Every year, more than 100 new obstetrician-gynecologists graduate from a Texas residency program and enter the medical workforce. Theoretically, all have had the opportunity during their four years of residency to learn about what’s called “induced abortion” — named that to distinguish it from a miscarriage. But the closure of abortion clinics in Texas — more than 20 since 2013 — has made that training increasingly difficult.
Texas has 18 residency programs in the field of obstetrics and gynecology, but only one allowed me to observe how abortion is taught. Because of the political pressures facing abortion providers, NPR agreed not to reveal the doctors’ full names or the clinic’s location. The resident agreed to be identified by her middle name, Jane.
Medical residents can opt out of abortion training for religious or moral reasons, but Jane felt a professional obligation to learn the procedure.
“This is part of OB-GYN — it’s not an optional part, per se,” Jane said. “Women can choose if they want an abortion or not, but you as their doctor need to be able to provide them with all the choices available.”This story is part of a partnership that includes Houston Public Media, NPR and Kaiser Health News. It can be republished for free. (details)
Jane spent that morning performing ultrasounds on pregnant women, working alongside a senior doctor who supervised.
Together, the two women examined a printout from a fetal ultrasound, and the senior doctor offered some feedback.
“On this image here, you want it more of a plane, as if you were opening it like this, so that you have the hypothalamus in your picture,” the senior doctor advised Jane. “That’s going to give you a better measurement.”
Doctors do ultrasounds before abortions in order to date the pregnancy, which helps determine which technique will be used to terminate it. In some states — including Texas — an ultrasound is also mandated by state law.
Jane spent about a month at this family planning clinic during the third year of her residency. Being able to perform the abortion is just one set of skills she learned. She also learned to counsel patients about abortion, contraception and sexually transmitted diseases, and learned techniques for pain management and dilation of the cervix.
The rotation taught her things that will be useful in other practice areas, Jane said. For instance, OB-GYNs use ultrasounds for many different reasons.
“Before in residency, we were doing ultrasounds maybe once during a clinic afternoon, or a few ultrasounds in the OB triage area,” Jane said. “But here we do 30 ultrasounds in a morning, so it’s a lot of good learning about how to do ultrasounds.”
It may be good learning, but in Texas this training happens quietly, almost in secret.
“Doctors working in these institutions are walking a very delicate line,” said Carole Joffe, a medical sociologist at the University of California, San Francisco. Joffe studies doctors who do abortions.
“Some of them want very much to be able to train residents,” she said. “But they are fearful of the other sectors of the university coming down on them and saying, ‘You’re threatening our funding.’ ”
Academic medical centers in Texas receive tens of millions of dollars a year in state funding. Many of those centers sponsor residencies, which are the training programs that come after medical school. They last four or more years and allow doctors to focus on a specialty.
It’s understandable why an OB-GYN resident in Texas might think twice about providing abortions. Doctors who provide the service must think about security issues for themselves and their staff. They also have to deal with the scrutiny of state inspectors as well as anti-abortion protesters.
Last summer, hundreds demonstrated outside the Planned Parenthood affiliate in Houston after an anti-abortion group released a series of undercover videos purporting to shed light on problems with fetal tissue research. (Planned Parenthood maintains the videos are deceptively edited and denies wrongdoing.)
“Aren’t you glad you’re from Texas, a pro-life state?” a man shouted into a microphone. “We’ve got great, pro-life leaders, like Sen. Ted Cruz,” he added, as the crowd burst into cheers. Later, they prayed and sang The Battle Hymn of the Republic.
Surveys and other research show that doctors who do abortions may have fewer job opportunities. That’s because many hospitals and group practices refuse to employ doctors who do abortions, even if they do so during evenings or weekends, on their own time.
A few years ago, 48 doctors in Texas did abortions, but a recent study shows it’s now down to 28. And some of the remaining doctors are nearing retirement.
Dr. Bernard Rosenfeld, 74, hasn’t been able to line up a successor to lead his medical practice. He says he understands — he’s been dogged by protesters for years.
“They’ve picketed my house where I live,” he said. “They put bullets in our parking lot.”
