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13. K. Outterson, “Regulating Compounding Pharmacies After NECC,” New England Journal of Medicine 367, no. 21 (2012): 1969---1972. 14. 131 S. Ct. 2653 (2011). 15. Id. at 2667 quoting R.A.V. v. St. Paul, 505 U.S. 377, 382 (1992). 16. 131 S. Ct. at 2667. 17. U.S. v. Caronia, 703 F.3d 149 (2nd Cir. 2012). 18. RJ Reynolds Tobacco. Co. v. FDA, 696 F.3d. 1205, 1222 (D.C. Cir. 2012). 19. Id. at 1219, n.13 (D.C. Cir. 2012). 20. Discount Tobacco City & Lottery Co. v. U.S., 674 F.3d 509 (6th Cir. 2012). 21. Almasy, “FDA Changes Course.” 22. Ibid.

30. 553 U.S. at 551. See also 23---34 94th St. Grocery Corp. v. N.Y.C. Bd. Of Health, 685 F.3d 174 (2d Cir. 2012) (finding city tobacco control laws preempted). 31. E.g., Turek v. Gen. Mills, Inc., 662 F.3d 423 (7th Cir. 2011)(finding preemption); N.Y. State Rest. Assoc. v. N.Y. City Bd. of Health, 556 F.3d 114 (2008) (rejecting preemption); Reid v. Johnson & Johnson, 2012 U.S. Dist. LEXIS 133408 (S.D. Cal. Sept. 18, 2012)(finding preemption); Boyd v. Sioux Honey Assoc., 2012 U.S. Dist LEXIS 12931 (N.D. Cal. Sept 11, 2012)(finding preemption); Lam v. General Mills, Inc., 859 F. Supp. 2d 1097 (N.D. Cal. 2012)(same); Smajlaj v. Campbell Soup Co., 782 F. Supp. 2d 84 (D. N.J. 2011)(rejecting preemption).

23. New York v. United States, 505 U.S. 144 (1992).

32. N.Y. State Rest. Ass’n v. N.Y.C. Dep’t. of Health, 556 F.3d 114 (2d. Cir. 2009) (rejecting preemption claim).

24. E.g., Lopez v. United States, 514 U.S. 549 (1995).

33. RJ Reynolds Tobacco Company v. FDA, 696 F.3d 1205 (D.C. Cir., 2012).

25. NFIB v. Sebelius, 567 U.S. ___, 132 S. Ct. 2566 (2012).

34. Id. at 1219.

Interventions” (abbreviated), 2013, http://www.thecommunityguide.org/ tobacco/massreach.html (accessed November 21, 2013). 38. D.P. Hopkins, P.A. Briss, C.J. Ricard, C.G. Husten, V.G. Carande-Kulis, J.E. Fielding, M.O. Alao, et al., “Reviews of Evidence Regarding Interventions to Recuce tobacco Use and Exposure to Environmental Tobacco Smoke,” American Journal of Preventive Medicine 20, suppl. no. 2 (2001): 16---66. 39. R.C. Brownson, J.E. Fielding, and C.M. Maylahn, “Evidence-Based Public Health: A Fundamental Concept for Public Health Practice,” Annual Review of Public Health 30 (2009):175---201, at page 182. 40. Discount Tobacco City & Lottery, Inc. v. United States, 674 F.3d 509 (6th Cir., 2012).

35. Id.

41. See, e.g., EME Homer City Generation, L.P. v. EPA, 696 F.3d 7, 38 (D.C. Cir. 2012) (Rogers, J., dissenting), reh’g and reh’g en banc denied, No. 11---1302 (D.C. Cir. Jan. 24, 2013).

28. Medtronic v. Lohr, 518 U.S. 470, 485 (1996).

36. C.J. Armitage and M. Conner, “Efficacy of the Theory of Planned Behavior: A Meta-Analytic Review,” British Journal of Social Psychology 40, pt 4 (2001): 471---499.

