STERLING HEIGHTS, Michigan — When she lived in Baghdad, Bushra Rahameed would often step outside the door, just to run errands, and see corpses. “With our own eyes,” she said over and over recently, breaking into English for emphasis, then returning to Arabic. “Like a movie.”
There was one day when a suicide bomber exploded in front of Rahameed, 46, and her young children as she walked to the market to get a loaf of bread. And there was the day terrorists ambushed a van carrying her husband, Amri, and a dozen other passengers, and he was the only survivor. Sometimes Rahameed would shake as bombs went off nearby — but when her kids asked what was happening, she said she was dancing, and turned on some music.
When Rahameed came to the United States in 2012 as a refugee and settled into a one-story brick house in the Detroit suburbs, she suddenly felt an overwhelming sense of security. But there was one thing missing.
Rahameed and her family — a husband and three children — did not have health insurance. Refugees get eight months of health coverage when they arrive in the United States but are then left on their own. Rahameed and Amri worked low-wage jobs that didn’t provide coverage. A bill for $981 showed up after they took their young daughter, Leeandra, to the emergency room for the flu. They took out seven credit cards to cover their medical bills.
“Every day I would pray that my kids don’t get sick,” Rahameed said.
She said she only felt completely safe in the United States when she signed up for Obamacare’s Medicaid expansion, around Christmastime last year. It meant that she could get seen for a persistent rash she’d had for years, that her husband could have surgery on a hernia he developed in a job requiring heavy lifting.
Refugees are a population that have quietly benefited from the Affordable Care Act, a group that historically struggled to make sense of the country’s complex, expensive health system — and one that has an immense amount at stake as the Senate continues its debate over Obamacare repeal and replacement Wednesday.
Detroit has unusually robust Obamacare enrollment for an urban area. One explanation for it is that the city has an especially high Arab-American refugee and immigrant population, whose members have signed up for the coverage expansion in droves.
The high enrollment among this groups in many ways represents the exact goals Democratic legislators had in mind when they passed the health care law: expanding coverage to vulnerable, marginalized populations.
But the type of Obamacare enrollment happening in Detroit also represents exactly what many Republicans voters hate about Obamacare: another government handout to a population that some of those voters believe takes more from the country than it gives.
The nonprofit Arab Community Center for Economic and Social Services (ACCESS) holds the Detroit area’s largest Obamacare enrollment grant. It has signed up more than 29,000 people for the coverage expansion, and 90 percent of those enrollments have been within Detroit’s Arab-American community.
“Before the Affordable Care Act, there were a lot of gaps in terms of who was eligible,” says Farah Erzouki, who oversees ACCESS’s Obamacare enrollment work as the organization’s public health manager. “Not only was it unaffordable, but our clients wouldn’t see the necessity. Now they know about the mandate, that America is a place where you carry health insurance, and they’re getting signed up.”
Macomb County, where Rahameed and her family live, is a hub for Iraqi immigrants to the United States. It is a sprawling suburban county just north of downtown Detroit. It is also among the 12 Michigan counties that flipped from voting for Obama in 2012 to supporting Trump in 2016. There are signs of tension from the quick expansion of benefits to the county’s rapidly growing immigrant population.
“I’m standing in the damn welfare office, and I’m looking around at all of these people that can’t even say hello to me in English,” one Trump voter in Macomb County said in a recent focus group. “They’re all there with appointments for their workers, which means they have health care. If you can come from somewhere else, why can’t we all get it?”
Macomb helped propel Trump into the White House, where he has remained a vociferous advocate for repealing and replacing the Affordable Care Act. As some Republican legislators have grown weary of the task and suggested moving on to other priorities, the president has remained firm.
“Republicans have a last chance to do the right thing on repeal & replace after years of talking & campaigning on it,” Trump tweeted early Monday morning.
Obamacare repeal in Macomb County would mean massive coverage loss among the Arab-American immigrant population. Whether that feels like a win or a loss will depend a lot on whether voters experienced the expansion of benefits in the first place.
“In Iraq, health services don’t cost like they cost here”
The American health care system is complex and expensive for those who grow up within it. For new immigrants and refugees, it can be absolutely baffling.
Immigrants and refugees often end up in desperate situations without health coverage. One Iraqi asylum applicant told me about relocating his mother across the border to Canada when she needed a $60,000 heart surgery (she still lives there today). A Lebanese couple who immigrated got scammed by a seeming good Samaritan who offered to marry their young adult son when he got cancer and provide health insurance — only to attempt to seize all his assets when that son passed away.
