White House Releases Draft Rule Rescinding Right-to-Refuse Regulation

Emily Douglas

Let's see some proof, the Obama administration said, in essence, today, to those who claimed that health care providers desperately needed further protection to prevent discrimination based on their religious objection to providing abortion care.

Let’s see some proof, the Obama administration said, in essence, today, to those who claimed that health care providers desperately needed further protection to prevent discrimination based on their religious objection to providing abortion care.  The administration proposed a rule to rescind a previous HHS regulation, promulgated last December, to allow individuals and institutions much greater leeway in refusing to provide care (including permitting them not only not to refer patients but to neglect to inform patients of the care they weren’t getting).  The proposed rule, which you can read here, acknowledges existing protections for provider conscience objections to care and proposes to rescind the rule entirely.  However, the rule also makes clear that HHS is seeking information on what the likely impact of the conscience expansion regulation would be and whether it is justified.

During the 30-day comment period that commences now, the Department is seeking:

 1.  Information, including specific examples where feasible, addressing the scope and nature of the problems giving rise to the need for federal rulemaking and how the current rule would resolve those problems; 
 2.  Information, including specific examples where feasible, supporting or refuting allegations that the December 19, 2008 final rule reduces access to information and health care services, particularly by low-income women;
 3.  Comment on whether the December 19, 2008 final rule provides sufficient clarity to minimize the potential for harm resulting from any ambiguity and confusion that may exist because of the rule; and
 4.  Comment on whether the objectives of the December 19, 2008 final rule might also be accomplished through non-regulatory means, such as outreach and education. 

"The Obama
administration deserves great praise for its move today to rescind this
harmful rule, which serves only to undermine patients’ access to vital
health care services and information, and poses especially grave risks
to women’s health and lives," said the National Women’s Law Center’s Marcia Greenberger. 

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Analysis Politics

Donald Trump and Mike Pence: The Anti-Immigrant Ticket

Tina Vasquez

“My greatest fear is that this ticket doesn’t seem to realize immigrants are actually an incredible resource that fuels our country," Wendy Feliz of the American Immigration Council told Rewire.

On Friday, Republican presidential candidate Donald Trump announced Indiana Gov. Mike Pence as his running mate, giving legitimacy to concerns a Trump presidency would be anti-choice and decimate LGBTQ rights. As Rewire reported last week, Pence has voted against nondiscrimination efforts, signed a so-called religious freedom bill, opposed marriage equality, and attemptednumerous times—to defund Planned Parenthood, something Trump has promised to do if elected president.

But the two Republicans also have something else in common: They are brazenly anti-immigrant.

Despite a misleading article from the Daily Beast asserting that Pence has had a “love affair with immigration reform” and has “spent his political career decrying anti-immigrant rhetoric,” the governor’s record on immigration tells a different story.

Let’s take a look at Trump’s “xenophobic” and “racist” campaign thus far, and how closely Pence’s voting aligns with that position.

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Donald Trump

For months it seemed, Donald Trump’s talking points in the media rarely drifted away from anti-immigrant rhetoric. During his kickoff speech, he referred to Mexican immigrants as “rapists” and “killers” and in the months since, has promised to build a 2,000-mile-long wall along the United States-Mexico border to keep “illegals” out, a wall the billionaire has promised that Mexico will pay for.

Despite being called “racist” by members of his own party, Trump’s immigration plan is largely consistent with what many Republicans have called for: a larger border wall, increasing the number of Immigration and Customs Enforcement (ICE) officers, requiring all U.S. companies to use E-Verify to check the immigration status of employees, increasing the use of detention for those who are undocumented and currently residing in the United States, and ending “birthright citizenship,” which would mean the U.S.-born children of undocumented parents would be denied citizenship.

Again, Trump’s proposed immigration policies align with the Republican Party’s, but it is the way that he routinely spreads false, damaging information about undocumented immigrants that is worrisome. Trump has repeatedly said that economically, undocumented immigrants are “killing us by “taking our jobs, taking our manufacturing jobs, taking our money.” 

