ACE

Category: ACE Research

  • Introduction to U.S.-West Africa Relations

    Introduction to U.S.-West Africa Relations

    West Africa is the most populated region in Africa, home to over 420 million people and natural resources such as petroleum, diamond, gold, timber, and cacao. West Africa and the United States cooperate on issues including trade, development aid, climate-related issues, intra-African conflicts, and immigration. 

    Trade and Development

    West Africa has experienced GDP (Growth Domestic Product) growth of 3.5% in 2019 and 3.6% in 2020. The U.S. has significantly increased trade with several West African countries including Nigeria ($3.2 billion), Ghana ($1.8 billion), and Cote d’Ivoire ($1.2 billion) in total goods traded (two-way) during 2019. The primary platform created in an attempt to stimulate U.S.-Africa trade is the African Growth and Opportunity Act (AGOA), established under the Clinton administration in 2000. This preferential trade agreement facilitated stronger commercial ties between the U.S. and selected beneficiary countries in Sub-Saharan Africa by allowing eligible countries to gain duty-free access to the U.S. market for thousands of products. Fifteen countries in West Africa were eligible for AGOA benefits in 2020, although many argue the eligibility requirements for countries can be too stringent, and the trade growth since AGOA was established has been inconsistent. Most countries registered gains in exports, although many exports, especially those derived from fuel, have been largely unsteady and have limited market diversification and expansion. 

    The United States Agency for International Development’s (USAID)’s West Africa Trade and Investment Hub (WATIH) exemplifies a more recent venture to further integrate West African businesses into U.S.-African trade through a five-year $140 million trade and investment activity. This program seeks to catalyze sustainable economic growth and increase competitiveness through market-based strategic partnerships with the private sector. The primary objectives are to improve food security in West Africa, create job opportunities for women, and increase investment and exports in key growth sectors.

    Other initiatives enacted by Congress such as the U.S. African Development Foundation (USADF) aim to provide grants to small enterprises in underserved communities in Sub-Saharan Africa to strengthen operational assistance, business expansion, and market integration. USADF has made strides in generating partnerships with Benin, Nigeria, Ghana, and Niger with over $20 million in investments in more than 50 local businesses impacting millions of lives. 

    Dissension over the history of United States development programs in Africa is pervasive. Many experts argue the system is plagued with profligate investment and is unsustainable or inefficient, frequently only benefitting a small fraction of individuals. Despite these concerns, trade between the United States and West Africa is on the rise.

    Intra-African conflicts

    Since 2020, West Africa has experienced 5 coups d’état in Chad, Mali, Guinea, and Burkina Faso due to security challenges aggravated by ongoing conflicts with jihadist insurgents in the greater Sahel region. The region is no stranger to internal conflict, with the recent turmoil aggravating the situation of food insecurity, political corruption, violence, inflation, and refugees or displaced peoples. 

    Washington attempts to mitigate conflict through the United States Africa Command (AFRICOM), established in 2007 as a combatant command responsible for U.S. Department of Defense operations and security cooperation on the African continent. American troops have been deployed to Niger to provide training, logistics, and intelligence to assist the Nigerien and Malian military’s fight against jihadists affiliated with Al-Qaeda, and to assist in the Boko Haram-induced conflict in northern Nigeria. In 2020, the U.S. halted military cooperation with Mali following the coup and has limited most of its military presence in West Africa to Niger. 

    Climate Change

    Conflict in the Sahel has complicated access to food and water in the region and is a major contributor to the high number of nearly 40 million food-insecure people in West Africa. This situation has been exacerbated by climate-related issues, with climate change likely to lower crop yields and production, resulting in a rise in the price of food for communities, especially in rural areas. Following the minimal success of the West Africa Biodiversity and Climate Change (WA BiCC), a five-year climate support juncture that ended in 2021, USAID created the West Africa Biodiversity and Low Emissions Development (WABILED) program. WABILED aims to enhance the capacity of national and regional networks and institutions to enforce wildlife trafficking laws in West Africa, lower deforestation and forest degradation, and reduce greenhouse gas emissions through technology and knowledge management support and funding. 

    Immigration

    Rural to urban movement has dominated internal migration patterns as well as the crucial seasonal migration from inland to coastal areas due to droughts, reduced crop yield, or heat waves. By 2050 it is predicted that nearly 32 million people will be displaced within their own countries in West Africa due to climate factors. Those already attempting to leave the region have been characterized as climate migrants or climate refugees.

    In 2019, approximately 2.1 million sub-Saharan African immigrants lived in the United States. While the region accounts for roughly one-third of the population of sub-Saharan Africa, the chart below demonstrates that West Africans make up nearly half of the total population of sub-Saharan African migrants to the United States. The Trump administration was criticized for its 2020 travel ban, which restrained entry and visa issuance that could lead to permanent residency for several Muslim-majority countries, including Nigeria. The Biden administration lifted the ban, although the impact it had on West African immigration today is still unclear. 

  • Closing Guantanamo Bay

    Closing Guantanamo Bay

    The Problem that has Stumped Four Administrations  

    The fate of Guantanamo Bay has been a topic addressed by four Administrations in the last two decades. Efforts have been made to close down the detention center which has held nearly 800 suspected terrorists and criminals. Guantanamo remains open first and foremost because the process for reviewing and trying detainees is extensive in order to ensure the individual does not represent a threat to U.S. safety. In addition, it is a polarizing issue mired in partisan politics which has prolonged and, at times, prevented the enforcement of other solutions for detainees. President Obama’s plan to send a number of detainees to the U.S received intense political backlash from Republican senators, and ultimately failed. 

    President Bush established Military Commissions to try the first group of detainees brought to Guantanamo and accused of war crimes. During Bush’s Administration, approximately 500 detainees were transferred out of Guantanamo or released. Obama also approved the use of military trials; however, he also enforced Periodic Reviews as a way to re-evaluate the threat posed by Guantanamo detainees who were designated for indefinite detention. According to a 2015 report by IACHR, 8% of detainees were characterized as “fighters” for terrorist organizations.

    Currently, detainees can be released from Guantanamo Bay through adjudication from military trials or Periodic Review Boards.

    Military Trials

    Of those detainees remaining in Guantanamo, the Defense Department reports that 10 are undergoing military commission proceedings, and two detainees have been convicted. Military Commissions are intended to “promote justice, to assist in maintaining good order and discipline in the armed forces, to promote efficiency and effectiveness in the military establishment, and thereby to strengthen the national security of the United States.” according to the Manual for Military Courts. 

    Military trials are different to civilian courts in several ways:

    • Military trials are not restricted by the Federal Rules of Evidence, extending the types of evidence which prosecutors can display in their testimonies;
    • Military Commissions may allow the use of evidence obtained by inhuman and cruel treatment, potentially leading to questions about the credibility of the evidence;
    • Military Commissions require more time to reach a conviction compared to civilian courts. It is rare for a Military Commission to reach a decision in fewer than five years. 

    The military court and prison at Guantanamo has cost over $6 billion. The yearly cost of the military court and the prison at Guantanamo is $380 million. 

    Periodic Reviews

    The Periodic Review Board is composed of officials from the Department of Defense, Homeland Security, Justice, and State; Joint Staff, and director of national intelligence. The Board assesses the potential threat detainees might pose on the United States in order to make informed decisions on whether detainees should remain in Guantanamo Bay. 

    The Periodic Board allows Detainees to participate in the process review. Detainees work with a military officer to help them through the process. In addition, detainees can request witnesses to offer information regarding whether the detainee should be kept in Guantanamo. If a detainee is found to be non-dangerous to the security of the US, they will be ready for transfer. If they are found to be dangerous they are again held indefinitely. 

