Dr. Mercado, Pediatrican: Dr. Mercado, Pediatrican: Atlanta Grady Memorial Atlanta Grady Memorial Hospital Hospital “ “ As an American citizen, I As an American citizen, I understand that you want to understand that you want to make sure the resources are make sure the resources are there for the right people. there for the right people. Yet, how can you deny someone Yet, how can you deny someone health access? If we don’t health access? If we don’t treat and prevent illness…our treat and prevent illness…our community is going to suffer.” community is going to suffer.”
Transcript
Dr. Mercado, Pediatrican: Atlanta Dr. Mercado, Pediatrican: Atlanta Grady Memorial HospitalGrady Memorial Hospital
“ “As an American citizen, I As an American citizen, I understand that you want to make understand that you want to make sure the resources are there for the sure the resources are there for the right people. Yet, how can you deny right people. Yet, how can you deny someone health access? If we don’t someone health access? If we don’t treat and prevent illness…our treat and prevent illness…our community is going to suffer.” community is going to suffer.”
Immigrants and Health Immigrants and Health CareCare
Lynn Christiansen, MSWLynn Christiansen, MSWNew Mexico Title V CYSHCN DirectorNew Mexico Title V CYSHCN Director
Susan Chacon, MSWSusan Chacon, MSWNew Mexico Title V CYSHCN ProgramNew Mexico Title V CYSHCN Program
Oklahoma Bill 1804Oklahoma Bill 1804 The State of Oklahoma finds that illegal immigration is causing The State of Oklahoma finds that illegal immigration is causing
economic hardship and lawlessness in this state and that illegal economic hardship and lawlessness in this state and that illegal immigration is encouraged when public agencies within this state immigration is encouraged when public agencies within this state provide public benefits without verifying immigration status. provide public benefits without verifying immigration status. The State of Oklahoma further finds that when illegal The State of Oklahoma further finds that when illegal immigrants have been harbored and sheltered in this state and immigrants have been harbored and sheltered in this state and encouraged to reside in this state through the issuance of encouraged to reside in this state through the issuance of identification cards that are issued without verifying immigration identification cards that are issued without verifying immigration status, these practices impede and obstruct the enforcement of status, these practices impede and obstruct the enforcement of federal immigration law, undermine the security of our borders, federal immigration law, undermine the security of our borders, and impermissibly restrict the privileges and immunities of the and impermissibly restrict the privileges and immunities of the citizens of Oklahoma. Therefore, the people of the State of citizens of Oklahoma. Therefore, the people of the State of Oklahoma declare that it is a compelling public interest of this Oklahoma declare that it is a compelling public interest of this state to discourage illegal immigration by requiring all agencies state to discourage illegal immigration by requiring all agencies within this state to fully cooperate with federal immigration within this state to fully cooperate with federal immigration authorities in the enforcement of federal immigration laws. The authorities in the enforcement of federal immigration laws. The State of Oklahoma also finds that other measures are necessary to State of Oklahoma also finds that other measures are necessary to ensure the integrity of various governmental programs and ensure the integrity of various governmental programs and services. services.
Penalties HB 1804Penalties HB 1804
A. It shall be unlawful for any person A. It shall be unlawful for any person to transport, move, or attempt to to transport, move, or attempt to transport in the State of Oklahoma transport in the State of Oklahoma any alien knowing or in reckless any alien knowing or in reckless disregard of the fact that the alien disregard of the fact that the alien has come to, entered, or remained in has come to, entered, or remained in the United States in violation of law, the United States in violation of law, in furtherance of the illegal presence in furtherance of the illegal presence of the alien in the United States. of the alien in the United States.
Penalties HB 1804Penalties HB 1804
B. It shall be unlawful for any person B. It shall be unlawful for any person to conceal, harbor, or shelter from to conceal, harbor, or shelter from detection any alien in any place detection any alien in any place within the State of Oklahoma, within the State of Oklahoma, including any building or means of including any building or means of transportation, knowing or in transportation, knowing or in reckless disregard of the fact that the reckless disregard of the fact that the alien has come to, entered, or alien has come to, entered, or remained in the United States in remained in the United States in violation of law. violation of law.
