www.undocumentedpatien ts.org Undocumented Immigrants: Access to Prenatal Care
www.undocumentedpatien ts.org Undocumented Immigrants: Access to Prenatal Care Copyright 2014 The Hastings Center www.undocumentedpatie nts.org Access to prenatal care for women who are undocumented immigrants varies widely across the United States due to differences in state policies and differing state level interpretations of federal policies that fund health services for pregnant women. This resource provides an overview of this access problem and the consequences of policy related uncertainty or variation for undocumented patients, their families, and the health care safety-net.
For additional resources and state-by-state references on this topic, visit: http://www.undocumentedpatients.org/issuebrief/undocumented-immigrants-i n-the-united-states-access-to-prenatal-care /. www.undocumentedpatient s.org Why is access to prenatal care for undocumented immigrants important? Prenatal care is fundamental to womens reproductive health and to infant health. Undocumented immigrants in the U.S. are less likely to have adequate prenatal care, compared to other immigrants and U.S. born citizens. The reasons for this gap include a lack of means to pay for prenatal care, lack of access to sources of prenatal care, and mistrust of the health care system [1-4]. Other barriers that undocumented immigrants face when seeking health care include:
Difficulty navigating safety-net health care systems Language and literacy Inability to take time off from work Misinformation about the immigration related consequences of using health care services Perceived and actual risks of encountering immigration authorities or local law enforcement  www.undocumentedpatients .org Lack of access to prenatal care: health consequences for undocumented women and their children Lack of access to prenatal care increases the risk of premature birth and low birth weight, and may be a factor in a range of poor health outcomes experienced by undocumented pregnant women and their babies, including higher rates of labor and delivery complications such as: precipitous labor, excessive bleeding, breech presentation, cord prolapse, and fetal distress. [9-10] These risks and outcomes have consequences for:
the viability and health of newborns infant and child development the health of mothers costs associated with treating medical conditions that could have been prevented or detected and managed before birth www.undocumentedpatients.or g The Emergency Medical Treatment and Active Labor Act (EMTALA) EMTALA prevents hospitals from turning away uninsured patients in need of emergency treatment. EMTALA encompasses labor and delivery. Most emergency health are services used by undocumented immigrants are related to childbirth. State-level emergency Medicaid programs provide some reimbursement to hospitals for treatment provided under EMTALA [6-8]. Undocumented immigrants may account for
99% of Emergency Medicaid expenditures in some states; approximately 80% of these costs relate to childbirth or to complications in pregnancy and labor. EMTALA is designed for emergent conditions. It is not a mechanism for access to routine prenatal care that could prevent or monitor pregnancy-related complications . www.undocumentedpatients.or g State and local policy provisions covering prenatal care for undocumented immigrants Most states provide some access to prenatal care for undocumented immigrants through state funded policy mechanisms such as Medicaid. Some states explicitly exclude undocumented immigrants from coverage for prenatal care. The scope of services and length of coverage for prenatal care varies from state to state; local level provisions also vary. Health care professionals should know current policy concerning access to prenatal care in the state where they practice. In their role as advocates, they should also be aware of policy mechanisms used in other states that could potentially
expand access to care in their state. CHIP Unborn Child Option www.undocumentedpatients.or g As of September 2014, 16 states had implemented a State Plan Amendment (SPA) to the Childrens Health Insurance Program (CHIP), which is jointly supported by federal and state funds. An unborn child may be considered a target lowincome child who is eligible for this program. This provision would enable an undocumented immigrant to enroll her unborn child in the program so she can obtain coverage for prenatal care and labor and delivery services . Under this provision, pregnancy-related services such as prenatal vitamins and ultrasounds may be covered but For state-by-state detail, see services perceived as unrelated to pregnancy may not be
chart: http:// covered. www.undocumentedpatients.org/w p-content/uploads/2014/09/Access -to-Prenatal-Care-Chart.pdf Presumptive Eligibility for Medicaid (PE) Presumptive eligibility (PE) is a state-level mechanism that enables pregnant women to obtain immediate temporary Medicaid coverage without having to wait for a Medicaid application to be processed. As of September 2014, PE was available in 30 states, 13 of which explicitly restrict access to women with legal immigration status. Physicians who are qualified providers of Medicaid services and eligible to determine PE based on a patients self-reported income can provide Medicaid-funded care to any pregnant woman whose self-reported income meets that states eligibility threshold. During the time-limited PE period, women are expected but not required to submit an application for regular Medicaid coverage. PE coverage typically lasts two months, or until a decision approving the applicant for Medicaid is made. The scope ofFor services
covereddetail, under PE differs by state; some states cover state-by-state only ambulatory prenatal care, while others cover the full Medicaid scope see chart: of services. http://www.undocumentedpatien ts.org/wp-content/uploads/2014/ 09/Access-to-Prenatal-Care-Cha rt.pdf Other state-level policy mechanisms www.undocumentedpatients .org Expanding eligibility for safety-net health insurance programs to include coverage for low-income pregnant women regardless of immigration status is another way that some states provide coverage for prenatal care to undocumented immigrants: Three states New York, New Jersey, and Massachusetts offer public insurance for the duration of pregnancy and for two months after delivery: In New York, this coverage is offered as an entitlement program through a state-funded Medicaid expansion, supplemented by the CHIP Unborn Child
Option to cover ambulatory prenatal care services. In New Jersey, Medicaid coverage for prenatal care only is funded through the state budget and offered through community health centers and hospitals subject to the availability of grant funds. In Massachusetts, coverage is provided through a state-funded Medicaid expansion, supplemented by the CHIP Unborn Child Option to cover ambulatory prenatal care services. For state-by-state detail, see chart: http://www.undocumentedpatie nts.org/wp-content/uploads/20 14/09/Access-to-Prenatal-CareChart.pdf Local policy mechanisms www.undocumentedpatients.or g In some cities, undocumented immigrants are eligible for coverage for prenatal care and other health care services through locally-funded programs. In Washington D.C, for example, the D.C. Healthcare Alliance provides insurance coverage for low-income city residents who do not have Medicaid or other insurance.