    Periodic Review gives hope for detainees designated for indefinite detention at Guantanamo. Many critique the Board’s decision making process. According to Benjamin R. Farley, a trial attorney and law-of-war counsel in the U.S. Department of Defense, Military Commissions Defense Organization, “The PRB’s present inability to render any decision other than for continued law-of-war detention is particularly pernicious in light of how the government invokes the PRB’s continued operation to minimize judicial scrutiny of the Guantanamo detention regime in federal habeas corpus proceedings”. 

    Transfer of Detainees

    As of April 26th 2022, 20 detainees have been approved for transfer. After a detainee has been deemed non-dangerous by the Periodic Review Board, they are confirmed for release. Should the situation permit, some are transferred back to their homeland. If transfer to homeland is not possible for detainees, due to safety reasons or other reasons, the U.S. works with other countries to release detainees. Legislative prohibitions on the transferring of detainees into the United States have prevented approved detainees from being transferred to the United States. The transfer of detainees to other countries, especially in Europe, has become difficult with the rise in anti-immigrant sentiment.

  • DACA during Biden’s Era

    DACA during Biden’s Era

    The Deferred Action for Childhood Arrivals Act, more commonly known as DACA, was introduced during the Obama administration to protect young undocumented immigrants that entered the U.S unlawfully with their parents. Often referred to as “Dreamers,” almost 800,000 of these young immigrants have lived in the United States since 2007. DACA provides temporary protection from deportation for two years, and it can be renewed for a fee of $495. DACA in its current form does not offer a path to citizenship, so Dreamers regularly renew their status.

    Individuals that are eligible to apply for DACA must be under 31 years of age as of June 15, 2021; have been under the age of 16 when the individual came to the United States; continuously be in the United States from June 15, 2007; be in the United States without authorization; have not been convicted of a felony, and are currently in school or have obtained a GED.

    DACA programs grant the status holder temporary protection from deportation for two years. They can apply for a driver’s license, the license however contains a mark to signify that this ID is not valid for federal purposes such as voting. DACA status holders can get a work permit, called an EAD permit, and unlike other work permits, this permit currency does not have a cap for individuals with DACA status. They pay state and federal income taxes. DACA status holders currently do not have a path to citizenship or permanent residency, cannot vote, and cannot receive federal benefits such as Social Security or food stamps. 

    DACA Policies in the Past

    DACA is an executive order that was implemented by the Obama administration in 2012. Critics of the policy called it “a misuse of presidential power,” as they believed that the order overrode existing immigration law. The Obama Administration then planned to expand the executive order to try to create Deferred Action for Parents of U.S Citizens and Lawful Permanent Residents (DAPA) but their actions were halted due to lawsuits from states including Texas. The Supreme Court’s decision in United States v. Texas was split and the expansion was halted. The Court did not rehear the case and lower courts sided with Texas, agreeing that the expansion overrode immigration laws that were already in place.

    In 2017 the Trump Administration intended to phase out the DACA program over a six-month period, when the Justice Department would no longer accept renewal or new applications. However, three U.S district courts from California, New York, and the District of Columbia filed an injunction to halt the plan, based on the belief that terminating DACA was arbitrary and capricious. The Supreme Court sided with the states, ruling that the DACA program was able to stay due to the way the Trump administration had tried to end the program, but did not focus on the merit or the constitutionality of the program. 

    The Biden Administration on DACA

    Within the first 100 days in office, the Biden Administration signed an executive order to preserve DACA. The executive order stated that DACA recipients are protected from deportation and will remain eligible for work permits. 

    The Biden Administration is also assigning more immigration officers to review the backlog of DACA applicants. 81,000 first-time DACA applications and 13,000 DACA renewal requests were filed following the executive order. As of June 2021, more than 33,000 first-time applicants had completed their biometrics and 11,000 applicants have already had appointments. More than 37,000 individuals were waiting to receive an appointment date. 

    On January 20, 2021, the Biden administration announced the U.S Citizenship Act of 2021. The act would make 11 million undocumented individuals eligible for various legalization programs to lawfully reside in the U.S. It includes a pathway to lawful permanent residence for DACA recipients. If passed, the act would enable DACA recipients to apply for an adjustment of legal status.  

    Arguments in Favor of Biden’s DACA Policy

    Some praise DACA and Biden’s efforts to protect the policy, claiming that it protects young individuals and allows them to pursue their educational and professional career goals. Ted Mitchell, president of the American Council on Education, supports the policy because it gives young people the autonomy to make decisions regarding their education and involvement with serving in the military. A study conducted by Dartmouth University found that enacting DACA improved the attendance and graduation rates of undocumented youth by 40%. In addition, the study found that approximately 49,000 additional undocumented youth received a high school diploma due to DACA’s passage. Overall, DACA has shown to have a positive impact on educational outcomes among undocumented youth. 

    A study by the American Action Forum looks at the impact that DACA recipients have on the United States economy. The study found that DACA recipients make positive economic contributions through their presence in the workforce. Over 380,000 DACA recipients are employed. 23% of all DACA workers are employed in the arts and food service industry, contributing an estimated 4 million dollars annually to the United States GDP. In total, employed DACA recipients contribute $41.7 billion annually to the United States GDP.

    Arguments Against

    Critics of DACA claim that expanding the program to include a pathway to lawful permanent residency rewards illegal immigrants. The Heritage Foundation, for example, thinks that the U.S should focus on immigration laws that prioritize Americans without risking the U.S’s national and economic security. They think that DACA and a possible expansion will result in higher rates of illegal immigration and diminish security at U.S borders which would affect American taxpayers negatively. For instance, the Heritage Foundation believes that undocumented immigrants are costing American taxpayers money through their use of public services such as the fire department, police department, highways, and parks.

    Critics also claim that if DACA recipients receive amnesty from the Biden administration, they will take  employment opportunities away from native born U.S residents. A study by the General Accounting Office has shown that the large number of immigrant workforces would depress wages, or lower the wages for U.S-born workers. George J. Boras from Politico states in his article that wage trends have shown that a 10% increase in the number of workers for a certain job area will result in a wage decrease of 3%.

  • Puberty Blockers and Transgender Youth

    Puberty Blockers and Transgender Youth

    Transgender youth in America

    Transgender is an umbrella term used to refer to individuals whose gender identity does not align with the sex they were assigned at birth. Over 1.6 million people identify as transgender in the United States, with nearly 1 in 5 falling between the ages of 13 and 17. About 300,000 youth identify as transgender, making up about 1.4% of Americans within that age range. The age of coming out varies greatly; sometimes young children identify as transgender; other times people do not come forward or even understand themselves to be transgender until later adolescance or adulthood. 

    What are puberty blockers?

    Many transgender youth experience discomfort in their body at the onset of puberty because the development of secondary sex features such as breasts, facial hair, penis growth, etc, is at odds with their gender identity. This can lead to a form of psychological distress called gender dysphoria. 

    Puberty blockers are medications that young gender divergent individuals can take to temporarily suppress the release of sex hormones and therefore the effects of puberty. They are used to give young people more time to make a decision about transitioning and to prevent the irreversible effects of puberty that are causing the patient distress. If someone stops taking the medication, the release of hormones and normal development of secondary sex characteristics will resume. Taking them early is seen as important because, unlike puberty blockers, the effects of puberty itself are permanent.

    There are two main categories of puberty blockers:

    • Lueprolide acetate: an injectable shot taken every 1-6 months. 
    • Histreline acetate: a flexible rod inserted under the skin of the arm and lasting for 1 year. 

    Timeline of Youth Transition

    Puberty blockers are not taken in isolation; they are prescribed at a certain period of development and in the context of other types of transition.