Felony PenaltyFelony Penalty
D. Any person violating the D. Any person violating the provisions of subsections A or B of provisions of subsections A or B of this section shall, upon conviction, be this section shall, upon conviction, be guilty of a felony punishable by guilty of a felony punishable by imprisonment in the custody of the imprisonment in the custody of the Department of Corrections for not Department of Corrections for not less than one (1) year, or by a fine of less than one (1) year, or by a fine of not less than One Thousand Dollars not less than One Thousand Dollars ($1,000.00), or by both such fine and ($1,000.00), or by both such fine and imprisonment imprisonment
Exceptions to the LawExceptions to the Law Newborn Screening ProgramsNewborn Screening Programs Public laboratory servicesPublic laboratory services Acute and chronic disease servicesAcute and chronic disease services HIV/STD servicesHIV/STD services Terrorism response Terrorism response Child, adolescent and women’s health (MCH)Child, adolescent and women’s health (MCH) Early Intervention programEarly Intervention program Dental health program (excluding dental loan)Dental health program (excluding dental loan) Child guidance programChild guidance program WIC programWIC program
Immigrant Health CareImmigrant Health Care
Immigrants, on average, receive about half the health careImmigrants, on average, receive about half the health care services provided to native-born Americansservices provided to native-born Americans Immigrants received an average of $1139 worth of care, Immigrants received an average of $1139 worth of care,
compared with $2564 for non-immigrants, according to 2005 compared with $2564 for non-immigrants, according to 2005 study in AJPH.study in AJPH.
A much higher percentage of immigrants lack a high schoolA much higher percentage of immigrants lack a high school education, which makes it difficult for them to navigate the health education, which makes it difficult for them to navigate the health care systemcare system Immigrant children had fewer doctor visits, took less medicationImmigrant children had fewer doctor visits, took less medication and made fewer trips to the ER. But their ER costs were nearly and made fewer trips to the ER. But their ER costs were nearly triple those for non-immigrant children.triple those for non-immigrant children. Immigrant families are more likely to miss routine check-ups and Immigrant families are more likely to miss routine check-ups and
wait until a condition was more serious before seeking treatment. wait until a condition was more serious before seeking treatment. They are less likely to receive standard immunizations and more They are less likely to receive standard immunizations and more likely to let chronic problems go untreated.likely to let chronic problems go untreated.
Ceci Connolly, “Study Paints Bleak Picture of Immigrant Health Care,” 7/26/2005. Washington Post Online, accessed 9/11/2008.
Immigrant Health Care Cont’dImmigrant Health Care Cont’d
Notes contradiction in current policy: i.e. labor and delivery Notes contradiction in current policy: i.e. labor and delivery costs for undocumented immigrant women are covered costs for undocumented immigrant women are covered under EMSA, but prenatal care and family planning are not under EMSA, but prenatal care and family planning are not
2005 study in American Journal of public Health showed 2005 study in American Journal of public Health showed that annual per capita expenses for health care were 86% that annual per capita expenses for health care were 86% lower for uninsured immigrant children than for uninsured lower for uninsured immigrant children than for uninsured U.S.-born children; but emergency department U.S.-born children; but emergency department expenditures were more than three times as high.expenditures were more than three times as high.
Noncitizens make up 20% of the 46 million uninsured Noncitizens make up 20% of the 46 million uninsured people in the U.S. people in the U.S.
2005 Deficit Reduction Act requires all persons applying for 2005 Deficit Reduction Act requires all persons applying for or renewing Medicaid coverage to provide proof of identity or renewing Medicaid coverage to provide proof of identity and U.S. citizenship.and U.S. citizenship.
Susan Okie, MD, “Immigrants and Health Care—At the Intersection of Two Broken Systems,” Susan Okie, MD, “Immigrants and Health Care—At the Intersection of Two Broken Systems,” New England Journal of Medicine.New England Journal of Medicine.