Beyond publicly-funded insurance mechanisms, access to prenatal care for undocumented immigrants may also be provided directly by public health clinics and nonprofit organizations (such as Federally Qualified Health Centers) that offer health services for patients without insurance. These services may be available for free, or at sliding-scale fee based on a patients ability to pay. References www.undocumentedpatients.or g 1. American Academy of Pediatrics, Guidelines for Perinatal Care, 7th ed. 2012. 2. ACOG Committee Opinion No. 425: health care for undocumented immigrants. Obstet Gynecol, 2009. 113(1): 2514. 3. Cohen, G.J., The prenatal visit. Pediatrics, 2009. 124(4): 122732. 4. Korinek, K. and K.R. Smith, Prenatal care among immigrant and racial-ethnic minority women in a new immigrant destination: exploring the impact of immigrant legal status. Soc Sci Med, 2011. 72(10): 1695703. 5. Frisbie, W.P., S. Echevarria, and R.A. Hummer, Prenatal care utilization among non-Hispanic Whites, African Americans, and Mexican Americans. Matern Child Health J, 2001. 5(1): 2133. 6. Federal Funding for Unauthorized Aliens Emergency Medical Expenses, in CRS Report For Con
gress. 2004. 7. United States Congressional Budget Office, The Impact of Unauthorized Immigrants on the Bud gets of State and Local Governments. 2007. 8. DuBard, C.A. and M.W. Massing, Trends in emergency Medicaid expenditures for recent and undoc umented immigrants. JAMA, 2007. 297(10):108592. 9. Lu, M.C., et al., Elimination of public funding of prenatal care for undocumented immigrants in Cal ifornia: a cost/benefit analysis. Am J Obstet Gynecol, 2000. 182 (1 Pt 1): 2339. 10. Reed, M.M., et al., Birth outcomes in Colorados undocumented immigrant population. BMC Pub lic Health, 2005. 5: 100. Web-based resources www.undocumentedpatients.or g On immigrants eligibility for public benefits, including Medicaid and CHIP, see Overview of Immigrants Eligibility for SNAP, TANF, Medicaid, and CHIP, Office of the Assistant Secretary for Planning and Evaluation (March 2012): http://aspe.hhs.gov/hsp/11/ImmigrantAccess/Eligibility/ib.shtml. For Medicaid Provider Manuals and related documents for all
50 states, see: http ://www.undocumentedpatients.o rg/issuebrief/undocumented-im migrants-in-the-united-states-ac cess-to-prenatal-care /. For Kaiser Family Foundation list of states with Presumptive Eligibility as of January 2013, see: http://kff.org/medicaid/state-ind icator/presumptive-eligibility/ . Web-based resources www.undocumentedpatients.or g On access to prenatal care in the context of ACA implementation, see: Getting into Gear for 2014: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP, 20122013, Kaiser Commission on Medicaid and the Uninsured (January 2013): http
://kaiserfamilyfoundation.files.wordpress.com/2013/05/8401.pdf On Medicaid Presumptive Eligibility in the context of ACA implementation, see: Implementation of the Affordable Care Acts Hospital Presumptive Eligibility Option: Considerations for States, Center for Medicare and Medicaid Services (November 2013): http:// www.medicaid.gov/State-Resource-Center/MAC-Learning-Collabo ratives/Learning-Collaborative-State-Toolbox/Downloads/State-Ne twork-CHCS-Implementation-of-the-Affordable-Care-Acts-Hospital -P.pdf ; see also: The New Hospital Presumptive Eligibility Opportu nity, Enroll America (March 2014): http ://www.enrollamerica.org/toolkits/pe/home.html www.undocumentedpatients.o rg This resource from the Undocumented Patients Project of The Hastings Center was edited by Nancy Berlinger and designed by Chelsea Jack based on the September 2014 issue brief Undocumented Immigrants in the United States: Access to Prenatal Care. The issue brief was drafted by Rachel Fabi with research assistance from Mohini Banerjee, edited by Michael K. Gusmano and Nancy Berlinger, and
designed by Mohini Banerjee. Evan A. Ashkin, MD, Associate Professor of Family Medicine, University of North Carolina at Chapel Hill; Kate Bicego, Consumer Assistance Program Manager, Health Care For All, Boston, MA; Caroline Rath, physician assistant, Gouverneur Healthcare Services, New York City; and Eva Turbiner, President and CEO, Zufall Health Center, Dover, NJ served as expert reviewers. For the issue brief and further resources, see: http://www.undocumentedpatients.org/issuebrief/undocumen ted-immigrants-in-the-united-states-access-to-prenatal-care /. Informationaboutpolicymechanismswascompiledusing publiclyavailabledocuments,includingMedicaidProvider Manualsforeachstate;seeReferences.Allinformationiscur
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