Highlights

• Special Supplement: Immigration Enforcement
• Draft EO Would Change Immigrant Access to Benefits
• Winter Moratorium Extended
• Poor Transparency in Funeral Costs
• Tax Prep Assistance
• Mass Legal Answers Online
• MassHealth Waivers Now Have Spousal Asset Limit
• New Medicare Ombuds
• Caring for Immigrant Patients In Uncertainty
• LGBTQ Immigrants and Intersectionality

Sections

• Program Highlights
• Health Care Coverage
• Policy & Social Issues
• Of Clinical Interest

Questions, comments about the newsletter? Contact Ellen Forman, 617-726-5807.

MBTA Expands Uber Pilot to All Ride Users

The MBTA just announced it is expanding its paratransit relationship with the ride-hailing services Uber and Lyft in a bid to offer customers of The Ride more convenience and lower the T’s overall costs.

The transit authority tested the concept over the last five months with 400 RIDE customers, who as a group took 10,000 trips with Uber and Lyft. T officials say users were offered more convenience at less cost and the transit agency saved money, too.

With the ride-hailing apps, eligible customers with disabilities can call for service when they need it rather than having to schedule a day in advance. Uber and Lyft customers are also carried direct to their destination rather than being bundled with other riders. And the price to the user is generally less ($2 per trip plus any charges over $15) and the T’s average cost is far less ($46 with the traditional RIDE versus $9 with the ride-hailing apps).

While RIDE customers are not required to use Uber and Lyft, the T is hoping the ride-sharing apps will catch on and help reduce costs.

Customers interested in applying to the expanded pilot can learn more and be directed to sign up for Uber or Lyft accounts at www.mbta.com/paratransitpilot. After the MBTA verifies customer eligibility, further instructions and access to the program will be sent via e-mail from Uber or Lyft within 1-2 weeks of sign-up. Once contacted by Uber or Lyft, customers can book trips via a smartphone mobile app. Lyft also has a phone call-in option and a limited number of Uber customers can utilize Uber-provided smartphones for use on a limited basis specifically to book trips.

T officials say about 80 percent of RIDE customers are ambulatory and the remaining 20 percent require wheelchair-accessible vehicles. T officials say Uber and Lyft are given some financial incentives to make wheelchair-accessible vehicles available, but they noted the RIDE’s existing fleet of accessible vehicles is not going anywhere.

Editor’s note: this great news for our patients trying to manage the unpredictability of pick-up times to return home after appointments. We encourage patients to consider this program if they are able, and for staff to help spread the word. Our The Ride set-up handouts will be updated shortly.

-See the full Commonwealth Magazine Story

-Additional material from the MBTA Press Release.

After signing several executive orders aimed at deporting undocumented immigrants, President Donald Trump may target legal immigrants next.

A leaked executive order would drastically expand the number of public programs that are off-limits to legal immigrants who aren't citizens, such as green-card holders. If found using them, they could face deportation and their sponsors -- usually a family member or employer -- would have to reimburse the federal government for unauthorized use of those benefits.

Immigrants can currently be deported for using cash welfare or long-term institutionalized care. Under the draft order, they could be deported for using any federal benefit given "on the basis of income, resources or financial need." The order could change the definition of “Public Charge” to include food stamps, Medicaid, free or reduced school lunch, home heating assistance and college financial aid.

"This is really a major change for social welfare institutions and the social welfare system," said Michael Fix, president of the Migration Policy Institute.

State and local agencies manage many of those programs and could be responsible for reporting immigrants' use of them. That would create new administrative burdens for counties, said Jack Peterson, assistant legislative director for the National Association of Counties (NACo). Peterson's group is also worried about the order having a negative impact on public health.

"Some of our members have expressed concerns that ... [this] could have the [effect] of driving folks that need care into the shadows," he said. If parents stop taking their children to get immunizations, for example, it "not only has impacts for them and their lives but for broader community at-large."

In the past, NACo has taken the position that legal noncitizens should be eligible for federal health benefits, and that the federal government should reimburse counties for the cost of health care provided to legal noncitizens. The group is meeting for its annual conference in late February, and Peterson said Trump's recent immigration policies are on the agenda.

The Washington Post first reported on the draft order Jan. 31. Since that time, the Trump administration hasn't commented on it. So far, though, most of the leaked executive orders have turned out to be virtually the same.

The leaked order is short on important implementation details, such as what role state or local agencies could be expected to play.But if it's up to states and localities to report immigrants to the federal government, they may resist.

The leaked order also calls for the federal Office of Management and Budget to study the estimated savings of restricting more benefits to legal immigrants. Such a report would likely require data collection by state and local agencies.

The order would also prevent undocumented immigrants from receiving federal child care tax credits, even if their kids were born in the U.S. and are citizens.

Congress reduced immigrants' access to public benefits in 1996 with the welfare reform law. But in the past two decades, it restored or increased access to some public benefits, such as food stamps and health insurance for children who are legal permanent residents. The Trump order would reverse that trend.

According to the order, immigrants -- both legal and undocumented -- are more likely to use public benefits. That's true in general but not when taking income into account. Research by the National Academies of Sciences, Engineering, and Medicine, the right-leaning Cato Institute and the left-leaning Center for American Progress have all found that low-income immigrants are less likely to use public benefits than low-income U.S.-born individuals.

-From Governing.com
-See additional coverage from the Washington Post.

At the request of the National Consumer Law Center, joined by the Office of the Attorney General and state's utility companies, the Department of Public Utilities has extended the winter moratorium through April 1 for 2017 (without the extension it would end on March 15). The winter moratorium prohibits utility companies from terminating heat-related utility service for low-income customers.

The notice states that companies should refrain from sending second requests for payment until April 1, 2017. Since April 1 falls on a Saturday this year, those second notices will probably not go out before Monday, April 3. Final notices will probably not go out until the last week of April. All of this means that low-income customers who have winter moratorium protection will not be terminated prior to around the end of April. (The exact date will vary a bit from company to company and customer to customer, depending when the notices are actually mailed).

Despite the fact that the winter moratorium protects customers from being terminated, it is in a low-income customer's interests to make regular payments, no matter how small. Customers who pay zero all winter are likely to be the ones terminated first, once the moratorium ends. Low-income customers who are behind on their bills should make sure to apply for fuel assistance (LIHEAP), get on the low-income discount rate, sign up for the Arrearage Management Program (AMP) or assert any other shut-off protections for which they are eligible.

-Adapted from DPU extends winter moratorium thru to April 1, utilitynetwork@lists.nclc.org, on behalf of Charlie Harak, National Consumer Law Center, February 07, 2017.

In a months-long investigation into pricing and marketing in the funeral business, also known as the death care industry, NPR spoke with funeral directors, consumers and regulators. We collected price information from around the country and visited providers. We found a confusing, unhelpful system that seems designed to be impenetrable by average consumers, who must make costly decisions at a time of grief and financial stress.

Funeral homes often aren't forthcoming about how much things cost, or embed the information in elaborate package deals that can drive up the price of saying goodbye to loved ones.

While most funeral businesses have websites, most omit prices from the sites, making it more difficult for families to compare prices or shop around. NPR reporters also found it difficult to get prices from many funeral homes, and federal regulators routinely find the homes violating a law that requires price disclosures.

For example Service Corporation International (SCI) is a multibillion-dollar company traded on the New York Stock Exchange. The Houston-based firm claims 16 percent of the $19 billion North American death care market, which includes the U.S. and Canada. Company documents say it has 24,000 employees and is the largest owner of funeral homes and cemeteries in the world.

