HUSR 318 MIDTERM REVIEW 2

Occupational Safety and Health Act

Occupational Safety and Health Act of 1970 (OSHA) provides workers with the right to a safe and healthy workplace.

THE TRIPLE TRAUMA PARADIGM

Orley (1994) proposed that new immigrants are often in the midst of a chronological intersection of three distinct traumatic periods. The individual is first affected by the trauma in his or her country of origin, which precipitated his or her flight from the country. These experiences may include, but are not limited to, oppression, discrimination (denial of employment, housing, medical care, or basic human rights based on a perceived identification with an undesired group), increased targeting (threats, vigilance, interrogation, detention, forced relocation, etc.), and torture (severe physical emotional distress, including beatings, mock assassinations, isolation, sexual violation, injury and death of family members, starvation, exposure to extreme conditions, etc.).

Availability of Health Care

PRWORA includes exceptions for certain types of services that are not affected by immigrant status. All immigrants, regardless of status, have "access to public health programs providing immunizations and/or treatment of communicable disease symptoms (whether or not those symptoms are caused by such a disease)" (Broder, 2007, p. 3). EMTALA provides emergency medical treatment for all immigrants, regardless of status or ability to pay; and PRWORA continues to allow all immigrants, regardless of status, to be eligible for emergency Medicaid if they would be eligible for their own state's Medicaid program (Broder, 2007). Emergency Medicaid provides time-limited coverage for a medical emergency that is defined as "any severe medical condition (including labor and delivery) for which the absence of immediate medical attention could place an individual's health in serious jeopardy, seriously impair bodily functions, or result in serious dysfunction of any bodily organ or part" (Fremstad & Cox, 2004, p. 14). Once the coverage expires, it is up to the treating physician, health clinic, or hospital to reapply if the situation is still life-threatening.

Three special populations for healthcare

Elderly, female, and child immigrants face special health challenges.

DACA

- President Obama issued a memorandum entitled Deferred Action for Childhood Arrivals (DACA) -As noted in the preceding text, undocumented immigrants, including DACA grantees, are ineligible for almost all federal programs except emergency Medicaid, hospital emergency department care, immunizations, and testing and treatment of symptoms of communicable diseases

Title VI

-For example, Title VI of the Civil Rights Act of 1964 prohibits organizations that receive federal funds from discriminating against individuals on the basis of race, creed, color, or national origin. - The provision of nondiscrimination based on national origin, by agencies that receive federal funds, may result in the provision of oral and written language assistance (interpreters and translators) to those who do not speak, understand, or read English well, as is mandated by Title VI of the Civil Rights Act of 1964; and this does reduce the barrier somewhat.

Federal Legislation Affecting Immigrant Health

-In 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act of 1986, which included the Emergency Medical Treatment and Labor Act (EMTALA). This law ensures emergency medical care for all people who enter the emergency department of a hospital, including undocumented immigrants, regardless of their ability to pay. Hospital emergency departments must screen and stabilize all patients and cannot reject uninsured patients or transfer them to charity or county hospitals without first stabilizing them. This law makes it possible for immigrants to receive emergency treatment even if they do not have insurance or the financial resources to pay for their health care -The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) bars immigrants other than refugees and asylees from enrolling in Medicaid and State Children's Health Insurance Programs (SCHIPs) for the first 5 years of residency if they entered the United States on or after August 22, 1996. However, after 5 years, qualified immigrants can apply for Medicaid and SCHIP if they meet eligibility requirements (Broder, 2007). Unfortunately, not all immigrants are qualified. Section 1011 of the Medicare Modernization Act of 2003 authorized the disbursement of $250 million per year for fiscal years 2005 to 2008 to hospitals and other facilities that provide emergency health care to undocumented immigrants

PRWORA

-The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) bars immigrants other than refugees and asylees from enrolling in Medicaid and State Children's Health Insurance Programs (SCHIPs) for the first 5 years of residency if they entered the United States on or after August 22, 1996. However, after 5 years, qualified immigrants can apply for Medicaid and SCHIP if they meet eligibility requirements -PRWORA includes exceptions for certain types of services that are not affected by immigrant status. -PRWORA continues to allow all immigrants, regardless of status, to be eligible for emergency Medicaid if they would be eligible for their own state's Medicaid program -PRWORA bans most immigrant access to public health insurance for the first 5 years of residence in the United States. -Another barrier to immigrant health care is the confusion about who is and is not eligible for various federal programs, a confusion that was compounded by PRWORA -PRWORA guarantees all immigrants, regardless of status, access to programs providing immunization and/or treatment of communicable disease symptoms.

