Introduction and background
The Trump administration and congressional Republicans have taken actively hostile stances against both immigrant and refugee communities as well as reproductive rights. President Donald Trump has signed two executive orders, currently held up in court, which block the entry of immigrants into the United States from six predominantly Muslim countries and prevent refugees in general from entering the country.1 In addition to blocking the entry of refugees, these executive orders also attempted to reduce the refugee admissions target for the current fiscal year from 110,000, set in 2016, to 50,000—the lowest number ever set in a presidential determination since the enactment of the Refugee Act of 1980.2 On World Refugee Day, it is critical that we examine the ways in which refugees can feasibly access the resources that they need to live healthy, sustainable lives once resettled. Refugees face many intersectional threats from the Trump administration, and refugee communities would be significantly harmed by many of the administration’s proposed actions.
Parallel to these anti-immigrant efforts, in the U.S. House of Representatives, Republicans have passed the American Health Care Act (AHCA)—a plan to repeal the Affordable Care Act (ACA). The AHCA weakens the standard for reproductive health care established under current law. Additionally, the Trump administration has taken steps to withhold reproductive rights for women abroad. During his first week in office, President Trump signed an executive order reinstating the Global Gag Rule, which bans U.S. foreign aid3 from servicing clinics that offer abortion-related services. The Trump administration has also defunded the U.N. Population Fund,4 an organization working in developing countries to ensure that women and girls have access to family planning, HIV/AIDS testing and treatment, and maternal health care. President Trump and congressional Republicans are on a steadfast mission to dismantle reproductive health and rights. Not only does this mission have implications for the health of American women, but it also affects U.S.-based refugees in need of reproductive health care.
At the intersection of the battle for access to reproductive health and the fight for refugees to resettle in the United States exists a community that is uniquely affected by both limitations. Upon entering the country, refugees can face barriers5 to accessing health care in general, including limited access to employer-sponsored health insurance coverage and limited resources or language capability to acquire quality health care services. Additional barriers to accessing reproductive health care in particular—social stigma, restrictive state and local legislation, as well as other hurdles—are compounded by refugees’ limited access to health care in general. While refugees often enter the United States as low-income, there has been significant research showing that refugees integrate well over time by entering the labor force, moving up the occupational ladder, and starting businesses after resettlement.6 A recent study has also shown that refugees pay more taxes than they use in government-sponsored benefits over time.7 Combined with the proven positive economic indicators for women and families8 that have increased access to reproductive health care, it is crucial that the refugee community have access to these comprehensive, high-quality services. Access to reproductive health care services, in addition to strong social safety net programs and career pathways for refugees, can be a critical springboard for the community to economically thrive in America.
Importantly, this population is particularly vulnerable to reproductive health issues because many refugees in the United States have fled from countries9 where rape is used as a weapon of war. This increases their risk of unwanted pregnancies, sexually transmitted infections (STIs), and other concerns of sexual health. Therefore, it is important to recognize that while the refugee community is a population in great need for reproductive health care, it is often systemically excluded from high-quality, low-cost reproductive health services. Threats to publicly funded health care services—including those provided through Title X clinics, Planned Parenthood health centers, the Medicaid program, and Refugee Medical Assistance—will inhibit the ability of refugees to access the entire spectrum of reproductive health services, including birth control; family planning information and counseling; abortion; and maternal health care. Additionally, repeal of the ACA would drastically change access to affordable reproductive health care through the insurance marketplaces.
Health care options for refugees
Upon entering the United States, refugees do have options for accessing health care coverage.10 Medicaid eligibility varies by state, but eligibility is based on income; whether or not the applicant has dependents; disability status; pregnancy status; and other qualifications. The Medicaid program was expanded under the ACA as a way to widen the net of low-income individuals eligible for publicly funded health insurance coverage. Medicaid expansion also allows low-income recipients to receive tax credits and qualify for lower-cost sharing, income permitting. Under Medicaid, refugees have access to a somewhat-wide range of reproductive health services, including family planning, testing and treatment of STIs, pregnancy-related care, and more. Unfortunately, the Hyde Amendment has prohibited federal funding for abortion for under the program for more than 40 years.11
As of 2016, Medicaid provides health care for nearly 74.2 million people,12 and it covers 1 out of every 5 American women of reproductive age.13 Despite the U.S. Supreme Court giving states the option to expand Medicaid, only 31 states and the District of Columbia chose to do so. The ACA made it easier for states to pursue options for different health services through a state plan amendment rather than a waiver, which was the only option for states before the ACA. For example, the ACA includes a provision known as the Medicaid Family Planning State Option,14 which allows states to expand eligibility for Medicaid to provide family planning services. Expanded eligibility paved the way for more low-income people to access reproductive health services through the Medicaid program. As previously mentioned, refugees in the United States depend heavily on the public options available for health care, and the reproductive health services provided by Medicaid and the protections of the ACA offer immense support for this population.