In Jacksonville, SCI sells cremations under the Hardage-Giddens/Dignity Memorial brand at large, luxurious funeral homes. The company also sells them for lower prices at strip-mall storefront outlets under other brands such as Neptune Society and National Cremation Society.

In communities around the country, it's common to find wide swings in prices for funeral services. The cremations are all the same, but some will cost much more than others, depending on where the consumer made the arrangements, and which of the company's brand names appears on the invoice.

"That to me, starts to cross a line into consumer deception," says Joshua Slocum, executive director of the Funeral Consumers Alliance, a death care industry watchdog group based in Burlington, Vt.

-See the full NPR story on the WBUR website.

A recent initiative of the Healthcare Transformation Lab at Massachusetts General Hospital, the new Interactive main campus map is now on the Mass General website. The map can highlight specific campus and area amenities, parking and transportation. Users can search the map, obtain walking directions between specific points and print.  Find it from the main Massgeneral.org website under Visit Us.

It’s that time of year again...

The Volunteer Income Tax Assistance (VITA) program offers free tax help to people who generally make $54,000 or less, persons with disabilities, the elderly and limited English speaking taxpayers who need assistance in preparing their own tax returns. The IRS-certified volunteers are able to provide free basic income tax return preparation with electronic filing to qualified individuals

In addition to VITA, the Tax Counseling for the Elderly (TCE) program offers free tax help for all taxpayers, particularly those who are 60 years of age and older, specializing in questions about pensions and retirement-related issues unique to seniors.The IRS-certified volunteers who provide tax counseling are often retired individuals associated with non-profit organizations that receive grants from the IRS. VITA and TCE sites are generally located at community and neighborhood centers, libraries, schools, shopping malls and other convenient locations across the country. 

Before going to a VITA or TCE site, see Publication 3676-A for services provided and check out the What to Bring page to ensure you have all the required documents and information our volunteers will need to help you. 

• To locate a VITA or TCE site or use the VITA Locator Tool  http://irs.treasury.gov/freetaxprep  or call 800-906-9887.

Note: Available services can vary at each site due to the availability of volunteers certified with the tax law expertise required for a particular return.

A majority of the TCE sites are operated by the AARP Foundation's Tax Aide program. To locate the nearest AARP TCE Tax-Aide site between January and April use the AARP Site Locator Tool or call 888-227-7669. Or see this list of 2017 VITA/AARP Free Tax Preparation Sites in Massachusetts.

Consumers are also encouraged to visit the Health Connector's Tax Filing page for other helpful resources and information:   https://www.mahealthconnector.org/taxes

 -Adapted from Health Connector Tax Communications & VITA-AARP Site Listing, 2/17/17, MA Health Care Training Forum e-mail, February 17, 2017.

Massachusetts has a new resource for low income people who need help with civil (non criminal) legal problems -- Mass Legal Answers Online: www.masslao.org  

Mass Legal Answers Online is part of the national Free Legal Answers project sponsored by the American Bar Association, and is being managed by the Massachusetts Law Reform Institute, with assistance from the Volunteer Lawyers Project.

Low income Massachusetts residents create an account on the secure website, then log in and post their legal questions. Volunteer lawyers answer the questions through the same website. There is no charge to use this service. People can access the site from anywhere that they have internet access, including smart phones.

Mass Law Reform or local Legal Services agencies are likely to be able to answer questions about public benefits more readily than private bar members. Some examples of situations when your low income clients may want to use the site:

• questions about public benefits eligibility and advocacy
• seeking basic information about their rights in an eviction or bad conditions in their apartment
• how they can defend themselves against debt collection
• advice if they have a claim against an employer who failed to pay them for hours worked
• brief questions about a divorce, a child custody matter or child support

Questions will be answered via the site -- the volunteer attorney won't be able to talk with clients by phone, represent them in court or prepare paperwork.

Eligibility

To qualify for this assistance, clients’ income must be at or below 250% of the federal poverty guidelines. They can only ask questions related to non criminal law issues, and can't already have another attorney.

Please note that MLAO is not able to answer queries from advocates- clients must create the account and ask the question themselves.

Attached is a flyer you can give to clients.

-Thanks to Rochelle Hahn, Co-Director, Massachusetts Websites Project, MLRI for her assistance with this article.

MassHealth is now imposing an asset limit of $120,900 for spouses of elders seeking eligibility for the Home and Community Based Serices Waiver (the "Waiver).

This applies to anyone who began Waiver services after January 1, 2014.  The Waiver provides services in the areas of:

• Home Care Aides
• Personal Care Services
• Skilled Nursing
• Housekeeping and Laundry
• Companion Services 
• Meal Delivery 
• Grocery Shopping and Transportation 

MassHealth is imposing the eligibility criteria for current applicants and for anyone who enrolled in the program after January 1, 2014.  MassHealth is not reviewing the eligibility of those who enrolled before that date.

The Waiver program provides the Commonwealth’s low-income and frail elders with the long-term care services and supports they need to remain living safely in their homes.  Some of the services provided under the Waiver are home care aides, personal care services, skilled nursing, housekeeping, laundry, companion services, meal delivery, grocery shopping and transportation.  Until now, a healthy spouse’s assets were not counted in determining an applicant’s eligibility for the Waiver.  This is no longer the case.

-See the full Margolis & Bloom blog post.

MassHealth will sunset its antiquated Automated Voice Response (AVR) system this spring. The AVR, which is currently used by providers to check member eligibility, will no longer be available on or after June 4, 2017. Providers are encouraged to utilize the Provider Online Service Center (POSC) direct data entry (DDE) or to submit the 270/271 Eligibility Inquiry and Response transaction to check member eligibility. 

If you have any questions regarding the sun-setting of the AVR, please contact the MassHealth Customer Service Center at 1-800-841-2900 or EDI@MAHealth.net. 

-From MA Health Care Training Forum e-mail, February 27, 2017.

IRS Will Accept Returns Silent on Insurance Coverage

The Internal Revenue Service has become the first agency to follow President Trump’s directive to start undermining the Affordable Care Act. In a quiet rule change, but an important one, the IRS has told tax preparers and software firms that it won’t automatically reject tax returns that fail to state whether the tax filer had health insurance during the year. That effectively loosens enforcement of the ACA’s individual mandate. It appears to be a direct response to Trump’s Jan. 20 executive order requiring federal agencies “minimize...the economic and regulatory burdens of the Act.”

The LA Times observed at the time that the executive order would cripple ACA insurance exchanges, not only by signaling the Trump Administration’s open hostility to Obamacare, but by kicking a leg out from the regulatory stool supporting the act.

The IRS action is the first manifestation of that. The agency hasn’t announced its rule change publicly, but it was picked up by Peter Suderman of Reason and Kathleen Pender of the San Francisco Chronicle, who both reported it this month. 

In an emailed statement, the IRS said that it was acting in direct response to the executive order, which it said “directed federal agencies to exercise authority and discretion available to them to reduce potential burden. Consistent with that, the IRS has decided to make changes that would continue to allow electronic and paper returns to be accepted for processing in instances where a taxpayer doesn’t indicate their coverage status.” 

The ACA requires individuals to carry health insurance or pay a penalty of as much as $695 per adult and $347.50 per child under 18. Line 61 of IRS Form 1040 requires taxpayers either to check a box certifying that family members had coverage during the year, or to enter their penalty, which is calculated on a separate form.