Phases of Immigrant Adjustment

A cultural transition involves a multitude of challenging tasks, including securing legal status, language acquisition, stable employment, safe housing, social integration, and family reunification. A new immigrant and a new immigrant community will move forward in the tasks on a chronological schedule unique to themselves and their experiences. However, there are stages of adjustment (not unlike the stages of processing grief) that one can anticipate in integration. Each phase has opportunities for support from social service and mental health providers.

Experiences of Trauma

A major mental health vulnerability in new immigrant populations is often the variety of traumatic experiences that has forced these individuals into the role of immigrants. It has been demonstrated that voluntary economic immigrants have different levels of psychological symptoms than do those with forced immigration scenarios (Escobar, Hoyos, Nervi, & Gara, 2000). Higher levels of mortality within first-generation immigrants have also been documented in those with refugee status as opposed to those selecting immigration

Vicarious trauma

A primary challenge in relationships with service providers may be the intensity of secondary or vicarious trauma experienced by the professionals working with new immigrant communities. In the face of the horror of the story, a provider may try, even unconsciously, to minimize or deny the veracity of the client's experiences that are overwhelming or unfamiliar to them. At times, a professional may be so shocked by the reality of the client's life that he or she is unable to offer normalization or controlled empathy to the client. Alternately, some practitioners become so attracted to the dramatic and "exotic" nature of the story that they focus on the trauma to the detriment of the treatment process. Mental health professionals may experience depression, anger, anxiety, and spiritual questioning in response to a client's experience. The practitioner may become politicized and focus on advocacy in order to balance the feelings of helplessness that working with an individual victim may invoke. Secondary trauma experiences are expected and demonstrate a healthy, committed, and compassionate understanding of the new immigrant's experience. In order to best address this experience, there are steps that mental health professionals can take to ensure their own efficacy. Adequate rest, exercise, and good health habits are essential for all caregivers. A reasonable balance between work and recreation, supportive social networks, and discovering a level of meaning in existence or work will enhance the provider's energy and passion for such intense work. Personal crisis, including any psychological/addictive symptoms experienced, should be addressed immediately by the mental health professional, apart from known colleagues.

ACA

Affordable Care Act of 2010 (also known as the Affordable Care Act or ACA) -The object of this Act is to increase the number of insured adults in this country by requiring that all U.S citizens and legal residents have qualifying health coverage or pay a tax penalty. The Act is implemented through a combination of requiring all employers with 50 or more full-time employees to offer health insurance or pay a yearly financial penalty; creating state and federal health insurance exchanges through which individuals and families can purchase health insurance (subsidized if their incomes are between 138% and 400% of the federal poverty level); and expanding Medicaid to 138% of the federal poverty level and opening it to individuals under age 65 who meet the income guidelines -The ACA makes it easier for some immigrants to get health insurance but continues the eligibility restrictions for others. -Since the enactment of the ACA, legal permanent residents who have been here for 5 years or more will continue to be eligible for Medicaid as long as they meet income guidelines.

Cultural definition

All cultures define, prioritize, measure, and treat mental health in diverse ways that are appropriate and utilizable in their context, for their communities, based on specific value-laden structures.