Rosenfeld has two medical offices but provides abortions at only one, a modest brick building in Houston’s museum district. He bought the clinic from other doctors in 1982, but now he can’t find anyone to buy it from him.
“I’ve talked to some doctors, but none of them are interested in the political consequences of providing abortions,” he said.
As the number of doctors in Texas dwindles, medical educators have raised the alarm about the need to train the next generation.
To find out how much abortion training was going on, I contacted all 18 OB-GYN residency programs in Texas. Although abortion is legal, and these programs are expected to provide some access to abortion training, my queries were frequently met with fear, evasion or even outright hostility.
One OB-GYN professor in Dallas hung up on me. Another agreed to an interview, then canceled.
Six of the programs, a third of the total, simply refused to answer questions about how the training takes place.
“UT Health does not want to participate in that story,” said a spokeswoman for the University of Texas Health Science Center in Houston. “It’s not a story that benefits us.”
UT Health sponsors two OB-GYN residency programs, both at Houston hospitals.
In the end, I could only confirm that three out of the 18 programs in Texas had made arrangements for residents to spend time learning at an outpatient family-planning clinic. Those types of clinics are where most abortions in Texas take place.
It’s unclear how some of the residency programs are handling the training requirement. Some directors point to the difficult fact that the nearest abortion clinic is now closed. Other directors may be providing some options for training, but wouldn’t talk about it publicly.
One doctor who would was Dr. Robert Casanova, who was recently the residency director at Texas Tech University Health Sciences Center in Lubbock. The last clinic that provided abortions in Lubbock closed in 2013.
“As of now, there’s really nothing in a close radius to us,” Casanova said. “Our patients will go to Albuquerque; they’ll go to Dallas; they’ll go to Denver.”
Casanova was left in a similar bind, with no local clinic where the OB-GYN residents could learn.
To compensate, Casanova created special seminars that cover elective abortion. He even arranged for guest speakers to fly down from Denver.
Since 1996, all OB-GYN programs in the U.S. must offer the residents at least the option to learn abortion techniques, even if the training happens elsewhere. If the residency programs don’t do so, it can affect their accreditation.
In Texas, all 18 programs are currently accredited — even in places like Lubbock, where there are no longer any clinics that perform the procedure.
Given the political climate in Texas, and the dwindling number of such clinics, residency directors have had to scramble to find other ways to fulfill the curricular requirement.
Dr. Tony Wen, the residency director at the University of Texas Medical Branch, in Galveston, said it’s one of the thorniest logistical problems he’s encountered. His OB-GYN residency program is a large one, with slots for 32 residents.
“We cannot teach them the procedure itself,” Wen said. “Can we teach them the concept and describe the procedure and that sort of thing? Yes, we can do all that.”
Wen explained he is hampered by three factors:
- Like most hospitals in Texas, UTMB does not allow elective abortions. Doctors must obtain special approval to do abortions for other reasons, such as severe abnormalities in the fetus or a threat to the mother’s life.
- Galveston does not have an outpatient abortion clinic. Wen has arranged for his residents to be able to travel for training to a clinic in Houston, an hour’s drive away, but almost none have gone.
- The faculty physicians at UTMB accept reimbursement from the Texas Women’s Health Program, a state-funded program for the medical treatment of low-income patients. The doctors cannot be paid if they perform elective abortions or affiliate with an organization that does. The upshot is that Wen and his colleagues cannot teach the procedure, even at an off-site clinic.
Most of his residents don’t seem bothered by the situation, Wen said.
“If this part of the training is very important to them, more likely they will probably rank and choose another residency program to go to, instead of come to Texas,” he said.
That’s not to say the politics haven’t affected the curriculum in other ways, explained Wen.
Because getting an abortion has become more difficult in Texas, more patients may be purchasing abortion drugs in Mexico to try to induce a miscarriage, and those pills don’t always come with clear instructions.
“Here in Texas, they could easily cross the border and get that medication,” Wen says. “A lot of people’s thinking process is ‘If five tablets [are] good, ten must be better!’ ”
Wen has started teaching the residents how to diagnose a woman who has overdosed on abortion drugs, and what to do to save her life.