    • Pre-puberty: Social Transition
      • Using the child’s preferred pronouns as well as outside signifiers such as dress and hairstyle to affirm the gender with which they identify. Does not involve any medical intervention.
    • Puberty: Puberty blockers
      • Best taken at the onset of puberty, but can still be effective if taken at later stages.
    • Late adolescence: Gender-Affirming Hormone Therapy
      • Traditionally, the minimum age for GAHT is 16 but recent guidelines are more flexible. Once necessary criteria are met, doctors and patients can decide whether the treatment is appropriate.
    • Adulthood: Gender Affirming Surgery
      • Surgery can only be performed on adults (with the exception of breast reduction surgery, which is also sanctioned for cisgender minors who have parental permission).
        • Note: A significant number of transgender individuals never get any surgery. For some, puberty suppression may reduce that need.

    Political context

    As of July 2022, at least 22 state bills have been introduced that would ban the use of puberty blockers as well as other forms of medical treatment for minors with gender dysphoria. Bypassing the legislature, the Texas Attorney General also declared medical treatments for gender dysphoria, including puberty blockers, to be child abuse and grounds for children to be taken from their parents. The order is currently being challenged in court. 

    As a result of state actions, over 45,000 youth 13 years and older may lose access to gender-affirming health care options. Major medical organizations, including the American Psychological Association and the American Academy of Pediatrics, oppose these restrictions. 

    The Intersex Exception

    It is noteworthy that the Texas order as well as all 22 bills specifically carve out exceptions for performing such treatments on intersex children. While transgender youth are individuals who identify with a gender that differs from the sex they were assigned at birth, intersex children are born with a combination of chromosomes, genitalia, and hormone levels that mean they do not fit neatly into our understanding of either male or female. The choice to allow actual surgical procedures to be performed on intersex children with no age limit belies the expressed concern about the safety and appropriateness of such procedures being performed on minors. 

    Many intersex advocates have decried the common practice of performing irreversible procedures on intersex infants and young children. Yet these bills explicitly deny any such protection. As a result, they do not protect children from irreversible medical interventions being done before they are able to consent, but rather limits their use to instances in which they reinforce a binary biological sex- even if that changes a child’s natural biology without their consent.

    The politicians and advocates working on these initiatives allege that puberty blockers are:

    • Not FDA approved
    • Irreversible
    • Impact large numbers of children who change their mind later
    • Have adverse impacts on mental health, bone health, and brain development. 

    The allegations and science will be discussed in detail below. 

    The Science

    Are puberty blockers FDA approved?

    In 1993, puberty blockers were approved by the US Food and Drug Administration for the treatment of  precocious puberty, a condition in which young children begin to develop sexually mature features before the age of 9. They are also approved to treat endometriosis and prostate cancer in adults. The FDA has not officially expanded this to include treatment for gender-affirming care, as research of this population is ongoing. That is in great part because drug companies have not performed the necessary studies to receive FDA approval. Combined with how small a population it is, this is not surprising because drug companies are reluctant to perform trials on children. For this reason, pediatricians frequently prescribe medications that have not been officially approved for minors. Despite the FDA not having officially approved puberty blockers for the treatment of gender dysphoria, they are commonly used for this purpose and seen as safe by the medical professionals who prescribe them.

    Are puberty blockers really reversible?

    All available evidence indicates that puberty blockers are fully reversible. For example, girls treated for precocious puberty are, once they stop taking the medication, able to resume normal puberty within 6 months and give birth in adulthood. Expert consensus from the Endocrine Society and the World Professional Association for Transgender Health is that this is also true for transgender youth. 

    The idea that puberty blockers are irreversible is due in part to the conflation of puberty blockers with Gender-Affirming Hormone Therapy (GAHT), which are medications that older adolescents and adults take. Puberty blockers hit ‘pause’ on both testosterone and estrogen production, thereby delaying the development of secondary sex characteristics. In contrast, GAHT actually introduces hormones into the system in order to induce feminine or masculine development. Because of this, GAHT is not entirely reversible and comes with different side-effects, including possible sterilization. Traditionally, the minimum age for GAHT is 16. However, recent guidelines focus more on whether the patient meets the necessary criteria, even if they are a year or two younger. 

    If there are legitimate concerns that the patient is not ready to add GAHT or that they do not yet have sufficient capacity to give informed consent, puberty blockers are an effective way to give the young person more time to decide. This is helpful if someone changes their mind and decides to ‘detransition’ to the gender that aligns with the sex they were assigned at birth. However, this is a small number, as research shows that few transgender youth change their mind. 

    Rate of ‘Detransition’

    Earlier studies that bills cite as evidence of high detransition rates have been criticized by experts for two key weaknesses: 1) they include significant numbers of children who never identified as transgender but were brought to doctors by concerned parents because they were gender-nonconforming (e.g. “effeminate” boys); and 2) the children that did want to transition were discouraged from doing so by parents and doctors 

    More recent studies select only children who self-identify as transgender and try to control for the level of parental support in transitioning. A 2022 study followed 317 initially transgender youth who socially transitioned to find whether they had changed their mind 5 years later. It found that 97.5% of youth still identified as transgender, with only 2.5% ultimately changing their minds. The latter group frequently began to socially transition before the age of 6 and often detransitioned before the age of 10. By the end of the study, 60% of participants had begun puberty blockers or hormones; of that group only one detransitioned. 

    Impact on mental health

    The study frequently cited as showing increased risk of suicide due to puberty blockers did not examine transgender youth who took puberty blockers. Instead, it looked at overall youth suicide rates in states with easier access to such treatment and compared them to suicide rates in states with more restricted access.

    Studies that focus on the relevant population find different results. Results show that access to puberty blockers and hormone treatments are associated with a 40% – 73% decrease in depression and suicide for gender nonconforming youth when compared to control groups of young people who wanted those treatments but could not get them. A 2022 study found that the control group’s risk of suicidal thoughts and depression doubled or tripled at three and six months into the study. The onset of puberty has been identified as an especially vulnerable time for transgender youth as they are at an elevated risk of self-harm because their bodies’ development exacerbates gender dysphoria.

    It is also noteworthy that the use of puberty blockers in combination with hormone treatments can result in a more masculine or feminine appearance for binary transgender individuals that not only affirms their internal identity, but also reduces the likelihood of transgender discrimination, which has been associated with harm to mental health.

    On the opposite end of the spectrum, gender identity conversion efforts (actions by a professional taken to force a self-identified transgender person to be cisgender) are linked to significant increases in lifelong suicide attempts in adulthood. 

    Side Effects and Risks

    No medication is entirely without risk. So, what do we know about the potential side effects of puberty blockers?

    Standard:

    Known side effects may include hot flashes, fatigue, and mood swings, comparable to other commonly prescribed medications.

    May reduce options for future surgery

    Puberty blockers may impact those who end up pursuing feminizing gender-confirmation surgery (GCS) in adulthood. Surgery and desirability rates show that this is relevant for approximately half of transgender women and about 10% of nonbinary people assigned male at birth.  

    • The most common type of feminizing “bottom surgery” used is penile inversion vaginoplasty. This uses tissue from the penis and testes to construct a vagina. Because puberty blockers halt development of male sexual organs, patients are likely to need the alternative option.
    • Intestinal or sigmoid vaginoplasty requires abdominal surgery in order to take tissue from the colon or omentum instead. This is the same type of surgery also used for cisgender women who have had a vaginectomy as a result of vaginal cancer, as well as those born without a vagina due to vaginal agenesis. While the surgery is more invasive, current research suggests that it is a reliable alternative and does not have increased complications at follow-up. 

