Excluded From Medicaid, Some Pregnant Immigrants Have Few Care Options | Side effects


Last spring, two pregnant women who had recently arrived from Myanmar showed up at Abigail Sui’s home in Des Moines, Iowa. They needed help finding prenatal care.

Sui, program director for BOARDan Iowa-based nonprofit that supports immigrants, thought it could help these women navigate the healthcare system.

“Because I’ve worked with EMBARC for eight years, I thought, ‘Oh, maybe I can advocate because people might listen,'” she said. “I thought my voice would be heard by people, but in reality, that’s not the case at all.”

Even though the women are in the United States on visas, they were unable to get Medicaid due to a federal law which bars many immigrants with visas and green cards from receiving public assistance, including Medicaid, for their first five years in the country. States can choose to remove people from this waiting period when they are pregnant. But many states – including the Midwestern states of Missouri, Indiana and Iowa – I did not do this.

This leaves many immigrants, like the women Sui was trying to help, with few, if any, options for affordable prenatal care.

Neither could get immediate, affordable coverage through plans offered by their husbands’ employers or the Affordable Care Act marketplace. Employer-based coverage wouldn’t start for months, and high deductibles made ACA plans too expensive, even with subsidies, Sui said.

She found that the only help women could get was two months of “presumptive” Medicaid coverage, which they would get automatically while waiting for their application to be processed. They lost this coverage once the state determined they were ineligible due to their immigration status.

Other than that, Sui said their only choice was to sign a contract with a local hospital agreeing to pay for prenatal care out of pocket.

While trying to navigate her choices, Sui said a woman received no prenatal care during her first and second trimesters and faced a hefty bill when she finally surrendered. on a date.

“So she’s already eight months old [pregnant]”, Sui said. “But she still has to pay her first [appointment], I think around $1,000. And… she just paid him.

Sui said EMBARC often hears from immigrants in similar situations who are shocked to learn they don’t qualify for Medicaid for prenatal care simply because of their immigration status.

This discourages some from having children, she says.

“I feel like you don’t get pregnant,” Sui said, “because you won’t have that benefit or you won’t have that prenatal care.”

“It comes down to politics”

Sui’s puzzling situation stems from President Bill Clinton’s Personal Accountability and Job Opportunity Reconciliation Act of 1996, popularly known as the Welfare Reform Actwhich issued a five-year ban on public assistance for certain immigrants to the United States with visas or green cards.

It was part of the larger policy that Clinton publicly opposedsaying he believed the provision had nothing to do with welfare reform and that “legal” immigrants who “were going through hard times through no fault of their own” should be able to access public assistance.

“The five-year bar was really designed as a cost-cutting measure. As part of a broader attempt at welfare reform and immigration reform. said Kelly Bleacherassociate professor at the Center for Children and Families at the McCourt School of Public Policy at Georgetown University.

“Separating eligibility for different benefits by citizenship status has saved money.”

The only way for immigrants to circumvent this waiting period is to become US citizensa process that typically takes years to qualify and pass.

Clinton pledged to “fix” this provision, but that never happened. It has remained in effect ever since.

It wasn’t until more than a decade later that the federal government changed this policy under the Children’s Health Insurance Program Reauthorization Act of 2009, or CHIPRAwhich allowed states to exclude immigrant children and pregnant women from this Medicaid waiting period.

As of July 2021, 34 states have chosen to exempt children from this waiting period, and 24 states have done the same for women during pregnancy. according US Medicare and Medicaid Services centers.

“It comes down to politics – that children are just a very politically acceptable group,” Whitener said. “There’s a lot of recognition that kids don’t make decisions.”

Some states, such as Illinois, have publicly funded support programs for pregnant immigrants covered by this ban.

But others don’t offer this group all public insurance coverage options until they spend their first five years in the United States or obtain citizenship.

This made the system even more confusing for immigrants, Whitener said.

” The evidence [issue] it’s that they’re being denied health care, which means they’re missing out on visits — it also means exposing families to very high medical costs and financial insecurity,” she said.

Clearing fees

In 2019, Iowa lawmakers filed an invoice this would allow pregnant women who are “legally resident” in the state to obtain Medicaid coverage without the five-year waiting period.