Market Watch, a publication focusing on financial news, reported that this falsehood is something that a bulk of Trump supporters believe; two-thirds of Trump supporters surveyed in the primaries said they feel immigration is a burden on our country “because ‘they take our jobs, housing and health care.'” This, despite research that says deporting the 11 million undocumented immigrants who currently call the United States home would result in a “massive economic hit” for Trump’s home state of New York, which receives $793 million in tax revenue from undocumented immigrants. A recent report by the Institute on Taxation and Economic Policy also found that at the state and local level, undocumented immigrants nationwide collectively pay an estimated $11.6 billion each year in taxes.

Trump has also been accused by Muslim Americans and members of the media of engaging in “reckless, dangerous Islamophobia” at every opportunity, using terrorist attacks to call for a ban on all Muslim immigration, while also using terrorism in a self-aggrandizing manner. In a statement released after the Pulse nightclub shooting, Trump said, “I said this was going to happen.”

These dangerous assertions that all U.S.-based Muslims are secretly harboring terrorists or that undocumented immigrants are killing “thousands of peoplea narrative he continued to push at the Republican National Convention by having the families of three Americans killed by undocumented people speak—can be deadly and inspire hatred and violence. This was made all the more clearer when in August 2015 two white brothers cited Trump when they urinated on and beat a homeless Latino man. According to Huffington Post, the men “alegedly [sic] told police they targeted the man because of his ethnicity and added, ‘Donald Trump was right, all these illegals need to be deported.’” Trump’s response? He said that his supporters are simply “passionate” people who want America “to be great again.”

Mike Pence

Wendy Feliz, a spokesperson with the American Immigration Council, succinctly summarized Pence’s immigration approach to Rewire, saying on Monday that he “basically falls into a camp of being more restrictive on immigration, someone who looks for more punitive ways to punish immigrants, rather than looking for the positive ways our country can benefit from immigrants.”

After Trump’s announcement that Pence would be his running mate, Immigration Impact, a project of the American Immigration Council, outlined what voters should know about Pence’s immigration record:

Pence’s record shows he used his time in Congress and as the Governor of Indiana to pursue extreme and punitive immigration policies earning him a 100 percent approval rating by the anti-immigration group, Federation for American Immigration Reform.

In 2004 when Pence was a senator, he voted for the “Undocumented Alien Emergency Medical Assistance Amendments.” The bill failed, but it would have required hospitals to gather and report information on undocumented patients before hospitals could be reimbursed for treating them. Even worse, the bill wouldn’t have required hospitals to provide care to undocumented patients if they could be deported to their country of origin without a “significant chance” of their condition getting worse.

Though it’s true that in 2006 Pence championed comprehensive immigration reform, as the Daily Beast reported, the reform came with two caveats: a tightening of border security and undocumented immigrants would have to “self-deport” and come back as guest workers. While calling for undocumented immigrants to self-deport may seem like the more egregious demand, it’s important to contextualize Pence’s call for an increase in border security.

This tactic of calling for more Border Patrol agents is commonly used by politicians to pacify those opposed to any form of immigration reform. President Obama, who has utilized more border security than any other president, announced deferred action for the undocumented in June 2012, while also promising to increase border security. But in 2006 when Pence was calling for an increase in border security, the border enforcement policy known as “Operation Gatekeeper” was still in full swing. According to the American Civil Liberties Union (ACLU), Operation Gatekeeper “concentrated border agents and resources along populated areas, intentionally forcing undocumented immigrants to extreme environments and natural barriers that the government anticipated would increase the likelihood of injury and death.” Pence called for more of this, although the undocumented population expanded significantly even when border enforcement resources escalated. The long-term results, the ACLU reported, were that migrants’ reliance on smugglers to transport them increased and migrant deaths multiplied.

There are more direct ways Pence has illustrated a xenophobic agenda, including co-sponsoring a congressional bill that would have made English the official language of the United States and as governor, blocking Syrian refugees en route to Indiana, saying he would not accept any more Syrian refugees out of fear they were “terrorists.” The governor also added Indiana to the Texas lawsuit challenging expanded Deferred Action for Childhood Arrivals (DACA) and Deferred Action for Parents of Americans and Lawful Permanent Residents (DAPA). And he praised the inaction by the Supreme Court last month to expand DACA and DAPA, which leaves millions of undocumented immigrants living in fear of deportation.

According to the Office of Refugee Resettlement, “when a child who is not accompanied by a parent or legal guardian is apprehended by immigration authorities, the child is transferred to the care and custody of the Office of Refugee Resettlement (ORR). Federal law requires that ORR feed, shelter, and provide medical care for unaccompanied children until it is able to release them to safe settings with sponsors (usually family members), while they await immigration proceedings.”