Overview of Federal Regulations Overview of Federal Regulations and Fundingand Funding
Immigrant Reform and Control Act/ IRCA-Immigrant Reform and Control Act/ IRCA-19861986
Personal Responsibility and Work Personal Responsibility and Work Opportunity Reconciliation Act/PROWRA-Opportunity Reconciliation Act/PROWRA-19961996
Examination and treatment for emergency Examination and treatment for emergency medical conditions and women in medical conditions and women in labor/EMTALA-1985labor/EMTALA-1985
Emergency Services for Undocumented Emergency Services for Undocumented Aliens/EMSA-1999Aliens/EMSA-1999
Federal Payments to Hospitals for Federal Payments to Hospitals for Emergency Room Care-2005Emergency Room Care-2005
Immigrant Reform and Control ActImmigrant Reform and Control Act
Restricts Medicaid and other Federal programs to Restricts Medicaid and other Federal programs to newly legalized immigrantsnewly legalized immigrants
U. S. Attorney General Ruling allowed:U. S. Attorney General Ruling allowed:– Exceptions-”don’t ask, don’t tell” also considered not a Exceptions-”don’t ask, don’t tell” also considered not a
provider, a contractor for servicesprovider, a contractor for services Emergency ServicesEmergency Services Services to pregnant women Services to pregnant women National School LunchesNational School Lunches Vocational Education ActVocational Education Act Headstart ProgramsHeadstart Programs Job TrainingJob Training Public Health Programs as set forth in The Public Health Public Health Programs as set forth in The Public Health
Service Act. “20 USC 1070”Service Act. “20 USC 1070” Federally Qualified Health CentersFederally Qualified Health Centers
RPHCA and FQHCRPHCA and FQHC RPHCA and FQHC clinics are the safety net for immigrants RPHCA and FQHC clinics are the safety net for immigrants RPHCA – Rural Primary Health Care Act provides state RPHCA – Rural Primary Health Care Act provides state
funding that is supplemental – intent is to help keep their funding that is supplemental – intent is to help keep their doors open for people who are unable to pay – should doors open for people who are unable to pay – should maximize resources with Medicaid and other insurance maximize resources with Medicaid and other insurance billing NM puts $13 mill into clinics - rarebilling NM puts $13 mill into clinics - rare
FQHC – receive federal funds to operate primary care clinics FQHC – receive federal funds to operate primary care clinics – determines payment mechanisms– determines payment mechanisms
Consumer boards oversee compliance and establish Consumer boards oversee compliance and establish regulations. Board determines sliding scale fees based on regulations. Board determines sliding scale fees based on their understanding of their individual communities. Sliding their understanding of their individual communities. Sliding scale goes to 0 in some cases. Fee not always collectedscale goes to 0 in some cases. Fee not always collected
Provider shortages – limited resources Provider shortages – limited resources All are 501c3All are 501c3 93 clinics in NM: some don’t get federal funding93 clinics in NM: some don’t get federal funding
Personal Responsibility and Work Personal Responsibility and Work Opportunity Reconciliation ActOpportunity Reconciliation Act
Welfare reform that restricted Welfare reform that restricted immigrant access to all programs immigrant access to all programs receiving state and/or federal receiving state and/or federal funding such as Medicaidfunding such as Medicaid
Required immigrants wait 5 years Required immigrants wait 5 years after obtaining green card before after obtaining green card before applying for benefitsapplying for benefits
Shifted responsibility to the statesShifted responsibility to the states
Title V PROWRA OpinionTitle V PROWRA Opinion Many HHS programs are targeted to meet the needs of Many HHS programs are targeted to meet the needs of
certain populations such as children or pregnant women. certain populations such as children or pregnant women. But unless the authorizing statutes require that the But unless the authorizing statutes require that the characteristics of these groups form the basis for denial of characteristics of these groups form the basis for denial of services or benefits, these are not benefits that go to services or benefits, these are not benefits that go to “eligibility units.” The authorizing statutes of these “eligibility units.” The authorizing statutes of these programs identify populations with specific characteristics programs identify populations with specific characteristics to clarify the types of services that should be provided; to clarify the types of services that should be provided; they do not contemplate that providers use variations in they do not contemplate that providers use variations in individual characteristics as a basis for determining individual characteristics as a basis for determining eligibility, on a case by case basis. eligibility, on a case by case basis.
Therefore a benefit targeted to certain populations based Therefore a benefit targeted to certain populations based on their characteristics, such as a benefit provided under on their characteristics, such as a benefit provided under the Maternal and Child Health program, which provides the Maternal and Child Health program, which provides health services to women and children, is not a “Federal health services to women and children, is not a “Federal public benefit.” public benefit.”
