Barred from Medicaid, some pregnant immigrants have few options for care

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

Sui, program director EMBARCIowa-based nonprofit, Immigrant Support, saw the potential to help these women navigate health care.

“Because I have been working 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, it’s not at all.”

Even though the women are in the U.S. on visas, they couldn’t get Medicaid due to a federal law This bans many immigrant on green cards and visas from receiving public assistance. States can choose to opt people out of this waiting period when they’re pregnant. But many states — including the Midwest states of Missouri, Indiana and Iowa — haven’t done this.

Many immigrants, such as the Sui-sanitized women, have few options for affordable prenatal healthcare.

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

She found the only assistance the women could get was two months’ worth of “presumptive” Medicaid coverage, which they’d automatically get while they wait for their applications to be processed. They lost that coverage once the state determined they weren’t eligible due to their immigration status.

Sui explained that their only option was to sign a contract at a hospital in the area, agreeing to pay prenatal care out-of-pocket.

While trying to navigate her choices, Sui said one woman didn’t receive any prenatal care during her first and second trimesters, and faced a steep bill when she finally did go in for an appointment.

“So she’s already eight months [pregnant],” Sui said. “But she still has to pay for her first [appointment]It was probably about $1,000. And… she just paid it.”

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

She said that it discourages people from having children.

“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’

The confusing situation Sui experienced stems from President Bill Clinton’s 1996 Personal Responsibility and Work Opportunity Reconciliation Act, more commonly known as the Welfare Reform ActThe five-year ban on public aid for certain immigrants to the U.S. who are not eligible for green cards or visas was imposed by the.

It was part of Clinton’s larger policy. Public opposition, saying he believed the provision had nothing to do with welfare reform and “legal” immigrants who “fall on hard times through no fault of their own” should be able to access public assistance.

“The five-year bar really came about as a cost-savings measure. As part of a broader attempt around welfare reform and immigration reform.” said Kelly Whitener, an associate professor with Georgetown University’s McCourt School of Public Policy’s Center for Children and Families.

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

This waiting period can only be eluded by immigrants if they are willing to work. become U.S. citizensThis is a lengthy process that can take years to complete.

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

It wasn’t until more than a decade later that the federal government made a change to this policy under the 2009 Children’s Health Insurance Program Reauthorization Act, or CHIPRAThis allowed states to opt out immigrant children or pregnant women from the waiting period for Medicaid.

At July 2021, 34 of the states had exempted their children from this waiting period. 24 states also did the same thing for women during pregnancies. According to The U.S. Centers Medicare Services and Medicaid Services.

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

Some states have state-funded programs, like Illinois. Support for pregnant immigrants This ban has affected many people.

But others don’t offer this group There are any public options for insurance coverage They must complete their first five year stay in the U.S. before they can obtain citizenship.

Whitener explained that this has made the system more confusing for immigrants.

“The obvious [issue] is that they’re missing out on health care, which means missing out on visits – also means exposing families to really high medical bills and financial insecurity,” she said.

Costs offset

In 2019, Iowa lawmakers Filed a bill that would allow pregnant women who are “lawfully residing” in the state to obtain Medicaid coverage without the five-year waiting period.

The bill did not move in the legislature. However, the fiscal note estimated that 559 Iowans could be affected annually by the changes. This move would have cost Iowa Department of Human Services approximately $939,000 to cover the group in the 2020 fiscal year and $739,000 in the 2021 fiscal year.

The note indicated that Iowa has already paid for the birth under its Medicaid program. short-term emergency Medicaid coverage program, which is for Iowans who don’t “meet citizenship, alien status or social security number requirements.”

“These costs may be offset by potential Medicaid savings due to preventing premature births and low birth weights,” the fiscal note said.

Experts in the field of health policy agree that funding preventive prenatal healthcare has financial benefits.

“Finding the funds for $1 million on the front end is the smart way to do this kind of public health work,” said Daniel SkinnerOhio University associate professor of Health Policy. “Because we know that $1 million on the front end is probably going to become $10 or $100 million or $1 billion down the road.”

The five-year ban will have a greater impact on immigrant status for women of color who are likely to have higher immigration numbers. Rates of maternal death Low birth rates for infants As compared to White women.

Federal data shows that almost 14 percent of all immigrants who became naturalized in the fiscal year 2021 were born in Mexico. India, Cuba, Cuba, and the Dominican Republic followed closely. These are the top three countries that have the highest number of immigrant immigrants. 36 percent of all naturalizations.

Plugging gaps

Doctors like those at the Iowa City Free Medical Clinic are available. Alka Walter They strive to offer the best prenatal care for pregnant clients who are either uninsured, or partially insured. Many immigrant clients are seen by them under the five year ban.

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

The Free Clinic will see patients until they’re about 20 weeks pregnant, she said.

Then they’ll sign them up for their two months of presumptive Medicaid coverage so they can have insurance to go to a larger, more well-equipped clinic, “and then try and get as much of their important prenatal care done – lab tests, blood type, and screen their growth in anatomy, ultrasound, [and see] if they need any consultations with any specialists,” Walter said.

When their 60-day Medicaid coverage runs out, they’ll go back to the Free Clinic until they give birth in a hospital, which is covered by Iowa’s Emergency Medicaid coverage programThen, you will return to the clinic for another two months of postnatal treatment.

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

Iowa was home to two of her children.

Mangabu arrived in Iowa during her second childbirth. A local hospital referred Mangabu the Free Clinic at her first prenatal visit, when they discovered she was still under the five year ban.

She said that she received outstanding care at Iowa’s Free Clinic. This helped her feel that Iowa is her new permanent residence.

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

“For the kids’ school – very good. Many things are good here,” she said. “That’s why I’m here.”

Mangabu is expecting her husband to return home soon, as he wraps up his DRC-based business.

Both of Mangabu’s pregnancies went smoothly, but the Free Clinic’s patchwork system can be more challenging for patients with high-risk pregnancies, Walter said, because they need additional expensive tests or ultrasounds on equipment the Free Clinic doesn’t have.

“Patients can’t afford to get an ultrasound every week,” Walter said. “At that time then we monitor patients as closely as we can 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.

Walter stated that the clinic sees about a dozen patients every Thursday night and continues to receive referrals.

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

This story comes from a partnership between Iowa Public Radio and Side Effects Public Media — a public health news collaborative based at WFYI. Follow Natalie on Twitter @natalie_krebs.

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