Cover Story — December 2016
Tex Med. 2016;112(12):22-29.
By Amy Sorrel
Dallas obstetrician-gynecologist Samar Al Hesan fled to the United States as a refugee in June after the Syrian government arrested her husband, also a doctor, for helping the wounded and tortured in her home country. He died in prison, and she came to this country with her four children, now college-age, one of whom has applied to medical school.
"I was living a good life. I'm a physician, and I worked for 17 years there and seven with the United Nations taking care of the medical needs of refugees in Syria and in different places," said Dr. Al Hesan, who received her medical degree from Damascus University in 1992 and did her residency training in obstetrics and gynecology surgery at the Syrian Ministry of Health in 1997.
Now, if Dr. Al Hesan were to go back to Syria, she, too, could be arrested the moment she arrives at the airport, and she lives in fear the Syrian government could kidnap her children.
"We suffered a lot, and I left my husband there. I don't want my children to suffer the memories of their father. So we decided to escape, and whatever the coming life, I would accept it for the future of my kids. So we came to the U.S. and restarted our lives."
Now she helps coordinate care for refugees in Texas as a medical case manager for the nonprofit resettlement organization and the Texas Medical Association Foundation grant recipient Refugee Services of Texas (RST).
Until recently, Texas participated in the federally funded refugee resettlement program, which helps refugees relocate to the United States with a host of services to help them find jobs, learn English, and get basic social services, including health screenings, immunizations, and other medical care.
Unlike other refugees, Dr. Al Hesan, as a physician, could take care of her family's basic health care needs. But most refugees don't speak English, don't have relatives or anyone to help, and have no idea how to navigate the U.S. health care system.
Quickly overcoming that learning curve herself, she now helps refugees secure transitional Medicaid coverage and accompanies them to appointments for primary care or specialty care, which often include mental health treatment. "Most everyone went through a trauma, and leaving their countries, their home, their jobs is very hard for them. I understand their feelings and challenges, and that's why I chose to do this."
Since Texas withdrew from the federal resettlement program in September, some physicians and resettlement organizations worry those services could be disrupted for what Dr. Al Hesan describes as a vulnerable population. Others say the shift, while not ideal, could present opportunities to improve refugee care.
"These people are coming from a lot of suffering. They have nothing, and for many years, they don't even have good shelter or medical care. For sure, our goal is to help refugees be self-sufficient. I am working hard to be self-sufficient. We are only supporting them six to eight months, and we still find a lot of people on the streets suffering from sicknesses and illnesses. It will be more trouble for them [without assistance]," Dr. Al Hesan said. "Refugees are coming here to be safe, and now they feel unsafe. How can we manage that? We have to find a solution."
Texas historically has helped refugees through a combination of federal, state, and local cooperation.
Through several avenues, the federal government gives states money to accommodate refugees, asylees, victims of human trafficking, unaccompanied refugee minors, and other groups approved by the U.S. Department of State to resettle in this country. Texas acted as an intermediary, distributing to local agencies funds it receives from the federal Office of Refugee Resettlement (ORR) under the U.S. Department of Health and Human Services for employment and housing assistance, health screenings, and in some cases, more intense medical assistance, if needed.
Texas receives about 8,000 to 9,000 refugees annually, 13,000 including the other aforementioned groups. In 2016, Texas spent roughly $68 million on refugee-related services, according to the Texas Department of State Health Services (DSHS).
Per national ORR and U.S. Centers for Disease Control and Prevention (CDC) guidance, Texas' Refugee Health Program has covered initial health screenings to refugees within 30 to 90 days of arrival, including comprehensive health assessments, vaccinations, and follow-up and referrals for health conditions identified in the assessment process. In 2016, DSHS gave out $15.7 million in grants to seven local health departments to operate refugee health clinics to provide the health screenings, immunizations, treatment for intestinal parasites, and referrals for other conditions, as needed. (See "Snapshot: Texas Refugee Health Program.")
The state also distributed grants to local voluntary community organizations that sponsor and resettle refugees to offer social services, including medical case management, and help with eligibility, transportation, language interpretation, and follow-up related to health assessments and referrals. Refugees also are eligible for temporary Medicaid coverage for eight months to help cover ongoing care.