Abortion is one of the more common procedures performed in the U.S., more common even than appendectomy. But as clinics in Texas close, finding a place in the state where medical residents training to be OB-GYNs can learn to do abortions is getting harder.
“There are places in Texas where there are OB-GYN residents who can’t get anywhere to be trained,” said a senior doctor at one Texas clinic who is also a medical school professor. The physician asked not to be named to avoid backlash from anti-abortion groups and politicians.
Clinics that used to perform abortions have closed recently in Lubbock, Odessa and other Texas cities. But the professor’s clinic, which still does abortions and trains some OB-GYN residents, can’t take up the slack.This story is part of a partnership that includes Houston Public Media, NPR and Kaiser Health News. It can be republished for free. (details)
“We’ve been approached by many different residency programs about the ability to train their residents,” she said. “Unfortunately, we just don’t have the capability to train everyone.”
The day we spoke, the doctor was spending the afternoon at the clinic, supervising a third-year resident. The resident agreed to be identified by her middle name, Jane.
During her four years of residency, Jane spent about a month doing rotations at this clinic. The experience improved her medical skills, she said, but also gave her a new political perspective on what it means to be a doctor.
“It makes it even more obvious how important it is for women to have access to abortions,” she said. The rotation made her more committed to providing abortions throughout her career, she added. “If I think a woman needs access and I have the skills to provide access, I should,” she said.
Jane listened as the senior doctor prepared her for the next patient: “She’s 21 years old, and this is her first pregnancy. She is at about eight weeks today. Do you have any questions about what we’re going to be doing or the procedure?”
Later, I asked the professor if it’s hard to teach abortion. She said it’s not difficult to teach the procedure.
“The technical procedure is the same, whether you are doing it for a miscarriage, or whether you’re doing it to terminate an ongoing pregnancy,” she said.
That procedure is known as a dilation and curettage, or “D and C.” The cervix is dilated, and then a suction instrument is inserted to remove tissue from the uterus.
D and Cs are also used to treat excessive bleeding, or to take a biopsy from inside the uterus.
“I like to say that a D and C, a suction D and C even, is bread and butter gynecology,” she explained.
OB-GYNs have always learned the D and C procedure. There’s nothing controversial about it, per se. But when it’s done because a woman chooses to end a pregnancy, it’s called an elective abortion, and to be able to perform the procedure in such a case, the doctor needs to have additional training.
Elective abortions are almost always done on an outpatient basis. To do them, doctors learn how to counsel the patients and manage their pain during the five-minute procedure. They also need to learn how to administer medical abortions — the ones that use pills.
In addition, many states like Texas require doctors to perform extra steps, such as reading out loud a state-mandated script to the woman or having her listen to the fetal heartbeat.
OB-GYN residents can’t learn all that’s required without spending time at an outpatient clinic, which is where most abortions in Texas take place.
But in Texas, there are only 18 of those clinics still in operation.
(Story continues below)
Use the “+” sign above to zoom in and see how residency programs responded to the question: “How are ob-gyn residents trained in abortion?”
- Green dots indicate the residency is located in an area where clinics still offer elective abortion (12).
- Yellow dots indicate that a nearby clinic still provides abortion, but the clinic could close soon depending on the U.S. Supreme Court’s interpretation of Texas law (2).
- Red dots indicate that none of the clinics left in the area provide abortion (4).
That worries Lori Freedman, a medical sociologist at the University of California, San Francisco. “How can you have abortion provision if you don’t have trained doctors?” Freedman said. “Especially the ones likely to stay in your state.”
Abortion training has become more common in the U.S. but only in some areas in the country. “We’ve trained a lot of people, but they’re staying in relatively liberal, urban areas,” Freedman said.
Texas has 18 OB-GYN residency programs. All of them undergo periodic reviews by the Accreditation Council for Graduate Medical Education, or ACGME, in Chicago.
One of the things the reviewers look for is whether residents have opportunities to learn about induced abortion, called that to distinguish it from a miscarriage.
All 18 residency programs in Texas are currently accredited, even though some of them are located in cities where outpatient abortion providers have closed.
Programs without abortion providers nearby have other options for fulfilling the training obligation, said Dr. John Potts, ACGME’s senior vice president for surgical accreditation.