Response to PROWRAResponse to PROWRA
Illinois, NY, D.C., and some CA counties Illinois, NY, D.C., and some CA counties used own funds to expand health used own funds to expand health insurance coverage for undocumented insurance coverage for undocumented immigrant children and pregnant women immigrant children and pregnant women with low incomewith low income
AZ, CO, GA, VA and OK passed laws AZ, CO, GA, VA and OK passed laws making it more difficult for noncitizens to making it more difficult for noncitizens to obtain health careobtain health care
AZ and OK criminalized provision of AZ and OK criminalized provision of services to immigrantsservices to immigrants
Examination and treatment for emergency medical Examination and treatment for emergency medical conditions and women in labor (EMTALA-1985)conditions and women in labor (EMTALA-1985)
– Medical screenings for those who come to the Medical screenings for those who come to the ER with a complaint and a request to have ER with a complaint and a request to have their condition evaluatedtheir condition evaluated
– Necessary stabilizing treatment for emergency Necessary stabilizing treatment for emergency medical conditions and labormedical conditions and labor
Restricts transferring of patients until patient is Restricts transferring of patients until patient is
stabilizedstabilized
Emergency Services for Emergency Services for Undocumented Aliens (EMSA)Undocumented Aliens (EMSA)
Provides Medicaid payments to Provides Medicaid payments to hospital emergency rooms on behalf hospital emergency rooms on behalf of undocumented immigrantsof undocumented immigrants
2005 Federal Appropriation2005 Federal Appropriation
Provided funding to Emergency Provided funding to Emergency Rooms and doctors for services to Rooms and doctors for services to undocumented immigrants/others undocumented immigrants/others who do not have pay sourcewho do not have pay source
Largest allocations went to: CA: Largest allocations went to: CA: $70.8; TX $46; AZ $45; NY $12.3; ILL: $70.8; TX $46; AZ $45; NY $12.3; ILL: $10.3; FL$ 8.7 and NM $5.1 million $10.3; FL$ 8.7 and NM $5.1 million the first yearthe first year
““Dumping?”: Efforts to coerce undocumented Dumping?”: Efforts to coerce undocumented immigrants to leave U.S.immigrants to leave U.S.
Under federal law, hospitals receiving Under federal law, hospitals receiving Medicare funds must transfer or refer Medicare funds must transfer or refer patients to “appropriate” post-patients to “appropriate” post-hospital care (NY Times) hospital care (NY Times)
Some hospitals choose to return Some hospitals choose to return immigrants to their home countries immigrants to their home countries
Advocates view practice as Advocates view practice as international “dumping”international “dumping”
Immigrant Health Care Services in Immigrant Health Care Services in New MexicoNew Mexico
Title V CYSHCN Program – comprehensive care for those Title V CYSHCN Program – comprehensive care for those with medical and fiscal eligibilitywith medical and fiscal eligibility
New Mexico Medical Insurance PoolNew Mexico Medical Insurance Pool Service to immigrant families often begins with ER visit, Service to immigrant families often begins with ER visit,
then referred to clinics and CMS for CYSHCNthen referred to clinics and CMS for CYSHCN FQHC and RPHCA funded community health care clinics FQHC and RPHCA funded community health care clinics
provide comprehensive primary care with sliding scale feesprovide comprehensive primary care with sliding scale fees Healthier Kids Fund provides primary careHealthier Kids Fund provides primary care Family Infant Toddler Program provides early intervention Family Infant Toddler Program provides early intervention Some counties provide county indigent coverageSome counties provide county indigent coverage Family PlanningFamily Planning Project ACCESS and Healthy Tomorrows Van in Santa Fe – Project ACCESS and Healthy Tomorrows Van in Santa Fe –
primary care – and some surgeries doctor donatedprimary care – and some surgeries doctor donated
New Mexico Issues in Immigrant CareNew Mexico Issues in Immigrant Care
Families being divided by (ICE) Immigration and Families being divided by (ICE) Immigration and Customs Enforcement Agency is deporting some Customs Enforcement Agency is deporting some family members, leaving others. Primary income family members, leaving others. Primary income provider may be deported; separation from provider may be deported; separation from parents parents
Since 9/11, CYSHCN program no longer able to Since 9/11, CYSHCN program no longer able to use Angel Fightuse Angel Fight
Families fear deportation when flying or traveling Families fear deportation when flying or traveling for care in other statesfor care in other states
Immigration check points in NM bar access to Immigration check points in NM bar access to Albuquerque specialistsAlbuquerque specialists
CYSHCN who are immigrants face funding and CYSHCN who are immigrants face funding and citizen barriers when coordinating care for citizen barriers when coordinating care for kidney, liver transplants and cardiac surgerykidney, liver transplants and cardiac surgery