    Bone Density

    Several studies indicate that transgender children who take puberty blockers tend to have below-average bone mineral density. For this reason, the Endocrine Society recommends that once puberty blockers are prescribed bone density should be regularly monitored by doctors. In addition, if a patient has been taking puberty blockers for years by the time they turn 16, then it may be time to either stop taking puberty blockers or to begin hormone therapy, either of which may then mineralize the bone. In light of this recommendation, the Arizona bill passed in February is noteworthy as it did not outlaw puberty blockers but does ban treatments that are “irreversible” – including Gender-Affirmation Hormone Treatments.

    Brain Development

    There appears to be no evidence for the claim that puberty blockers adversely impact brain development in humans. A study cited as showing a decrease in spatial reasoning was done on sheep; a 2015 study found that puberty blockers did not appear to impact executive functioning in humans. 

    Expert Guidelines

    It is important to note that not all transgender youth are diagnosed with gender dysphoria—and not all people who are diagnosed with dysphoria choose to get medical treatment. However, many young people in the US do experience distress and need medical intervention. 

    There is a hunger for more data, but based on the current science experts consider puberty blockers to be safe for short-term use in adolescents, including for the treatment of gender dysphoria. The American Academy of Pediatrics recommends that pediatric providers use a gender-affirmative care model that is centered on understanding and appreciating a patient’s gender experience in a developmentally appropriate way. The Endocrine Society has published accessible patient resources as well as the clinical guidelines that set the standard of care for the safe and responsible use of puberty blockers in gender divergent youth. This may involve an evaluation with a mental health provider with experience in gender identity, a diagnosis of gender dysphoria, and assistance with social transitioning. Fact-based discussions between doctors and patients about risks, side-effects, and the potential benefits are key. Because many (although not all) youth who take puberty suppressors go on to receive gender-affirming hormone treatments, which may impact the ability to have children, doctors should go over options for fertility preservation with patients prior to starting suppressors.

    The Endocrine Society and WPATH SOC recommend that puberty blockers not be used until the onset of puberty. Until that point, transition should be social but not medical. Patients should meet certain qualifications before suppressors are prescribed. Namely: 

    • Diagnosed with gender dysphoria by a qualified mental health provider;
    • Gender dysphoria worsens with the onset of puberty. 

    Experts also recommend that once someone begins taking puberty suppressors they get lab work done regularly to monitor:

    • Height and weight
    • Bone health
    • Hormone and vitamin levels

    There is a consensus that when done responsibly, puberty blockers and subsequent gender-affirming treatments can be greatly beneficial for transgender and nonbinary youth. A groundbreaking long-term retrospective case-study of a patient who received puberty suppressors in childhood was published in 2011. 22 years after initial assessment, the patient still identified as transgender and had undergone surgery. Their anthropomorphic, endocrine, and bone density tests were normal and they were functioning well psychologically, socially, and intellectually.

  • The KORUS Free Trade Agreement

    The KORUS Free Trade Agreement

    Historically, the United States and South Korea have had a strong military alliance, and moved to expand economic relations through the KOR-US Free Trade Agreement (FTA), which entered into force in 2012. An FTA is an economic agreement between two nations setting expectations and obligations in terms of the exchange of goods and services, protection of investors, etc. For the US, the aim is to protect US economic interests abroad and to aid US exports. Key provisions in the FTA include:

    • Consumer and industrial products became duty free and 95% would be expected to be duty free within three years.
    • Textiles and apparel—“yarn forward” treatment allowing for apparel that uses materials from US/SK qualifies for preferential treatment.
    • Trade remedies (actions taken in response to import surges, fair value sales, etc.) which allowed for US to exempt SK imports if it did not endanger the US domestic industry, and established a third-party committee— Medicines and Medical Devices Committee— to review government reimbursements and pricing on pharmaceuticals and medical devices. 
    • Some provisions for digital trade, but they are less extensive than other agreements, and some have called for updates to this specific provision. 

    The KORUS Free Trade Agreement is the United States’ second-largest FTA by trade-flows, only surpassed by NAFTA, now called the United States-Mexico-Canada Agreement (USMCA). US-SK exports were $80.5 billion, imports were $88.1 billion, totalling an estimated $168.6 billion (2019) in trade flows. 

    Challenges to the Free Trade Agreement

    When negotiating the final agreement, the beef and auto sectors were two major sticking points. South Korea had banned American beef after the outbreak of mad-cow disease in 2003, and there was significant debate about lifting that restriction. The issue of beef was perceived as a public health issue and became highly politicized. In the initial 2007 agreement, beef was avoided entirely because of its sensitive nature in South Korea, but eventually restrictions were lifted on boneless beef under 30 months old. On the US side, the auto industry had concerns over the rising imports and a weakening domestic market—General Motors, Ford, and Chrysler sales in 2007 fell 7.3% while U.S. sales of foreign brands (U.S.-based production plus imports) rose about 3%. Because of these conflicts, President Bush did not submit legislation to ratify the agreement 

    The Obama Administration took office focused on improving terms for the US auto industry in the FTA, leading to a supplemental trade agreement. The new terms expanded on Korean safety standards and allowed for 25,000 cars per US automaker to be imported into Korea as long as they meet US federal safety standards, and more leniency for small-volume importers (up to 4500 vehicles) in terms of environmental standards. The letter also specifies under Section A that there would be a reduction in duties (taxes), and in Section B desires more transparency from South Korea in preventing delays and barriers to trade while establishing an early-warning system. The beef issue was resolved when South Korea eliminated its 40 percent tariff, which was projected to save $1,300 per ton of beef imported to Korea and would approximately total $90 million annually for US beef producers at 2010 sales levels.

    Recent Developments and Critiques

    According to the Office of the United States Trade Representative, as of 2019, South Korea is the US’ 6th largest goods trading partner with $134.0 billion in total (two way) goods trade during 2019, and the US is South Korea’s 2nd largest trading partner. However, under the Trump Administration, the US threatened to leave the agreement, leading to increased economic tension between the two countries. Trump blamed Korea for an increase in trade deficit, and wanted Korea to reduce policies which disadvantage American firms so that trade would be more balanced, with the current trade deficit at 29 billion (2021). He also raised concerns over non-tariff barriers (NTBs) in the steel and auto industry that disadvantaged American markets by protecting Korean manufacturers. Non-tariff barriers are restrictions in trade that arise due to sanctions, domestic laws, quotas, etc. and are outside the agreed upon terms of an FTA. Minor revisions were made to the FTA in 2019 to address these concerns. 

    • The previous limit of 25,000 cars per US automaker imported by Korea was raised to 50,000 cars.
    • The 25% tariff on Korean trucks that was supposed to expire in January 2021 was extended to 2041.
    • The US restricted imports on steel and washing machines (Section 201 and 232). 
    • Minor changes were made to pharmaceuticals, customs, and investor-state dispute settlement.

    When Trump threatened to leave the agreement in 2017 due to the deficit, 2017 (Jan-May) data showed that US merchandise exports to Korea were up 23% year over year and and US imports from Korea were down 2%. It was suggested that trade diversion (where imports shift from lower cost nations to higher cost nations, something that can follow free trade agreements) may have contributed to the trade deficit, but ended up leaving the global trade balance largely unchanged in the long term. From 2012, the date of implementation, the US trade deficit in goods with Korea increased by 75% from $13.2 billion to $23.1 billion in 2017. 

    The rising trade deficit has led to concerns over the FTA, but many economists argue that the balance of trade is not an accurate way to measure the benefits of a trade agreement. For example, high US imports indicate consumers have access to products at lower prices, or better-quality goods at similar prices. Currency value also plays a major role in trade deficits; when the dollar is strong American consumers can afford to buy more imported goods, but American goods on foreign markets are comparatively more expensive. 