He explained the residents don’t have to perform elective abortions. They can practice terminating pregnancies in the hospital, for other reasons.
“As long as they’re getting sufficient experience in some form of abortion, you know, where the mother’s life is in danger, where there’s significant neonatal abnormalities,” Potts said.
In other words, to become an OB-GYN, the resident must know how to safely empty a woman’s uterus if her pregnancy is experiencing a medical complication. For situations when it’s the woman choice to end pregnancy, residents can hear lectures about it, perform simulations or practice counseling skills on each other.
Some Texas professors maintain that minimal standard of experience is good enough — or, at least, the best they can do under the circumstances.
But I asked Dr. Bernard Rosenfeld, who has been providing abortions in Houston for decades, if he thought it really was enough to learn how to perform elective abortions.
“No, absolutely not,” he said.
When residents are learning to do D and Cs, they usually do them in the hospital, and the patient is often asleep, Rosenfeld pointed out. But most abortions in this country take place in outpatient clinics.
At the clinics, patients get a local anesthetic or none at all. That makes the abortion safer for the patient, but it requires more skill on the part of the doctor, according to Rosenfeld and other experts.
“Time is a big factor, and causing as least pain as possible, and having a very gentle touch,” Rosenfeld said. “But all that is learned.”
Residents won’t have competence in performing abortions until they do dozens of outpatient abortions, Rosenfeld said.
“Nobody would ever say that about a cesarean delivery or a regular delivery: ‘Well, OK, you just saw one or two, so you can just do them,’ ” he said. “Lots of time you’ll have uterine abnormalities and you’re not going to know unless you’ve done many procedures what to do with a uterine abnormality.”
There’s one more intangible, but critical, experience residents get from abortion training, many doctors say.
Jane summed it up this way: “Every woman has a different story and a different reason why she chooses to end her pregnancy.”
Hearing those stories from patients is crucial to a an OB-GYN’s professional development, said Dr. Jody Steinauer, an OB-GYN professor and researcher at the Bixby Center for Global Reproductive Health at UCSF.
The experience teaches valuable bedside skills like compassion, empathy and political awareness.
“When they spend time in a setting that provides abortion care, they have real epiphanies,” Steinauer said. “They become more aware of their biases. They’re surprised that more than half of women having abortion are already mothers, for example.”
Steinauer’s research also shows that OB-GYNs who have access to training during their medical residencies are more likely to provide abortion later in their careers.
But some doctors question the need for more training, saying if residents really want abortion skills they can leave Texas to acquire them, and then come back to the state to practice.
Other OB-GYNs, like Dr. Donna Harrison, executive director of the American Association of Pro-Life Obstetricians & Gynecologists, condemn the entire concept. Harrison believes abortion is killing an unborn child.
“It should not be part of any kind of medical training to do elective, induced abortions,” she said.
Residents have always been able to “opt out” of abortion training if they have moral or religious objections, Harrison acknowledged. But some residents might feel pressured to do the rotation, she said, and they could end up indoctrinated with the view that elective abortion is OK.
“If you do a procedure that you have moral qualms with, there’s a kind of desensitization that goes on,” Harrison said. “The attempt to force residents to participate in abortion is an attempt to desensitize those residents, so they will have less ability to think clearly about what that procedure is actually about.”
But Freedman, the medical sociologist, disagreed that abortion training amounts to indoctrination.
“If you look at medicine in general, how many things do we do to teach people empathy, sensitivity, compassion about a lot of things?” she asked.
Doctors will always have patients whose life decisions they privately disagree with, Freedman said, but it doesn’t help the patient when doctors judge them or withhold a treatment or procedure.
“Things happen to people that they don’t want, health-wise, all the time,” she said. “We just need doctors to know how to do this.”
According to a national survey, 97 percent of OB-GYNs have had a patient who wanted an abortion. But only 14 percent of those doctors actually provide abortions.
Thanks To Efforts Of 4 Moms, Broad Institute Launches Initiative To Better Understand Food Allergies
Six years after promising a plan to “repeal and replace” the federal health law, House Republicans are finally ready to deliver.
