New York lawyer Brett Stark, who has worked with dozens of unaccompanied Central American children who crossed into the United States in the past year, says getting the courts to grant these kids asylum is extremely difficult. So he often turns to a special advocate — a doctor.

Such medical-legal partnerships have cropped up in New York and California, where thousands of unaccompanied minors have settled with their families or friends who were already in the U.S.

One child in New York, a teenager from Honduras, carried a mark of his country’s gang violence in his back—a bullet lodged in the middle of his spine.  He ended up in the Bronx, where his immigration case was taken up by Stark, who works with the Immigrant & Refugee Division at Catholic Charities New York. Asylum cases are among the most difficult immigration status cases to win, Stark says, and a doctor’s testimony can help sway the decision.

“I could say to the judge, ‘Your honor, this child is fleeing gangs in his home country and because of that, he’s eligible for asylum,’” Stark explains. “But what’s more powerful and has more impact is to say, ‘Here’s a letter from Dr. Alan Shapiro, where he reports this child has a bullet lodged in his spine in the L6 region.’ And the judge can look at this and say, ‘This corroborates what you’re saying, and we can put this in a legal context.’”

With testimony from Shapiro, a pediatrician and senior medical director of South Bronx Health Center, a program of Montefiore and The Children’s Health Fund, the judge granted the Honduran teenager a special visa for victims of crimes, another immigrant classification allowing the boy to stay in the country legally.

As 68,000 unaccompanied minors crossed the border between October 2013 and September 2014, controversy erupted over whether they should be allowed into the U.S. or sent back to their home countries of Guatemala, Honduras, and El Salvador. One concern was whether the children might bring infectious diseases across the border.

In July, Republican representative Phil Gingrey, from Georgia, wrote a letter to the director of the Centers for Disease Control and Prevention expressing concern about “reports of illegal migrants carrying deadly diseases such as swine fly, dengue fever, Ebola virus, and tuberculosis.”

But Shapiro says infectious disease hasn’t been an issue for the unaccompanied minors who come to his clinic. They need standard primary care like any child, such as vaccinations before they can start school.

The problems he sees have much more to do with the physical and emotional scars the children bear from the violence in their home countries and the long trek to the United States.  Many suffer from depression, anxiety, adjustment disorders, and post-traumatic stress disorder.

“They’re in a highly alert, anxious state,” Shapiro says. “Many kids have witnessed the murders of their relatives and had threats on their own lives.”

Often, those are the very factors that could help the children get permission to stay in the U.S., but they can be difficult to demonstrate in a courtroom. Having medical testimony from a doctor, Shapiro says, “greatly bolsters the case.”

For cases involving emotional trauma, the bulk of the evidence may come from a psychologist.  The lawyer can try to describe the trauma, Stark says, but it’s much more effective for a psychologist to contribute testimony that the child presented with symptoms consistent with PTSD or other trauma.  “A psychologist’s contribution can be very moving and vital,” Stark says, especially when a child is unable to speak for himself.

But Mark Krikorian, executive director of the Center for Immigration Studies, a think tank in Washington that favors tighter immigration controls, warns that emotional trauma is not cause for asylum. To be granted asylum, immigrants must be able to prove that they fear persecution in their home countries based on race, religion, nationality, membership in a particular social group, or political opinion.  “That doesn’t apply to these kids,” Krikorian says.

“What I fear is that this kind of testimony will be designed to elicit sympathy so that immigration authorities grant a green card whether or not it’s warranted under the law,” he adds. “Even the majority of those who do get asylum really don’t warrant it.”

From October 2013 to June 2014, 1,532 unaccompanied minors applied for asylum in the U.S. The United States Citizenship and Immigration Services (USCIS), one of two government agencies that hear asylum cases, adjudicated 167 such cases during that period. Of those cases, 108 of the children were granted asylum.  Many unaccompanied minors have applied for other categories of protection that allow them to stay in the country.

Meanwhile, from July 18, 2014 to October 7, 2014, immigration judges ordered 1,252 unaccompanied children deported, according to the Executive Office for Immigration Review, part of the Department of Justice. Often, those orders are appealed.

Many unaccompanied minors across the country do not have access to an attorney: The government is not required to provide legal representation in immigration court to children who aren’t citizens, and few can afford to hire an attorney.

In the Bronx, Shapiro and Stark are trying to serve as many of the 433 unaccompanied minors who have settled in the borough as they can. They’ve named their medical-legal clinic Terra Firma, where they have seen about 50 unaccompanied minors since October 2013; they hope to help 200 more in 2015.

“The reason we’re pediatricians is that we’re looking out for the well-being of the child,” Shapiro says. “These are very vulnerable children who have needs that go above and beyond the other children you might see.”