ESTABLISHING THE THERAPEUTIC RELATIONSHIP

As in any client population, the best indicator of treatment success will be the therapeutic relationship between the mental health provider and the client (Kinzie & Fleck, 1987). This is especially true for immigrants who may be socially isolated and marginalized, separated from family and friends, and for whom the therapist may be the only representative conduit of the host culture. For new immigrant communities, trust is a major theme in all interactions. Immigrants, especially those who have experienced intentional human violence or oppression, have seen a side of human nature that to which most people are never exposed. They are aware of the human capacity to harm, violate civil rights, and disregard individual dignity. These experiences may certainly leave these individuals with high levels of suspicion about the integrity of both people and institutions. Furthermore, for all immigrants, having to address mental health issues with service providers who may be of a different religion, culture, race, or gender than themselves may cause significant barriers to trust. Trust will be a sensitive issue for new immigrants who are exposed to regulations, which appear nonsensical in the host culture (e.g., you can live here but you may not have permission to seek employment, yet your children are required to receive a free public education). In these cases, trust is difficult to establish in the face of fear of violating unknown rules or social norms. In order to create a trusting therapeutic bond, it may be necessary for the practitioner to be more forthcoming and disclose more personal information than he or she is accustomed to when dealing with individuals from the host culture. For many new immigrants, distinctions among religions, ethnicities, and classes are assumed to be conflictual and potentially dangerous

Undocumented Immigrants and DACA Grantees

As noted in the preceding text, undocumented immigrants, including DACA grantees, are ineligible for almost all federal programs except emergency Medicaid, hospital emergency department care, immunizations, and testing and treatment of symptoms of communicable diseases. In addition, they may be eligible for care at city, county, and state public health clinics depending on local laws as well as nonprofit neighborhood clinics staffed by volunteers (Broder, 2007; Staiti et al., 2006). With the enactment of the ACA, undocumented immigrants will still not be eligible for Medicaid and are prohibited from purchasing health coverage on the exchanges (Artiga, 2013). They can, however, purchase private health insurance in the open market, without subsidy options, if they can afford it. They are also not subject for fines if they do not have health insurance (Healthcare.gov; Rejeske, 2013). They also can enroll in health insurance offered by an employer.

Barriers to health care for immigrants

Despite the existence of laws that provide health care protection to immigrants, regardless of legal status, immigrants nevertheless face barriers that limit their access to health care. In addition to immigration status (if the immigrant is undocumented or has not lived in this country for 5 years), other barriers also exist that prevent or deter immigrants from receiving health care. These challenges include fear, lack of money or health insurance, language barriers, cultural issues, lack of knowledge of the U.S. health care system, and lack of facilities and transportation.

FAMILY OR COMMUNITY INTERVENTION

Despite the fact that mental health symptoms most frequently present in a particular individual, in many cases, the best interventions may be targeted at the level of the family, community, or society as a whole.

STUDENT RIGHTS IN SCHOOL

FREEDOM OF EXPRESSION:Under the First Amendment to the United States Constitution, students have a right to express their ideas and opinions in school. At the same time, this right is limited in some important ways. For example, speech that causes a substantial disruption of the educational process can be prohibited (although the mere fact that other people take offense at what is said does not necessarily constitute disruption). Schools can also prohibit speech advocating the use of illegal drugs or lewd speech. Schools generally cannot prohibit students from speaking a language other than English outside the classroom setting. This area can be complicated; the important point is that students do have substantial free-speech rights and that policies that infringe on those rights may be illegal. The First Amendment also protects students from being forced to say things with which they disagree. Thus, for example, the courts have held that students cannot be required to say the Pledge of Allegiance (West Virginia Board of Education v. Barnette, 1943). FREEDOM OF RELIGION:Yet another set of First Amendment protections involves religion. Under the Free Exercise Clause of the Amendment, students are generally free to maintain their own religious beliefs, to pray, and to wear religious items. Again, there may be some limitations on these rights. Under the Establishment Clause, public schools are prohibited from teaching religious beliefs, conducting school-sponsored prayers, or endorsing particular religious holidays or symbols. Schools may, on the other hand, teach about religion and religions, include religious music in school concerts (so long as the effect is not to promote a specific religion). DISCRIMINATION AND EQUAL ACCESS:Under federal law and most states' laws as well, public schools are prohibited from discriminating on the basis of race, ethnicity, national origin, religion, and gender. This means that, in general, none of these grounds may be the basis for excluding a student from a school program or providing him or her with services that are inferior to those provided to others. All students, regardless of race, ethnicity, national origin, religion, and gender, have a right of equal access to school programs and services. SAFETYFinally, under the No Child Left Behind Act, a student who is the victim of a violent crime has the right to transfer to another school in the district (20 U.S.C. § 9532). This provision can be of benefit to some students, although it has the obvious drawback that it can only be requested after the fact and is useful only if the district operates more than one school at the student's grade level. FAIRNESS IN DISCIPLINE:Under court decisions interpreting the Due Process Clause of the U.S. Constitution, schools must notify students, generally in writing, concerning school rules and penalties for violations. As noted earlier, translation must be provided for non-English-speaking students and their families