However, the potential for security threats over resettling the influx of Syrian refugees sparked a political storm that prompted Gov. Greg Abbott to withdraw Texas from the federal refugee resettlement program on Sept. 30.
The U.S. government and national and state resettlement agencies have refuted claims most refugees are dangerous, pointing to an extensive screening process they undergo that can take up to two years before arriving in the United States.
Unconvinced, Governor Abbott wrote in a Sept. 21 letter expressing Texas' intention to withdraw, "The federal government's refugee resettlement program is riddled with serious problems that pose a threat to our nation. … Empathy must be balanced with security. Texas has done more than its fair share in aiding refugees, accepting more refugees than any other state between October 2015 and March 2016."
Governor Abbott's decision followed a lengthy state Senate Health and Human Services Committee hearing in April. In the interim leading up to the 2017 legislative session, Lt. Gov. Dan Patrick charged the committee with studying "the impact to the state of the increasing number of refugees relocating to Texas, including the range of health and human services provided," and examining "the authority of the state to reduce its burden under the [federal] Refugee Resettlement Program, and any state-funded services."
Weighing the health costs associated with the Texas Refugee Health Program, during the April hearing, Committee Chair Sen. Charles Schwertner, MD (R-Georgetown), pointed to the $56 million in state money spent on Medicaid, the Children's Health Insurance Program, Texas Women's Health Program, and other joint state-federal programs for eligible refugees. Texas also receives federal matching funds for some of those programs, spending a total of approximately $189 million. He also raised concerns about the language interpretation costs that health care entities and schools bear when serving the refugee population.
"This committee [must] evaluate how best to honor our tradition of compassion, while at the same time protecting the safety of all Texans and ensuring our state is not unduly burdened by the provision of that assistance," Senator Schwertner said.
Because refugees legally enter the country and state, however, "they are legally entitled to those services," Sen. Jose Rodriguez (D-El Paso) said. In addition to gaining health literacy resources, he added that with resettlement agencies' help "82 percent [of refugees] find employment, which is higher than the national average of 65 percent. So naturally the question is, have we calculated state tax revenue generated by refugees who are employed?"
A "Partnership That Works"
TMA did not weigh in on the political controversy but submitted testimony pointing to the association's history of efforts to maintain the provision of state funds to assist with extreme health care needs and crises.
That includes physicians stepping in to care and coordinate services for children and families fleeing violence and persecution in their countries, including victims of human trafficking and legal refugees in diverse communities across the state. TMA testimony also cites physicians' response to the unprecedented events during the summer of 2014 when dozens of doctors across the state worked with local charitable organizations and public health officials to provide health screenings for unaccompanied minors and families entering Texas from Central America. (Read "On a Charitable Mission" in the December 2014 issue of Texas Medicine, pages 16–20.)
Many such victims, particularly children, suffer great trauma and are in need of mental health care, which can be complex to manage "and even more costly if not addressed as early as possible," TMA wrote.
Austin family physician Katharina Hathaway, MD, worked part-time at the Travis County refugee clinic in 2010–11. She is a past member of TMA's Rural Health and Primary Care and Medical Home committees.
"It changed my life in the sense that you never have a bad day," she said. "The most memorable patient was a women whose husband was murdered, and she had been raped and contracted HIV. She had kids and was focused on getting them cared for. How can I ever have a bad day when I see people like that? It gave me a huge perspective change."
Most of the refugees she treated were families who were relatively young and healthy, without too many health problems aside from infectious diseases she expected to see from other countries. Her clinic also had a social worker on site to make sure patients got referred appropriately for mental health care services.
"Any time we accept a refugee into our country and pat ourselves on the back saying we are doing something good, there are 20 more behind them still in refugee camps. And we are giving the refugees we do resettle just enough resources to barely survive, let alone thrive."
And when it comes to public health, local health departments are the first line of defense with the established infrastructure to detect and treat infectious diseases, Texas Association of City and County Health Officials (TACCHO) President-Elect Umair A. Shah, MD, wrote in a Sept. 23 letter to Governor Abbott expressing "extreme concern" about his decision. Services to assist refugees with health-related resettlement into the community "would be severely disrupted by the cessation of these funds. … But most importantly, regardless of how funding comes to Texas, we urge the governor to support funding to local health districts so they may continue providing refugee health screenings. This funding is a critical resource for the local health department to promote and protect the health of all persons living within, and coming to, their community."