Every other week, dozens of them file into the South Bronx Children and Family Health Center for Terra Firma. For two-and-a-half hours, the clinic provides health care, counseling, case management, and legal services for the children.  Both pediatric and mental health care are available in Spanish, which can be hard to find elsewhere in the city.

As part of the New York Immigration Coalition, Shapiro has been working with the New York City health department to develop a health alert for all pediatricians detailing the medical needs for unaccompanied children, and how best to help them.

So far, the Terra Firma model appears to be a rarity, but something similar is taking shape in California. Los Angeles has received 2,474 unaccompanied minors from January through September of 2014. Elena Fernandez, behavioral health director of St. John’s Well Child and Family Center, says psychologists at the clinic are being asked to provide psychological assessments for use in immigration hearings.  Other times, their job is to help children testify themselves and prepare for what may arise during a hearing.

“It’s the clinician who has to determine whether the child is ready to testify and disclose in a hearing the level of trauma. Because you run the risk of them re-experiencing that trauma in a courtroom,” Fernandez says.

St. John’s has seen more than three times as many undocumented kids this fall as they did at the same time last year.  Most of them, CEO Jim Mangia believes, are unaccompanied minors.  The additional visits, most of which were pro bono, he says, have cost his clinics about $250,000 over a three-month period.

“This is a humanitarian crisis, a refugee crisis,” Mangia says. “These children have been kidnapped, brutalized, beaten, raped, sexually abused, and that’s why they’ve fled in the first place. … There’s just a tremendous amount of trauma.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Confusion about whether some types of job-based coverage disqualify consumers from signing up for subsidized insurance through the health law’s marketplaces may lead some people to buy skimpier employer plans instead.

In recent weeks, some assisters who help consumers find coverage say people are being told by their employers that their bare-bones plans – which, for example, may cover preventive benefits only — meet “minimum essential coverage” requirements. That’s the type of coverage most people must have to satisfy the health law’s requirement that they have health insurance.

The problem is that consumers mistakenly think that having access to such coverage means they don’t qualify for subsidies if they want to buy a policy on the exchanges instead.

But that’s not necessarily the case.

Rather, they would be ineligible for subsidies if their employer plan is deemed affordable under the law and pays for 60 percent of allowed medical charges, on average.  Coverage is considered affordable if it costs no more than 9.5 percent of an employee’s income for self-only coverage.

Some of the confusion relates to the similar-sounding bureaucratic names for these different health law standards.  Minimum value coverage means the plan pays for 60 percent of allowed medical charges, on average.

Minimum essential coverage, which can include a range of things from grandfathered health plans to some of the prevention-only plans being offered by large employers, refers to what large employers must offer to avoid paying penalties for not offering coverage, as well as what individuals must carry to comply with the law’s coverage requirement.

Some consultants have reportedly developed job-based plans that cover very little other than preventive benefits. Unlike small group and individual plans, which are required to provide comprehensive coverage under the health law, no such requirements exist for large group plans.

“It’s hard for consumers to understand how a plan that is lousy in their eyes could somehow prevent them from getting subsidies on the exchange,” says JoAnn Volk, a senior research fellow at Georgetown University’s Center On Health Insurance Reforms.

The federal government recently released guidance saying that plans that don’t include coverage of hospitalization services and doctor’s visits don’t satisfy the minimum value standard even if they manage to meet the 60 percent actuarial value threshold without those benefits. Until final regulations are released next year, workers who are offered such plans won’t be barred from qualifying for premium tax credits on the exchanges, the guidance said.

The vast majority of plans are believed to meet the minimum value standard, however. No more than 2 percent of people covered by employer-sponsored insurance — 3.2 million people — are enrolled in plans with an actuarial value of less than 60 percent, according to a 2011 estimate by the federal Department of Health and Human Services. Those affected are more likely to be in low-wage jobs and may not have had health insurance before.

In addition, because the 9.5 percent affordability standard is based on the cost of employee-only coverage rather than family coverage, most plans will be considered affordable, says Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

Having said that, “we know there were some pretty shabby plans being offered out there,” Solomon says.

During open enrollment, health plans are all supposed to provide a “summary of benefits and coverage” that explains the details of the plan and also states whether it provides minimum essential coverage and meets minimum value standards.

“We were hearing from assisters that people were having trouble understanding this employer coverage information,” says Cheryl Fish-Parcham, private insurance program director at Families USA, a consumer advocacy organization.

Families USA and other advocacy groups sent a letter to the administration requesting that it amend the summary of benefits and coverage requirements to add language informing people that they could be eligible for premium assistance on the marketplace if their employer plan doesn’t meet the minimum value standard, Fish-Parcham says.

Workers who are filling out an application for a marketplace plan and are uncertain about whether their on-the-job coverage meets minimum value standards can download an “employer coverage tool” from healthcare.gov and ask their employer to complete it.

However, employers aren’t required to fill out the form.

“It’s a bewildering process,” says Fish-Parcham.

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

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