Starting this year, the IRS was planning to reject returns automatically that left line 61 blank, known in agency parlance as “silent” returns. That would give taxpayers an early warning — for electronic filers, an almost instant warning — that they might be in violation of the individual mandate.

But early in February, the agency told tax-preparation firms that it was reversing the rule and would continue to accept returns that were blank on line 61. The agency didn’t announce its policy to the general public, but word spread rapidly in the tax-preparation community. Drake Software, which produces tax preparation software for accountants, posted a notice of the rule change on Feb. 9 and updated its program to allow for e-filing of client returns without filling in line 61.

The IRS statement notes that its rule change doesn’t alter taxpayers’ responsibility to obtain health insurance and pay any penalty for noncompliance:  “Legislative provisions of the ACA law are still in force until changed by the Congress, and taxpayers remain required to follow the law and pay what they may owe‎.” The agency says that although silent returns won’t be automatically rejected, they may eventually be questioned by the agency and the penalty assessed.

The practical effect of the IRS rule change is impossible to gauge. Tax year 2016, for which the standard filing deadline is this coming April 18, is the first year for which the agency was planning to reject silent returns. 

Confusion over Republican plans for the repeal of the Affordable Care Act already has roiled the individual insurance marketplace. Humana, which covers 150,000 ACA customers in 11 states, announced this month that it would pull out of that market entirely next year. Aetna, which already had reduced its individual customer base to about 240,000 this year from 965,000 at the end of 2016, also has signaled that it may be entirely out of the market starting in 2018. Aetna cited the uncertainty about the market’s future coming from the Trump White House and the GOP-controlled Congress. Aetna and Humana had been planning to merge, but their deal was blocked by a federal judge in January. 

-See the full LA Times article.

Shorter ACA Enrollment Period Proposed

The Department of Health and Human Services this month made its first substantive proposals to change the marketplaces for individual coverage, commonly known as Obamacare.

The proposed rules aim to keep insurers in the market during a transition to a new system. One way is to tighten up when people can sign up for coverage.

HHS's proposed changes are designed to make the individual health care market less vulnerable to gaming by consumers. Insurance companies have complained that many people delay signing up until they're sick and then drop coverage after getting care.

The administration's proposals include cutting the annual open enrollment period to about six weeks instead of three months — to reduce the number of people who buy a policy because they find out about a health issue during that time.

HHS will also require people who want to sign up for coverage during so-called special enrollment periods to first prove they qualify because of a life change like losing a job or getting divorced.

"The overall effect of many of the policies here would actually, over time, I think, actually shrink enrollment, not grow enrollment," says Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms.

The rules would make it harder to enroll, and adding more paperwork will just turn off more people, she says, citing research into Medicaid and other public benefit programs.

And the people who leave are likely to be the healthier ones, making the situation even worse for insurance companies. "Your healthy people are the ones who are going to be more likely to say, 'Oh, this is too much of a pain in the neck. I'm not going to go through with this,' " Corlette says. According to the New York Times, the administration acknowledged that the shorter sign-up period “could lead to a reduction in enrollees, primarily younger and healthier enrollees” who often sign up near the deadline.

Loosened Coverage Standards and Requirements to Pay Old Premiums

The HHS proposal also allows insurers to increase deductibles and copayments, by loosening the standards of coverage. Right now plans are rated in terms of what proportion of the costs a customer pays. The new rules would widen the band by 2 percentage points, so that a plan that's marketed as covering 60 percent of health costs could actually pay for as little as 56 percent of those.

The proposal also says insurance companies can demand consumers pay off any missed premiums before they get a new policy.

Today, a consumer can enroll in a plan, pay for just one month and then continue coverage for 90 days before getting cut off. The following year, the insurance company has to write a new policy even if the person hasn't paid for those three months.

Insurers and Republican members of Congress welcomed the proposed changes, which were to be published in the Federal Register this month, giving the public until March 7 to comment. Final rules are likely to be issued in March or April. Insurers must decide by early May what kinds of health plans they will offer in 2018.
But insurers cautioned that the proposed rules, while helpful, would in no way provide a solution if, in a few weeks, Republicans introduce legislation to repeal major provisions of the Affordable Care Act, such as the requirement for most Americans to have coverage.

Caroline Pearson, senior vice president at consulting firm Avalere, says the combined actions by HHS and the IRS could lead healthy people to drop their insurance coverage. "In total, I actually think the exchange market is going to shrink in size, dramatically, as a result of both the rule and the IRS move."

Christopher W. Hansen, the president of the advocacy arm of the American Cancer Society, said the tighter restrictions on special enrollment periods could “cause problems for cancer patients,” delaying treatment and reducing their chances of survival.

-See the full NPR story.
-See the full The New York Times article.

In December, the Centers for Medicare & Medicaid Services (CMS) finalized a demonstration program that will test new ways for Medicare to pay hospitals that perform heart or hip surgeries. Under the new model, Medicare will pay participating hospitals one payment, known as a “bundled payment,” for a person’s hospital stay and the 90 days following a heart attack, cardiac bypass surgery, or surgical hip treatment. The hospital stay and 90-day post-stay period together are known as an “episode of care.” As part of this demonstration, CMS announced the creation of an ombudsman to serve people with Medicare in this model and other similar programs—a move applauded by the Medicare Rights Center.

Bundled payments are designed to enhance the overall quality of care provided by creating new incentives for hospitals to better manage and coordinate patient care. These payments are coupled with quality measures to assess how well hospitals are providing care to patients. If hospitals spend resources efficiently, while also performing well on quality, they can receive higher payments known as “shared savings.”

Medicare Rights has been generally supportive of value-based demonstrations like this one, because we believe they can benefit both taxpayers—by spending Medicare dollars more wisely—and people with Medicare—by improving people’s care and well-being. Still, we often urged CMS to rigorously monitor patient experiences in these new care models and to more thoroughly educate people about how their care may or may not change and what their rights are as a Medicare recipient.

An ombudsman can serve as an effective, centralized resource for this monitoring. Typically, ombudsman programs track questions and complaints, troubleshoot and resolve beneficiary problems, and provide systemic data and information about what’s working in a program as well as what can be improved.

Following Medicare Rights’ recommendation, CMS committed to developing a new ombudsman program, the Alternative Payment Models Beneficiary Ombudsman, devoted to ongoing and emerging care models. CMS says this ombudsman will complement and work closely with other CMS entities that help beneficiaries navigate their coverage and care, including 1-800-MEDICARE, the Medicare Ombudsman, and Quality Improvement Organizations (QIOs).

With a new President, the fate of bundled payments and other care models is somewhat unclear. The new Administration could choose to move ahead with these promising programs, significantly or minimally change them, or choose not to carry them forward at all, after seeking public comment.

-See the full Medicare Rights Center blog post.  

The Centers for Medicare and Medicaid Services (CMS) requires that sponsors of Medicare Part D prescription drug plans provide beneficiaries with access to transition supplies of needed medications to protect them from disruption and give adequate time to move over to a drug that is on a plan’s formulary (medication list), file a formulary exception request or, particularly for Low Income Subsidy (LIS) recipients, enroll in a different plan.

Transition rules apply to stand-alone Medicare Prescription Drug Plans (PDPs), Medicare Advantage Plans with Prescription Drug Coverage (MA-PDs), and Medicare-Medicaid Managed Care Plans participating in the Dual Eligible Financial Alignment Demonstrations.

