Could Sexual Abuse or Trafficking Become a Pre-existing Condition?
When Jenny walked into my office, her stomach was so swollen that I thought she was pregnant. The social worker at her side gestured to her: “Show Margarita what happened.” Jenny got up and lifted her shirt. She wasn’t pregnant – her skin was blackened and purple, distended off her skinny frame by necrosis and infection. I nearly called for an ambulance. But Jenny had already been to the hospital, where doctors had stabilized her condition with antibiotics and skin treatment. Since Jenny was undocumented and lacked health insurance, the doctors couldn’t do anything more than a patch job. Without extensive surgery and specialist treatment, Jenny was going to die.
Fifteen years earlier, Jenny had been trafficked into the United States against her will and forced to work in a brothel. Among the many tortures her traffickers inflicted was something called “free silicone injection.” This form of cosmetic surgery, meant to plump up the breasts and buttocks, was banned by the FDA in 1992, but black marketeers even today will perform it without anesthesia, antiseptic, or medical-grade silicone. Jenny’s traffickers thought that a more “Barbie” body would allow them to charge more for her services. The worst harm often comes many years after the injections, when the silicone (often from automotive suppliers) migrates to different parts of the body, causing excruciating pain and disfiguration. In the worst cases, the silicone can break free and cause a deadly embolism in the heart, lungs, or brain; or infection can set in, like it did for Jenny, causing the flesh to blacken and rot from the inside.
Over the years I have served more than a hundred immigrant victims of trafficking and domestic violence. Every one of them bears scars from their experiences. Some are visible, from beatings and tortures like Jenny’s, or from chronic diseases like HIV, syphilis and hepatitis, but others are harder to see. Overwhelming rates of post-traumatic stress disorder, depression and anxiety afflict these victims for years and sometimes forever.
Last week the House of Representatives passed the American Health Care Act (AHCA), which if it were to become law could force these victims to face yet another horror – the inability to get health insurance and the treatment they need.
I was able to help Jenny secure state-funded Medicaid. She was eligible under special rules allowing individual states to expand health care coverage to categories of low-income residents using local tax dollars, even if those residents (often immigrants, including people with valid immigration status) were ineligible for federal benefits.
Under the AHCA, both poor people like Jenny who rely on Medicaid, and the middle class who have finally become insured through subsidized private plans on the Marketplace, would suffer.
Gutting Health Care Protections for Vulnerable People
As has been widely reported, the AHCA would allow states to waive protections introduced under the ACA, like coverage for people with pre-existing conditions (PECs) and eliminating minimum level of coverage requirements. For a typical applicant, exclusion of PECs can lead to lack of treatment for things like diabetes and prenatal care. But for a survivor of sexual assault or trafficking, the harm can be even broader, preventing treatment for mental health, sexually transmitted infections, and physical injury. To make matters worse, the AHCA would implement per capita funding caps and roll back the Medicaid expansion, another welcome provision under the ACA. This would endanger the health of people like my clients, but also for a spectrum of other vulnerable populations including the poor, the elderly, those with disabilities and children with special needs.
New York has historically worked to protect its most vulnerable residents, but federal funding still accounts for an enormous amount of the state’s Medicaid spending. Passage of the AHCA would slash Medicaid funding across the board, and put states that do not apply for waivers on the hook to pay for individuals who require more care than “average.” That would create the most harm for people like Jenny, with chronic pre-existing conditions and disabilities.
New York State would not be able to pay for this sudden sinkhole on its own, and would be forced to cut benefits and tighten eligibility requirements just when vulnerable New Yorkers needed help the most. Additionally, the state will likely be forced to cut the premiums it pays to the insurance plans that manage the Medicaid services for over four million New Yorkers. The companies that run these insurance plans – both for-profit and non-profit – that provide medical services for poor New Yorkers would be under pressure to reduce or deny care altogether. Cruelly, if victims like Jenny manage to overcome their horrible experiences, recover and get back to work, they are in an even more dangerous position. Like everyone else, they would be subject to the loss of health care in the private marketplace or in employer-sponsored coverage.
Without health insurance, Jenny’s life was in danger. It was only with the help of Medicaid (thanks in part to the ACA) that she was able to access the care she needed. In a post-AHCA world, I don’t know that she would be able to.
The State Assembly has the power to protect New Yorkers with legislation that could mitigate the worst of the collateral damage if Congress is irresponsible enough to make the AHCA the law of the land. But the reality of losing billions in federal funds will tie their hands. Let’s hope it doesn’t come to that. The AHCA targets people who have already been victimized by the worst of humanity. We don’t need to add Congress to the list of people who hurt them.