HEALTH CARE FOR SENIOR IMMIGRANTS

Elderly immigrants are the most underserved seniors in the health care system because of language and cultural barriers -Many elderly immigrants do not speak English well, if at all, making it difficult to describe symptoms and understand physician recommendations. It becomes even more difficult if the provider does not understand the patient's culture. In addition, Mui and colleagues (2007) report that elderly Asians who do not speak English often choose not to get health care in order to save face by not having to admit that they do not speak English or understand what is being said. Social workers need to factor in the idea of saving face when working with LEP individuals, particularly seniors.

McKinney-Vento Act

Finally, the McKinney-Vento Act, a federal law, entitles homeless families to send their children to school in the district in which they last resided before becoming homeless or in the district in which they are currently living (42 U.S.C. § 11431 et seq.). This act can be helpful because of its broad definition of "homelessness," which may cover many situations in which immigrant and refugee children find themselves. The Act also provides that when there is a dispute over whether the child qualifies as "homeless," the child must be permitted to enroll while the dispute is sorted out. The National Center for Homeless Education, a project of the U.S. Department of Education, provides additional information online about the McKinney-Vento Act and related issues affecting children experiencing homelessness. As mentioned earlier, a child's immigration status does not affect eligibility for enrollment and should not be confused with residency. An immigrant child who meets the normal residency requirements for school attendance is entitled to attend school—regardless of the child's immigration documents or, indeed, of whether the child has any immigration documents at all.

Immigration law sections

Grounds of inadmissibility:6 This section of the law applies to noncitizens seeking admission to the United States, such as people entering the United States from abroad or individuals already in the country seeking to adjust their status to lawful permanent resident. It is also applicable to certain lawful permanent residents seeking to return to the country after travel abroad. •Grounds of deportability:7 This section of the law applies to noncitizens who have already been admitted to the United States, such as lawful permanent residents or refugees. •Good moral character:8 This section of the law applies to noncitizens seeking certain forms of relief from removal and lawful permanent residents pursuing U.S. citizenship.

Immigration Reform and Control Act

Immigration Reform and Control Act (IRCA).7 In an effort to reduce unlawful immigration into the United States, Congress enacted IRCA, which made it unlawful for employers to knowingly hire a person who was not authorized to work in the United States.8 IRCA also provided sanctions against employers who violated this new provision.9 A new employment eligibility verification process—commonly referred to as the "I-9 process"—was created as a means of monitoring the employer sanctions scheme. All employers must complete the I-9 form for all new workers hired after November 6, 1986.

EMTALA

In 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act of 1986, which included the Emergency Medical Treatment and Labor Act (EMTALA) EMTALA provides emergency medical treatment for all immigrants, regardless of status or ability to pay;

HEALTH CARE FOR IMMIGRANT CHILDREN

In 1997, the American Academy of Pediatrics stated, "Every child within the geographic boundaries of the United States, regardless of that child's 'status,' should have full access to all social, educational, and health services that exist at the local, state, and federal levels for the care and benefit of children" (American Academy of Pediatrics, 1997, p. 153). The United States still has a long way to go to implement these recommendations. According to a report on young immigrant children issued by the Urban Institute (Fortuny, Hernandez, & Chaudry, 2010), immigrant children under 8 make up 24% (8.7 million) of the 8-and-under population of the United States; 93% of those children are citizens, with 53% of the children living in mixed-status families; over 50% live in low-income families; and immigrant children are more than twice as likely to be uninsured as children of native citizens (Fortuny, et al., 2010). -Because many immigrant children do not have regular health care providers or receive regular well-baby/child visits, they may not have received appropriate immunizations and may have undiagnosed health problems, including parasitic and infectious diseases and vaccine-preventable diseases (American Academy of Pediatrics, 1997). The aforementioned barriers to access to health care (fear, language, culture, income, and insurance) also apply to children, many of whom are eligible for Medicaid or SCHIP coverage based on family income and child citizenship status. Unfortunately, it will take significant culturally appropriate outreach efforts in the community to increase enrollment in these programs. Once the children have insurance, it will take more outreach to get them, and their families, into the habit of accessing preventive health care and seeking treatment for easy-to-treat conditions before they become critical (Lessard & Ku, 2003).