Transition rules are particularly important for low-income beneficiaries who were automatically reassigned to new plans, which may or may not cover their medications.

In addition, all plans change their formularies each year, so even people who remain in the same plan may find that their plan no longer covers their medications or has newly imposed utilization management requirements.

To assist advocates with transition issues, this fact sheet sets out the CMS minimum requirements for all plans.

-From Justice In Aging.

More than half of Bay State seniors are struggling to pay for housing, food and health care as the cost of living in Massachusetts continues to surge, a troubling trend that has elder advocates calling for legislation aimed at ensuring that older residents who worked their whole lives aren’t falling through the cracks.

The Bay State has the second-largest population of elderly residents who are scraping to get by, second only to Mississippi, according to the 2016 Elder Economic Security Standard Index, which was compiled by UMass Boston professor Jan Mutchler. And though the index shows our local elders are having a harder time than most, it also highlights that the issue is widespread — with an average of 53 percent of older adults who live alone falling into poverty or already living in it.

The sobering figures were released as city officials are preparing to release a three-year plan aimed at making Boston more age-friendly and exploring how best to assist older residents with housing, transportation, social activities and health care, according to Elder Affairs Commissioner Emily Shea. That report is expected over the next few months, she said.

 “I think Social Security is the core of what a lot of people rely on, but it hasn’t kept pace,” said Massachusetts Senior Action Council Executive Director Carolyn Villers. “Pensions have been cut back. Expenses have gone up much faster and the cost of housing and health care are particularly challenging for folks.”

In the hopes of reversing the troubling trend, the American Association of Retired Persons is spearheading an effort to lobby congressional leaders from coast to coast to protect Social Security and Medicare benefits, according to AARP Massachusetts director Michael Festa.

“Every delegation in the country has been contacted,” Festa said. “We’re encouraging members all around the country to visit their Congress people and deliver the message that Medicare needs to be protected.”

And the fight to make changes at the state level is being led by the recently formed Coalition for Elder Economic Security, a group of Bay State elder advocacy organizations, including the AARP and the Massachusetts Senior Action Council, that is lobbying for a handful of policy proposals — including a push to up the asset limit for seniors to qualify for MassHealth, increasing income eligibility for the Medicare Savings Program, and creating a common application for benefit programs.

-See the full Boston Herald article.

Ashish Jha, MD, is an internist at the VA Boston Healthcare System, a professor of health policy at the Harvard T.H. Chan School of Public Health, and director of the Harvard Global Health Institute. Here he details his experience on a high-deductible health plan.

Enrollment in high-deductible health insurance plans has exploded over the past five years. I’m learning the hard way how these plans do — and do not — work.

About one-third of American workers covered by health insurance are now in high-deductible health plans, in which the policy holder pays a substantial portion of the cost of health care services out of pocket before insurance coverage kicks in. Many economists and health policy experts believe that these plans are a promising way to reduce health care spending.

So when a high-deductible plan became available through my employer, Harvard University, a couple years ago, I decided to enroll my family in it. If this is going to be a big national experiment, I thought that I, as a physician and a health policy scholar, ought to know what it’s like to live with this kind of health insurance. Debra, my wife, was not convinced.

While I am a proponent of experiments and evidence, Deb wasn’t interested in including our kids in this one. The notion of having to think about shopping for health care if any of us got sick wasn’t attractive to her. But if we stay healthy all year, I argued, we would actually come out financially ahead.

She reminded me that we have plenty of other reasons to stay healthy all year, and the potential financial savings didn’t feel like a particularly compelling additional reason. Defeated by her logic, I turned to pleading.

I made the point that we had a lot of advantages in navigating the health care system effectively and that she and I should go about making the same health care decisions that we would have otherwise. She relented.

My family is now in its second year under a high-deductible plan. That means we are responsible for paying the first $6,000 of our health expenses for the year, for everything from a doctor visit for a flu shot to surgery.

It has been an educational enterprise.

Our experiment is showing me again and again that it’s extremely hard to be a health care consumer in Massachusetts — just as I’m sure it is in other states. Want to know how much a particular type of health care costs, like a visit to a specialist or getting a minor surgery? Good luck figuring it out. My insurance company’s online tool was hard to use and, even as a physician, I could almost never guess what sets of services a visit to the doctor might generate. What’s more, there was no useful information about the quality of care. Price information without quality information is not particularly helpful when shopping for medical care.

The second lesson was that being a health care consumer is stressful, at least the way the system is currently set up. Here’s an example. Our son had surgery last year. We got a call saying it was time for his one-year follow-up. Deb stressed for nearly two months over whether or not to make the appointment. Of course she wants our son to get the care he needs, but did he truly need this follow-up? That’s both the promise and the peril of high-deductible plans — they are supposed to make you think twice about consuming health care.

She eventually went with our son for his one-year follow-up — they spent two minutes with the surgeon — and paid $465 for the visit. I’m not sure my son, or my spouse, felt any better afterward. There were many examples like this sprinkled throughout the year, but the most profound one was the one I experienced for myself.

I have supraventricular tachycardia, a common heart rhythm problem. When it hits, my heart races at about 180 beats per minute. It comes on a couple of times a year, lasts a few minutes, and usually isn’t a big deal. But one morning I woke up with my heart racing. After 30 minutes, I wondered if I should go to the emergency department, knowing that I’d probably get stuck with a multi-thousand-dollar bill. So I kept waiting. After an hour, during which my heart kept beating furiously, my chest started to hurt. I knew what that meant — I was at risk of having a heart attack.

Deb asked me what I would tell a patient in this situation. That was easy: I’d tell him or her to call 911. But I kept waiting. Finally, about 15 minutes later, the abnormal rhythm finally broke and I felt my heart calm down. I was lucky — I had rolled the dice and things had worked out.

That brings me to the third lesson of high-deductible health plans, the lesson of what didn’t happen — I didn’t really have a choice of where to go for treatment.

Imagine that for dinner on any given night, your two choices were eating at a very expensive gourmet restaurant or not eating at all. I bet that more of us would forgo dinner a lot. (Thank goodness we have a range of options.)
The US health system is something like that. During my heart rhythm problem, I realistically had only one choice — going to the emergency department. Knowing that they are usually the only option, hospital administrators make emergency departments super expensive.

One promise of high-deductible plans is that if we have a real market for health care, we will see lots of innovation, including different types and levels of urgent care centers. But that hasn’t happened.
During my heart episode, all I really needed was a place that had a heart monitor and that stocked common, inexpensive rhythm-restoring heart medicines. The real cost should have been $200 to $300. If I had known that such a place existed, I would have gone there. But this mid-price range of options is rarely available in health care. So I skipped it. And that’s what people are doing under high-deductible plans — skipping needed care.

Here’s my major takeaway so far from this ongoing experiment: Simply asking people to pay out of pocket for their health care doesn’t create a health care marketplace. If we are going to be serious about creating one, we have to generate much more innovation in care delivery models, including much more leeway on the scope of practice regulations, such as letting nurses do a lot of the things that only doctors can do today.

We must be much more aggressive about price transparency and make quality data ubiquitous. The way we’re doing it now, even I as a doctor and a health policy expert can’t figure out when I or my family’s needs are worth the expense.

If we continue with high-deductible health plans the way they exist today, more and more people will experience what my family did — the stress of having to make medical decisions with little information and few choices. At best, we’ll have a health care system that might save a little money — but at the risk of harming the health of our citizens.

-From Stat News.

