Clinics catering to immigrants take a hit from White House policy

It was just a couple of years ago that Sinai Health System's Touhy Health Center in Chicago stood as the primary site in the state for newly arrived refugees. At that time, as many as 60% of all refugees who arrived in the U.S. and resettled in Illinois visited the clinic, which saw an average of about 500 new refugees a month.

These days, the Touhy clinic is preparing to close its doors permanently.

Sinai Health CEO Karen Teitelbaum announced last week the clinic will close in December. She attributed the closure to the Trump administration's decision in the past year to significantly limit how many refugees can enter the country, which has led to an 85% drop in new patient visits to the clinic since January 2017, which now has less than 50 visits a month.

"We held off on any action for as long as we could, hoping for a reversal or stabilization of the immigration activity," Teitelbaum said. "With none in sight, and with the clinic requiring a large subsidy, we had to make the decision to close the clinic and transition care to other agencies. We were left with little choice."

But what's happened at Touhy speaks to the growing financial pressures that U.S. clinics specializing in caring for refugees face because of the Trump administration's hard-line immigration policies.

Such clinics play a valuable role in helping refugees navigate the complexities of the healthcare system, which advocates say goes far toward to getting them to better acclimate to their new surroundings. Touhy's staff of 15 comprises people who speak up to 25 different languages, which allows patients to get health screenings, follow-up care,and other services in their native language, in a culturally sensitive manner.

But the bulk of the Touhy clinic's funding comes from federal grant money distributed by the state to provide health assessments to new refugees. Refugees are required to receive a health assessment within 90 days after arriving in the country. Grant funding allocated to clinics like Touhy is based on the number of new patients they receive for health assessments.

While much of the health screening across the country is conducted by state and local public health departments, a number of clinics like Touhy also serve as comprehensive care sites where patients are referred by public and private resettlement agencies, and they can receive their health assessment as well as follow-up care if needed. Teitelbaum said the decline in new refugees because of the federal policy shift has caused a steep drop in funding for assessing new patients. She estimated it has left a funding gap of around $800,000.

"Isolated (screening) programs that stand alone fill a check box," said Dr. Gary Kaufman, medical director of the Touhy clinic. "But if you're talking about the actual care to a patient, that's when things fall short."

Over the past year the Trump administration has drastically lowered how many refugees are admitted to the country in a series of moves seen by many as part of an overall agenda to impose tougher immigration restrictions and make claiming refugee status more difficult.

It began in January 2017, when President Donald Trump signed an executive order to reduce the Obama administration's limit of 110,000 admitted refugees to 50,000, suspend all admissions for 120 days, and ban admissions from seven majority-Muslim countries. The result has been the lowest number of refugee admissions in more than 40 years.

Over a 12-month period ended Sept. 30, 22,491 refugees were allowed entry into the U.S., the fewest number admitted under the program since 1977, according to State Department data. The number of new refugees actually admitted into the country fell way short of the cap of 45,000 refugees set by the administration for fiscal 2018. Last month, the White House announced plans to lower the cap on refugee admissions even further to 30,000 next year.

Declines in the number of new arrivals has also meant fewer visits to refugee health clinics. For many, the decrease has begun to cause financial strain and to raise uncertainty for some about their ability to meet the needs of refugees already living here and help them better integrate into society.

"The number of people that have come in through that pathway has pretty much disappeared," said Dr. Sarah Kimball, director of resident education for the Immigrant and Refugee Health Program at Boston Medical Center, which also provides healthcare services to individuals with any immigration status as well as asylum seekers.

Since 2011, an average of 1,800 to 2,400 refugees a year have resettled in Massachusetts and received care through one of 10 designated refugee clinics in the state. In 2018, the state has received just 464 individuals.

Refugees can get up to eight months of federal medical assistance. Once that period ends, they are expected to either find employment that provides health insurance or purchase a plan on the market if they are not eligible to receive Medicaid or disability coverage. But many have difficulty after the eight-month period gaining coverage on their own.

The uninsured rate among lawfully present non-elderly immigrants, which include refugees, asylum seekers and lawful permanent residents, among others, was 17% in 2016, according to a Kaiser Family Foundation analysis, nearly double the uninsured rate among non-elderly U.S. citizens.

Kimball said many of BMC's clients have needs beyond their medical conditions and that the clinic provides assistance to help them better integrate into society. Like Touhy, BMC offers culturally sensitive mental health services that includes trauma-related care, as well as case management to connect them with social service supports.

She said while the decrease in refugee visits had strained the hospital financially, Kimball felt the impact was buffered because the clinic is part of Boston Medical Center's primary-care clinic. She said the clinic's decision to serve all immigrants regardless of their status has also helped to offset the loss in refugee visits.

"It would definitely have (financial) consequences for our clinic if that was the only type of care we were doing," Kimball said regarding refugee clinic visits. "Because our model is that we're seeing any immigrant who needs our services, we are able to stay afloat."

Dr. Jeffrey Walden, director of Cone Health's Refugee and Immigrant Health Clinic, said the number of new refugee visits have fallen from an average of five patients a week to just two new patients between June and the beginning of October. It has been able to sustain itself because it's part of the family medicine residency program at the Greensboro, N.C.-based health system.

Like Sinai, Cone Health's refugee clinic specifically serves refugees. But similar to BMC, Cone Health's clinic does not rely solely on patient volume, but instead benefits from its status as an educational training program for residents.

"If you were trying to rely specifically on refugee patients to maintain viability, from a financial standpoint that would be close to impossible to do," Walden said. He said the clinic is not really affected financially by a drop in the number of refugee visits, but there were concerns over whether the dearth in patients would jeopardize its viability as a training resource. "For four months over the summer we were really having discussion about what we were going to do next," Walden said.

For the Touhy clinic, its closure means the loss of the only site within Chicago and all of Cook County designated to provide new refugee health screenings, which means patients will have to travel nearly an hour to be assessed. Teitelbaum said Sinai has been working with the state's Bureau of Refugee and Immigrant Services to develop a plan to transition patients to other providers and is also working on finding other employment opportunities for Touhy's 15 staff members.

For many, Touhy's closure will signify the loss of a trusted resource that will be hard to replace. As of Oct. 26, nearly 2,200 people had signed a petition on Change.org calling for the Touhy clinic to remain open. When asked about the possibility of re-opening the clinic if the federal government began admitting more refugees, Teitelbaum said it would be difficult to once again find personnel who have the right clinical, language and cultural skills.

"Once you dismantle a program that is as special as this, I don't know how you really put it back together," Teitelbaum said. "It's an unfortunate fatality of bad federal policy."

Correction: An earlier version of this story gave an incorrect title for Dr. Gary Kaufman. Kaufman is medical director of the Touhy Health Center.