“In Iraq, health services don’t cost like they cost here,” says Kaes Almasraf, who worked as a dentist in Iraq before immigrating to the United States in 2014. He now works in Affordable Care Act enrollment. “You can pay something like less than $1 to see a doctor there. There’s no insurance. The health system is complicated here. Everything is totally different.”
Historically, the United States has focused more on screening immigrants for communicable diseases than on treating them. Refugees are given eight months of medical assistance when they arrive in the United States and then are left to fend for themselves.
“By the ninth month, a lot of refugees aren’t that established, and then all of a sudden they lose their coverage,” says Susan Reed, a managing attorney with the Michigan Immigrant Rights Center.
Refugees and immigrants have the same right to enroll in safety net programs as those born in the United States. This means they qualify for Medicaid, which provides health coverage to low-income Americans. Refugees are eligible for those benefits immediately, while immigrants must reside in the country for five years before participating.
Prior to the Affordable Care Act, that safety net had plenty of holes that left millions of Americans uninsured. These holes were especially easy for refugees to fall through.
For example: New arrivals to the United States often end up employed in low-wage work or small businesses that typically do not offer health benefits. Medicaid was an option but only for certain types of people — like people with disabilities and pregnant women. Poor, able-bodied adults could rarely enroll, whether they were a refugee or born in the United States.
Prior to the Affordable Care Act, for example, Michigan limited Medicaid eligibility among working adults to those earning less than 64 percent of the poverty line. A family like Rahameed’s would have needed an income lower than $17,644 to qualify.
Rahameed, her husband, and her adult son weren’t getting wealthy working full-time, low-wage jobs at a hotel. They earned far too little to purchase private coverage but far too much to qualify for Medicaid. So they went without health insurance, took out credit cards, and prayed for the best.
Their situation wasn’t unique: Numerous studies have found high uninsured rates among refugee and immigrant populations. One of the most in-depth studies, published in the Journal of Immigrant Minority Health in 2012, found that 48 percent of refugees lack health coverage.
It also discovered that among those uninsured refugees, 87.6 percent lived in households in which either the primary immigrant or their spouse was employed. The average income of uninsured, working refugee families was $24,000, putting both Medicaid and private coverage out of reach.
“Our experience, clinically, is a lot of people would become uninsured,” says Katherine Yun, the lead author of that study, who is also a practicing emergency physician at the Children’s Hospital of Philadelphia. “Before the Affordable Care Act, there would be a big push during the initial eight months to try and get as much done as possible.”
“We were thinking like she’s an angel, she’s going to help”
May ElHaddad immigrated to the United States in 2005 and became a citizen in 2010. She works as a hairdresser in a local salon and recently started teaching Arabic lessons to keep up with her bills.
Her family, in the early 2010s, had begun to set up a life in Sterling Heights, a small suburb about 30 minutes north of Detroit. Her young adult son, Marc, worked in a mechanic shop. He liked the work so much, they took out a loan so he could pay rent on his own place.
“We took a mortgage on our house to help him open a big mechanic’s place,” ElHaddad says. “He was a good mechanic; we were working to help him pay the rent of the store, to help it survive.”
But in 2013, Marc was diagnosed with testicular cancer. The family had never purchased health insurance because it was too expensive, and they suddenly found themselves with a mounting pile of bills. They had already paid $15,000 out of pocket for chemotherapy and wanted to get him into an oncology surgery clinic that would only accept patients with coverage.
A staff member at the office knew of the challenge and made a surprising proposal to help.
“She was offering ... I will get married to [your son], and I will give [him] insurance,” ElHaddad recalled. “So we were thinking like she's an angel, she's going to help. This lady said, ‘I can give you health insurance. I’ll marry him.’”
ElHaddad had a funny feeling about the proposal — but then again, the whole American health system struck her family as overwhelming and complex. People did desperate things to get coverage. Without any other options, the marriage went through.
The medical staff member’s insurance covered two major surgeries, but Marc died of internal bleeding during the second operation. And the assistant’s offer of help quickly turned into a nightmare, when the assistant went to the mechanic store and claimed all the cars and supplies sitting there, bringing the marriage certificate that showed her to be the owner’s wife.
“You don’t imagine how hard and how bad a situation you can have in the United States,” ElHaddad said. “It was like, not even animals do this to each other. She took everything.”
ElHaddad buried her son in late 2013. Two years later, in 2015, she was diagnosed with breast cancer. She has since had a double mastectomy and is remission, but she receives regular treatments to increase her bone density in the aftermath of the treatment.
ElHaddad has Medicaid, which covers her bill. She knows what cancer treatment looks like for the uninsured. She doesn’t want to imagine going down that path again.
“I don't imagine my life now without Medicaid,” she said. “Without insurance, it's not okay, okay to live.”