The annual policy research conference of the National Academy of Social Insurance (NASI) recently met in Washington and focused on the group's new report to the Donald Trump administration and Congress on the future of all our social insurance programs - those that cover retirement, but also those that protect the disabled, jobless, impoverished and frail.

NASI is a consortium of many of the nation's top social insurance researchers. The new report includes input from 80 experts in the field with a wide array of ideological and political perspectives. It describes the challenges facing these programs and provides a menu of solutions reflecting a variety of ideological perspectives.

As such, it reflects a set of consensus facts that should inform the looming debates about the future of social insurance at a time when these programs certainly will be under assault from budget cutters.

Here are a few facts on Social Security and Medicare:

FACT: Social Security benefits already have been cut. Raising the retirement program's full retirement age to 70 is mentioned often as a way to solve the program's long-term imbalance between costs and revenue. But did you know that Social Security benefits already are scheduled to be cut 24 percent? That is the average cumulative reduction in enrollee benefits by 2050 due to reforms passed by Congress in 1983, driven mainly by a gradual increase in full retirement ages from 65 to 67.

Since Social Security cannot deficit-spend as a matter of law, legislative reform will be needed by 2034 in order to avoid an immediate 21 percent cut in benefits. The reforms could include new revenue to the system, benefit cuts or a combination of both. Raising the retirement age to 70 would effectively cut benefit payouts by raising the bar on the age an enrollee must reach to receive her full benefit.

Raising the retirement age would whack benefits further, and we have much better options, including lifting the cap on wages subject to property taxes, or raising payroll tax rates very gradually.

FACT: Social Security matters to high-income households. We will hear calls to transform it into a means-tested program for the poor. But Social Security is the largest source of income for a majority of retired workers and their surviving spouses.

Eighty-four percent of all people over 65 and about 90 percent of surviving spouses over 65 receive income from Social Security, and for three-fifths of them, Social Security makes up at least 50 percent of their income. "Many upper middle class people assume that it's mostly important for poor people, but that's not the case," said Benjamin Veghte, NASI's vice president for policy.

Proposals to restore solvency by means-testing Social Security would tear at a core design feature - its universality. At a time when a majority of households have not been able to save adequately for retirement, Social Security will remain critical.

Medicare: No Cause for Alarm

FACT: Medicare is not facing a financial crisis. Politicians pushing Medicare reforms often claim that the program is teetering on the brink, but the NASI researchers conclude otherwise.

Let us start with the basics on how Medicare's various "parts" are funded. Part A (hospitalization) is funded mainly by a 2.9 percent payroll tax split by employers and workers. For Parts B (outpatient services) and D (prescription drugs), 75 percent of funding comes from general federal revenue, with the remainder funded by enrollee premiums.

The Hospital Insurance trust fund that finances Part A can meet all its obligations through 2028, according to the program's trustees. At that point, incoming revenue would cover 87 percent of expected costs, so there is a need to close the shortfall with additional revenue, less spending or a combination of the two.

But the NASI experts note that historical trustee projections regarding how soon the trust fund will become insolvent have varied widely - as little as two years, and as much as 28. "There's no big cause for alarm in the current projection," said Veghte.

Parts B and D cannot run out of money because they have permanent appropriations to cover whatever premiums do not. The cost of those programs will grow in the years ahead as the population ages, and as healthcare costs rise - especially prescription drugs. But that trend is not driven by Medicare itself, but by the cost of healthcare.

Overall Medicare spending is not out of control - per-enrollee outlays rose at an average annual rate of 5.5 percent, somewhat slower than the 6.3 percent average annual growth rate in private insurance spending per enrollee between 1989 and 2014. In addition, cost containment measures within the Affordable Care Act improved the outlook substantially, pushing the insolvency date out by 11 years.

"The problem really is healthcare cost, and how to control it," said Veghte.

The 200-page report is exhaustive, thorough and authoritative. I encourage anyone interested in the facts on any of our social insurance programs to download it and read. You can find it here.

- The Facts About Social Security, Medicare May Surprise You. Medscape. Feb 02, 2017.

The Trump administration is rescinding protections for transgender students in public schools.

The move by the Justice and Education departments reverses guidance the Obama administration publicized in May 2016, which said a federal law known as Title IX protects the right of transgender students to use restrooms and locker rooms that match their gender identities.

The decision would not have an immediate impact on the nation’s public school students because a federal judge had already put a hold on the Obama-era directive. And in Massachusetts state law should protect Transgender students.

But this month the two federal departments said the Obama documents do not "contain extensive legal analysis or explain how the position is consistent with the express language of Title IX, nor did they undergo any formal public process. This interpretation has given rise to significant litigation regarding school restrooms and locker rooms."

A letter issued by the departments also says there "must be due regard for the primary role of states and local school districts in establishing educational policy."

About 150,000 young people ages 13 to 17 identify as transgender, according to the Williams Institute at the UCLA School of Law.

Civil rights groups say they worry that the reversal could lead to bullying and violence against vulnerable transgender kids.

When then-President Barack Obama issued the guidelines last year, the White House directed schools to allow students to use the restrooms and locker rooms that match their gender identities, citing a federal law that protects students from gender discrimination.

As NPR's Scott Horsley reported, the Obama administration "warned that schools that defied the recommendation could be at risk of losing federal funds. Thirteen states challenged the Obama guidelines, and a Texas judge put them on hold."

That administration said the directive was meant to help school districts avoid running afoul of civil rights laws.

Under Obama, the Department of Justice sued the state of North Carolina over its so-called bathroom law, which prohibits municipal governments in the state from passing laws protecting the rights of transgender people. It also requires trans people in government facilities to use the bathroom corresponding to the sex on their birth certificate.

North Carolina has lost business over the law, including NCAA championship events that were scheduled to be held in the state.
State legislatures in New Hampshire, Colorado and Texas, among other states, have also considered bills that would restrict access to restrooms for transgender people.

On March 28, the Supreme Court is scheduled to hear oral arguments in a lawsuit filed by a high school student in Virginia. As NPR's Nina Totenberg has reported:

"Gavin Grimm, a 17-year-old senior in Gloucester County, [Va.] ... came out as transgender when he was a freshman in high school. The school principal allowed him to use the boys' bathroom, until some parents complained, and the school board adopted a policy that required students to use the bathroom that corresponds with their biological sex, or a separate single-stall restroom office."

Grimm sued the school board. His lawsuit argues the bathroom policy is unconstitutional under the 14th Amendment and violates Title IX of the U.S. Education Amendments of 1972, which prohibits sex discrimination by schools.

The American Civil Liberties Union's James Esseks says in a statement:

"While it's disappointing to see the Trump administration revoke the guidance, the administration cannot change what Title IX means. When it decided to hear Gavin Grimm's case, the Supreme Court said it would decide which interpretation of Title IX is correct, without taking any administration's guidance into consideration. We're confident that that the law is on Gavin's side and he will prevail just as he did in the Fourth Circuit."

Massachusetts Law Protects Students

In Massachusetts, however, those students may not be impacted by the decision like those in other states. That’s because Gov. Baker in July signed into law a transgender public accommodations law that allows people in Massachusetts to use bathroom facilities based on their gender identity. The governor signed the state law after months of criticism for his ambiguity on the controversial issue.

-See the full NPR story.
-Additional material from the Boston Globe.

Emergency rooms are not meant, of course, to serve as emergency housing.

