"We're Here to Take Care of Our Community": Lessons Learned From the U.S. Federal Health Center Covid-19 Vaccine Program.

Equitable access to vaccination is crucial to mitigating the disproportionate impact of Covid-19 on low-income communities and people of color in the United States. As primary care clinics for medically underserved patients, Federally Qualified Health Centers (FQHCs) emerged as a success story in the national effort to vaccinate the U.S. public against Covid-19. In February 2021, the Federal Health Center Covid-19 Vaccine Program began allocating vaccine supply directly to FQHCs in an effort to improve vaccine equity. This qualitative study documents how FQHCs in two states successfully mitigated barriers to vaccine access, responded to patient concerns about vaccination, and worked to maintain and grow community trust in a climate of uncertainty and fear during early vaccine roll-out to the general population. Using a socio-ecological model, we show how FQHCs intervened at multiple levels to advance vaccine equity, revealing valuable lessons for health promotion practice in primary care settings or underserved communities. Our findings provide descriptive context for existing quantitative evidence showing FQHCs' greater success in vaccinating people of color, and foreground valuable and innovative strategies for trustworthy health communication practices and equitable resource allocation to medically underserved patients and populations.

State Public Insurance Coverage Policies and Postpartum Care Among Immigrants.

Importance: Professional medical organizations recommend that adults receive routine postpartum care. Yet, some states restrict public insurance coverage for undocumented immigrants and recently documented immigrants (those who received legal documentation status within the past 5 years). Objective: To examine the association between public insurance coverage and postpartum care among low-income immigrants and the difference in receipt of postpartum care among immigrants relative to nonimmigrants. Design, Setting, and Participants: A pooled, cross-sectional analysis was conducted using data from the Pregnancy Risk Assessment Monitoring System for 19 states and New York City including low-income adults with a live birth between 2012 and 2019. Exposure: Giving birth in a state that offered public insurance coverage for postpartum care to recently documented or undocumented immigrants. Main Outcomes and Measures: Self-reported receipt of postpartum care by the category of coverage offered (full coverage: states that offered publicly funded postpartum care regardless of immigration status; moderate coverage: states that offered publicly funded postpartum care to lawfully residing immigrants without a 5-year waiting period, but did not offer postpartum care to undocumented immigrants; no coverage: states that did not offer publicly funded postpartum care to lawfully present immigrants before 5 years of legal residence or to undocumented immigrants). Results: The study included 72 981 low-income adults (20 971 immigrants [29%] and 52 010 nonimmigrants [71%]). Of the 19 included states and New York City, 6 offered full coverage, 9 offered moderate coverage, and 4 offered no coverage; 1 state (Oregon) switched from offering moderate coverage to offering full coverage. Compared with the states that offered full coverage, receipt of postpartum care among immigrants was 7.0-percentage-points lower (95% CI, -10.6 to -3.4 percentage points) in the states that offered moderate coverage and 11.3-percentage-points lower (95% CI, -13.9 to -8.8 percentage points) in the states that offered no coverage. The differences in the receipt of postpartum care among immigrants relative to nonimmigrants were also associated with the coverage categories. Compared with the states that offered full coverage, there was a 3.3-percentage-point larger difference (95% CI, -5.3 to -1.4 percentage points) in the states that offered moderate coverage and a 7.7-percentage-point larger difference (95% CI, -10.3 to -5.0 percentage points) in the states that offered no coverage. Conclusions and Relevance: Compared with states without insurance restrictions, immigrants living in states with public insurance restrictions were less likely to receive postpartum care. Restricting public insurance coverage may be an important policy-driven barrier to receipt of recommended pregnancy care and improved maternal health among immigrants.

Bioethics, (Funding) Priorities, and the Perpetuation of Injustice.

If funding allocation is an indicator of a field's priorities, then the priorities of the field of bioethics are misaligned because they perpetuate injustice. Social justice mandates priority for the factors that drive systematic disadvantage, which tend not to be the areas supported by funding within academic bioethics. Current funding priorities violate social justice by overemphasizing technologies that aim to enhance the human condition without addressing underlying structural inequalities grounded in racism, and by deemphasizing areas of inquiry most frequently pursued by Scholars of Color. This lack of attention to upstream determinants of health in bioethics research perpetuates a gap in the resources needed to understand the experiences of communities disproportionately experiencing poor health, which is itself a form of epistemic injustice. Both social and epistemic injustices are apparent in the impact of these funding priorities on people of color, both in the public and in the bioethics community.

State Policymaking and Stated Reasons: Prenatal Care for Undocumented Immigrants in an Era of Abortion Restriction.