    Future Developments

    During a May 2021 summit, President Biden and President Moon Jae-in announced plans for greater cooperation to address trade and industry developments, but the Trump-era restrictions remained in place. The Korean government urged the Biden administration to ease the steel restrictions, but they remain in place as of July, 2022. South Korea recently elected a new president, so the future of the FTA could change. In their joint statement, both leaders reaffirmed their support for the FTA and discussed close cooperation on foreign exchange market developments. It is important to keep an eye on the renewable energy, semiconductor, and auto industries for the future, especially considering Biden’s $5 billion investment in an electric vehicle plant. 

    Reopening the FTA discussion would affect current steel restrictions and open conversations about the auto industry again, but also provide an opportunity to fill in the gaps of the digital industry which currently exist in the FTA, and add updated provisions about climate change. President Biden also recently launched the Indo-Pacific Economic Framework for Prosperity (IPEF), which includes South Korea, that aims to address supply-chain issues, climate change, business ethics, and more. As the IPEF develops and more details are finalized, it may create more opportunities for cooperation between the US and South Korea. 

  • Basic Needs Insecurity in Higher Education

    Basic Needs Insecurity in Higher Education

    Within higher education, many students face basic needs insecurities including insufficient food and housing. In the largest annual assessment of basic needs security amongst college students, results indicate that:

    Additionally, of these respondents, only 20% of food insecure students receive the Supplemental Nutrition Assistance Program (SNAP), and only 7% of students who experience homelessness receive housing assistance. For students at both two- and four-year institutions, 75% of Indigenous students, 70% of Black students, and 64% of Hispanic or Latino students experienced basic needs insecurity, compared with 54% of white students.

    Basic Needs for Postsecondary Student Program

    The U.S Department of Education currently funds a program called the Basic Needs for Postsecondary Student Program. This program provides grants to eligible institutions of higher education, supporting programs that address the basic needs of students and ensuring practices that improve student outcomes are reported. These grants awarded have a performance period of 3 years and the projects implemented must take a systemic approach to improve outcomes for underserved students through coordinating efforts with Federal, State, or local agencies, or community-based organizations that support students. 

    For example, Passaic County Community College in New Jersey received one of these grants in 2021 to support the installation of a multicultural wellness and resource center. The project will provide basic needs services to 5,000 low-income, first-generation, minority students who also comprise underserved populations such as nontraditional adult students, parenting students, and undocumented students.

    Introduced Legislation

    There are a few proposed pieces of legislation coming from the Democratic Party circulating the House and the Senate. Two of these include the BASIC Act and the Student Food Security Act, both of which are currently under committee review. 

    The Basic Assistance for Students in College Act, or BASIC Act, was introduced to the Senate in 2019. It proposes a $1 billion grant program to help colleges and universities research, plan, and implement a basic needs infrastructure. The grant money could be used to provide free or subsidized food, offer temporary housing, help students apply for public assistance programs, or collaborate with community organizations. 

    The Student Food Security Act was introduced to the House in 2021. It proposes expanding SNAP eligibility to students who are eligible for work-study, have a $0 Expected Family Contribution, meet the financial eligibility criteria for a maximum Pell Grant (even if they have not filed the Free Application for Federal Student Aid (FAFSA)), or are an independent student whose household is otherwise eligible. It also creates a SNAP student hunger demonstration program that would allow students to use their SNAP benefits at on-campus dining facilities at up to ten institutions and establishes a $1 billion per year grant program to help institutions identify and meet the food and housing security of their students.

    Arguments For Expanding Basic Needs Programs

    Proponents of expanding basic needs programs argue there are record high numbers of low-income students enrolling in college to increase their chances of social and economic mobility. Concurrently, increased tuition costs and the student debt crisis make it difficult for low-income students to reach their aspirations. Food and housing insecurity undermine academic success, so expansion of basic needs programs will increase college completion rates, persistence, and credit attainment of low-income students. Senator Alex Padilla, a California Senator pushing for the BASIC Act to pass, emphasizes this by saying, “​​We cannot let our students go hungry or sacrifice their health in order to afford a higher education… The BASIC Act will help students focus on their goal – graduating. For these students to compete in a modern workforce we must give them the tools they need to succeed.”

    Arguments Against Expanding Basic Needs Programs

    Those against expanding basic needs programs argue there is currently limited research on basic needs insecurities on college campuses, so there is a limited understanding of the scope of the problem. Besides the annual survey previously discussed, only 31 quality studies of campus basic needs insecurity have been conducted, few of which involve multiple colleges. 

    Most proposed legislation lack support from conservative members of Congress. In 2020, Republican Rep. and top member of the House Agriculture Committee Michael Conaway shared he was opposed to increasing food stamp benefits during the pandemic, calling SNAP expansion a “backdoor way to get permanent changes.” He and other Republican officials believe that these programs foster long-term dependency on the federal government for low-income Americans. Many argue it is also not financially feasible to expand federal assistance. These proposed legislations both propose $1 billion grant programs and are extremely costly.

  • Introduction to The New Atlantic Charter

    Introduction to The New Atlantic Charter

    History

    The first Atlantic Charter between the United States and the United Kingdom was signed August 14, 1941 by then-President Franklin D. Roosevelt and Prime Minister Winston Churchill. The Charter marked one of the founding agreements of what was to become the United Nations, and connected two countries around shared principles and policies. Since the conclusion of World War II, the U.S. and the UK have maintained strong diplomatic relations—often referred to as the “Special Relationship”. This Special Relationship commenced in 1946 giving rise to one of the most significant international partnerships of the modern day. 

    The U.S. and the UK’s military and security relations have strengthened through cooperation in conflicts such as the Korean War, the Persian Gulf War, the Iraq War, and military operations in Afghanistan, alongside founding the North Atlantic Treaty Organization (NATO). The U.S. and the UK have often supported similar economic policies, including the shift towards privatization and promotion of capitalism during the Reagan Administration and a UK government led by PM Margaret Thatcher. Ultimately, the two countries remain committed to the protection of democratic values and cooperation against adversaries who fail to recognize or adhere to alliances or institutions. Thus, on June 10, 2021, President Biden and Prime Minister Johnson signed The New Atlantic Charter, reaffirming the historic alliance. 

    Outline of The New Atlantic Charter

    The New Atlantic Charter has eight sections:

    1. Defending democracy be it democratic values, ideals, and institutions that contribute and protect to this form of governance. This paragraph also expands into supporting transparency, the protection of civil society and human rights, and the commitment to protecting an independent media. 
    2. Sustaining international co-operation through developing laws, norms, and strengthening existing institutions to face the challenges of today. This component advocates for a “rules-based” approach to facing the good and bad impacts of emerging technologies, economic development while protecting the workers that enable it, and supporting free trade between countries.
    3. Sovereignty, territorial integrity, and peaceful resolution to disputes, with both the U.S. and UK uniting and standing against interference with these principles. Much of this alludes to opposing the growing issue of disinformation, election interference, and reaffirming the need for debt transparency and debt relief. Moreover, this paragraph concludes with the commitment to defend lawful international “freedom of navigation” be it by air or seas.
    4. Innovation in Science and Technology, seeking to continue to promote development of these areas to support shared security, create employment domestically, foster global development, and create technologies to be deployed for the support of democratic values. 
    5. Collective security and international stability through reaffirming the shared responsibility to protect these principles in the modern world. This component re-emphasizes both the U.S. and the UK commitment to NATO and its allies, particularly with modern day security threats, be it cyberspace, arms control, and the disarmament or proliferation of nuclear weapons. The notable tone of this paragraph is that these threats are a collective issue for both countries and therefore should be tackled through international cooperation.
    6. Building a sustainable global economy that is free, fair, sustainable, climate-friendly and rules-based. Both countries are committed to fighting corruption, encouraging financial stability and transparency, while working towards fair and environmentally mindful global innovation and competition.
    7. Tackling the climate crisis by recognizing the immediate threat this poses and as such, both the U.S. and the UK seek to prioritize this issue in all their respective international actions.
    8. Addressing health crises through collaboration to advance health systems and protections, to strengthen collective defenses against health threats and assist in others striving to do the same.