But hospital officials and some advocates for homeless families say that the number of homeless families turning to emergency rooms — and not the state — for shelter is on the rise. And data reviewed by WGBH News suggests an increase in the proportion of families turning to state shelter in Massachusetts —the only “Right to Shelter” state in the country — after having already gone without adequate shelter.
It’s hardly an ideal solution for anyone. Families, Dr. Lois Lee, an emergency medicine physician at Boston Children’s Hospital, notes, risk exposure to contagious disease. Children could witness traumatic events in E.R. Lee says she regularly sees probably between ten and fifteen families a month, and similar reports have surfaced at other area hospitals. And the number of these families appears to be growing.

Since Lee and her colleagues began collecting data on these visits, about eight years ago, the number of families reporting to the Children’s Hospital E.R. because they were homeless has grown from just seven families showing up without a place to sleep in 2012 — to some one hundred forty families in 2015. In just the first two months of 2016, the last for which they collected data, they saw over forty families — about the same number who showed up all year in 2013.

What the numbers don’t explain is: why?

Some advocates for homeless families blame changes made years ago to the state’s “Emergency Assistance” program for homeless families — as well as a recent push by Governor Charlie Baker to eliminate the use of hotels and motels as emergency housing.

State officials, meanwhile, deny those claims and emphasize that families facing homelessness are placed in the state’s Emergency Assistance program “presumptively,” — with an assumption, in other words, of eligibility for assistance.

Massachusetts is the only state in the country that guarantees that homeless families be provided shelter, at the state’s expense, immediately.

But a 2012 change to the law spelled out certain eligibility criteria, including fleeing domestic abuse, fire or natural disaster, eviction, substance abuse or safety threats — or having spent the previous night in a place “not meant for human habitation.”

It’s that last threshold that has caused the most controversy.

Prior to the change, said Kelly Turley, director of legislative advocacy for the Massachusetts Coalition for the Homeless, families who found themselves suddenly upended from housing — kicked out of a friend’s house, for example — “would apply for shelter and they would be placed that night.” “But now they have to wait to show that they’ve gone to the extreme of staying in an unfit place,” Turley said — like an emergency room.

Paul McMorrow, a spokesman for the state Department of Housing and Community Development, says that families are placed in the state’s Emergency Assistance program “presumptively,” — with an assumption that they are eligible — and that no family should ever feel forced to approach an emergency room for shelter. McMorrow said the Department has met with hospital officials to work on the issue.

Some critics of the state’s apparatus, meanwhile, point to another change in the landscape of shelter for families: the rapid decline of the state’s use of hotels and motels as temporary housing. Under a directive by Governor Charlie Baker the state has gone from housing over fifteen hundred families in hotel rooms just over one year ago to fewer than ninety now. The use of hotels has long been controversial, and there is widespread agreement that they are hardly ideal shelter for families.

But as the use of hotels has dwindled, while some capacity has been replaced with shelter units — not all of it has (the state has increased the use of vouchers and other programs to “divert” families who might otherwise become homeless).

In December, the nonprofit law firm Greater Boston Legal Services sued the state’s Department of Housing and Community Development, which oversees the state’s Emergency Assistance program, alleging, in part, that in its push to end the use of hotels the state has been failing to meet its legal obligations to house families.

State officials forcefully dispute the claim that eligible families are being turned away and say that the department is meeting its obligations under the law.

State data reviewed by WGBH News does not indicate that the state’s placement rate for homeless families has changed substantially over the last year (though critics contend that the numbers don’t include families turned away before they apply).

But the proportion of families seeking shelter after having stayed in a place “not meant for human habitation” did increase, according to state records — from 11 percent in 2015 to 19 percent last year.

Legislation recently submitted by State Representative Marjorie Decker, of Cambridge, would change the program’s requirement language, removing the criteria of having already spent the night in an unsafe place. “The idea that someone who is not really entitled to emergency shelter wants to spend one night voluntarily in a shelter, with their children —” said Decker, “To suggest that they have a better alternative, but they’re not choosing it, is absurd.”

New Report Finds Increase in Family Homelessness

A report released late this month also sheds some light. Since 2008, Massachusetts has experienced one of the highest increases in family homelessness in the U.S., according to the Boston Foundation report.

Massachusetts is one of just two states -- the other being New York -- where more than half the homeless population is comprised of families. There are also a growing number of families with two spouses entering the state's shelter system -- 20 percent of families in shelter in fiscal 2016 had two adults, compared to just 8 percent in fiscal 2008.

Recent data suggest that that the number of people entering or returning to the shelter system is declining, but the length of stay in shelter is increasing to an average of nearly a year statewide. The longest shelter stays are in the Boston area. This is likely due to factors including the high cost of housing and the limited availability of public subsidies.

Read the full report.

-See the full WGBH story
-See the full MassLive story

This month Republicans released their latest proposal outlining their ideas to repeal and replace the Affordable Care Act. This proposal radically changes the Medicaid program by capping the amount states will receive in federal funding to deliver healthcare to low-income individuals. These capped proposals, either block grants or per-capita allotments, aim to catastrophically cut Medicaid and eliminate important consumer protections currently in place.

States will be forced to make difficult choices regarding what services they can deliver and what populations they will be able to serve, placing increased pressures on state budgets. Crucial programs that allow seniors to age at home rather than receiving care in institutional settings are at risk.

This latest replacement proposal does not come close to the improved coverage and affordability offered through the ACA for older adults. The plan will increase the cost of care and limit access to health care for older adults, especially low-to-middle income older adults. Specifically, the plan decreases tax credits, reintroduces high-risk pools for the most sick, and increases the availability of health savings accounts that provide little benefit for low to middle income consumers.

Justice in Aging has developed a new fact sheet showing how cuts to Medicaid through capped Medicaid funding would hurt older adults. For more detailed information on how capped funding would impact older adults, see the issue brief.

-From How Medicaid Caps Ration Care for Older Adults, Justice in Aging, February 17, 2017.

Commentary on WBUR’s CommonHealth blog from Dr. Elisabeth Poorman, a primary care physician in Everett.

The young woman sat in the corner of my exam room, facing away from me as I asked her questions. Her answers were short. "I’m from El Salvador." Why did she come? "Because of the violence." Her voice was flat. Her hands trembled. I knew she had suffered terribly and I needed to ask her how.

Slowly, quietly, she recounted the gang violence she had fled in El Salvador. The assault she’d been too afraid to tell her family about lest they be targeted. The death threats to her children that finally led her to seek asylum in the United States.

"They can do what they want to me," she said. "But they are not going to hurt my children." She gradually met my eyes as hers filled with tears.

As my patient unburdened herself, I was grateful for her trust. I knew that there were hundreds more young women like her who were afraid to set foot in the clinic.

I wanted to reassure this patient that she would be safe in the clinic with me and safe when she went back to her home in Everett. But as awareness of the world outside filled the space between us, I wasn’t sure I could.
On Jan. 25 President Trump signed an executive order that calls, among other things, for a 50 percent increase in the number of Immigration and Customs Enforcement (ICE) officers; the expanded use of detention centers; and the use of local law enforcement officers to enforce immigration policy. Officers will be allowed to deport immigrants who have been charged with any crime, even if they haven’t been convicted.

Two days later, the president signed another executive order which banned all refugees from any country for three months, and any type of travel from seven predominately Muslim countries. Courts have suspended that second order, but the first remains in place.

Meanwhile, on Tuesday, the Trump administration published new Department of Homeland Security rules that greatly expand the number and classes of people who can be deported.