TMA testimony recognizes the state's "concerns and responsibility for addressing public safety and security, but Texas can be confident in the effectiveness and management of the state's refugee resettlement activities. Our state refugee program has been a federal-state and public-private partnership that works. In dozens of Texas communities, private, non-profit organizations work with the Health and Human Services Commission (HHSC) to coordinate support for our newest Texas residents until they are able to support themselves. The minimal funding which assists with these services, most especially in the area of health care case management, should not be cut."
The TMA Foundation has bestowed grants to a number of community resettlement organizations for their medical case management (see "TMA Foundation Grants Support Refugee Health Services."), many of which protested the governor's decision over concerns it could seriously disrupt health care and other social services for this vulnerable population.
"We are counting on the state of Texas and its Health and Human Services Commission to ensure there is no gap of promised [services]. By providing a welcoming and safe experience for our newest Texans, and on-time payments to the agencies that take care of our refugees, we ensure a stable, positive outcome in helping these thousands of individuals adapt to and smoothly transition into our culture and systems," states a Sept. 19 letter on behalf of six resettlement agencies in Houston.
Aaron Rippenkroeger is chief executive officer of RST, which signed on to the letter and serves nearly 2,000 refugees through five agencies it operates across the state.
Roughly a dozen states do not partner with the federal government to assist refugees. Instead, ORR designates a charitable organization to distribute federal funds, which is likely to happen in Texas, he says. The governor's decision does not mean Texas won't receive federal support, but it does mean the state will have to adopt a new model for directing funds to refugee care.
"But Texas is so much bigger than any other state doing this, so there are a lot of questions around how that might work," Mr. Rippenkroeger said. "We are all disappointed because Texas has done such a fantastic job as a partner in providing these services, and it works best for refugees when everybody is participating: the state, cities, counties. It's a shame because Texas has built an international model of success, and we'd like to see something similar set up."
Case Management Key
Physicians like Dr. Al Hesan worry the transition could disrupt funding streams that medical case managers like her and partnering resettlement agencies, local health districts, and clinics depend on to ensure refugees get required and necessary care.
RST and other organizations provide comprehensive case management that, per state and federal guidelines, requires refugees to get a basic health assessment from one of several DSHS-contracted clinics that includes:
- A complete health history, with review of any available medical documents that came from overseas;
- A physical exam, lab tests, and vaccinations;
- Assessment of mental health and social service needs; and
- Referral for health issues revealed in the screening process.
While many refugees are healthy when arriving in the United States, more targeted medical case management programs like the one Dr. Al Hesan operates in Dallas provide intensive assistance to those with complex needs. They also address some of the top barriers most refugees face: language, transportation, and literacy.
Dr. Al Hesan typically gets medical documentation from overseas prior to the refugee's arrival to help arrange emergency and specialty care, often plastic surgeries for reconstruction due to violence refugees have suffered. "One patient we had to admit to the hospital the same day she arrived," she said.
She makes appointments, trying to link refugee patients to care as close to where they live as possible, and accompanies them to help with language translation and physician-patient communication about unfamiliar health care topics.
RST also focuses on helping refugees find jobs and hopefully employer-based health insurance coverage. But until then, Dr. Al Hesan and other case managers help them apply for Medicaid. RST Dallas also has a close relationship with the local hospital district, Parkland, which receives DSHS grants and where refugees ineligible for Medicaid can enroll in the hospital's health plan for low-income individuals.
To arrange care, "I use the network through Medicaid and figure out [which] doctors [are] accepting Medicaid, and the private network through my community," Dr. Al Hesan said, adding that she is not shy to recruit private physicians and dentists to help.
"I feel the hospital and doctors cooperate very well with us and accept patients even if they don't have Medicaid. We just go and explain the condition of the refugee. But I don't hesitate to ask for help from anybody," she said. Hitting some of the same roadblocks traditional Medicaid patients do, however, she adds, "mental health and dental care are a really big challenge because doctors and mental health centers, not all of them accept Medicaid," making it difficult to get timely care in sensitive situations.
