Understanding the Safety Net: Medicaid’s Role in Providing Care to Afghan Evacuees

I recently hosted a conversation with several Medicaid leaders who gather each month to talk about health equity and Medicaid’s role in advancing it. This month the discussion was about states receiving, intaking and connecting thousands of Afghan evacuees to the US health care system. This process started in August 2021 when the US withdrew from Afghanistan at the end of the 20-year war. The US evacuated 120,000 people from Afghanistan, 70,000 of which came to eight US military bases early last fall.

States, including Medicaid agencies, are well-versed in refugee resettlement and know how to process documentation, determine eligibility, and connect people to care and services. They do it all the time. The difference, however, with this situation was the size and speed with which the evacuees came to the US. Tens of thousands came to the military bases over the course of a several weeks. In part because they had left Afghanistan with such urgency, they often came without documentation that would have facilitated resettlement. But they didn’t fit into a clear-cut eligibility category, or have a social security number or employment authorization papers. Someone called it a “non-traditional resettlement,” and it certainly has been.

As you might imagine, the conversation with the Medicaid leaders was fascinating. They talked about the significant health needs of the evacuees, the trauma they have faced, and how they struggled to make sense of our health care system. All states led with public health triage, including getting everyone vaccinated (e.g., measles, mumps, COVID-19). All states had a high percentage of pregnant women and women in their third trimester, so coordination with hospitals was urgent. Many people were amputees, had head traumas and/or undiagnosed physical disabilities. The largest group was kids – some with their parents, some with relatives, and some facing the evacuation alone. The concept of a health care system – as crazy as we know ours can be – was totally foreign to the evacuees, as was the importance of presenting a health insurance card. And for some who were on bases that bordered multiple states, the reality that health care programs could change completely at a state line seemed insane.

There were some differences in how individual Medicaid agencies approached the challenge, but very few. Some states with larger evacuee populations deployed staff to be on-site on the military bases, which was helpful, while states with smaller groups worked remotely. One state used WhatsApp and said it was a lifesaver for quickly accessing translation services when translators were unavailable or hard to find. Some states referred to the evacuees as “clients” while others called them “guests.”

The states talked about experiencing a rocky start at the beginning, but quickly adapting and revamping their approach to try to ease the burden on the evacuees as much as possible. The states also said they could see with new eyes just how incredibly complicated and confusing our health care system can be.

Finally, the states talked about uncovering “trip wires” that had been present in our health care system but were readily exposed through this crisis. (Where have I heard that before?) The good news is, trip wires eventually make themselves known and can therefore lead to resolution. Here were a few the states shared:

• Real and timely coordination among various agencies at the federal, state and local levels is a necessity for sufficient support of complex populations
• Technology is a great facilitator and should be used whenever possible and in new and creative ways
• Social safety net programs that are designed to talk to each other give a tremendous leg up to accuracy, efficiency and effectiveness
• Centering our work around the human story brings us closer to understanding each other and finding solutions

My gratitude goes out to those who have spent so much of your time, energy and heart to help resettle the Afghan evacuees. What we learn from your experience can lead us to improve care for all.