The 37-page white paper, called “A Better Way,” includes virtually every idea on health care proposed by Republicans going back at least two decades. It would bring back “high risk pools” for people with very high medical expenses, end open-ended funding for the Medicaid program and encourage small businesses to band together to get better bargaining power in “Association Health Plans.”
What the plan does not include, however, is any idea of how much it would cost, or how it would be financed.
“It’s a framework,” a senior House Republican leadership aide said on a conference call with reporters Tuesday, with the specifics to be determined next year by congressional committees, assuming the GOP maintains its majority. He likened the document to the white paper issued just after President Barack Obama’s election by then-Senate Finance Committee Chairman Max Baucus, a Democrat. That document foreshadowed many of the key elements of the Affordable Care Act.
The plan starts with repeal of the health law and its requirements and taxes, but it would then put back many of its most popular elements: Allowing young adults to stay on their parents’ health plan to age 26; banning insurers from charging people with pre-existing health problems higher premiums; and forbidding insurers from dropping coverage if a policyholder gets sick.
It would repeal the current scheme of exchanges where consumers buy insurance and government tax credits to help moderate-income Americans pay their premiums if they don’t have an employer to help. Instead, everyone buying policies in the individual market would receive tax credits. Older people charged more by insurers would receive larger credits, though the House Republicans don’t specify how much.Use Our Content This KHN story can be republished for free (details).
But the GOP plan also would likely make insurance more expensive for older people by proposing a broader range for premiums based on age. Current premiums can vary only three-fold based on age, which is “driving out younger and healthier patients” who can’t afford them, the GOP aide said.
Under the plan, insurance companies could not charge higher rates to people with pre-existing conditions so long as they maintain continuous coverage, whether from an employer or in a policy they purchase themselves. The new high-risk pools would be available for those who have a break in coverage, or who fail to purchase during a one-time open enrollment under the plan.
The plan would get rid of most of the coverage requirements under the Medicaid program for the poor, so states could make them more or less generous than they are currently. It would also limit funding. States could opt for either a per-person cap or a block grant to spend much as they wish.
On Medicare, the proposal would encourage the existing movement of patients from the program’s traditional fee-for-service program to managed care plans, and would transition from the existing financing structure based on benefits to a controversial structure called “premium support” that puts cost-controlling responsibilities more on private insurance companies. That change has been pushed by House Speaker Paul Ryan for nearly a decade.
Backers of the existing health law were quick to criticize the GOP outline.
“Make no mistake, Ryan’s approach is not a better way forward, but a bitter path backward that returns us to the bad old days when vast swaths of Americans were left to the tender mercies of the insurance industry and could not afford needed care,” said Families USA Executive Director Ron Pollack, who pushed hard for passage of the Affordable Care Act.
“While House Republicans continue their efforts to repeal and undermine the Affordable Care Act, Democrats will work to defend the ACA so that every American has access to affordable and quality health care,” said House Minority Whip Steny Hoyer (D-Md.).
Mr. Chairman, Mr. Van Hollen, members of the Committee, I am always happy to come home to the House Budget Committee. My prepared testimony is brief. With your permission, I would like that testimony and three accompanying charts to be placed in the record.
In another sign of growing frustration with rising health costs, aerospace giant Boeing Co. has agreed to contract directly for employee benefits with a major health system in Southern California, bypassing the conventional insurance model.
The move, announced Tuesday, marks the expansion of Boeing’s direct-contracting approach, which it has already implemented in recent years in Seattle, St. Louis and Charleston, S.C.
Other large employers are also pursuing this idea in regions where they have big concentrations of workers. In some cases, they refer employees to nationally top-performing hospitals for select surgeries.
MemorialCare Health System said Chicago-based Boeing selected it from a group of bidders for the five-year contract in Southern California, where the company has roughly 37,000 employees and dependents. Financial terms weren’t disclosed.Use Our Content This story can be republished for free (details).
“More employers are interested in moving in this direction,” said Barry Arbuckle, chief executive of the MemorialCare Health System, based in Fountain Valley, California. “It reflects the desire of these employers to participate in bending the cost curve for health care, and it allows the provider to have a more unfettered relationship with the employer and employees.”