And precisely because insurance and health care in the United States are what Dr. Al Hesan describes as "very complicated," RST also uses the transition process to teach refugees to navigate the system and manage their care independently.
When she first came to the United States, Dr. Al Hesan did not have access to that kind of assistance; now she's an expert. "I had to learn and google and ask people and contact doctors. Now I don't hesitate to call three times to learn something to help my clients. And in my speeches, I encourage them to get a job and work very hard and learn as much as they can to survive in this country."
Opportunity for Improvement
Because refugee care is complex, Dr. Hathaway is optimistic the governor's decision, albeit unwelcome, may help call more attention to the issue. "It's a great opportunity for certain things about the program to be fixed. Just because Governor Abbott doesn't want to resettle refugees, doesn't mean there isn't a work-around and we can't do it better."
For instance, she would like to see more funds directed to community-based care to help doctors on the ground address areas of need they see day in and day out. After leaving the Travis County refugee clinic, Dr. Hathaway tried to start a nonprofit organization focused on increasing access to care for refugees with chronic hepatitis.
On the one hand, Texas has good mechanisms to treat prevalent infectious diseases like tuberculosis among refugees, she says. Now with targeted and more accurate blood tests, for example, "it's a little more expensive [to test], but we have fewer referrals and it taxes the system less." On the other hand, despite more awareness of chronic noninfectious diseases like hepatitis, the state has not typically prioritized those conditions because they are less transmittable and less likely to affect the masses. Since her initial efforts, she says resources for chronic hepatitis are hopefully improving through new projects under the Medicaid 1115 Waiver.
Dr. Hathaway also acknowledges that for a variety of cultural reasons, refugees don't always follow up on referrals post-screening. But for those who do, she says there has not always been support to help put a good system in place for communicating screening results from the public health setting to those providing ongoing care in the community, creating confusion for refugees and those caring for them.
An April 2016 Harvard Public Health Review article cites this and other "poorly understood" challenges to refugee care in hopes of augmenting current CDC guidelines.
"Why isn't money going to community care where we can actually incorporate primary care into the screening process, instead of it being strongly siloed?" Dr. Hathaway asks.
That could help encourage more private doctors to participate in refugee care, she adds, as would coverage for expensive language translation services, a cost practices must incur because Medicaid does not pay for it.
"It can be a challenging population to deal with, and it's hard to make extra time for those appointments. So on the one hand, we need more doctors involved, but it does take a certain level of commitment. So one solution we proposed was having grants pay for interpreters to see private physicians." (See "Cost in Translation.")
It remains to be seen what kind of new model Texas will adopt. At the time of this article's writing in October, HHSC officials said the state would continue to help administer refugee services until Jan. 31, 2017, while the federal government works to appoint a new intermediary. But TMA officials say the state has made no announcements as to how Texas and local government authorities would ensure public health measures going forward.
Amy Lynn Sorrel can be reached by phone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.
TMA Foundation Grants Support Refugee Health Services
The TMA Foundation (TMAF), TMA's philanthropic arm, engages medicine, business, and the community to participate in and support TMA and Family of Medicine initiatives that carry out TMA'’s vision: to improve the health of all Texans. TMAF grants provide annual support to many TMA programs such as Hard Hats for Little Heads, the Minority Scholarship Program, the University of Health forums, and Walk With a Doc Texas. Over the years, TMAF has awarded several grants to refugee assistance organizations and efforts that help refugees get access to needed medical care, including:
- Refugee Services of Texas' intensive medical case management program;
- The biannual Alliance Refugee Wellness Fair at Baylor College of Medicine;
- Hope Medical Clinic of Austin; and
- The Center for Refugees Triage Clinic and Refugee Accompaniment Health Partnership at The University of Texas Health Science Center at San Antonio (UTHSCSA), run by Bexar County Medical Alliance volunteers and students from UTHSCSA's health profession schools, respectively.
TMAF has granted more than $5 million to TMA's health improvement, quality of care, and science initiatives since 1990. Since 1998, more than 150 grants totaling $650,000 have been awarded to county medical societies and alliance and medical student chapters, allowing TMA and TMA Alliance members to meet community health needs through outreach activities. Visit the TMA Foundation webpage for more information.
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