Policy Points States can create policies that provide access to publicly funded prenatal care for undocumented immigrants that garner support from diverse political coalitions. Policymakers have used a wide range of moral and practical reasons to support the expansion of care to this population, which can be tailored to frame prenatal policies for different stakeholder groups. CONTEXT: Even though nearly 6% of citizen babies born in the United States have at least one undocumented parent, undocumented immigrants are ineligible for most public health insurance. Prenatal care is a recommended health service that improves birth outcomes, and some states, including both traditionally "blue" and "red" states, have opted to provide publicly funded coverage for prenatal services for people who are otherwise ineligible due to immigration status. This article explores how courts and legislatures in three states have approached the question of publicly funded prenatal care for undocumented immigrants and its relationship to the abortion debate, with a particular focus on the moral and practical justifications that policymakers employ. METHODS: We employed a review and qualitative analysis of the documents that comprise the legislative histories of prenatal policies in three case states: California, New York, and Nebraska. FINDINGS: This review and analysis of policy documents identified moral reasons based on appeals to different conceptions of moral status, respect for autonomy, and justice, as well as prudential reasons that appealed to the health and economic benefits of prenatal care for US citizens and legal residents. We found that much of the variation in reasons supporting policies by state can be traced to the state's position on the protection of reproductive rights and whether the policymakers in each state supported or opposed access to abortion. Interestingly, despite these differences, the states arrived at similar prenatal policies for immigrants. CONCLUSIONS: There may be areas where policymakers with different political orientations can converge on health policies affecting access to care for undocumented immigrants. Future research should explore the reception of various message frames for expanding public health insurance coverage to immigrants in other contexts.

Reproductive Injustice at the US Border.

The detention of immigrants inside US borders is not a new phenomenon. However, a dramatic shift has occurred in both the number and treatment of immigrants in detention.We examine recent changes in immigration policies that have systematized the mistreatment of children and pregnant immigrants, including a ban on abortion for unaccompanied minors in immigration detention, the neglect and mistreatment of pregnant immigrants in detention, and the separation and prolonged detention of parents and children in unsafe facilities.We employ the reproductive justice framework to demonstrate how these policies violate all 3 primary values of reproductive justice: the right to have children, the right not to have children, and the right to parent children in safe and secure environments. We argue that, when analyzed through the lens of reproductive justice, these policies can be seen as manifestations of a single targeted strategy to control the reproductive autonomy of migrants as a tool of immigration enforcement. We conclude with a call to action to the public health community.

Responding Effectively to Disruptive Patient Behaviors: Beyond Behavior Contracts.

This Viewpoint discusses the use of behavior contracts with patients in response to increasing workplace violence in health care, and highlights the importance of building the evidence base for approaches to dealing with violent behaviors that are effective and just.

Providing Level-of-Match Information to Perfectly Matched Unrelated Stem Cell Donors: Evaluating Acceptability and Potential Changes in Donor Availability.

Patients with blood-related diseases often cannot identify a matched related donor and must seek donors in unrelated donor registries. These registries face the challenge of ensuring that potential donors are available when contacted. Donor attrition is especially problematic when there is only a single perfectly matched potential donor. One way to improve donor availability might be to present perfectly matched donors (high-priority donors [HPDs]) with more precise information about their match status. This project evaluated the impact of providing such information to HPDs at the National Marrow Donor Program (NMDP)/Be The Match. Objectives were to determine the acceptability of the new messaging to both HPDs and the donor contact representatives (DCRs) who delivered the message, consistency of message delivery, and whether the new messaging was associated with improved donor availability. Mixed methods were used to collect telephone interview data from HPDs, matched samples of non-HPDs, and DCRs. Donor availability data came from NMDP records. Key findings were as follows: (1) the HPD message was acceptable to potential donors and did not seem to produce undue pressure, (2) the message was acceptable to DCRs who became more comfortable and consistent in delivering the message over time, but (3) the new messaging did not significantly increase availability. Despite the lack of evidence for increased availability, there may be ethical benefits and little harm to providing well-matched donors with more information about their degree of matching. Research should examine stronger match status messages and delivery of new messaging to additional highly-matched donor groups.

Enacting Relational Public Health: Federally Qualified Health Centers During the COVID-19 Pandemic.

Federally Qualified Health Centers (FQHCs) proved to be critical points of access for people of color and other underserved populations during the COVID-19 pandemic, administering 61% of their COVID-19 vaccinations to people of color, compared to the 40% rate for the overall United States' vaccination effort. To better understand the approaches and outcomes of FQHCs in pandemic response, we conducted semi-structured interviews with FQHC health care providers and outreach workers and analyzed them using an inductive qualitative methodology.