If refugees are not eligible for Medicaid, they are able to enroll in the Refugee Medical Assistance program (RMA). The RMA program is a temporary health care program that lasts eight months. After that time, if the family or individual still does not have employer-sponsored health insurance, they may apply to enroll in Medicaid or an insurance plan within the insurance marketplace. To promote health education and to provide case management for specific health topics, several states fund refugee health promotion grants that focus on increasing refugee health literacy and providing case management for specific health topics. Women’s health is considered an allowable activity under these grants.15 RMA and Medicaid are largely the only health care options that refugees have when first entering the country. In 2013, 61 percent of refugees who found jobs16 received employee health insurance coverage. That process takes time, and refugees depend heavily on publicly funded health care options in the interim.
Health care coverage through the ACA’s insurance market place is also an option for refugees. Refugees are eligible for the same protections and benefits17 as U.S. citizens under the ACA. Refugees are covered for pre-existing conditions, preventive health services, and essential health benefits (EHBs). Preventive health services, including contraception, are covered without cost-sharing. Some of the other services covered include annual wellness exams; breast and cervical cancer screenings; services to support survivors of violence; breast feeding services and support; and screening and treatment for STIs. These are all services that are critical in helping refugees lead healthy reproductive lives. The ACA also includes maternity coverage as part of the EHBs as well as prescription drug coverage and mental and substance abuse treatment.
Refugees may also access health services through safety net providers, many of which are working at the front lines to ensure access to health services for hard-to-reach populations. Planned Parenthood is a leader in this network, operating 650 health centers18 throughout the country. Planned Parenthood provides compassionate, patient-centered care to more than 2 million people annually. And while the organization currently receives federal funding through Medicaid and the Title X Family Planning Program, it is at risk for being defunded due to the fact that abortion is also an aspect in the full continuum of reproductive health services offered at Planned Parenthood health centers. Planned Parenthood provides abortion with nonfederal funds, and the service represents approximately 3 percent of the total services provided. Abortion care is an important component in the full continuum of reproductive health care. Community health centers (CHCs) are clinics that serve the uninsured, underinsured, low-income, or individuals living in an area where there are few other health care options available. CHCs are also a potential health care access point for refugees. However, these centers are often limited in the expertise and ability to offer comprehensive reproductive health care.19
What’s at stake in health care access for U.S.-based refugees
The counter to the ACA—the AHCA—passed in the House of Representatives on May 4. Some iteration of the legislation will likely be voted on in the Senate next week. Congressional Republicans have made it clear that they will prioritize cutting Medicaid in whatever ACA replacement they provide.20 As a result, any proposal will inevitably reduce access to reproductive health care for low-income populations, including refugees. While the bill did not attempt to dismantle the contraception mandate put into place under ACA regulations, the ACHA did propose severe cuts to funding that provides reproductive health care access to refugee communities. The proposal cut Medicaid by $834 billion over the next decade;21 sought to defund Planned Parenthood22 for one year; and restricted private insurance coverage of abortion.23 Senate negotiations around an ACA replacement plan have been shrouded in secrecy with no legislative text made available to the public; no hearings; and no mark-up process. Yet, senators are aiming to pass their version of the bill before the July 4 recess. Based on reports in the media, we can expect the Senate bill to make health insurance coverage less comprehensive and less affordable—if not completely out of reach—for the most vulnerable communities.24 Any proposal from the Trump administration and Congress to replace the ACA that does not support coverage of vital reproductive health services; preserve Medicaid and federal funding to Planned Parenthood; and ensure access to private insurance coverage of abortion will directly threaten health care access for the refugee population. The AHCA would also cause an additional 23 million people to become uninsured by 2026.
Another program under threat that would hurt refugees attempting to access reproductive health care is the Title X Family Planning Program. Title X focuses solely on providing family planning services and contraception—as well as educational and counseling services—to millions of people each year who otherwise would not have access. President Trump recently signed a bill to unravel an Obama administration rule that protected Title X providers that offer abortion services with nonfederal funds, which will result in decreased family planning services for predominantly low-income women and women of color.25 Title X providers play an integral role for the refugee community, and the clinics also serve uninsured populations. They fill the gap in certain services, such as abortion, contraception, and educational and counseling services,26 that can be difficult to receive through Medicaid or the RMA. Although Title X clinics are forbidden from using federal funds for abortions,27 the fact that some of these clinics offer abortion in a safe and relatively low-cost way expands access to key populations. Access to Title X clinics is crucial for refugees, as they are providers that require no insurance, will serve the most low-income and low-resourced populations—which at times do include refugees—and offer services that are unattainable elsewhere.
U.S.-based refugees deserve access to comprehensive, compassionate reproductive health care. Importantly, this population is able to access health coverage through key programs, including Medicaid and the RMA. Health coverage is also currently available through the insurance marketplaces under the ACA, and reproductive health services can be accessed through front-line providers, including Planned Parenthood health centers and Title X clinics. However, current threats to roll back reproductive health and rights, as well as efforts to restrict refugees from entering the country, will only serve to undermine the ability of refugee communities to lead healthy, productive lives.
Jamila Taylor is a senior fellow at the Center for American Progress, serving as an expert on domestic and international women’s health, reproductive rights, and reproductive justice. Anusha Ravi is a special assistant on the Poverty to Prosperity team at the Center.