For those who have worked with immigrants for years, it is difficult to explain how the current situation differs from the last 20 years. Both President George W. Bush and President Obama massively increased deportations — sending home 2 million and 2.5 million people, respectively, a huge increase over previous years. They created an efficient system for removals which our current president has inherited.

But under the Obama administration, "deportations were typically done under a Priority Enforcement Program," said Liza Ryan of the Massachusetts Immigrant and Refugee Advocacy Coalition. Priority was given to those who had committed serious crimes, had recently entered the country, or were deemed a threat to national security. Now, under the executive order currently in force, "they basically don’t have priorities. It’s so extremely broad that it basically encapsulates everyone," she told me.

My medical school in Atlanta didn’t offer a class on immigration policy. We discussed politics between classes. Taking care of a diverse population in Georgia, our first concern was always not to offend with our personal political beliefs, damaging in some way the patient-physician relationship.

In my third year of medical school, however, I had a crash course in immigration policy while taking care of migrant laborers in rural Georgia. We set up tents in the fields and treated hundreds of patients under the hot Georgia sun.

While we were there, the state of Georgia passed a law allowing local police to demand immigration papers from anyone they stopped. Overnight, before the law was even enforced, thousands of immigrants fled the state, leaving $140 million in crops rotting on the ground. Some mornings, we would pitch our tents only to find the camps had become ghost towns.

Now, with ongoing changes in federal immigration policy, many patients are afraid to even come to clinic. Once again, I sometimes feel like I’m pitching a tent in an empty field.

Dr. Rob Marlin, a primary care physician in Cambridge who directs the Refugee Health Assessment Program, recently provided training for physicians who take care of immigrant patients. He told us we must "individually and institutionally have greater knowledge of immigration policy to take care of our patients."

Knowing patients’ immigration status and the reasons they came to this country can affect the services they are eligible for, the relative costs of medications, the fears that may keep them from returning for needed services, and even the diagnosis of unexplained symptoms.

Immigration policy, Marlin told us, "is no longer a spectator sport" for us or for our patients.

But it is not simple to practice medicine under these new and uncertain circumstances. The fear that young woman from El Salvador felt in clinic was partly a fear of me — an authority figure she did not know if she could trust. While we like to think our clinics and hospitals are safe for everyone, that’s not always the case.

A woman who showed up to her gynecologist’s office in Houston two years ago presented a fake ID. Staff reported her to ICE officers, who waited for her in the clinic room. Instead of having a pap smear, she was deported, leaving her 8-year-old daughter in the waiting room.

In my current practice, I need to know why my patients might be afraid of the police and of me. However, I do not directly ask about their immigration status because I don’t want them to be fearful of how that information will be used.

I’m also careful what I document in the medical chart because we can never assume any data are secure. Though federal medical privacy law is commonly understood to protect our clinic notes from immigration and law enforcement officers who don’t have a warrant or patients' permission to disclose, it’s not clear that will always be the case.

Unclear and changing immigration rules make it impossible for me to assure my immigrant patients that their fears are unwarranted.

Nonetheless there are many things we caregivers can do to improve our current situation. We can refer patients to local agencies that can help. We can get trained in asylum evaluations. We can leave the hospital and go into the community to let patients know we provide a safe space for them.

We can advocate for bills like the Safe Communities Act, currently opposed by Massachusetts House Speaker Robert DeLeo, which prevents local law enforcement from acting as immigration officers.

We can also seek to understand the existential threat that our patients face and the ways it is changing. Only then can we avoid false reassurance.

There may be more executive orders coming. A leaked draft of one order reveals it might become possible to deport immigrants who are legally here simply because they access federal aid, including federally funded health insurance programs.

Few immigrants qualify for Medicaid, but for legal permanent residents with green cards who do, such an order could threaten their ability to stay if they enroll in the insurance program.

Shawn Gremminger, director of legislative affairs for America’s Essential Hospitals, worries that if President Trump issues this order, it would not only threaten the status of legal immigrants but the funding of public hospitals across the country who care for them.

Gremminger wrote in an email to me that if this is order is signed, it would be immediately challenged in court. Unfortunately, even the possibility can be enough to scare patients away from applying for programs like Medicaid, or food stamps for their children.

In the room that day with my patient, I wanted to tell her that she was going to be fine. I wanted to assure her that her children wouldn’t be sent back to El Salvador, perhaps to be be killed. But I couldn’t. All I could do was say “I am here for you. Right now, you are safe.”

-See the full WBUR CommonHealth blog post.
-Thanks to Debra Drumm and Marie Elena Gioiella for sharing this article.

Related story: The Black Cloud of Deportation and Stress in Immigrant Children on Medscape (free registration required).

Massachusetts prides itself on being a medical mecca, but transgender people say they regularly encounter ignorance, discrimination, and even hostility in the doctor’s office.

Mason Dunn, a 31-year-old transgender man, painfully recalls being turned away from a specialist’s practice. While he has transitioned to male, he still requires routine pap smears and other gynecological care. “They told me they don’t serve my needs,’’ Dunn said. “It was really hard.’’

Dunn participated in a 2016 panel investigating transgender health care in Massachusetts.

Another participant said he went to a hospital emergency room for an asthma attack. But once in the exam room, the doctor called in colleagues to “take a look at this.’’ Another patient was mortified to hear a registration clerk “loudly insisting that I had to be either male or female, so which one was it.” The person walked out.

These experiences are described in the first report from The Health Equity Roundtable, run by the foundation of Harvard Pilgrim Health Care, a large New England health insurer. The program is intended to help the health care industry tackle health disparities by soliciting input from individuals directly affected.

An analysis last year from The Williams Institute at UCLA School of Law estimated that about 1.4 million American adults identify as transgender. That same report put the Massachusetts transgender population at about 30,000 adults. These estimates are far higher than previous ones, and medical providers are just beginning to recognize this group’s huge unmet needs.

Participants said that medical professionals often lack even basic knowledge about transgender health issues, and caregivers on the panel reported a widespread lack of training.

Dunn, executive director of the Massachusetts Transgender Political Coalition, said there are a handful of medical providers that specialize in caring for transgender patients, including Fenway Health and Children’s Hospital. And many colleges are bringing in trainers to improve campus health services.

But wait lists can be long for appointments with experienced providers, some of whom have closed their practices to new patients. And outside of Boston, such providers are few and far between. Children wait up to two years for appointments with pediatric endocrinologists who treat transgender patients. The delay can be problematic because drugs that block puberty milestones, such as the development of breasts or an Adam’s apple, must be timed to the child’s physical development, the Roundtable report said.

Seeking care from non-experienced providers can be worse, however, as they may lack both medical and cultural competency. Emergency rooms are particularly frightening, given the large number of caregivers and other patients who may never have had contact with a transgender person.

Dr. Joyce Rosenfeld, an emergency physician who works at HealthAlliance Hospital in Leominster, said transgender patients often try to avoid the health care system because they fear hostility and a loss of privacy. “Because they have tried not to access care, they are sicker than the average patient. What started out as a little cold can turn into something so much worse,’’ she said.

The Massachusetts Medical Society, which represents the state’s physicians, is working to increase training of its members, said Dr. Marian Craighill, head of the committee on transgender issues. The organization recently set aside $48,000 for grants, one of which went to Lawrence General Hospital -- whose patients don’t have easy access to Fenway Health -- to train residents on caring for the transgender population. These doctors-in-training can then spread their knowledge to other institutions and practices when they get jobs.

The Massachusetts Health and Hospital Association said it held two training sessions last year on caring for transgender patients.