The ORR added that these sponsors “live in many states,” including Indiana, which received 245 unaccompanied minors between January and July 2014. Pence was reportedly unaware that unaccompanied minors were being placed in his state by the federal government, something he said he was made aware of by media reports. These are asylum seeking children, often girls under the age of 10, escaping violence in their countries of origin who arrive at the United States-Mexico border without an adult. Many, including advocacy organizations and the Obama administration, have contended that the circumstances surrounding unaccompanied minors is not simply an immigration issue, but a humanitarian crisis. Not Pence. In a letter to President Obama, the Indiana governor wrote:

While we feel deep compassion for these children, our country must secure its borders and provide for a legal and orderly immigration process …. Failure to expedite the return of unaccompanied children thwarts the rule of law and will only continue to send a distorted message that illegally crossing into America is without consequence.

In the four days since Pence was named Trump’s running mate, he’s also taken a much harsher stance on Muslim immigration. Back in December when Trump called for a “total and complete shutdown of Muslims entering the United States,” Pence tweeted that banning Muslims from entering the United States was “offensive and unconstitutional.” However, on Friday when Pence was officially named Trump’s VP pick, he told Fox News’ Sean Hannity, “I am very supportive of Donald Trump’s call to temporarily suspend immigration from countries where terrorist influence and impact represents a threat to the United States.”

Wendy Feliz of the American Immigration Council told Rewire that while Pence’s rhetoric may not be as inflammatory as Trump’s, it’s important to look at his record in relation to Trump’s to get a better understanding of what the Republican ticket intends to focus on moving into a possible presidency. Immigration, she said, is one of the most pressing issues of our time and has become a primary focus of the election.

“In a few days, we’ll have a better sense of the particular policies the Republican ticket will be pursuing on immigration. It all appears to point to more of the same, which is punitive, the punishing of immigrants,” Feliz said. “My greatest fear is that this ticket doesn’t seem to realize immigrants are actually an incredible resource that fuels our country. I don’t think Trump and Pence is a ticket that values that. An administration that doesn’t value immigrants, that doesn’t value what’s fueled our country for the past several hundred years, hurts all of us. Not just immigrants themselves, but every single American.”

Analysis Politics

Advocates: Bill to Address Gaps in Mental Health Care Would Do More Harm Than Good

Katie Klabusich

Advocates say that U.S. Rep. Tim Murphy's "Helping Families in Mental Health Crisis Act," purported to help address gaps in care, is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

The need for reform of the mental health-care system is well documented; those of us who have spent time trying to access often costly, out-of-reach treatment will attest to how time-consuming and expensive care can be—if you can get the necessary time off work to pursue that care. Advocates say, however, that U.S. Rep. Tim Murphy’s (R-PA) “Helping Families in Mental Health Crisis Act” (HR 2646), purported to help address gaps in care, is not the answer. Instead, they say, it is regressive and strips rights away from those diagnosed with mental illness. This leaves those in the LGBTQ community—who already often have an adversarial relationship with the mental health sector—at particular risk.

“We believe that this legislation will result in outdated, biased, and inappropriate treatment of people with a mental health diagnosis,” wrote the political action committee Leadership Conference on Civil and Human Rights in a March letter to House Committee on Energy and Commerce Chairman Rep. Fred Upton (R-MI) and ranking member Rep. Frank Pallone (D-NJ) on behalf of more than 100 social justice organizations. “The current formulation of H.R. 2646 will function to eliminate basic civil and human rights protections for those with mental illness.”

Despite the pushback, Murphy continues to draw on the bill’s mental health industry support; groups like the American Psychiatric Association (APA) and the National Alliance on Mental Illness (NAMI) back the bill.

Murphy and Rep. Eddie Bernice Johnson (D-TX) reintroduced HR 2646 earlier this month, continuing to call it “groundbreaking” legislation that “breaks down federal barriers to care, clarifies privacy standards for families and caregivers; reforms outdated programs; expands parity accountability; and invests in services for the most difficult to treat cases while driving evidence-based care.”

