Note: please note that this issue brief should (a) link back to the issue overview on this topic, (b) be focused either the local, state, national, or global level, and (c) be neutrally presented, based on facts, and include footnotes for each of the items.  See the Research Guide and Information Sources to assist you. 

Goal Statement

• To address health disparities in Maine; To address the lack of funding for adult immunizations in Maine which disproportionately affects refugees living in Lewiston

Scope of the Problem  factual statements on the extent of the problem in the past, current, or future

 Health Disparities

The rate of racial and ethnic minorities, comprising over 33 percent, 100.7 million people, of the US population in 2007, is rising.[i] Despite their growing presence, minorities still lag behind other groups in terms of access to necessary services, such as health care. “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” the 1999 federally-funded report on health disparities, found that in contrast with the general population, racial and ethnic minorities within the US experience a lower quality of health care and are less able to utilize routine medical services.[ii] Accessing adequate and appropriate health care is one of the greatest challenges facing ethnic minorities in America due to the exorbitant cost of health care and health insurance as well as the language and cultural barriers often associated with minority status.

Immigrants and refugees encounter their own set of health risks as a result of exposure to infectious diseases in their country of origin in addition to the terms of their migration. Many refugees arrive in the US with vitamin deficiencies, intestinal parasites, stress-related trauma and tuberculosis among other infectious diseases.[iii]

The health risks facing refugees pose a health threat to much of the US, including Maine.[iv] Maine currently hosts between 8,000 and 12,000 refugees.[v] Since 2001, over 4,000 refugees from Somalia and elsewhere have moved to Lewiston, alone.[vi]

Lewiston has tried to respond to the arrival of new citizens but struggles to provide all of the needed services. A compromised nutritional status, for instance, makes recently-arrived refugees more susceptible to environmental health challenges, such as lead poisoning. As a result, organizations in Lewiston, like United Somali Women of Maine, have developed specific programs to educate the refugee population on the risks of lead poisoning. Unfortunately, many other health challenges, including immunization coverage, still require specialized programming in the area.

Examining risk factors for infectious diseases confirms that the national burden of disease is directly related to race and ethnicity. Immunization coverage among minorities nationwide is much lower than the surrounding population despite an increased risk of infectious disease. Rates of influenza, pneumococcal and Hepatitis B immunizations are significantly lower for African American and Hispanic adults than for white adults.[vii] 54.6 percent of non-Hispanic Black women and 44.9 percent of Hispanic women as opposed to 62.6 percent of non-Hispanic White women received the Hepatitis B vaccine in 2004, for instance.

While the spread of infectious diseases and the neglect of pressing health conditions is detrimental not only to the health status of minorities and refugees but to Maine’s total population, state-wide budgetary choices have not acknowledged the importance of adult immunizations among the refugee population.

Issue of Immunization Coverage in Maine

The utilization of immunization programs across the US for decades has decreased the risk of infectious diseases among the national population. At the same time, newly arrived refugees exhibit an increased risk for infectious diseases due to a lack of preventive health measures in their country of origin, a compromised nutritional status upon arrival and the potential harm of new exposures in the US. Nevertheless, many adult refugees are falling through the cracks when it comes to immunizations due to the lack of financial support from the government and related organizations.

No state health insurance plan, including MaineCare or the Maine Immunization Program, covers adult immunizations. MaineCare cut funding for adult immunizations in 2005. As the state Medicaid provider, MaineCare is a health insurance program for low-income and disabled families and individuals in Maine, serving many primary and secondary refugees living in Lewiston. MaineCare’s tight budget has prompted other sources to cut their funding as well. Every $10 that is cut from the Maine Medicaid budget translates into a loss of $18.50 in federal matching funds.[viii]

Major hospitals, including the Central Maine Medical Center, have been filling in the gap and covering the cost of adult immunizations. January 2009, however, marked a stark transition where these hospitals stopped covering these costs and many adults have been forced to forgo their immunizations.

In an area like Lewiston where the urban environment lends itself to outbreaks and the population of at-risk adults, refugees from disease-ridden areas like Somalia, has been inclining, a lapse in immunization coverage poses harm to the community at large.