-See the full Boston Globe article.

The William's Institute Study at UCLA Law School  provided a clear snapshot of a doubly vulnerable population that remains at risk in the current political climate of the United States. "There are approximately 267,000 LGBT-identified individuals among the adult undocumented immigrant population and an estimated 637,000 LGBT-identified individuals among the adult documented immigrant population. The report finds that approximately 71 percent of undocumented LGBT adults are Hispanic and 15 percent of undocumented LGBT adults are Asian or Pacific Islander" (Gates, 2013).

The Windsor Policy change of the Department of Homeland Security was a watershed moment regarding LGBTQ immigration. In this one change, the US opened the door for many same-sex married immigrant couples and allowed adjustment of status for tens of thousands more. The US caught up with many other nations.

But after approvals and arrivals for some, and border crossing for others, integration is yet another battle. Ethnic communities generally hold onto the values of their countries of origin which may present a challenge to the minority member of that community who fled bigotry or worse For most, the course of action for LGBTQ immigrants is to seek connection with the LGBTQ community in the United States. Language and culture make this a complex journey. After experiencing suppression, self-identification--let alone social identification--is often a long process for LGBTQ immigrants. Finding security in the laws of the United States is primary. Finding welcome and acceptance of their identity demands unfamiliar trust of strangers. Furthermore, the LGBTQ community in the United States has been accused of ignoring intersectionality, thus leaving those who are LGBTQ and immigrants to sometimes feel unheard or unsupported even within LGBTQ spaces in the U.S. (Balsam et al, 2011).

An environment of increased hostility in the United States toward both the LGBTQ and immigrant communities further complicates integration. On June 12th, 2016, 49 Latinos, many of whom were immigrants or descendants of immigrants, were murdered in the Pulse Night Club on Latin Night. Furthermore, state policies such as North Carolina's HB2, which stripped LGBTQ persons from protections against discrimination in employment and allows employers, businesses, and even healthcare providers to discriminate against a person based on their sexual orientation, are a threat to LGBTQ immigrant integration. Many states, such as West Virginia, are threatening to pass similar legislation, and there are threats that a federal “Religious Freedom Bill” may be passed which will eliminate federal nondiscrimination protections.

Additionally, conversion therapy - an ineffective therapy that attempts to force a person into heterosexuality - is still legal in 45 states, including Massachusetts. In fact, Vice President Mike Pence has openly supported, and funded, conversion therapy programs.

It is important to recognize that recent attacks on immigrant rights are also attacks on LGBTQ rights. For example, the unconstitutional "Muslim Ban" puts LGBTQ Muslims fleeing persecution at greater risk for detention and deportation. Increased raids by Immigration and Customs Enforcement directly impact those who are both undocumented and queer (See the UndocuQueer Movement). President Trump's threat to reinstate Stop-and-Frisk policies on a national level will mean that more LGBTQ persons of color will be targeted by police violence, as we know that LGBTQ persons of color already experience the highest rates of police violence in the country. In fact, trans women of color are six times more likely to experience police violence. Trans persons are also at higher risk for maltreatment, abuse, and even death in immigrant detention facilities.

Social service agencies bear a notable responsibility at this intersection. It is often apparent that LGBTQ immigrants are isolated. Finding social supports to connect this population with like-ethnic community, as well as supports that encourage and strengthen their sense of self, will be a powerful tool toward integration and all the benefits of mobility, work and civic participation that can ensue. Those who work with LGBTQ immigrants can also utilize their voices as advocates for better policies that will protect the intersectional identities of LGBTQ immigrants.

Awareness of the growing networks described within this issue is a valuable resource for the social worker, clergy and educator who are often among the first trusted agents of the new homeland.  Familiarity with cultural resources and services accelerates the journey toward wellbeing for the newcomer directed into friendly and supportive environments. Meanwhile ethnic networks take on an increasing role as advocates for their own diaspora, advocating for inclusivity and a recognition of past abuses back in the homeland so as to avoid those abuses being repeated here in the United States. Islamic societies or Latino clubs are expanding and the additional networking that these spaces provide within the diaspora for persons with similar sexual orientation and background becomes invaluable for initial socialization but also as a launch for full participation in the cultural and civic life of the community.

The Journal of Citizenship Studies (Vol 18,14) had one of the few studies on the intersection of sexual orientation and citizenship and noted the complexity of orientation in seeking US residency. However, the positive attachments fostered by connecting to a local network are evident. Little research exists on the variables of documented/undocumented immigrants, but the direction of study reinforces the critical role of the US in being a refuge and providing welcoming communities for those repressed in other nations.

Middle and high schools are a place of particular concern. Dual minorities, by nationality and sexual orientation, face particular risks. LGBTQ students are at greater risk for bullying and social ostracism from both classmates native to the United States and classmates from the immigrant student's native culture, as biases against LGBTQ persons occur in many cultures.  Teens are at a crucial time in their identity formation, and this kind of ostracism can have deleterious effects on their physical and mental health. Just as with adults, fostering connections between adolescents and accepting communities is vital. Outreach by LGBTQ organizations that speak multiple languages is rare but can be of great assistance in integrating newcomers.

Fortunately, the Human Rights Campaign and local initiatives are increasing connections with progressive elements in the immigrant community as communities mobilize against the threat of an increasingly restrictive set of initiatives by the current US Administration. Community forums at universities working with civil rights groups can foster shared resources, joint action, the creation of missing services, and media attention to hold public systems accountable.

Through agencies such as those highlighted, a small but growing body of scholarship, new alliances and effective human services, one can see evidence that intersectionality is leading to richer understanding and specialized efforts that in turn lead to a more inclusive, diverse America with support for all newcomers.

Selected Boston Area Resources

Queer Muslims of Boston (QMOB) is a safe space for Queer Muslims residing in the Greater Boston area.  Aiming to increase the visibility of Queer Muslims while maintaining a private and intimate gathering space, QMOB hosts monthly dinners and discussion meetings which are accessible through emailing  queermuslimsofboston@gmail.com, or visiting their Facebook page. Regular social events, which are open to allies, include coffee meetings, concerts, and dancing. Their WordPress blog includes a list of resources for the LGBTQ community in Boston.

The Hispanic Black Gay Coalition (HBGC) of Boston is a non-profit organizations focused on the intersectional needs of the Black, Hispanic, and Latinx LGBTQ community in Boston. Founded in 2009, the Coalition works to inspire and empower Latinx, Hispanic and Black LGBTQ individuals through activism, mental health counseling, education, and outreach. More information can be found by emailing info@hbgc-boston.org.

The Queer Asian Pacific Islander Alliance (QAPA) serves the New England Asian community by providing social, political, and educational support for LGBTQ individuals of Asian and Pacific Islander heritage residing in the Greater Boston area. Founded in 1979, the QAPA is the oldest organization for Asian queer individuals in the United States, and currently has over 300 members in the alliance. QAPA helps to host events such as the Quincy Lunar New Year Festival and the Boston Pride festival. QAPA welcomes all members, partners, and their allies at their events. They request that individuals interested in attending meetings join their Meetup platform to better expand their community outreach. More information can also be found on their Facebook page, including discussions about news, daily life, and political issues.

-Excerpted from: Immigrant Integration Lab, Westy Egmont, IIL Newsletter 5.5: LGBTQ Immigrants and Intersectionality in the U.S., Boston College, February 21, 2017.

-For a copy of the full e-mail and resource list contact Ellen Forman.