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Some of the stated goals of HR 2646 are important: Yes, more inpatient care beds are needed; yes, smoother transitions from inpatient to outpatient care would help many; yes, prisons house too many people with mental illness. However, many of its objectives, such as “alternatives to institutionalization” potentially allow outpatient care to be mandated by judges with no medical training and pushed for by “concerned” family members. Even the “focus on suicide prevention” can lead to forced hospitalization and disempowerment of the person the system or family member is supposedly trying to help.

All in all, advocates say, HR 2646—which passed out of committee earlier this month—marks a danger to the autonomy of those with mental illness.

Victoria M. Rodríguez-Roldán, JD, director of the Trans/GNC Justice Project at the National LGBTQ Task Force, explained that the bill would usurp the Health Insurance Portability and Accountability Act (HIPAA), “making it easier for a mental health provider to give information about diagnosis and treatment … to any ‘caregiver’-family members, partners or spouses, children that may be caring for the person, and so forth.”

For the communities she serves, this is more than just a privacy violation: It could put clients at risk if family members use their diagnosis or treatment against them.

“When we consider the stigma around mental illness from an LGBT perspective, an intersectional perspective, 57 percent of trans people have experienced significant family rejection [and] 19 percent have experienced domestic violence as a result of their being trans,” said Rodríguez-Roldán, citing the National Transgender Discrimination Survey. “We can see here how the idea of ‘Let’s give access to the poor loved ones who want to help!’ is not that great an idea.”

“It’s really about taking away voice and choice and agency from people, which is a trend that’s very disturbing to me,” said Leah Harris, an organizer with the Campaign For Real Change in Mental Health Policy, also known as Real MH Change. “Mostly [H.R. 2646] is driven by families of these people, not the people themselves. It’s pitting families against people who are living this. There are a fair number of these family members that are well-meaning, but they’re pushing this very authoritarian [policy].”

Rodríguez-Roldán also pointed out that if a patient’s gender identity or sexual orientation is a contributing factor to their depression or suicide risk—because of discrimination, direct targeting, or fear of bigoted family, friends, or coworkers—then that identity or orientation would be pertinent to their diagnosis and possible need for treatment. Though Murphy’s office claims that psychotherapy notes are excluded from the increased access caregivers would be given under HR 2646, Rodríguez-Roldán isn’t buying it; she fears individuals could be inadvertently outed to their caregivers.

Rodríguez-Roldán echoed concern that while disability advocacy organizations largely oppose the bill, groups that represent either medical institutions or families of those with mental illnesses, or medical institutions—such as NAMI, Mental Health America, and the APA—seem to be driving this legislation.

“In disability rights, if the doc starts about talking about the plight and families of the people of the disabilities, it’s not going to go over well,” she said. “That’s basically what [HR 2646] does.”

Rodríguez-Roldán’s concerns extend beyond the potential harm of allowing families and caregivers easier access to individuals’ sensitive medical information; she also points out that the act itself is rooted in stigma. Rep. Murphy created the Helping Families in Mental Health Crisis Act in response to the Sandy Hook school shooting in 2012. Despite being a clinical psychologist for 30 years before joining Congress and being co-chair of the Mental Health Caucus, he continues to perpetuate the well-debunked myth that people with mental illness are violent. In fact, according to the Department of Health and Human Services, “only 3%-5% of violent acts can be attributed to individuals living with a serious mental illness” and “people with severe mental illnesses are over 10 times more likely to be victims of violent crime than the general population.”

The act “is trying to prevent gun violence by ignoring gun control and going after the the rights of mentally ill people,” Rodríguez-Roldán noted.

In addition, advocates note, HR 2646 would make it easier to access assisted outpatient treatment, but would also give courts around the country the authority to mandate specific medications and treatments. In states where the courts already have that authority, Rodríguez-Roldán says, people of color are disproportionately mandated into treatment. When she has tried to point out these statistics to Murphy and his staff, she says, she has been shut down, being told that the disparity is due to a disproportionate number of people of color living in poverty.

Harris also expressed frustration at the hostility she and others have received attempting to take the lived experiences of those who would be affected by the bill to Murphy and his staff.

“I’ve talked to thousands of families … he’s actively opposed to talking to us,” she said. “Everyone has tried to engage with [Murphy and his staff]. I had one of the staffers in the room say, ‘You must have been misdiagnosed.’ I couldn’t have been that way,” meaning mentally ill. “It’s an ongoing struggle to maintain our mental and physical health, but they think we can’t get well.”