Hepatitis B, a liver disease caused by a virus in the blood which can lead to cirrhosis and liver cancer, has emerged as a serious concern in Maine. While the rate of acute Hepatitis B decreased from 3 to 1.7 per 100,000 people in the US from 2000 to 2006, this rate increased from 0.5 to 2.0 per 100,000 people in Maine.[ix]

During these same six years, Maine experienced a rapid influx of minorities, particularly the arrival of immigrants and refugees to urban areas like Portland and Lewiston. Since refugees from sub-Saharan Africa exhibit the highest prevalence of Hepatitis B among all refugees within the US, the growing population of Somalis in Lewiston and Portland poses a health risk to the state as a whole.[x] Hepatitis B within an adult population could spark an outbreak in the community as the infection can be transmitted through childbirth or the spread of contaminated blood or bodily fluids.

Across the nation, “black teenagers and young adults become infected with Hepatitis B three to four times more often than those who are white.”[xi] As health disparities inhibit access to health education and direct health services among racial and ethnic minorities, African Americans are less able to receive immunizations or protect themselves against Hepatitis B.

Luckily, the US has access to vaccines to effectively prevent many diseases, including Hepatitis B. The US Center for Disease Control (CDC) finds that immunizations are cost-effective because they provide preventive health care, reducing the disease incidence and costs for disease treatment overall. As a result, the CDC seeks to increase the rate of influenza and pneumococcal immunizations to 60 percent of all seniors in the US.[xii] By cutting its funding of immunizations for this population, Maine’s insurance programs are working in opposition to the goals of the CDC. To meet the immunization standards of the CDC and the pursuit to eliminate all disparities by 2010, Maine needs to broaden its coverage to include high-risk populations, such as the refugee population of Lewiston. By addressing the immunization rates among refugee adults, this policy could effectively respond to the desire of the CDC to reduce disparities of health status among different populations.

The Office of Minority Health together with the Office of Multicultural Affairs has indicated the importance of providing health services for the refugee population and needs help investigating funding options for adult immunizations in Maine.

Various states have made additional efforts to secure funds to cover adult immunizations for refugees. The Florida Refugee Health Program, for instance, relies on Refugee Medical Assistance from the federal Office of Refugee Resettlement to fund adult immunizations within the community.[xiii]

Other immunization programs receive federal grant funding from the Public Health Service Act, Section 317, in order to reduce the incidence of vaccine-preventable disease across their state. Specifically designed for populations with the greatest risk for undervaccination and disease, Section 317 grants align well with the needs of the Lewiston refugee community. Unfortunately, Section 317 grants cannot afford to cover vaccines for all children and adults seeking immunization coverage and place priority on immunizing children. Less than 5 percent of 317 vaccine purchase grants are spent on immunizations for adults.[xiv] The lack of immunization coverage among adult refugees sparks public concern that serious infectious diseases, like Hepatitis B, will transmit to infants despite the emphasis placed on vaccinating children. 

Past Policy  key legislation and milestones including significant policy and funding shifts, major studies, etc.

Current Policy  summary of current policies in the form of legislation, programs, and funding

• Currently, neither state Medicaid (MaineCare) or the Office of Refugee Resettlement direct funding toward covering immunizations for residents about 18 years of age in Maine.

   

Policy Options   

• 1. MaineCare should cover immunizations for all adults at risk for infectious diseases, particularly primary and secondary refugees. Hepatitis B is one of the most pressing health concerns within this population and the state health insurance plan, MaineCare, should cover the Hepatitis B vaccine for the state’s low-income and disabled citizens.
  2. Maine’s Department of Health and Human Services should initiate a pilot project with the Central Maine Medical Center and B Street International Clinic to fund the most critical immunizations for adult refugees and evaluate the expected decline in disease incidence in Lewiston and Auburn. While coverage of all available immunizations would be ideal, the most critical vaccines for refugees include Measles, Mumps and Rubella (MMR) and Hepatitis B. Research suggests that vaccines for MMR and Hepatitis B are likely to be the most cost-effective method for reducing the incidence of these diseases within the community and thus, promote good health within the state.
  3. The Office of Refugee Resettlement should allot a portion of its Refugee Assistance Cash toward refugee adult immunizations in Maine as exhibited in Florida.

•  

  As a state, Maine needs to respond to the needs of its citizens, including the growing refugee populations in Lewiston and Portland. Specifically, the refugee communities need to be able to access immunizations in order to keep infectious diseases, like Hepatitis B and MMR, in check, reduce health disparities across the state and allow for better health of the community at large.

Key Organizations/Individuals   contacts for public and private organizations and key individuals

• MaineCare, Maine’s Department of Health and Human Services, Local medical centers serving the refugee population (Central Maine Medical Center, St. Mary’s Hospital, B Street International Clinic), Office of Refugee Resettlement 

Glossary of Terms

Bibliography   web sites, reports, articles, and other reference material