Healthcare Access and Acculturation

Obstacles to Obtaining US Citizenship” (2021) Aviva Friedman, MD

Models of Refugee Health Care” (September 2020) Deson Haynie

Refugee health care has many unique challenges, including language barriers, cultural differences, complex medical problems, significant past trauma, limited financial resources, and more. Caring for the needs of such a diverse population is challenging, yet worthy of consideration. As human beings who have experienced significant hardship, they are deserving of the same quality of care afforded to other members of the community, and it is important to find the most efficient and equitable care practices to best serve this population. This paper explores various models of care currently in practice to address the unique concerns of caring for refugees, with the aim of finding what has worked well and has not worked as well, uncovering common challenges and focusing on lessons learned and key take-aways for improving the care of this vulnerable patient population.

Keywords: Models of Care

Fast Facts About Special Immigrant Visas (SIVs)” (March 2016) Lauren Klein

This paper offers a summary of facts related to Special Immigrant Visas (SIVs). Topics covered include SIVs for Iraqi and Afghan Translators/Interpreters, SIVs to Iraqi Nationals, SIVs to Afghan Nationals, and important laws relating to SIVs. The paper also includes insights related to news on Muslim immigration and presidential campaign attitudes concurrent with the paper’s preparation, and outlines Muslim Americans throughout US history and prominent Muslim Americans. Also included is a summary of the International Neighbors organization, and some insights about refugees from Tim Leroux of International Neighbors. Another local resource, Jefferson Area CHIP, is also explained.

Keywords: Special Immigrant Visas, SIVs, Iraqi, Afghan, Local Resources, International Neighbors, CHIP


Timeline of US Naturalization Law/Civics Exam” (June 2015) Sarai Martinez-Suazo

This paper describes the laws concerning immigration and naturalization over the history of the United States, from 1790 until the present, focusing on the origins of the US citizenship exam as it is today for refugees and immigrants. A summary of the naturalization exam, including speaking, reading, writing, and civics, is also presented. Exceptions and accommodations related to the immigration and naturalization process are also explored.

Keywords: Immigration, Naturalization, Civics Exam, History, Exceptions, Accommodations


“Paths to Citizenship” (April 2013) William Gilmore

A collection of documents detailing many aspects of the refugee naturalization process, as summarized below:

  • Appendix A: Medical Waiver Process” – Explanation of key components of Form N-648 (see below) for patients seeking medical exception to English and/or civics testing for citizenship. Also contains suggestions for how to properly complete the form and the criteria upon which the form is reviewed.
  • Form N-648, Medical Certification for Disability Exceptions” – Example of the form used for applicants who seek an exception to the English and/or civics requirements due to physical, developmental, or mental impairment, as certified by a physician or clinical psychologist licensed to practice in the United States.
  • Appendix B: Failing to Acquire Citizenship within Seven Years” – Most federal benefits expire after seven years if the individual has not obtained citizenship, and are not reinstated until greater than 15 years after arrival in the United States. Review of multiple benefit programs including SNAP, Medicaid, TANF. Also reviews exceptions to English and civics requirements, as well as challenges to refugees in meeting the seven-year time mark for obtaining citizenship.
  • Appendix C: Social Security Supplemental Security Income (SSI)” – Summary of SSI eligibility criteria, application process, and benefits that apply to refugees on a time-limited basis of seven years. The history of SSI policies and their changes related to refugees since 1996 is also presented.
  • Appendix D: Early Benefits Available to Refugees” – Discussion of the programs particular to refugees who fail to meet specific criteria for TANF/Medicaid. This includes the Refugee Cash Assistance Program, Refugee Social Services Employment Program, Refugee Medical Assistance, and Refugee School Impact Program. Also summarizes implications of the Affordable Care Act for refugees.
  • Appendix E: Good Moral Character” – Review of permanent and conditional bars to naturalization as related to convictions within 5 years prior to filing for general naturalization, or severe cases outside of the 5 year window. Special cases are also addressed.
  • Appendix F: Economic and Work Data” – Data related to refugee employment rates, reasons refugees are not looking for work, reasons refugees do not find work, and time until first employment.


“Factors Influencing the Acculturation of Burmese, Bhutanese and Iraqi Refugees Into American Society: Cross-Cultural Comparisons” (September 2010) Elsbeth Lo, Anne Maxwell, Preston Reynolds, MD, PhD, Fern R. Hauck, MD, MS

Hauck FR, Lo E, Maxwell A, Reynolds P. “Factors Influencing the Acculturation of Burmese, Bhutanese, and Iraqi Refugees Into American Society: Cross-Cultural Comparisons.” Journal of Immigrant & Refugee Studies. Vol 12, Iss. 3, 2014. Published online 20 Aug 2014.

This publication was an expansion of work done previously by Krishika Acharya, Sara Bouberhan, and Emi Bretschneider.

Abstract: “Based on J.W. Berry’s model of acculturation, we examined the acculturation process and stressors experienced by the Burmese, Bhutanese and Iraqi refugee communities in central Virginia. We posited that levels of acculturative stress would vary according to English language proficiency, level of social support, and financial stability. We interviewed refugees who have been in the U.S. for less than five years. Through qualitative analysis, we found that individuals with lower English proficiency had greater difficulty accessing employment and support services. The Burmese and Bhutanese found social support within their cohesive cultural communities, while the Iraqis experienced social support from their immediate families and American friends. Barriers to accessing education and employment opportunities, as well as the high cost of housing, food and health care caused stress in all cultural groups. Despite these stressors, nearly all refugees were happy they had immigrated due to the personal freedom, safety and hope for the future they found in the U.S.”

Key words: Acculturation, Burmese, Bhutanese, Iraqi, Barriers to Health Care, Social Support, Stress


Survey of Refugee Patients with Reduced Post-Medicaid Health Care” (September 2005) Jennifer Carnahan

Abstract: “This project identified refugee patients at risk of not returning to the International Family Medicine Clinic for recommended follow-up care due to lack of health insurance coverage.  This involved a detailed analysis of the clinic’s patient database and a subsequent comprehensive chart review of records identified by the database analysis.  The second part of this project was to contact patients to elicit their own reasons for reduced or non-existent follow-up care at IFMC.  This phase of the project was begun but not completed by the end of the summer, and will be continued by other clinic staff.” Appendix A and Appendix B are versions of the questionnaire used to gather this data.

Keywords: Health Insurance, Medicaid, Follow-Up Care