PRACTITIONER'S DEFINITIONS OF MENTAL HEALTH

In exploring the client's beliefs, it is also imperative for the mental health practitioner to question, and in some cases, decide to put aside his or her own beliefs, assumptions, and "expertise" in a Westernized concept of mental health to join with the client in a therapeutic manner (Sachs, 1987). A culturally competent mental health provider, in a nonjudgmental, skilled manner, balances his or her own definitions, beliefs, and methodologies while respecting and working within the system adhered to by the client. The inability to establish collaboration, mutual respect, and understanding will leave a new immigrant client and mental health practitioner at odds and make positive intervention impossible. Psychotherapists in particular need to understand and validate their immigrant client's individual/cultural conceptualization of the symptom or the problem. They must also recognize their own value-laden judgments as to the functioning and lifestyles of their diverse clients (Kleinman & Good, 1985). Western-trained mental health providers are frequently criticized by immigrant communities for their focus on feeling "good" and equating happiness with mental health. The isolation of individual well-being to the possible detriment of the family or cultural unit may also be a source of conflict between immigrant clients and mental health providers. In collective cultures, guidance based on the idea that personal growth or achievement is the final goal will be unintelligible. One of the m

National Labor Relations Act

Labor and employment laws govern individuals' rights at the workplace. For example, the National Labor Relations Act of 1935 (NLRA) gives workers the right to organize, elect, or join a union.

CULTURALLY COMPETENT MENTAL HEALTH SERVICES

Mental health professionals in the United States frequently pride themselves on being "color-blind" and laud themselves for believing that their cultural view can accommodate any level of diversity (Ivey, 1995). Most immigrant clients, however, are hyperaware of differences between themselves and the professionals they are exposed to and are frequently uncomfortable about them. Differences in gender, race, age, education, and class may create barriers within their cultural context that need to be overcome in working with a mental health professional (Freire, 1973). In such cases, the opinion, will, and belief of the professional about his or her own cultural competence is irrelevant. The immigrant must also be able to access benefit from a service provider who meets personal needs and preferences. There are many ways for a practitioner and an agency to expand or enhance prevention, psychoeducation, and ultimately treatment services to include new immigrant populations. The first and most obvious is to ensure representation from the community, including ethnic-insider mental health professionals at all levels of the program design, implementation, and evaluation. Within cultural groups, there will always be diversity. However, utilizing ethnically based providers will reduce the gap of understanding and increase the appropriateness of the services

SCHIP

State Children's Health Insurance Programs (SCHIPs) for the first 5 years of residency if they entered the United States on or after August 22, 1996. However, after 5 years, qualified immigrants can apply for Medicaid and SCHIP if they meet eligibility requirements -Refugees and asylees are exempt from the 5-year ban and are eligible for Medicaid and SCHIP benefits for the first 18 months they are in the United States as long as they meet income requirements. -Other qualified immigrants are eligible for Medicaid and SCHIP benefits 5 years after entry into the United States as long as they meet eligibility requirements -Medicaid and SCHIP health insurance coverage, whereas others have not. -Eligibility requirements for immigrant health care get even more confusing when one considers state-funded and state-run Medicaid and SCHIP programs that are open to documented immigrants and sometimes even to undocumented immigrants.

Healthy migrant phenomenon

The "healthy migrant phenomenon" has been described by Fennelly (2006) as the idea that, when individuals migrate from their country of origin to the United States, they arrive in a healthier state than native-born residents. Although they have higher rates of some infectious diseases, Fennelly (2006) reports that they generally receive better ratings in the areas of health risk factors, chronic conditions, and mortality. Schenker (2007) describes a similar concept, which he calls the "healthy immigrant hypothesis," when he talks about immigrant Latina women who have better-than-expected birth outcomes when they first arrive in the United States.

