Trump's 'Public Charge' Plan 'Jeopardizes' Health, Groups Say

Alicia Ault

October 19, 2018

The Trump administration's proposal to potentially deny permanent residency to immigrants if they've applied for or have received a number of public benefits will cause millions to drop out of Medicaid and would likely lead to thousands turning away from needed healthcare, public health officials and physician groups said.

In a joint statement, the American Academy of Family Physicians, the American Academy of Pediatrics (AAP), the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Psychiatric Association said that the proposal means that rather than face potential deportation, "many of the patients served by our members almost certainly will avoid needed care from their trusted providers, jeopardizing their own health and that of their communities."

The deferred care "leads to more complex medical and public health challenges, [and] will also significantly increase costs to the health care system and U.S. taxpayers," they said.

These organizations, along with public health leaders and immigration advocates, are leading the battle against the so-called "public charge" proposal, which could go into effect in early 2019.

In the past, the government has determined whether someone would become a public charge — primarily dependent on the government to meet his or her basic needs — by weighing their receipt of federal, state, local, or tribal cash assistance, Temporary Assistance for Needy Families (TANF), Supplemental Security Income (SSI), and Medicaid for an emergency condition. The new proposal wants to expand the consideration to include not just receipt of, but application for, cash assistance, SSI, and TANF, plus emergency and nonemergency Medicaid, the Medicare Part D Low-Income Subsidy, the Supplemental Nutrition Assistance Program (SNAP, or food stamps), institutionalization for long-term care at government expense, the Section 8 Housing Choice Voucher, Section 8 Project-Based Rental Assistance, and Public Housing programs.

"I think they're going after things that are essential to human survival — food, health care, housing," Georges Benjamin, executive director of the American Public Health Association, told Medscape Medical News. "We need to fix this. It's wrong. It's just wrong."

Benjamin said he thinks that if those dismayed by the proposal make enough noise the administration will withdraw it from consideration. If not, "then many of us will be seeing them in court."

A Deterrent to Immigration?

It is unclear if the proposal, published October 10 in the Federal Register for a 60-day public comment period, would actually deter people from coming to the United States, or steer others already here from seeking a green card, known as legal permanent residency.

The administration said it wants to ensure that people who seek a green card will be able to support themselves. "This proposed rule will implement a law passed by Congress intended to promote immigrant self-sufficiency and protect finite resources by ensuring that they are not likely to become burdens on American taxpayers," US Department of Homeland Security (DHS) Secretary Kirstjen M. Nielsen, said in a statement. DHS issued the rule and would be responsible for enforcement.

The proposal reflects the desires of long-time immigration foes like the Center for Immigration Studies (CIS). CIS — and a network of organizations stemming from the same founder — have been labeled as hate groups by the Southern Poverty Law Center because of their association with white nationalists.

As the proposal was unveiled, CIS Executive Director Mark Krikorian wrote in the National Review, "For our fellow citizens, such assistance is justified, though we can argue about the best way to go about it. But what justification can there be for admitting people from abroad who can't pay their own way?"

The idea that keeping immigrants from using benefits would save money — as Nielsen seemed to suggest — doesn't wash, said Benjamin. "When you put a barrier in place, people go back into the woodwork," he said. "But they come out when they get sick, and they don't go home, and we all pay for that."

For instance, by not paying for prenatal care for a pregnant immigrant mom, she may have a baby who ends up in neonatal intensive care, he said. "We're still going to provide the ICU care for that kid," Benjamin said, adding that if the child — who, if born here, becomes a citizen — survives, taxpayers will pay more for that child's care and schooling.

Frederick Isasi, JD, MPH, executive director of Families USA, agreed with Benjamin.

"Let's be clear, all Americans are impacted when families are too afraid to seek treatment for their medical conditions — for example, costs go up for everyone when people delay receiving needed health care," he said, in a statement.

Chilling Effect

Clinicians said the proposal could lead to some dire outcomes — and appears to already be having a chilling effect.

"The public charge proposal presents immigrant families with an impossible choice: keep yourself or your children healthy but risk being separated, or forgo vital services like preventive care and food assistance so your family can remain together in this country," AAP President Colleen Kraft, MD, MBA, FAAP, said in a statement.

Washington, DC, pediatrician and AAP spokesperson Lanre Falusi, MD, FAAP, said her patients began asking in early 2018 whether it was safe to apply for SNAP or WIC (Special Supplemental Nutrition Program for Women, Infants, and Children), or if they should withdraw from the programs if already enrolled. The rumors had already started: they had heard it might affect their ability to get a green card, Falusi told Medscape Medical News.

The benefits the government is seeking to weigh as negative factors "are things we know that help people stay healthy so they can contribute to society," said Falusi, who practices in a Children's National Health System primary care clinic that serves many Hispanic immigrants.

Her patients are not coming to the United States with the intention of receiving benefits, Falusi said. "More often than not, they are fleeing — they are fleeing violence, gangs threatening their young children, fleeing severe domestic violence," she said. "Their goal is really to protect their kids and leave that situation."

The new rule — if enacted — would exempt refugees and people granted asylum, and would not weigh disaster relief, emergency medical assistance, benefits received by an immigrant's US citizen children, or Medicaid benefits received by children of US citizens and potential adoptive children of US citizens.

Even so, the Kaiser Family Foundation estimates that 94% of noncitizens who originally enter the United States without a green card have at least one characteristic the government could weigh against them. In 2017, 1.1 million people obtained a green card — about half after having been in the United States for a while and half who applied before coming, Kaiser said. At least two-thirds of those were Hispanic, 19% were Asian, 9% were white, and 5% were black. A quarter were parents.

The organization said that because of fear, confusion, and misinformation some 2 to 5 million individuals might drop out of Medicaid and the Children's Health Program (which is not currently weighed against anyone).

Kaiser concluded that, "individuals with lower incomes, a health condition, less education, and/or who are enrolled or likely to enroll in certain health, nutrition, and housing programs would face increased barriers to obtaining" a green card.

The medical organizations see another chilling effect: in their joint statement, the groups said that the proposal "puts a governmental barrier between health care providers and patients and stands in stark contrast to the mission each of our organizations shares: ensuring meaningful access to health care for patients in need."

Falusi agreed that it's creating some boundaries. "It's difficult these days for us to know how to guide families," she said. Usually, she'd feel comfortable advising her patients to apply for benefits. But now, both she and the parents of the children she sees are "being put into a difficult position," Falusi said.

Because nothing has changed yet, she said that, for now, she's focusing on what's best for the children's — and their parents' — health.

DHS is receiving comments until December 10. A final rule could go into effect 30 days later.

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