready for release into less costly residential health care facilities but who cannot be placed into such facilities because of their lack of eligibility for federal benefits. In some instances, patients were in (or eligible for) legal status at one time, but lacked the capacity to file the necessary legal papers. Among the recommendation in this report are the assignment of staff to work exclusively with this population and the possible establishment of a state-funded community placement option for such patients, which might prove more cost effective than prolonged hospital stays. Robert Like, MD, et al,  "Educating Physicians to Provide Culturally Competent, Patient-Centered Care," Perspectives (New Jersey Association of Family Physicians), Summer, 2008, 11 pp. In 2005, the New Jersey legislature passed a law requiring all physicians to complete cultural competency training as a condition of re-licensure and mandating the inclusion of such training in the curriculum of New Jersey medical schools. This article reviews the requirements of the law, as well as related legislation elsewhere in the United States One of the six required New Jersey training areas deals with techniques for overcoming language barriers, including best practices in working with interpreters.  The article features a extensive listing of web-based continuing education and professional development courses in cultural competence in health care.  Cultural and Linguistic Competence Implementation Guide, Technical Assistance Partnership for Child and Family Mental Health, January, 2008, 116 pp. In sponsoring this Guide, the Child, Adolescent and Family Branch of the Center for Mental Health Services (SAMHSA) noted that the mental health field "has changed little" since the 1989 release of Towards a Culturally Competent System of Care, and that "there is still only limited understanding of how to operationalize cultural competence." The Guide is organized around six domains:  governance and organizational structure; services and supports; planning and continuous quality improvements; collaboration; communication; and workforce development. Within each domain, the Guide provides specific implementation strategies and related performance indicators, along with examples of best practices in the field. The major premise of this Guide is that Cultural and Linguistic Competence (CLC) must be infused through every aspect of the mental health system of care. "This requires transformation at the policy, administrative, practice, and consumer levels of service." One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populations, The Joint Commission and The California Endowment, 2008, 60 pp. Based on research conducted at 60 hospitals in the United States, this report recommends a common planning framework to address the growing linguistic and cultural diversity of hospital patients. The report argues that planning must be on-going and that solutions must be tailored to the needs and circumstances of individual hospitals. Serving Patients with Limited English Proficiency:  Results of a Community Health Center Survey, National Association of Community Health Centers (NACHC), June 16, 2008, 19 pp. Representing over 1,150 community health centers in the United States, NACHC undertook a survey of its membership to determine the extent to which limited English proficient patients are served by local centers and the range of techniques used to bridge the language gap. Among other things, the report found that one in every three patients seen in local centers is LEP, and that 74% of centers use bilingual nonclinical staff, 59% use bilingual clinical staff, 47% use staff interpreters, 27% use telephonic and/or video services, and 15% use external language agencies. Hospitals, Language, and Culture: A Snapshot of the Nation, The Joint Commission, 2007, 107 pp. This report analyzes how 60 selected hospitals around the country are providing health care to culturally and linguistically diverse patients and offers recommendations for improving hospital responsiveness to this patient population. Language Services Resource Guide for Health Care Providers, National Health Law Program, October, 2006, 186 pp. This useful guide contains state-by-state listings of language service associations, providers, and trainers. It also includes a directory of web-based health information resources in foreign languages. Other sections cover assessment tools and signage.  Certification of Health Care Interpreters in the United States: A Primer, a Status Report and Considerations for National Certification, The California Endowment, September, 2006, 95 pp. Author Cynthia E. Road compares and contrasts nine different existing certification programs for health care interpreters, as well as the eight state certification programs that were in various stages of development at the time of publication. She also explains the various strategies for providing quality assurance in interpreting, of which certification (assessment) is only one part. These strategies include appropriate recruiting, language screening, training, monitoring, and continuing education. Globalization, Migration Health, and Educational Preparation for Transnational Medical Encounters, Peter H. Koehn, Global Health 2006 2:2 This article argues for a new paradigm in medical training called “transnational competence (TC).”  Noting that more than 700 million people cross international borders every year, whether as visitors, businesspersons, or immigrants, the author argues that the quality of health care, as well as the success of disease prevention efforts, hinge on the ability to identify “ the special circumstances that surround and define each individual’s health.”   According to the author, TC as a model is preferable to traditional culture-competence education, which tends to reify cultural characteristics within particular groups, ignoring intra-group variations,  as well as differences of class, generation, experience, and education. The author proposes a far-reaching set of reforms in medical school education designed to prepare a new generation of medical students for “ethnically and socially discordant clinical encounters.”  The Interpreter's World Tour:  An Environmental Scan of Standards of Practice for Interpreters, Publication of The California Endowment for the National Council on Interpreting in Health Care, March, 2005, 44 pp. As part of an effort to draft a national code of ethics for interpreters in health care, this project reviewed 145 standards documents in 11 languages from 25 countries, including 36 U.S. states. The scan was inclusive of all fields of interpreting. The scan uncovered both similarities and contradictions in these documents. Bridging the Cultural Divide in Health Care Settings:  The Essential Role of Cultural Broker Programs, National Center for Cultural Competence, Georgetown University Center for Child and Human Development, Spring/Summer 2004, 39 pp. Defining cultural brokering as "the act of bridging, linking, or mediating between groups or persons of different cultural backgrounds for the purpose of reducing conflict or producing change," this report spells out the four primary functions of cultural brokers (liaisons, cultural guides, mediators, and catalysts for change) and the many contexts in which they work. Most cultural brokers assume multiple roles and may not work exclusively as cultural brokers. Cultural brokers, for example, may be health care professionals, social workers, or community members. They may work at community health centers, hospitals, government offices, community-based organizations, or religious institutions. The report features numerous case examples of successful cultural brokering initiatives. The authors also see cultural brokering as an "essential" to the reduction of health disparities for racial and ethnic populations.  Language Access: Helping Non-English Speakers Navigate Health and Human Services, National Conference of State Legislatures, January, 2003, 24 pp. As the U.S. population has become more diverse, language has emerged as a critical factor in health care access and quality. This report indicates that the language gap can lead to delays in or denial of service, unnecessary tests, more costly or invasive treatment of disease, racial or ethnic disparities in insurance, and other problems. The report surveys the demographic landscape and current governmental efforts to address language access, focusing on four states that are using federal matching payments from Medicaid and SCHIP to pay for language interpretation. The report also outlines "next step" options for states and the federal government. National Standards for Culturally and Linguistically Appropriate Services in Health Care, Final Report, Office of Minority Health, U.S. Dept. of Health and Human Services, March, 2001, 132 pp. In 1997, the Office of Minority Health (OMH) began a study and consultation process leading to the publication of this standard-setting document four years later. A prime motivation for this project was widespread dissatisfaction with the earlier patchwork of standards that often left health care providers without clear guidance as to what constitutes culturally and linguistically appropriate services (CLAS). OMH consulted with numerous stakeholders in the field, and after publication of draft standards in the Federal Register, received comments from 413 individuals and organizations. The standards were published in final form in 2000. The 14 standards are organized by themes:  Culturally Competent Care (1-3), Language Access Services (4-7), and Organizational Support for Cultural Competence (8-14). Part II of the Report discusses each standard in detail, covering intent, supportive research, and implementation issues.