How to Stop Helping Refugees: An N-648 Parade
By: P.J
Tags: Discrimination, Refugees, Citizenship, Government, English

When a foreigner resides among you in your land, do not mistreat them. The foreigner residing among you must be treated as your native-born. Love them as yourself, for you were foreigners in Egypt. (Leviticus 19:33–34)

Until they have lived with you for 7 years. Then stop giving them food and medical assistance.

At least that is how I understand it. I am family doctor for ten thousand refugees who have resettled to the Denver, Colorado area. In 10 years of doing this work, I have learned a few things about the process.

Warning: This writeup is about a specific corner of a specific issue, so may be dry unless you have specific interest in this subject.

Refugees are legal residents on arrival. A year later they can easily get Permanent Resident Status, also known as a Green Card.

About five years after arrival they can apply to be a citizen, which allows them to vote and travel abroad a little easier, but more importantly, to keep their public assistance benefits. That means free healthcare (Medicaid), free food (food stamps), and free money (TANF aka Cash Benefit aka welfare). Taken together we call these “benefits.” I think this is the modern society interpretation of that Leviticus verse. These benefits are how you take care of those foreign born, or the poor, or poor people who were foreign born.

Certainly many refugees get jobs or open businesses, and have too much income to qualify for these benefits. But many don’t, because they are handicapped by language, culture, age, or disability, or simply because their job pays too little. So they get these benefits. However, by U.S. law, if they have not become citizens by seven years after arriving, they lose these benefits.

So they start trying to apply for citizenship at five years, and hope they get it by seven years. That’s 2 years to get through the red tape of the citizenship process.

The crux of the process is a test of English and Civics, administered in spoken English. It is 20 factual questions, taken from a list of 100 questions, and 12 of those 20 must be answered correctly. Many refugees speak enough English, and they memorize the answers to the 100 questions. Actually the number of questions recently increased to 128, some of which are not simple facts, and many “native Americans” may even find it difficult. Click on those links to learn more or try the questions yourself.

An English class for adult resettled refugees. Some learn enough to pass the test.

To an elderly refugee, 100 vs 128 questions doesn’t matter. Nor does it matter that they only have to answer 6 out of 10 questions correctly (if over age 60), not 12 out of 20: They are never going to learn English to pass that test. Have you tried learning a second language? It is difficult after age 30 and almost impossible after age 60.

Some of these refugees are not only elderly, they are also blind, deaf, mute, have seizures, are missing limbs, have mental disorders, are on dialysis, or have other medical problems that make it hard to get around, much less learn anything. I know this because I am their doctor. These are medical issues shared by many Americans who were born in America, who are disabled and can’t work. These are exactly the Americans that need benefits like free healthcare, free food, and free money. But if they are refugees, these are exactly the ones who can’t get it, unless they learn English.

Or unless they submit a form “N-648,” where a doctor says that they can’t learn English for a medical reason. If the N648 is accepted by USCIS (the government immigration department), then they need not take the English and Civics test, and can just do some paperwork to become a citizen and keep their benefits.

You would think a doctor’s writeup would be readily accepted by USCIS, just like doctor’s notes are accepted by every school, workplace, airline, and more. But it’s not that easy.

I’m not an expert on immigration or the Bible, but I do have a degree in 648ing. I’ve done hundreds of 648s — so many that I have a clock in my office, with the hands permanently set to 6:48. I will now describe the 648 game.

About two-thirds of my 648s are approved on the first try. The rest come back rejected. I redo those ones, and the applicant submits it again. Some get rejected multiple times. One was rejected 5 times. Each reject takes a few months or a year to fix and reapply, by the time the bureaucratic wheels turn. So this process takes years for some people, making them lose their benefits in the process (if their 5 years passes 7), or lose their mind and just give up. Some move to another state because they hear the USCIS agents pass you easier there.

I have many refugee patients who passed the 7 years, and have no insurance, and we usually see them free in our outpatient clinic. But they can’t get free ER visits, free hospital stays, free medicine, free Xrays, or free specialists.

Some try to get a lawyer or a mental health professional to help with the 648 process. I have learned those things do not help. Whether the 648 is approved has nothing to do even with what I write. It has everything to do with the agent they meet the day they go for the interview. I have never been to the USCIS office, but I know some folks who help take many refugee patients for their “interview”. They tell me that the moment the door opens, they see which agent it is, and they know whether their 648 is going to be accepted or rejected. One might think there were more rejections under Trump, but it seems about the same as under Obama. The President doesn’t matter, the USCIS agents do.

I have learned to try to not write about any physical problems like missing limbs, dialysis, blind or deaf. I only write mental problems now, mainly dementia.

What does it look like when a 648 gets rejected? That is what I have here, a parade of rejections from the last 10 years.

You will see that many of the rejection letters have template wording, with only a few sentences that are unique to that letter. For each one, I have circled the substantive part in red and wrote some comments in red.

I will start with a standard example. They almost always pick on question #10.

Huh? Unable to remember language, names, directions, activities- doesn’t that indicate that they can’t learn English?

Another common one. They like using the word “nexus” to make their rejection sound reasonable:

I failed to establish how illiteracy, lack of education, and psychological trauma result in an inability to speak English or answer Civics questions in any language.

Here is one referring to 5 years prior, 2010, when the refugee arrived in the U.S:

Not all genetic mental disorders manifest at birth. Many start in teens or 20s.

And here are some about patients with hearing or speech problems:

Hellen Keller wasn’t age 60 when she started communicating.

Here is another deaf and mute that should learn English visually, or lose their healthcare:

I guess I forgot to ink sign that one. It only had my signature printed by my printer.

But really, so what if this guy learns sign language, and can answer questions about the U.S. government in sign language? Does that make for a better society? This patient is not going to ever interact with anyone other than his immediately family anyway, because he is so disabled.

This is the same deaf 42 year old as just above, with his 2nd rejection.

Not only do they maintain that he can learn visually, they again go after my signature. I signed in ink next to my printer printed signature. Two identical signatures is certainly fishy.

Here is an elderly, mute and deaf patient:

Since this one, I have a paragraph about how a lack of education leads to earlier dementia.

And the 648 asks for DSM codes, but DSM codes are for mental issues, not physical ones like mute+deaf. So I listed no DSM code. Just for reference, here is the N648 form asking for the DSM code.

I get a bunch where they say that if you can remember your kids names, address, and special dates, then you can learn a new language:

Another similar one. If the applicant answer a couple questions correctly, the USCIS agent says they can learn English, and that the doctor is lying:

And an ironic one about templates:

Everyone in any industry uses templates. But since this one, I now use “she” or “he” instead of “one” or “them”. Also, note the word “regrettably” — it is patronizing the way it is used here.