September 18, 2008

Department of Health and Human Services

Office of Public Health and Science

Attn: Brenda Destro

Hubert H. Humphrey Building

200 Independence Avenue SW, Room 728E

Washington, DC 20201

**Re: RIN 0991-AB48:** "**Provider Conscience Regulation"**

Dear Secretary Leavitt,

We are writing on behalf of Enlace Comunitario, an Albuquerque, New
Mexico organization that provides support and services to
Spanish-speaking immigrant women who are victims of domestic violence to
urge you to abandon the proposed "Provider Conscience Regulation." We
share the concerns and join in the objections raised by other New
Mexico-based agencies, including those submitted by Young Women United
and the Southwest Women's Law Center. But we write separately to
emphasize our unique perspective as advocates and service providers for
some of the most vulnerable women in our community, immigrant victims of
intimate partner violence.

New Mexico is home to significant and growing immigrant communities that
are overwhelmingly poor, uninsured and underserved. According to the Con
Alma Health Foundation (CAHF) 2006 Report, *Closing the Health Disparity
Gap in New Mexico*, 42% of New Mexico\'s foreign-born children live in
poverty, and families with a foreign-born Hispanic/Latino householder
are more than twice as likely to be poor as those with a native-born
householder (CAHF Report at 17). The report also found that the New
Mexicans most likely to have no health insurance are women and men
18-34, which are the primary childbearing years for women during which
their need for reproductive health information and services is at its
peak. (Id. At 19) The CAHF Report also found that federal restrictions
on immigrant access to public health services, particularly Medicaid,
have exacerbated existing barriers in for immigrants seeking health care
services (Id. at 18).

There are many federal programs that do provide benefits to immigrant
women for reproductive health and family planning services, depending on
the immigration status of the patient and the specific healthcare
service sought. We assist our clients in obtaining healthcare services,
but our clients are often afraid to seek services. They have been
abused, many cannot speak English, most are extremely poor, and as
immigrants, they are subject to significant discrimination. Our clients
already face so many barriers to obtaining healthcare and this
regulation will create more. Many immigrant women live in small
communities with few healthcare options. Particularly because immigrants
already face a patchwork of available government-funded services,
immigrant women could find themselves without any options for obtaining
family planning and reproductive health services.

We are also deeply concerned that the regulation could impact other
government-funded programs that benefit immigrants and victims of
domestic violence generally but we cannot tell from the definitions
which streams of funding that originate at HHS will be impacted by this
regulation. The proposal states that an estimated 76,000 "grant awards"
from HHS will be impacted. Which programs, specifically, are included?
Will these regulations apply to domestic violence programs, shelters,
and providers? Will they apply to rape crisis centers and other programs
providing support to sexual assault survivors? All of these programs
serve vulnerable women and we work to overcome barriers within those
programs facing immigrant women.

The proposed regulations state the following:

> In general, the Department is concerned that the development of an
> environment in the health care field that is intolerant of individual
> conscience, certain religious beliefs, ethnic and cultural traditions,
> and moral convictions may discourage individuals from diverse
> backgrounds from entering health care professions. . . . A trend that
> isolates and excludes some among various religious, cultural, and/or
> ethnic groups from participating in the delivery of health care is
> especially troublesome when considering current and anticipated
> shortages of health care professionals in many medical disciplines
> facing the country.

Proposed Rule at 9-10. We are struck by the failure of the proposed rule
to even mention the needs of *patients* of diverse religious, ethnic and
cultural backgrounds -- the people we serve. These regulations would
isolate and exclude *patients* from participating in the delivery of
health care, and makes no effort to address the impact on a patient
whose provider refuses to provide healthcare services or even tell her
about such services.

We urge you to withdraw these proposed regulations.

> Sincerely,

Claudia Medina

Executive Director

Antoinette Sedillo Lopez

President