42. New York Statewide Coal. of Hispanic Chambers of Commerce v. N.Y.C. Dep’t of Health, 2013 N.Y. Misc. LEXIS 1216, 2013 NY Slip Op 30609(U) (N.Y. Sup. Ct., N.Y. Cty, March 11, 2013).

29. Mutual Pharmaceuticals Co. v. Bartlett, __ U.S. __, 133 S.Ct. 2466 (2013)(generic drugs); Riegel v. Medtronic, 552 U.S. 312(2008)(medical devices).

37. Guide to Community Preventive Services, “Reducing Tobacco Use and Secondhand Smoke Exposure: MassReach Health Communication

43. Id., slip op at 33.

26. Id. at ___, 132 S. Ct. at 2566. 27. Cipollone v. Liggett Grp., Inc. 505 U.S. 504, 516 (1992).

44. New York Statewide Coal. of Hispanic Chambers of Commerce, 970 N.Y.S.2d 200.

45. Id. at 211. 46. Id. at 213. 47. New York Statewide Coal. of Hispanic Chambers of Commerce, 2013 N.Y. Misc. LEXIS 1216, Slip Op at page 13. 48. L.O. Gostin, “Banning Large Sodas is Legal and Smart,” CNN Opinion, March 13, 2013, http://www.cnn.com/2013/ 03/13/opinion/gostin-soda-ban (accessed November 21, 2013). 49. P.D. Jacobson and W.E. Parmet, “A New Era of Unapproved Drugs: The Case of Abigail Alliance v. von Eschenbach,” Journal of the American Medical Association 297, no. 2 (2007): 205---208. 50. L. Barraza, D.C. Orenstein, and D. Campos-Outcalt, “Denialism and Its Adverse Effect on Public Health,” Jurimetrics 53 (2013): 307---325. 51. A. Kirkland, “The Legitimacy of Vaccine Critics: What Is Left after the Autism Hypothesis?” Journal of Health Politics, Policy, and Law 37, no. 1 (2012): 69---97. 52. See, e.g., EME Homer City Generation, L.P, 696 F.3d at 7. 53. 533 U.S. at ___, 132 S. Ct. at 2579 (opinion of Roberts, C.J.). 54. Institute of Medicine, Committee for the Study of the Future of Public Health, The Future of Public Health, (Washington, D.C.: National Academies Press, 1988), 19.

Impact of Alabama’s Immigration Law on Access to Health Care Among Latina Immigrants and Children: Implications for National Reform Kari White, PhD, MPH, Valerie A. Yeager, DrPH, Nir Menachemi, PhD, MPH, and Isabel C. Scarinci, PhD, MPH

We conducted in-depth interviews in May to July 2012 to evaluate the effect of Alabama’s 2011 omnibus immigration law on Latina immigrants and their US- and foreign-born children’s access to and use of health services. The predominant effect of the law on access was a reduction

in service availability. Affordability and acceptability of care were adversely affected because of economic insecurity and women’s increased sense of discrimination. Nonpregnant women and foreign-born children experienced the greatest barriers, but pregnant women and mothers of US-born

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children also had concerns about accessing care. The implications of restricting access to health services and the potential impact this has on public health should be considered in local and national immigration reform discussions. (Am J Public Health. 2014;104:397–405. doi: 10.2105/AJPH.2013.301560)

IN THE ABSENCE OF RECENT national immigration reform, state legislatures have increasingly proposed measures to address local immigration issues. Since 2007, legislators have put forth more than 1300 immigration-related bills and resolutions annually.1 Most of these failed to become