“I’m all for everybody having the American dream, but I feel that it’s being taken away from a lot of people”
Rahameed and ElHaddad both live in Sterling Heights, a small suburb about 30 minutes north of Detroit. It’s a sprawling city with no downtown but rather strip malls that go on for blocks and neat rows of compact brick houses with American flags waving.
It’s the kind of suburb where kids ride bicycles aimlessly in cul-de-sacs at dusk on a hot July day, and where neighbors wave at one another.
And it is part of Macomb County, one of the 12 counties in Michigan that flipped to support Trump in the 2016 election after voting for Obama in 2012.
Macomb County has become home to a growing population of Arab-American immigrants. In particular, Iraqi Christians have settled in Sterling Heights. Their presence is obvious. Strip malls have signs in Arabic next to those in English, advertising hair salons, Middle Eastern groceries, and halal butchers.
Voters have noticed the presence of these businesses and seen Arab-American immigrants in the welfare offices. In some instances, that breeds resentment.
The pollster Stan Greenberg went to Macomb County this past spring to conduct focus groups with 35 voters who supported Trump in 2016. He found a frustration with those who receive publicly funded benefits that range from the Medicaid program to public schools.
“My grandson’s school, I went to as a child, there are hardly any — I’ll just say American families there now,” a woman named Gina told Greenberg. “It’s mostly Middle Eastern, and people all standing outside waiting for their kid, to pick them up at the end of the day, and nobody’s speaking English.”
This resentment toward Medicaid enrollees and its role in the 2016 election is not unique to Macomb County. In southeastern Kentucky, for example, voters expressed similar frustration with those enrolled on Medicaid who they felt didn’t deserve that coverage. In Macomb, that frustration is wrapped up in racial tension.
As one voter told Greenberg, “I’m all for everybody having the American dream, but I feel that it’s being taken away from a lot of people by people coming and taking advantage.”
But the story of Macomb County and its flip to become a pro-Trump county is not just about race. The area has become home to a sizable minority of Chaldean Christian refugees, who have fled Iraq facing religious persecution from ISIS.
Trump repeatedly made promises to this community to protect their members and fight ISIS on their behalf. “Christians in the Middle East have been executed in large numbers. We cannot allow this horror to continue!” he said on Twitter in January.
Chaldean Christians liked what they heard, and many, like Fadil Fardiha, a 56-year-old Obamacare enrollee, voted for Trump. He’s participated in Medicaid expansion for the past year and raves about how well the program works.
Fardiha and his family immigrated to the United States in 2006 and became citizens in 2011. Fardiha cast his first vote for president in 2012 and supported Obama. But he’s among the Macomb county voters who flipped to Trump in 2016. He liked Trump’s “tough on terrorism” pitch and his opposition to same-sex marriage, which he described as a key voting issue.
Fardiha and his wife, Hayfa, signed up for Medicaid expansion in May 2016, after Fardiha left an assembly-line job. His legs ached from standing for eight hours each day, and after a decade, he needed surgery.
Medicaid covered Fardiha’s surgery last summer. It also meant that the family paid no bills when Hayfa had a 20-day hospital stay that summer. During that stay she fell into a four-day coma, seemingly caused by low plasma levels.
The couple really likes their Medicaid coverage but says that while they heard Trump talk about Obamacare repeal, they didn’t consider it a main voting issue. And they didn’t understand why the president would entertain such an idea in the first place.
“America is rich,” Fardiha said. “It is better to spend the money here than in Iraq.”
As we talked more about Medicaid expansion, Fardiha asked me questions about why Trump would consider ending the program. He became more agitated with the idea. He heard Trump talk about Obamacare repeal but, similarly to voters I interviewed in Kentucky, didn’t think Trump would actually take away anyone’s insurance.
“How would we pay?” Fardiha asked. “We would get sick and die. If you don’t have health insurance...”
He trailed off for a moment.
“I just don’t know.”
Rahameed is worried too. Right now, it feels like her family is settling into the United States. Her daughter Leeandra, now 10, bounces around their house with her face glued to her iPhone. Her husband had surgery for a hernia he developed from a job that required strenuous, heavy lifting. He has since recovered and now drives for Uber.
But the debate in Washington, which Rahameed follows, worries her. She hears about Obamacare. She knows it provides her health insurance. She doesn’t know what would happen without it.
“I don’t want anything from the government,” she says. “I don’t need the food stamps. Not anything. Just Medicaid.”
Eva Jirjis, another enrollment worker at ACCESS, hears this a lot from her clients. “They keep coming in to ask me questions about Trumpcare,” she says. “They don’t care about the food. They don’t care about the cash. They care about the medicine. That’s really all there is.”