The new health plan will be offered to Boeing workers in Southern California during open enrollment this fall alongside some existing options, including a Kaiser Permanente HMO. Coverage starts Jan. 1.
MemorialCare, a large integrated health system spanning Los Angeles and Orange counties, partnered with other hospital systems and physician groups to create a broader network.
The partners include UC Irvine Health, Torrance Memorial Health System and PIH Health.
This MemorialCare Health Alliance will include nine hospitals, about 2,400 physicians and other providers, as well as 71 surgery centers, urgent-care facilities and other freestanding clinics.
“MemorialCare and its partners have a long track record of health care leadership and innovation in Southern California, as well as a strong market presence,” Jeff White, Boeing’s director of health care strategy, said in a statement. “Creating these partnerships is one of the innovative ways we are managing our health care programs to improve quality and efficiency.”
Boeing and other self-insured employers have typically hired health insurance companies to contract with hospitals and doctors and design their employee benefits. As medical costs kept escalating, employers and health insurers often narrowed their networks to negotiate lower rates and shifted more of the costs onto workers through higher deductibles.
Direct contracting is seen as another way to potentially save money while improving care and patient satisfaction.
In these contracts, health systems usually take on the financial risk of managing the health of a large population. The provider groups are often organized as accountable care organizations, in which physicians and hospitals share the financial responsibility for coordinating care and avoiding unnecessary spending.Accountable Care Organizations, Explained
An ACO is a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending.
This MemorialCare ACO designed for Boeing must meet numerous performance measures of quality, access and savings, Arbuckle said.
The Boeing contract “allows us to earn certain incentives or, if we don’t meet certain criteria, incur a loss on that particular aspect,” Arbuckle said. “There is no incentive to keep people in the hospital and go to multiple specialists. For us, this is where health care needs to go.”
Steve Valentine, vice president and West Coast consulting leader at health-care firm Premier Inc., said MemorialCare was a logical fit for Boeing, but plenty of health systems will be competing for these types of contracts.
“Most health systems have been building up their infrastructure to do exactly this kind of relationship,” Valentine said.
MemorialCare won’t have to handle all of the administrative chores of an insurer. Boeing uses its national insurance administrator, Blue Cross and Blue Shield of Illinois, to process claims for its direct contracts.
Boeing will offer workers several incentives to choose this new provider-backed health plan in California.
Enrollees will have no copays for primary-care visits. They will get full coverage for generic drugs and the freedom to choose specialists within the network without a referral. Emergency care will be covered as in-network even if it’s received outside MemorialCare. Boeing will also offer increased contributions to workers’ health savings accounts.
In other examples, Intel Corp. contracted directly with a major health system in New Mexico, where it has several thousand employees.
Retailers Wal-Mart and Lowe’s took a different approach, striking deals with select hospitals across the country for bundled prices on specific surgeries. The companies steer workers to those hospitals.
Amid early signs that insurance premiums under Obamacare might rise significantly next year, administration officials Tuesday previewed their plans to increase enrollment in the marketplaces, particularly among young adults who have been slow to sign up.
Open enrollment starts Nov. 1 and ends Jan. 31.
For the first time, the administration said it would send letters about marketplace coverage to uninsured people and to families who paid the individual mandate penalty for not having coverage or claimed an exemption from the health law requirement that they have coverage.
About 7.9 million Americans paid a penalty for lack of coverage in 2014. The Internal Revenue Service has not disclosed how many paid the fine for lacking coverage last year.Use Our Content This KHN story can be republished for free (details).
About 45 percent of 2014 taxpayers who paid a penalty or claimed an exemption from the penalty were under age 35, according to the Health and Human Services Department.
“This new strategy…will let us directly reach millions who were recently uninsured and may appreciate the value of marketplace coverage,” HHS said.
The administration will also:
- Email people if they open an account on www.healthcare.gov but do not select a plan and pay a premium.
- Encourage insurers to contact young adults before they turn 26 and move off their parents’ health plans to tell them about marketplace coverage options. New guidance from the Department of Labor makes clear that the sponsors of employer plans are allowed to provide specific information on health insurance plans that 26-year-olds can buy on the marketplace, HHS said Tuesday. The health law allows people to stay on their parents’ health insurance until 26.