    One of the overarching takeaways from the signing of The New Atlantic Charter is the return of diplomacy as the key American tool in international relations, a mechanism long used and endorsed in UK foreign policy actions. Much of the agreement reaffirms prior understandings, but it also attempts to reference the challenges of the twenty-first century, some of which are cited throughout the document.

    The Future

    The New Atlantic Charter signals a new dawn of the U.S.–UK relations at a time when many feel the rules-based world order is at its most vulnerable since World War II. While the charter steers away from naming specific adversaries, each component alludes to the perceived threat China and Russia, and a world that has been permanently changed by COVID-19. Over the past few years, the U.S. and the UK have embodied that vision by expanding their collective presence in the Indo-Pacific Region with the introduction of the Australia-United Kingdom-United States (AUKUS) Partnership to counterbalance China, and supporting Ukraine’s sovereignty following Russia’s invasion.

    However, recent data indicates many Americans are concerned about how much focus the U.S. places on global affairs, potentially to the detriment of domestic issues. This suggests a growing U.S. skepticism towards the importance or necessity of agreements with international allies, with a majority favoring a focus towards domestic policy rather than global affairs. At the same time, the UK’s influence on the global stage has been declining since the start of the “Special Relationship”. Many who support an outward-facing U.S. presence feel the U.S. needs to expand relations with other countries who can bring more to the table.

  • Solar Energy in the United States

    Solar Energy in the United States

    Solar power in the United States has a lengthy history—the first U.S. patents for solar cells were filed in the 1880s, and the first commercially viable solar cell was produced by Bell Labs in 1954. Despite being around for nearly 150 years, solar energy has remained a fringe source of power generation in the United States due to its historically high costs and lower efficiency compared to fossil fuels. Today, solar power accounts for around 3% of U.S. electricity, or enough to power 18 million average family homes. This represents rapid growth in solar power of roughly 4,000% over the last decade.

    This growth in the United States, and around the world, is largely due to a decrease in the cost of solar power systems. The National Renewable Energy Laboratory reports, “since 2010, there has been a 64%, 69%, and 82% reduction in the cost of residential, commercial-rooftop, and utility-scale PV systems, respectively.” According to the International Renewable Energy Agency, solar and wind energy are now cheaper than the lowest cost fossil fuel option 62% of the time.

    Cumulative U.S. Solar Installations (2007-Q1 2022), Solar Energy Industries Association

    Solar Energy Policies in the United States

    The U.S. federal government first supported solar energy in 1974, when Congress passed the Solar Energy Research, Development and Demonstration Act. Over the next decades, the government continued to support the development and use of solar energy by funding research, and providing tax incentives to those who used solar systems. The Solar Investment Tax Credit, passed by Congress in 2006, allows private individuals and businesses to write off 30% of the cost of installing a new solar system on their federal taxes. In 2020, the tax credit was extended by Congress through 2023, however the rate was lowered to 26%.

    President Biden has made addressing climate change a priority, aiming to ramp up solar energy in the U.S. to reduce carbon emissions. To work towards this transition, the Biden administration has deployed a range of policies designed to cut costs and increase adoption of solar technology. Biden used the Defense Production Act, a 1950 law giving the president the power to order companies to supply critical goods and services, to expand American manufacturing of solar panels for power generation. The administration implemented several other policies including lowering fees for solar projects on public lands by 50%, temporarily eliminating tariffs on solar panel materials from specific countries, and removing bureaucratic hurdles to implementing clean energy projects at a local level.

    The Department of Energy (DOE) Solar Futures Study, released in 2021, outlines how solar energy could play a role in decarbonizing the United States’ power grid, supplying as much as 40% of the nation’s electricity by 2035. In 2020, 15 gigawatts (GW) of solar power were added to the U.S. energy system, and the study calculates that this would need to increase to an average of 30 GW added per year from 2020-2025 and 60 GW per year added from 2025-2030 to achieve its 40% projection.

    States have also developed incentives for solar energy projects. The Database of State Incentives for Renewables & Efficiency by the North Carolina Clean Energy Technology Center provides an overview of these policies in each state.

    Challenges to Solar Energy Implementation

    Grid Modernization

    To connect more solar power to the U.S. electricity grid, major investments would be required to modernize old infrastructure that is already struggling due to climate change. The grid would need to be modernized to be compatible with a modern array of solar power (and other renewables, namely wind energy). A renewable-based grid would have to withstand even greater demand for electricity than the current grid. Plans to decarbonize the transportation and heating sectors, as well as industry, would mean a greater demand on a renewable grid. Due in part to this, U.S. electricity demand is projected to grow approximately 30% by 2050.

    Overall, consultancy firm Marsh & McLennan estimates the cost to fully update the nation’s aging power grid at $1 trillion by 2050. According to Reuters, part of these costs would likely be passed on to consumers through utility rate increases.

    Production vs. Use

    According to the California Independent System Operator, a non-profit utilities provider in California, solar power faces another difficulty arising from the mismatch between when solar power is generated and when people use the most energy. Solar power generation follows the sun, and peaks during midday. Energy use tends to ramp up in the morning as people wake up, peaks during midday as businesses are operating, and remains constant through the evening before dropping as people go to sleep. Around sunset, there is extremely high demand for energy as more lights are turned on and people are cooking dinner, which is problematic for a solar-based grid that can no longer actively generate power.

    Potential solutions to managing this disconnect are being studied. One strategy is to use diverse sources of energy, like wind, hydroelectric, and nuclear, to compensate for each other’s weaknesses. In addition, boosting storage capacity for electricity generated from the sun via better batteries could enable distribution of that energy outside of production hours. This is why the DOE finds that expanding solar energy storage capacity is vital if the U.S. is to implement more solar energy in the nation’s power grid.

    Supporters of Using More Solar Energy

    Solar energy in the U.S. is primarily seen as a means of reducing emissions from the U.S. energy sector, and eventually transitioning the entire country to be a net-zero emitter. Supporters of solar argue that lowering emissions will work towards mitigating the effects of rapid climate change and reducing pollution fossil fuels, which is known to contribute to illness and increased mortality.

    In addition, supporters note that the long run costs of renewable plants are lower than fossil fuel plants. Solar energy systems, once installed, are easy to run because they draw on the limitless and free supply of energy coming from the sun. Comparatively, fossil fuel plants are expensive to operate and require expensive fuels, which must constantly be sourced and extracted. Because of this, it is estimated that switching to a more renewable-based grid would help U.S. consumers save money in the long run through lower energy costs.

    Supporters also argue that diversifying sources of energy production boosts power grid resilience. A report by the Environmental Protection Agency (EPA) states that having diverse sources of energy shields consumers from price volatility, diminishes the likelihood of major power outages, and makes the grid less vulnerable to attacks or natural disasters.

    Proponents of solar energy also suggest it would be a boon for the economy through job creation and private investment. The Solar Energy Industries Association (SEIA) reports that roughly 10,000 solar companies employ 230,000 Americans, which generated $33 billion in private investment in 2021. It also finds that meeting the 40% solar by 2035 goal laid out by the DOE would create an additional 670,000 jobs.

