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Cuneo, C. Nicholas MD; Lin, Stephanie MPhil; Bernhardt, Lydia J. MD

doi: 10.1097/ACM.0000000000002990
Letters to the Editor

Fifth-year resident, Department of Medicine, Division of Global Health Equity, Brigham and Women’s Hospital and Department of Pediatrics, Boston Children’s Hospital and Boston Medical Center, Boston, Massachusetts;; Twitter: @nickcuneo; ORCID:

Fourth-year medical student, Johns Hopkins University School of Medicine, Baltimore, Maryland.

First-year resident, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Disclosures: None reported.

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In Reply to Rathbone:

We thank Rathbone for her comments, which highlight the potential relevance of applying the Refugee Health Partnership (RHP) model we developed at the Johns Hopkins University School of Medicine to the context of the United Kingdom’s National Health Service’s universal health care system. In providing British data, which show that many refugees and asylees are not receiving services to which they are entitled, Rathbone illustrates how imposed laws directed at other populations, such as the United Kingdom’s immigration health surcharge, can affect access for refugee/asylee populations, like they do in the United States.

In the United States, we are grappling with this issue in the form of the Department of Homeland Security’s 2019 rule “Inadmissibility on Public Charge Grounds.”1 This rule denies certain nonresident immigrants legal status to enter or continue to reside in the United States if they have previously used, or are deemed likely to use, public benefits, including Medicaid, our publicly funded health care plan for the poor. Although refugees and people granted asylum are exempted from the rule, the alarm and confusion it stokes is palpable and has a well-documented “chilling effect,” impacting food security and access to necessary medical care.2 There is evidence that many immigrants, including asylum seekers and even already-naturalized citizens, have begun forgoing these supports out of fear that accepting them may compromise their ability to remain in the country, thereby threatening their long-term safety.3

Students who participated in the RHP reported that their experiences working with refugee/asylee families provided invaluable lessons in understanding the obstacles such patients face in accessing care. Armed with deepened empathy toward this population, many RHP graduates have gone on to become advocates for refugees and asylees, multiplying their overall impact in health care and in the public domain. Although the RHP model by itself cannot solve the politicization and revictimization of refugees and asylees we are seeing on both sides of the Atlantic, we hope it can help encourage a generation of physician–leaders to advocate for the protection and dignity of this increasingly marginalized population.

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1. U.S. Citizenship and Immigration Services. Final rule on public charge ground of inadmissibility. Updated August 12,2019. Accessed September 4, 2019.
2. Batalova J, Fix M, Greenberg M. Chilling effects: The expected public charge rule and its impact on legal immigrant families’ public benefits use. Published June 2018. Accessed September 4, 2019.
3. Bernstein H, Gonzalez D, Karpman M, Zuckerman S. One in seven adults in immigrant families reported avoiding public benefit programs in 2018. Published May 22,2019. Accessed September 4, 2019.
Copyright © 2019 by the Association of American Medical Colleges