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law; however, in the past 4 years, Alabama, Arizona, Georgia, Indiana, South Carolina, and Utah have passed omnibus legislation to enforce immigration policy and discourage settlement of unauthorized immigrants.1 These laws contain numerous provisions that authorize local law enforcement personnel, employers, and others to verify an individual’s immigration status. All of these states also require verification of lawful presence in the United States for individuals seeking public benefits, such as health care, from state and local agencies; exceptions are made for prenatal and emergency care, child and adult protective services, and other services exempt under federal law (e.g., immunizations; the Special Supplemental Nutrition Program for Women, Infants, and Children; and short-term in-kind disaster relief).2 Previous research has found that laws aimed exclusively at restricting immigrants’ access to public benefits reduce immigrants’ use of health services. Following the 1994 passage of California’s Proposition 187, immigrants failed to receive or delayed medical care out of fear of deportation.3,4 As reported in one study, fear of deportation that results in delayed treatment of communicable diseases, such as tuberculosis, can pose significant health risks to the individual and the general public.3 Requirements to present proof of lawful residence to receive publicly funded health services, such as those established in the 2005 Deficit Reduction Act, can also affect eligible legal residents and US citizens,5---7 and groups that are less able to provide

appropriate documentation, such as adolescents and the elderly, may be deemed ineligible for services.6,8 The broader scope of recent state-level initiatives means that immigrants’ use of health care may be adversely affected not only because unauthorized immigrants are explicitly prohibited from receiving services, but also because the laws may exacerbate transportation and financial barriers, which affect other aspects of health care access. Anecdotal evidence suggests that recent state legislation has indeed hindered immigrants’ access to routine health care.9,10 However, few studies have assessed how these laws have affected immigrants’ use of health services.11,12 With growing calls for comprehensive national immigration reform, it is important to evaluate the impact of state-level laws on immigrants’ access to care to inform discussions that will shape future policies. We examined Latina immigrants’ experiences accessing health care following the June 2011 passage of the Alabama Taxpayer and Citizen Protection Act, House Bill 56 (HB 56), which was considered the toughest state immigration law in the United States.13 Specifically, we assessed the range of ways the law has affected several dimensions of access to care for Latina immigrants and their US- and foreign-born children. Latino immigrants constitute the largest immigrant group in Alabama and in the United States overall14,15; in fact, Alabama reported the second-largest percentage increase in its Latino population between 2000 and 2010, after South Carolina.16 We

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focused on Latinas because they have a primary role in their children’s health and health care and typically have more health needs and greater use of health services than men.17,18

CONCEPTUAL FRAMEWORK To evaluate how omnibus immigration legislation affects access to care, it is useful to conceptualize access as having multiple dimensions that influence a person’s use of health services: availability (an adequate supply of the types of services that clients need), affordability (clients’ ability to pay for services), accommodation (sufficient flexibility of services to meet clients’ needs), acceptability (clients’ comfort with health care sources and providers), and accessibility (clients’ ability to reach sources of care).19 Alabama’s HB 56 may affect Latino immigrants’ access to care across several of these dimensions. For example, the law requires verification of lawful US residence from persons seeking public benefits from state and local agencies, although exceptions are granted for select public health services, such as immunizations; testing and treatment of symptoms of communicable diseases; prenatal care; coupons for the Women, Infants, and Children’s nutrition program; and treatment of emergency medical conditions. This may directly affect availability, because unauthorized immigrants are no longer eligible for many subsidized services at publicly funded agencies, where they typically received care.20,21 Moreover, Latinos may be reluctant to seek care because exemptions under the

law are not well known, and they may believe they are ineligible for services of any kind at public clinics and hospitals. In addition, provisions authorizing local law enforcement to verify the legal residence of anyone they lawfully stop and suspect may be in the country without authorization may affect accessibility, because immigrants limit their mobility out of fear of being stopped while driving.11,22 The law also may affect affordability, because new documentation requirements and other employment-related provisions restrict immigrants’ job opportunities and create financial insecurity. Finally, the law may adversely affect acceptability by heightening immigrants’ perceptions of marginalization and discrimination by clinic staff or by creating fear that health care providers will report them to authorities.22-- 24