- Help people pay for transportation to open enrollment events this fall where they can find help signing up. HHS has contracted with the ride-sharing service Lyft to provide discounts for those customers.
Nearly 13 million people signed up for health coverage under the Obamacare marketplaces this year. About 28 percent of them were between ages of 18 and 34. That group has the highest uninsured rate and generally enjoys the best health, which helps insurers control costs and balance the risks of covering less-healthy people.
Since the health law was fully implemented in 2014, the uninsured rate in the United States has fallen below 10 percent for the first time. In May, the rate fell to 9.1 percent, according to the Centers for Disease Control and Prevention.
Recent reports suggest health insurance premiums could increase by double-digit rates in several states in 2017. About 80 percent of marketplace enrollees are insulated from such increases by the government subsidies they receive based on their income levels.
Previously on this blog we have published articles related to developments in the refugee laws of particular countries in response to the current refugee crisis. For example, Elin wrote two posts on the refugee laws of Denmark and Sweden, and Theresa wrote a post on the European Union’s approach to the crisis. There are also a number of relevant articles on the Global Legal Monitor, which can be easily found by clicking on the “Refugees” topic.
We now also have an in-depth report on our website, titled Refugee Law and Policy in Selected Countries, that provides information on the laws and policies of twenty-two countries and the European Union regarding asylum seekers and refugees. The report was prepared by the Law Library’s foreign law research staff and is part of a growing collection of reports on important legal issues around the world.
There has been a dramatic increase in the number of refugees around the world in recent years. The refugee population of the world, which was estimated at 10.5 million in 2012, has nearly doubled in just three years. According to United Nations High Commissioner for Refugees (UNHCR) statistics, in 2015 there were around 65 million forcibly displaced persons worldwide, around 21 million of whom were refugees, of which 10 million were stateless. Over half of the 21 million refugees were children.
The UNHCR also estimates that 34,000 people around the world are forced to flee their homes every day to escape conflict or persecution. One such conflict is the Syrian civil war, which has resulted in over 4 million registered refugees in the past four years, with that number constantly increasing.
This crisis is placing pressure on the resources of host communities and has led to considerable debate about how countries should respond to the vast numbers of asylum seekers and refugees. In Lebanon, for example, a country with a population of around five million, there are more than 1.4 million registered refugees as well as a large number of unregistered Syrians in the country (estimated to be between 300,000 and 500,000). This situation is creating various pressures in the communities across the country, including overcrowded schools and clinics and soaring rent prices. Wealthier countries that are receiving refugees, albeit in smaller numbers, are also facing resource pressures. For example Sweden, which received over 160,000 asylum claimants in 2015 alone, has faced issues in providing housing for asylum seekers and refugees.
At the global level, there is discussion about how to change or strengthen current models for responding to refugee crises and the increasing burden faced by different countries. At the domestic level, a number of individual countries are applying their own refugee laws and policies in processing and supporting varied numbers of refugees. In some cases, new policies, special processes, and specific quotas have been instituted in response to the current crisis. Our report examines these developments and a number of broader issues, including the legal framework for governing the admission of refugees and handling asylum claims; the protocols and processes in place for dealing with asylum seekers arriving at the border; the refugee status determination process; public accommodations and assistance provided to refugees and asylum seekers; and integration policies (including access to employment and pathways to citizenship). It also includes a bibliography of selected recently published resources on refugee law.
The new Refugee Law and Policy report covers the following jurisdictions:Australia Brazil Canada China Denmark Egypt European Union Finland France Germany Greece Israel Italy Japan Jordan Kenya Lebanon Russian Federation Spain Sweden Switzerland Turkey United Kingdom
We often introduce our new multinational reports through this blog. Our more recent reports cover a wide range of contemporary foreign, international, and comparative law issues including counter-terrorism laws and other security measures, training related to combating human trafficking, and campaign finance laws. You can read many more reports on the Law Library’s website.
The House is slated to consider a bill tomorrow that could cause over 100,000 modest-income people to forgo health coverage and boost premiums for millions more — to pay for expanding health tax breaks that mainly benefit high-income people.