The bill made little movement in the legislature, but it did come with a tax memo that estimated 559 Iowans would be affected by the change each year. The move would have cost the Iowa Department of Social Services about $939,000 to cover this group for fiscal year 2020 and about $739,000 for fiscal year 2021.

The note said Iowa was already paying for the birth under its short-term emergency Medicaid coverage program, which is for Iowans who do not “meet citizenship, alien status, or Social Security number requirements.”

“These costs may be offset by potential Medicaid savings due to the prevention of premature births and low birth weights,” the tax memo states.

Natalie Krebs


Public media on side effects

Alka Walter, a volunteer physician at the Iowa City Free Medical Clinic’s Prenatal Clinic, shows off an ultrasound machine the clinic can use to monitor fetal progress.

Health policy experts agree that there are financial benefits to funding preventive prenatal care.

“Finding the funds for $1 million up front is the smart way to do this kind of public health work,” said Daniel Skinner, associate professor of health policy at Ohio University. “Because we know that $1 million at the start will probably become $10 or $100 million or $1 billion later.”

Immigrants affected by the five-year ban are more likely to be women of color, who disproportionately have maternal mortality rate and low birth rate infants compared to white women.

Federal figures show nearly 14% of immigrants naturalized in fiscal year 2021 were born in Mexico, followed by India, the Philippines, Cuba and the Dominican Republic. Immigrants from these countries represented 36% of all naturalizations.

Fill gaps

At the Iowa City Free Medical Clinic, doctors love Alka Walter work to provide uninsured or underinsured pregnant clients with the best possible prenatal care. They see many immigrant patients under a five-year ban.

For Walter, a volunteer who helps run the clinic’s Thursday night prenatal clinic, it means navigating a confusing web of bureaucracy.

The free clinic will see patients until around 20 weeks pregnant, she said.

Then they’ll enroll them for their two months of presumptive Medicaid coverage so they can have insurance to go to a bigger, better-equipped clinic, “and then try to get as many of their important prenatal care — lab tests.” , blood type, and screen their growth in anatomy, ultrasound, [and see] if they need specialist consultations,” Walter said.

When their 60-day Medicaid coverage runs out, they will return to the free clinic until they deliver in a hospital, which is covered by Iowa. emergency Medicaid coverage programthen return to the clinic for two months of postnatal care.

The Free Clinic’s approach to assembling prenatal services worked for Ruth Mangabu, who came from the Democratic Republic of Congo in 2019 on a diversity visa.

Two of his three children were born in Iowa.

Mangabu arrived in Iowa in her second pregnancy and said a local hospital referred her to the free clinic during her first prenatal visit when they realized she was in the throes of a five-year ban.

She said she received excellent care at the free clinic, which has helped her affirm that Iowa is her new permanent home.


Natalie Krebs


Public media on side effects

Ruth Mangabu immigrated to Iowa from the Democratic Republic of the Congo on a diversity visa. Two of her children were born in Iowa, and she received prenatal care through the Iowa City Free Medical Clinic because she is ineligible for Medicaid due to her immigration status.

“Medical care – it’s very good,” Mangabu said in her native French before switching to English, which she is learning.

“For the children’s school – very good. A lot of things are good here,” she said. “That’s why I’m here.”

Mangabu expects her husband, who is winding down his activities in the DRC, to join his family in Iowa in the near future.

Mangabu’s two pregnancies went well, but the free clinic’s patchwork system may be more difficult for patients with high-risk pregnancies, Walter said, because they need additional expensive tests or ultrasounds on the equipment that the free clinic does not have.

“Patients can’t afford to have an ultrasound every week,” Walter said. “At that point, we monitor patients as closely as possible and compromise somewhere in between and make sure it’s safe for the patient.”

The need for the Free Clinic’s prenatal services is increasing.

The clinic sees a dozen patients in its Thursday evening clinic and continually receives additional referrals, Walter said.

“If we had the resources, the time and the staff, we could run this clinic twice a week, and we would still have enough patients,” Walter said. “We get referrals almost every day.”

This story was born out of a partnership between Iowa Public Radio and Public media on side effects – a public health information collaboration based at WFYI. Follow Natalie on Twitter: @natalie_krebs.


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