Public Reason, Public Comments, and Public Charge: A Case Study in Moral & Practical Reasoning in Federal Rulemaking.

The "public charge" rule is a long-standing immigration policy that seeks to determine the likelihood that a prospective immigrant will become dependent on the government for subsistence. When the Trump administration sought to expand the criteria that would count against an applicant for permanent residency to include public benefits historically excluded from the calculation, thousands of commenters wrote to oppose or support the proposed changes. This paper explores the moral and practical reasons commenters provided for their position on the public charge rule and considers the value of the public comment process for immigration, health, and social policy.

COVID-19 vaccination intention and behavior in a large, diverse, U.S. refugee population.

INTRODUCTION: Refugees often face increased risk of exposure to COVID-19 due to their disproportionate representation in the essential workforce and crowded household conditions. There is a paucity of data about risk factors for under-immunization for COVID-19 among refugees. METHODS: Refugees were surveyed in two phases that corresponded to before and after wide availability of COVID-19 vaccines. Participants were asked about their attitudes, and perceptions about COVID-19, previous acceptance of vaccines, sources utilized to obtain trusted health information, and intent to get vaccinated. The overall participant vulnerability was assessed using the social vulnerability index. In-depth semi-structured interviews were completed with key stakeholders through snowball sampling. RESULTS: Of 247 refugees, 244 agreed to participate in the initial survey. Among those, 140 (57.4%) intended to get vaccinated, 43 (17.6%) were unsure, and 61 (25%) did not intend to get vaccinated. In the follow up survey, all 215 who were reached, agreed to provide information about their vaccination status. Among those respondents, 141 (65.6%) were either vaccinated or expressed intent to do so, and 74 (34.4%) remained hesitant. We did not observe any significant correlation between socio-demographic variables, country of origin, and vaccination status/intent. Among those who initially intended to get vaccinated, nearly 1 in 5 changed their mind and decided to forego vaccination, and among those who initially did not plan getting vaccinated, 1 in 3 changed their mind and got vaccinated. Fears related to the vaccine, concerns that the vaccine is religiously prohibited, "wait and see" how others did with the vaccine, communication and transportation barriers were commonly cited as reason not to get vaccinated. CONCLUSIONS: Over a third of refugees in our study were hesitant to get vaccinated. Refugees desired additional education about the benefits and safety of vaccines along with easier access to vaccination clinics in their communities.

Publicly Funded Health Care for Pregnant Undocumented Immigrants: Achieving Moral Progress Through Overlapping Consensus.

What just societies owe to non-citizen immigrants is a controversial question. This paper considers three accounts of the requirements of distributive justice for non-citizens to determine what they might suggest about the provision of publicly funded health care to pregnant undocumented immigrants. These accounts are compared to locate an overlapping consensus on the duty of the state to provide care to pregnant undocumented immigrants. The aim of this paper is not to take a substantive position on the "right" prenatal policy, but rather to explore the moral space that this issue occupies and suggest that real moral progress can be achieved through the consistent application of shared values.

Why Physicians Should Advocate for Undocumented Immigrants' Unimpeded Access to Prenatal Care.

Nearly 7% of US citizens born each year have at least one undocumented parent, but many pregnant undocumented immigrants are ineligible for public insurance covering prenatal care due to their immigration status. This article reviews national-level and state-level policies affecting access to prenatal care for members of this population. This article also considers ethical challenges posed by some policies that create obstacles to patients' accessing health care that is universally recommended by professional guidelines.

Prenatal Care for Undocumented Immigrants: Professional Norms, Ethical Tensions, and Practical Workarounds.

This paper examines the practice implications of various state policies that provide publicly funded prenatal care to undocumented immigrants for health care workers who see undocumented patients. Data were collected through in-depth interviews with purposively sampled health care workers at safety net clinics in California, Maryland, Nebraska, and New York. Health care workers were asked about the process through which undocumented patients receive prenatal care in their health center and the ethical tensions and frustrations they encounter when providing or facilitating this care under policy restrictions. Respondents discussed several professional practice norms as well as the ethical tensions they encountered when policy or institutional constraints prevented them from living up to professional norms. Using Nancy Berlinger's "workarounds" framework, this paper examines health care workers' responses to the misalignment of their professional norms and the policy restrictions in their state. These findings suggest that the prenatal policies in each state raise ethical and professional challenges for the health care workers who implement them.