METHODS To examine how Alabama HB 56 has affected these dimensions of access, we conducted in-depth interviews with Latina immigrants of childbearing age residing in Jefferson County, Alabama, which hosts the state’s largest population of Latino immigrants.25 The main sources of primary and preventive health care for Latino immigrants in Jefferson County prior to HB 56 were the county health department, which is supported by a combination of federal, state, and local funds, and federally qualified health centers. Limited preventive and specialty care (e.g., dental cleaning) was also available at small nonprofit and faith-based organizations. The

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county hospital and a university hospital have served as the main centers for advanced health care services, including pregnancy-related care, which uninsured, unauthorized pregnant immigrants pay for out of pocket at a reduced fee, because Alabama does not cover prenatal care for this population through the Children’s Health Insurance Program. US citizens and eligible legal residents can obtain free or low-cost services through Medicaid or Medicaid expansion programs (e.g., the children’s insurance program) at the same county and university hospitals; the 2011 legislation did not affect Medicaid eligibility. Latinas were eligible for our study if they were aged 19 to 49 years, had children younger than 18 years, resided in Jefferson County, and were living in Alabama when HB 56 was passed (although being born outside the United States was not an eligibility requirement, all of our participants were immigrants). To reduce mistrust and thereby increase participation rates, we used snowball sampling to identify eligible women. We also hired native Spanishspeaking Latina interviewers who had developed trusted relationships in the Latino immigrant community through previous community-based participatory research initiatives.26,27 The interviewers’ existing contacts referred other women they knew, whom the interviewers then screened for eligibility and interest in the study. Only 2 women who were screened declined to participate. We recruited 30 participants by theoretical sampling,28 in which we selected participants according to characteristics that were most

likely to influence health care access. The main characteristic we theorized would affect children’s access to health care was their country of birth (United States or a foreign country), because this largely determines their eligibility for publicly funded health coverage, such as Medicaid; we sought a balanced sample of women who had only US-born children or at least 1 foreign-born child. We theorized that for women, a recent history of pregnancy would be the most influential characteristic affecting their own use of health services, because the majority of women in this population are of reproductive age,29 and prenatal care is exempt from the law’s documentation requirements, which may facilitate health care access. Women were eligible for this subsample if they were pregnant or had delivered a child within 6 months prior to the interview, because they would have spent all or much of their pregnancy in the period following the law’s enactment. Throughout recruitment, we reviewed the progress of sampling to ensure that women were included in each of the cells in our sample design. After 10 interviews with pregnant women, we had reached thematic saturation and recruited nonpregnant women for the remaining participants. Our final sample comprised 15 women with US-born children (9 nonpregnant and 6 pregnant women) and 15 women with at least 1 foreignborn child (11 nonpregnant and 4 pregnant women).

Interviews The in-depth interviews took place between May and July

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2012. We interviewed women in their homes or another place of their choosing. We conducted all interviews in Spanish and recorded them with participants’ permission. At the beginning of the interview, we asked women a series of sociodemographic questions; participant characteristics are presented in Table 1. The in-depth interview guide included sections on participants’ knowledge of HB 56, changes they had observed in their families and communities since the law was passed, and experiences accessing health care for themselves and their children before and after passage of HB 56. We

based questions about participants’ experiences obtaining care on our conceptual framework on the dimensions of access and on previous research identifying barriers to care among Alabama’s Latino immigrant population.23,24 We did not include any questions in the interview guide that specifically asked women about their own or their children’s legal status, to promote trust between participants and interviewers; however, some women volunteered this information. The interviews lasted an average of 40 minutes. Before the interview, participants provided written consent. They received $20 for their participation.

TABLE 1—Characteristics of Latina Immigrants Participating in Study of Effects of State Immigration Law on Health Care Access: Alabama, 2012 Characteristics

No. (%)

Country of origin Mexico Other foreign country

24 (80) 6 (20)

Duration of residence in Alabama, y

Impact of Alabama's immigration law on access to health care among Latina immigrants and children: implications for national reform.

We conducted in-depth interviews in May to July 2012 to evaluate the effect of Alabama's 2011 omnibus immigration law on Latina immigrants and their U...
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