HEALTH CARE FOR IMMIGRANT WOMEN

The LAFANS data from 2000 show that 20% of undocumented women had never received a checkup (four times the rate for native-born women) and 7% had never seen a physician. The numbers would be even more distressing if pregnancies (with their hospital deliveries) were not factored in. Although these numbers are for Los Angeles County, California, and not the entire United States, it is still possible to deduce that some of the barriers discussed earlier play a role in the low numbers of immigrant women who get checkups just as they do for most immigrants. With women's health issues, however, the literature indicates that culture, language, lack of a normal source of care, and access to health insurance are four of the most formidable barriers.

Fair Labor Standards Act

The Fair Labor Standards Act of 1938 (FLSA) provides workers the right to minimum wage and overtime payment

Mixed status families

The definition of a mixed-status family is a family in which a least one parent is a noncitizen and at least one child is a citizen -In 2008, 73% of the children who had noncitizen parents were citizens. The citizen children in mixed-status families are entitled to the same public insurance or health exchange options as all citizen children who are eligible based on income, yet 17% remained uninsured in 2011. This rate is significantly higher than children of citizen parents -The lack of insurance is often due to language barriers or lack of awareness of the child's eligibility for Medicaid or SCHIP. Sometimes, though, it is due to fear of the application process if a parent is undocumented

Resiliency

The idea of resiliency as a general concept describes the ability of a person or a people to withstand a physical, emotional, or social crisis and respond to such circumstances with a return to a sense of self-efficacy and a feeling of personal control as well as the ability to create supportive and mutually beneficial relationships and the desire to accept new challenges with the ability to gain mastery over new skills within a reasonable amount of time. It may be that the behavioral factors (what the outside world sees as "adjustment") are based on the ability to process the events of the trauma in a meaningful, rule-guided manner. The individual or group integrates the experience into a working schema (e.g., it was God's will and must be accepted) that creates a level of comfort rather than distress.

Context

This book ends with an exploration of systemic or macro advocacy aimed at changing city, state, or federal policies—another important function, particularly in the context of examining health care policies.

Documented Immigrants

This category includes refugees, asylees, and LPRs. Refugees and asylees are exempt from the 5-year ban and are eligible for Medicaid and SCHIP benefits for the first 18 months they are in the United States as long as they meet income requirements. After that, they must reapply in order to continue their coverage. Other qualified immigrants are eligible for Medicaid and SCHIP benefits 5 years after entry into the United States as long as they meet eligibility requirements

Equal Education Opportunities Act.

Two federal laws, Title VI of the Civil Rights Act of 1964, 42 U.S.C. § 2000d and the Equal Educational Opportunities Act, 20 U.S.C. § 1703(f), as well as many state laws, require that school districts make special arrangements for children whose native language is not English. More detail on the requirements discussed in the following text is available online from the U.S. Department of Education. First, schools are legally required to assess the child's English proficiency—to determine, for example, whether the child is at the beginning, intermediate, or advanced level in terms of reading, writing, listening to, and speaking the language. Careful assessment is important, especially because quick judgments about a child's English ability can often prove to be wrong. The child who can speak enough English to get by on the playground, for example, or even to converse with his peers, may be only partially able—or completely unable—to understand academic material presented in the language. Second, assuming that the assessment shows that the child is not yet proficient in English, he or she must be provided instruction in the language. This program must be based on sound professional judgment, which ordinarily means that the child will receive English as a Second Language instruction from a teacher with qualifications in the field of second language learning. (The teacher usually need not be bilingual, however, because the focus is on teaching English—not on translating from another language.) Because mere immersion in an English-language environment is rarely viewed as a professionally defensible form of instruction, except possibly for very young children or those who are nearing English proficiency, it makes sense to be skeptical when a child with limited English is simply placed in regular classes on the theory that he or she will gradually pick up the language. The same can often be said of situations in which the child is simply placed in a regular English class, because instruction in these classes ordinarily presupposes that the child is already as proficient in the language as other students of the child's age. Third, depending on the child's level of English proficiency, he or she may have difficulty making sense of academic classes (math, science, history, and so on) that are taught in English. This, of course, is the reason that some schools offer bilingual instruction, in which children are taught academic content in their native language. The more typical situation is that the child's coursework is delivered in English; in that situation, schools are required to find ways of adjusting the instruction so that the child can benefit from it to the same degree that a native speaker would benefit