    Opponents of Using More Solar Energy

    One major concern with expanding solar energy usage is the mining of materials involved in solar panel production. Solar panel manufacturing requires many different metals, and the higher demand for batteries to store captured solar energy drives mining of metals required for lithium-ion batteries. Mining can cause the destruction of habitats, environmental pollution, and biodiversity loss. It also affects communities near mining operations, which typically take place in developing countries, imposing health costs due to the release of toxic materials. Moreover, some of the metals contained in solar panels such as cadmium, lead, and arsenic can be harmful to environmental and human health, leading some solar panels to be classified as toxic waste when discarded.

    There are also concerns over land use. Solar farms take up considerably more space than power plants of equivalent electrical output. It is estimated that at current efficiency levels, solar panels would require 10 million acres, or 0.4% of the nation’s surface area, to completely power the U.S. Land clearing for the construction of solar farms, as with any human development, can be detrimental to wildlife, soil, and water sources. These arguments, as well as negative views on the aesthetics of large solar installations, are posed by residents of some rural desert communities that live near planned solar development sites. In California, Utah, and Nevada, opposition made up of concerned residents and conservation groups have pushed back on some large-scale solar infrastructure projects.

    Finally, many private utility and energy companies are opposed to solar energy, as it can present a threat to their business models. Private utility companies typically profit from their own capital investments and (in some markets) electricity sold, so cheap solar energy projects that can provide potentially off-grid power generation via rooftop solar are viewed as an acute risk. In 2021, a national network of utility interest groups and fossil fuel think tanks offered funding and consultancy services to utility companies seeking to block solar energy implementation in their home states.

  • Immigration Healthcare and the Five Year Bar

    Immigration Healthcare and the Five Year Bar

    Lawful permanent residents (LPRs) must wait 5 years before they can enroll in federally funded programs such as the Children’s Health Insurance Program (CHIP), Medicaid, Medicare, Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Supplemental Security Income (SSI). The five-year waiting period begins when individuals receive their qualifying immigration status and not when they first enter the US. This five-year waiting period, also known as the Five Year Bar, was part of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA). Qualified immigrants arriving in the US on or after enactment of PRWORA on August 22, 1996 may be ineligible for federal means-tested benefits for five years. Federal agencies clarified that the “federal means-tested public benefits” are Medicaid (except for emergency services), CHIP, TANF, SNAP, and SSI. 

    Who is Impacted by the Five Year Bar?

    PRWORA was created to limit welfare dependency by encouraging work and the maintenance of two-parent families. In 2019, 23 out of every 100 families with children living in poverty receive cash assistance through TANF. The law placed limitations on federal funding for benefits such as health coverage of immigrant families by creating 2 categories of immigrants that entered the US on or after August 22, 1996 called “Qualified Immigrants” and “Not Qualified Immigrants.” “Qualified Immigrants” can access federally funded programs if they meet the eligibility requirements but only after the five-year bar. Qualified Immigrants are ineligible for SNAP and SSI until they become a US citizen, which requires five years of residency. States have the control to determine their eligibility for TANF, Social Services Block Grant (SSBG), and Medicaid. Qualified Immigrants include:

    • Lawful permanent residents, or LPRs (people with green cards)
    • Refugees or people granted asylum 
    • People granted parole by the U.S. Department of Homeland Security (DHS) for a period of at least one year
    • Cuban and Haitian entrants
    • Certain abused immigrants, including children and parents
    • Certain survivors of trafficking 
    • Certain individuals residing in the U.S. pursuant to a Compact of Free Association (COFA) (for Medicaid purposes only)

    “Not Qualified Immigrants”—including undocumented immigrants and other noncitizens—are unable to access most federally funded programs regardless of their time of residency. Below are the individuals who are exempt from the Five Year Bar:

    • Refugees and asylees
    • Veterans including their spouses and unmarried dependent children
    • LPRs who have worked at least 40 qualifying quarters according to the Social Security Administration (SSA)

    Brief Background on Medicaid and CHIP

    Medicaid is a federal and state funded insurance program that is offered to low-income individuals. Undocumented immigrants are not eligible to enroll in Medicaid or CHIP however PRWORA allows undocumented immigrants to receive emergency Medicaid. Medicaid also establishes minimum requirements for eligibility and benefits. However, states are allowed to extend coverage beyond minimum levels so Medicaid coverage varies from state to state.

     The Children’s Health Insurance Program (CHIP) was established in 1997 and offers low-cost health coverage for children in families whose household income is higher than the standard to qualify for Medicaid. CHIP covers children under the age of 19 and a very limited number of parents above the Medicaid eligibility requirements. The 2009 Children’s Health Insurance Program Reauthorization ACT (CHIPRA) was signed by President Obama which had a provision called the Immigrant Children’s Health Improvement Act (ICHIA). This provision gives states the option to provide Medicaid and CHIP to LPR children and pregnant women without a five-year waiting period. 18 states have eliminated the Five Year Bar for LPR pregnant women and children since January 2022. Access to coverage and health care services among immigrant children has improved substantially in states that have taken the CHIPRA option, and it was not associated with reductions in private coverage. At the end of 2012, 62% of immigrant children had health coverage through Medicaid or CHIP in states that took CHIPRA, compared to 21% of immigrant children covered in states that did not take up the option. 

    Justifications for the Five Year Bar

    Congress emphasized the principle of self-sufficiency as a basic principle of US immigration law and policy when creating PRWORA. The law was described as a “reassertion of America’s work ethic” by the U.S. Chamber of Commerce. The policy emphasized that immigrants who are entering the US should only rely on their own capabilities and the resources of their families, sponsors, and private organizations. The policy also encouraged immigrants living in the U.S. to “not depend on public resources to meet their needs” and that the “availability of public benefits [does] not constitute an incentive for immigration to the United States.” PRWORA restrictions on immigrant access to public benefits originated from concerns that welfare programs were enticing American citizens to move to states with more generous welfare benefits. Proponents supporting PRWORA believe that welfare programs offered by the US have become a “magnet” for immigrants. Changes in the accessibility of means-tested programs post-PRWORA affected low-skilled unmarried immigrant women the most, who were more likely to settle in states that restored benefits and had the highest probability of welfare use. PRWORA laid the foundation for further exclusions as several public benefit programs and systems were created since 1996 including CHIP by imposing the Five Year Bar and the Affordable Care Act (ACA) which excludes healthcare coverage towards undocumented immigrants. 

    Arguments Against the Five Year Bar

    Many argue that the Five Year Bar is a barrier to immigrant healthcare access. For example, the Five Year Bar impacts older immigrants who do not have access to health insurance through employment and may not be able to qualify for specific benefits such as SSI and Medicare. PRWORA, which expired in 2002, has caused a “chilling effect” in immigrant communities due to its eligibility restrictions. Many qualified immigrants, who are eligible to access public benefits since they do not have to wait 5 years, do not access the healthcare they need. For example, foreign born immigrants who are 65 and older reported more chronic diseases, reduced Activities of Daily Living, and poor mental health compared to US born older adults. Some states are eliminating the Five Year Bar. For example, Illinois is using state funds to cover Medicaid for low-income undocumented seniors. In addition, some states are considering lifting the Five Year Bar in hopes of better health outcomes, especially among pregnant women and children who are LPRs. Advocates of lifting the Five Year Bar in Georgia believe that doing so would provide health insurance to more children and increase access to prenatal care. 