New Mexico Issues in Immigrant CareNew Mexico Issues in Immigrant Care
Need for culturally competent response when immigrants Need for culturally competent response when immigrants seek health care services seek health care services
Lack of prenatal care – immigrant Moms covered at birth – Lack of prenatal care – immigrant Moms covered at birth – not pre or post-natalnot pre or post-natal
Spontaneous and intermittent raids in certain areas of NM Spontaneous and intermittent raids in certain areas of NM create a culture of fearcreate a culture of fear
Language – limited number of interpreters - often rely on Language – limited number of interpreters - often rely on children to translate for health care children to translate for health care
Difficulties in compliance with Federal Civil Rights Law Difficulties in compliance with Federal Civil Rights Law NM is a bilingual language and requires translation for all NM is a bilingual language and requires translation for all
written communication – still not always available written communication – still not always available
New Mexico Issues in Immigrant CareNew Mexico Issues in Immigrant Care
Fear of ability to meet health care sliding scale Fear of ability to meet health care sliding scale fee fee
Education re: health and social service resources Education re: health and social service resources is limited is limited
Limited knowledge of immigrants rights re: Limited knowledge of immigrants rights re: human rights issues i.e., housing, etc. human rights issues i.e., housing, etc.
Transportation – no car for transport to work or Transportation – no car for transport to work or health care health care
Lack of resources – can’t apply for health Lack of resources – can’t apply for health insurance No sick leave to go to doctor and/or insurance No sick leave to go to doctor and/or take children to doctor take children to doctor
Immigrants are not eligible for many social Immigrants are not eligible for many social programsprograms
New Mexico Issues in Immigrant CareNew Mexico Issues in Immigrant Care
Response of health care system providers Response of health care system providers Poverty – lower socioeconomic status Poverty – lower socioeconomic status Little or no support system – family not present Little or no support system – family not present Significant oral health problems – young adults no Significant oral health problems – young adults no
oral health care and often lose teeth. Parents less oral health care and often lose teeth. Parents less likely to go for preventive health care – will take likely to go for preventive health care – will take care of children insteadcare of children instead
Elderly cannot apply for social security Elderly cannot apply for social security Families share housing – often 2 or 3 in 1 house Families share housing – often 2 or 3 in 1 house
Title V services do have a citizenship Title V services do have a citizenship requirementrequirement
State law passed that restricts all State law passed that restricts all public services to immigrantspublic services to immigrants
Comparing States: CaliforniaComparing States: California
Title V services do not have a Title V services do not have a citizenship requirementcitizenship requirement
Low/no-cost non-profit or private Low/no-cost non-profit or private clinics provide health careclinics provide health care
CA request for SCHIP for CA request for SCHIP for ImmigrantsImmigrants
Gov. Schwarzenegger’s health reform Gov. Schwarzenegger’s health reform proposal seeks health insurance through proposal seeks health insurance through Medicaid and SCHIP for all children at or Medicaid and SCHIP for all children at or below 300% FPLbelow 300% FPL
Republican legislators response: “…do not Republican legislators response: “…do not believe that state general fund revenues believe that state general fund revenues should be invested in people who are here should be invested in people who are here illegally and that extends to children.”illegally and that extends to children.”
Comparing States: FloridaComparing States: Florida Title 19 (Medicaid), Title 21 (SCHIP), are ineligible unless they Title 19 (Medicaid), Title 21 (SCHIP), are ineligible unless they
are qualified individualsare qualified individuals No state law or statute forbids utilization of funds, however Title V No state law or statute forbids utilization of funds, however Title V
CYSHCN follows operational policy of not providing care to CYSHCN follows operational policy of not providing care to unqualified individualsunqualified individuals
Title V may use Federal funds for care of unqualified individuals, Title V may use Federal funds for care of unqualified individuals, but MAY NOT use general fund match for unqualified individualsbut MAY NOT use general fund match for unqualified individuals
Federal laws were extended to apply to state laws even though, it Federal laws were extended to apply to state laws even though, it may not be legally binding.may not be legally binding.