Multiple attempts to reach Murphy’s office by Rewire were unsuccessful.

LGBTQ people—transgender, nonbinary, and genderqueer people especially—are particularly susceptible to mistreatment in an institutional setting, where even the thoughts and experiences of patients with significant privilege are typically viewed with skepticism and disbelief. They’re also more likely to experience circumstances that already come with required hospitalization. This, as Rodríguez-Roldán explained, makes it even more vital that individuals not be made more susceptible to unnecessary treatment programs at the hands of judges or relatives with limited or no medical backgrounds.
Forty-one percent of all trans people have attempted suicide at some point in their lives,” said Rodríguez-Roldán. “Once you have attempted suicide—assuming you’re caught—standard procedure is you’ll end up in the hospital for five days [or] a week [on] average.”

In turn, that leaves people open to potential abuse. Rodríguez-Roldán said there isn’t much data yet on exactly how mistreated transgender people are specific to psychiatry, but considering the discrimination and mistreatment in health care in general, it’s safe to assume mental health care would be additionally hostile. A full 50 percent of transgender people report having to teach their physicians about transgender care and 19 percent were refused care—a statistic that spikes even higher for transgender people of color.

“What happens to the people who are already being mistreated, who are already being misgendered, harassed, retraumatized? After you’ve had a suicide attempt, let’s treat you like garbage even more than we treat most people,” said Rodríguez-Roldán, pointing out that with HR 2646, “there would be even less legal recourse” for those who wanted to shape their own treatment. “Those who face abusive families, who don’t have support and so on—more likely when you’re queer—are going to face a heightened risk of losing their privacy.”

Or, for example, individuals may face the conflation of transgender or gender-nonconforming status with mental illness. Rodríguez-Roldán has experienced the conflation herself.

“I had one psychiatrist in Arlington insist, ‘You’re not bipolar; it’s just that you have unresolved issues from your transition,'” she said.

While her abusive household and other life factors certainly added to her depression—the first symptom people with Bipolar II typically suffer from—Rodríguez-Roldán knew she was transgender at age 15 and began the process of transitioning at age 17. Bipolar disorder, meanwhile, is most often diagnosed in a person’s early 20s, making the conflation rather obvious. She acknowledges the privilege of having good insurance and not being low-income, which meant she could choose a different doctor.

“It was also in an outpatient setting, so I was able to nod along, pay the copay, get out of there and never come back,” she said. “It was not inside a hospital where they can use that as an excuse to keep me.”

The fear of having freedom and other rights stripped away came up repeatedly in a Twitter chat last month led by the Task Force to spread the word about HR 2646. More than 350 people participated, sharing their experiences and asking people to oppose Murphy’s bill.

In the meantime, Sen. Lamar Alexander (R-TN) has introduced the “Mental Health Reform Act of 2016” (SB 2680) which some supporters of HR 2646 are calling a companion bill. It has yet to be voted on.

Alexander’s bill has more real reform embedded in its language, shifting the focus from empowering families and medical personnel to funding prevention and community-based support services and programs. The U.S. Secretary of Health and Human Services would be tasked with evaluating existing programs for their effectiveness in handling co-current disorders (e.g., substance abuse and mental illness); reducing homelessness and incarceration of people with substance abuse and/or mental disorders; and providing recommendations on improving current community-based care.

Harris, with Real MH Change, considers Alexander’s bill an imperfect improvement over the Murphy legislation.

“Both of [the bills] have far too much emphasis on rolling back the clock, promoting institutionalization, and not enough of a preventive approach or a trauma-informed approach,” Harris said. “What they share in common is this trope of ‘comprehensive mental health reform.’ Of course the system is completely messed up. Comprehensive reform is needed, but for those of us who have lived through it, it’s not just ‘any change is good.'”

Harris and Rodríguez-Roldán both acknowledged that many of the HR 2646 co-sponsors and supporters in Congress have good intentions; those legislators are trusting Murphy’s professional background and are eager to make some kind of change. In doing so, the voices of those who are affected by the laws—those asking for more funding toward community-based and patient-centric care—are being sidelined.

“What is driving the change is going to influence what the change looks like. Right now, change is driven by fear and paternalism,” said Harris. “It’s not change at any cost.”