    Immigrants subject to the Five Year Bar have few options for health insurance. In 2020, among the nonelderly population ages 0-64, 26% of LPRs and 42% undocumented immigrants were uninsured compared to fewer than 1 in 10 citizens. Immigrant women in the US also continue to face challenges when obtaining affordable health coverage and care including sexual and reproductive health services. Immigrant women are likely to obtain limited available services such as from publicly funded family planning centers where 7 of 10 immigrant women reported a safety-net site as their usual source of medical care. 41% of immigrant women who obtained contraceptive care in the years 2006-2010 did so at safety-net family planning centers, compared to 25% of their U.S.-born counterparts. 

    Another argument against the Five Year Bar is that it makes it difficult for immigrants to access healthcare due to the varying state-by-state policies. Differing state policies may result in varying population growth among states due to differences in health insurance coverage. States that offer more generous health insurance coverage may have an influx of immigrants they were not prepared for leading to a lack of resources. Many believe there should be national legislation on immigrant access to care rather than leaving the decision to states.

    Should there be Reforms?

    There are currently two proposed acts to address the Five Year Bar.

    1. The Health Equity and Access under the Law for Immigrant Families Act of 2021 (HEAL Act) allows immigrants to participate in health care programs. The Bill would remove the Five Year Bar and ensure all individuals, including LPRs and the Deferred Action for Childhood Arrival (DACA) recipients, are eligible for federally funded healthcare programs. The legislation also mandates that DACA recipients are able to obtain premium-tax and cost sharing reductions in order to purchase care through the ACA.
    2. The Lifting Immigrant Families Through Benefits Access Restoration Act of 2021 (LIFT the BAR Act), introduced by Representative Pramila Jayapal and Tony Cardenas, would restore access to public benefits such as SSI, TANF, SNAP, and Medicaid for LPRs, DACA recipients, individuals granted Special Immigrant Juvenile Status (SIJS), and other federally authorized non-citizens residing in the US. The Bill would also remove the Five Year Bar. Lastly, the Bill would consider all LPRs “qualified” immigrants for the purpose of federally funded benefit program eligibility.
  • Transgender Healthcare in the US

    Transgender Healthcare in the US

    General Health Care

    Transgender healthcare in the U.S. falls into two categories: general healthcare services for transgender individuals and transgender-related services. 

    Prior to the Affordable Care Act (ACA), many transgender individuals had limited access to both general healthcare services and transgender-related services. Being transgender was considered a pre-existing condition, which meant that health insurance companies could legally charge a transgender patient higher premiums or deny them coverage. The ACA made that practice illegal in 2014. Two years later, the federal government provided another layer of legal protection by adding gender identity to Section 1557 of the law, which already prohibited discrimination based on race, color, national origin, sex, age, or disability. 

    As a result, transgender individuals in the US now have the right to purchase insurance and receive general health servces equal to cisgender people. However, that does not necessarily mean that gender affirmation services are guaranteed to be covered.

    What are Gender Affirmation Services?

    Transgender is an umbrella term used to refer to individuals whose gender identity does not align with the sex they were assigned at birth. Many members of this population experience discomfort in their body as a result, potentially leading to psychological distress. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) calls this gender dysphoria. 

    While previous versions of the DSM instead listed “Gender Identity Disorder”, the authors of the DSM-5 concluded that there is nothing inherently wrong with varied gender identities and classifying them as a disorder was, like the inclusion of “homosexuality” in the DSM until 1973, unneccessarily stigmatizing. The DSM-5 clarifies that having a non-traditional gender identity is not an issue. However, if a person experiences persistent distress as a result of the conflict between their body and their identity, that “gender dysphoria” is a disorder in need of treatment. Effective treatment involves altering the person’s gender expression and body to better align with their identity. Gender affirmation services are medical services that achieve this purpose. Types of gender affirmation services include:

    • Gender-Affirming Hormone Therapy
      • Feminizing hormone therapy: Medications will a) block the production of testosterone, and b) introduce more estrogen into the system in order to induce feminine secondary sex characteristics such as breast development and facial/body hair reduction. 
      • Masculinizing hormone therapy: Medications will a) block the production of estrogen, and b) introduce more testosterone into the system in order to induce masculine characteristics such as a change in muscle mass as well as the production of facial/body hair. 
    • Pubertal blockers: Medications that young gender divergent individuals can take to temporarily suppress the release of sex hormones and therefore the effects of puberty. If someone stops taking the medication, the release of hormones and normal development of secondary sex characteristics will resume.
    • Surgery
      • Removal of breasts, ovaries, uterus, penis, testicals, and prostate gland; and genital reconstruction.
      • Facial contouring or hair transplants (often considered cosmetic and therefore commonly excluded even in plans that have broader coverage).

    Types of Insurance

    Whether a person experiencing gender dysphoria is able to access treatment depends largely on what type of insurance they have. 

    • Uninsured: If someone is uninsured, they pay for the entirety of the service out of pocket. Transgender adults are more likely to be uninsured than cisgender adults as well as to report barriers due to cost. Hormone therapy typically costs $100/month and gender affirmation surgery usually ranges from $7,000 to $50,000.
    • Employer Insurance: Nearly half of Americans receive health insurance through their employer. Employers (including 67% of Fortune 500 companies), increasingly offer health plans that include coverage for gender affirmation services, yet there is still variation in coverage. Employers can be as generous as they wish. When it comes to determining whether an employer is meeting minimum coverage requirements, however, it is far more complex. Self-insured and level-funded group health plans are only subject to federal nondiscrimination laws. Fully insured group health plans must also comply with non-discrimination laws of the state they are written out of. 
    • Medicaid: Medicaid is a government-provided health insurance option for low-income Americans. While the program receives federal funding, it is run and administered by the state. As a result, the 152,000 transgender adults on Medicaid experience different coverage depending on their location. However, evaluating coverage is not easy, as most states do not include information about gender affirmation services in their Medicaid handbooks/webpages. An analysis published in 2021 found that 67% of states cover hormone therapy and 49% cover surgery.
      • Hormone Therapy:
        • Covered: 34 of 51 states 
        • Not covered: 9 of 51 states and 2 of 5 territories 
        • Could not confirm: 8 of 51 states and 3 of 5 territories
      • Surgery
        • Covered: 25 of 51 states 
        • Not covered: 22 of 51 states and 3 of 5 territories 
        • Could not confirm: 4 of 51 states and 2 of 5 territories
    • Medicare: Medicare is a federal government health insurance program available to persons over the age of 65 and persons with disabilities. For decades, Medicare excluded transgender surgery and related procedures because procedures were deemed experimental. In 2014, the Centers for Medicare and Medicaid Services issued a new determination. Now Medicare determines coverage of transgender-related procedures on a case-by-case basis. As with other health services, it outlines requirements for diagnosis and proof of need. So long as that burden is met, Medicare now covers hormone therapy as well as most surgical procedures (with the exception of those deemed cosmetic, such as facial contouring and hair transplants). As of 2018, 10,200 individuals were accessing transgender services through Medicare. An analysis showed that 77% of transgender individuals on Medicare were under the age of 65, meaning they had access to this insurance option because of a disability. 
    • Non-Group Insurance: Individuals who do not qualify for Medicare or Medicaid and who do not receive insurance through their employer can purchase health insurance on the government-run Marketplace. Like with employer-sponsored insurance, there is extensive variation in clarity, coverage specification, and types of exclusions.
      • 9% of contracts excluded all trans-related services.
      • 25% of companies offered an exclusionary contract.

    According to Healthcare.gov, transgender individuals should look in contracts for:

    • “All procedures related to being transgender are not covered.”
    • Other sections using language: “gender change,” “transsexualism,”  “gender identity disorder,” and “gender identity dysphoria.”