Some counties are” turning the other cheek” to operational policy Some counties are” turning the other cheek” to operational policy (not to serve unqualified individuals)(not to serve unqualified individuals)
Political refuges are not seeking qualified individual status for fear Political refuges are not seeking qualified individual status for fear of deportation (kids go to public school, graduate and people of deportation (kids go to public school, graduate and people never become documentednever become documented
Law required immigrants to show proof of Law required immigrants to show proof of legal residency resulted in fewer kids legal residency resulted in fewer kids going to the doctorgoing to the doctor
Per Dr. Mercado, a Pediatrician: Many Per Dr. Mercado, a Pediatrician: Many clients are leaving and going to other clients are leaving and going to other states, some back to their countrystates, some back to their country
Hispanics stopped offering health fairs Hispanics stopped offering health fairs fearing police and immigration raidsfearing police and immigration raids
Media regularly blames illegal immigrants Media regularly blames illegal immigrants for decline in health care systemfor decline in health care system
Comparing States: IowaComparing States: Iowa
No citizenship requirement for Title V No citizenship requirement for Title V program; Title V services are direct program; Title V services are direct health care serviceshealth care services
Health and other assistance from the Health and other assistance from the refugee health programrefugee health program
Private health clinics as availablePrivate health clinics as available
Medicaid available to Medicaid available to all childrenall children with with no citizenship requirementno citizenship requirement
Title V programs require that the Title V programs require that the parent or the child be a citizen or a parent or the child be a citizen or a legal resident of the USlegal resident of the US
Comparing States: MinnesotaComparing States: Minnesota Title V programs do not have a citizenship Title V programs do not have a citizenship
requirementrequirement Community Health and Rural Health Community Health and Rural Health
Centers provide services without a Centers provide services without a citizenship requirementcitizenship requirement
CSHCN program provides a “health care CSHCN program provides a “health care flow chart” for non-citizens that helps flow chart” for non-citizens that helps identify avenues for treatmentidentify avenues for treatment
CSHCN program has compiled, with CSHCN program has compiled, with community partners, a comprehensive list community partners, a comprehensive list of low/no-cost clinics statewideof low/no-cost clinics statewide
Comparing States: TexasComparing States: Texas
Title V programs do not have a Title V programs do not have a citizenship requirementcitizenship requirement
Community Health and Rural Health Community Health and Rural Health Centers provide services without a Centers provide services without a citizenship requirementcitizenship requirement
Some cities have low/no-cost clinics Some cities have low/no-cost clinics availableavailable
SourcesSources Directors of State Title V CSHCN ProgramsDirectors of State Title V CSHCN Programs Minnesota Department of Health: Minnesota Department of Health: http://http://
www.health.state.mn.us/mcshnwww.health.state.mn.us/mcshn Iowa Department of Public Health: Iowa Department of Public Health: http://http://www.idph.state.ia.uswww.idph.state.ia.us EMTALA Online: EMTALA Online: http://http://www.medlaw.com/statute.htmwww.medlaw.com/statute.htm ““Payments to Help Hospitals Care for Illegal Immigrants,”Payments to Help Hospitals Care for Illegal Immigrants,” New New
York TimesYork Times, May 10, 2005. Accessed online 9/18/2008, May 10, 2005. Accessed online 9/18/2008 Kaiser Commission on Key Facts: Medicaid and the Uninsured: Kaiser Commission on Key Facts: Medicaid and the Uninsured:
Health Coverage for Immigrants Health Coverage for Immigrants http://www.kff.org/uninsured/upload/Health-Coverage-for-Immigrahttp://www.kff.org/uninsured/upload/Health-Coverage-for-Immigrants-Fact-Sheet.pdfnts-Fact-Sheet.pdf
Susan Okie, MD, “Immigrants and Health Care—At the Intersection Susan Okie, MD, “Immigrants and Health Care—At the Intersection of Two Broken Systems,” of Two Broken Systems,” New England Journal of Medicine.New England Journal of Medicine. 8/9/2007, 357:525-529.8/9/2007, 357:525-529.
Ceci Connolly, “Study Paints Bleak Picture of Immigrant Health Ceci Connolly, “Study Paints Bleak Picture of Immigrant Health Care,” 7/26/2005. Washington Post Online, accessed 9/11/2008Care,” 7/26/2005. Washington Post Online, accessed 9/11/2008.
