Health Organizations Decry New 'Public Charge' Rule

Alicia Ault

August 13, 2019

Many health providers are up in arms over the Trump administration's release of a rule that will prohibit many people in the country legally from securing permanent citizenship if they have received public benefits such as food stamps and Medicaid.

The rule is not a surprise. The administration first gave notice of its proposal in October 2018, as reported by Medscape Medical News. At that time, 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 warned that such a regulation would dissuade many from seeking needed healthcare, that it threatened public health, and that it placed a barrier between doctor and patient.

All of those organizations still oppose the rule. Individuals who might be affected by the rule "almost certainly will avoid needed care from their trusted physicians, jeopardizing their own health and that of their communities,"  the medical groups said, in an August 13 joint statement.

"Many of our members have already witnessed this chilling effect among their own patient populations, with patients avoiding health services and programs out of fear," they said.

Twenty-two other organizations — including the American Medical Student Association, the Children's Defense Fund, Families USA, the March of Dimes, MomsRising, the National Association for Children's Behavioral Health, and United Way Worldwide — joined with the AAP to condemn the rule.

In a separate statement, Mark Del Monte, JD, chief executive officer and interim executive vice president of the AAP, said, "Make no mistake: this rule is a threat to the health of immigrant children and families."

He said it would force immigrants into the "impossible choice" of keeping families healthy but risk being separated, and added that the rule's issuance "comes at a time of relentless hardship for immigrant families in the United States as a result of policies put forth by this Administration that harm their health and safety."

Rule Widely Decried

Health providers were not alone in expressing dismay at the proposed rule.

According to the Department of Homeland Security (DHS), which issued the rule, the government "received 266,077 comments on the proposed rule, the vast majority of which opposed the rule."

The rule redefines "public charge" to mean a legal immigrant who receives one or more of the benefits covered by the proposal for more than 12 months in any 36-month period; the receipt of two benefits in 1 month counts as 2 months.  

The benefits include cash assistance for income maintenance, including Supplemental Security Income and Temporary Assistance for Needy Families; the Supplemental Nutrition Assistance Program (SNAP); most forms of Medicaid; Section 8 Housing Assistance under the Housing Choice Voucher (HCV) Program, Section 8 Project-Based Rental Assistance, and certain other forms of subsidized housing.

The rule establishes a new income standard — families with incomes of 125% of the federal poverty level or less, about $62,000, will be given a negative rating.

Margaret A. Murray, chief executive officer of the Association for Community Affiliated Plans, which represents nonprofit health plans that serve 20 million people enrolled in Medicaid, Medicare, the Children's Health Insurance Program (CHIP), and other public health programs, said in a statement that the rule would increase the number of uninsured citizens and noncitizens.

That increase "would leave it to safety net providers — community health centers, public hospitals, county health departments and others — to clean up the mess by forcing them to provide uncompensated care when the uninsured get sick," Murray said, adding, "DHS should rescind this ill-considered rule."

The American Hospital Association, America's Essential Hospitals, the Association of American Medical Colleges, the Catholic Health Association of the United States, the Children's Hospital Association, and the Federation of American Hospitals also issued a joint statement condemning the rule, saying it could undermine access to care for legal immigrants. "We are concerned that this could lead to delays in care that would negatively impact the health of the communities we serve," they said. "We ask the administration to withdraw this harmful rule."

Sr. Mary Haddad, RSM, president and chief executive officer of the Catholic Health Association of the United States, said  that the rule would lead to millions of legal immigrants "losing their health coverage or choosing not to enroll," and lead to rising costs for uncompensated care and would threaten public health.

"These consequences directly contradict our government's interest in protecting the health and well-being of the nation as well as the Catholic health ministry's Gospel mandate and mission to care for the most vulnerable," Haddad said.

American Psychological Association (APA) chief executive officer Arthur C. Evans Jr, PhD, agreed with Haddad. "The decision to bar certain low-income immigrants from life-sustaining and often life-saving programs is a callous act that is not consistent with our values as a nation," he said, in a statement.

"This rule flies in the face of basic human decency and disrupts legal pathways to residency and citizenship," Evans said, adding that the APA is calling on Congress to overturn the rule by using the Congressional Review Act.

The APA also just approved a new policy at its annual meeting, calling on state and federal lawmakers to ensure that immigrants and refugees can access medical and mental health and social services.

The nation's insurers also objected to the rule. In 2018, when it was first proposed, America's Health Insurance Plans (AHIP) registered its opposition. "Based on our industry's experience, we believe such changes would have serious negative consequences for public health and the U.S. economy, including: sicker people, including seniors and children; weaker communities, resulting from sicker populations and weakened hospital systems; weaker American businesses, resulting from a sicker employee base; and higher taxes, as federal and state costs increase for emergency care and premiums go up for everyone, the organization said.

Litigation Expected

The rule does exempt some immigrants, including those who receive: emergency Medicaid; Medicaid for services provided under the Individuals with Disabilities Education Act and school-based benefits; Medicaid and are younger than 21, or during pregnancy and 60-day postnatal; and Medicare Part D low-income subsidies. AHIP had suggested this Part D exemption in its 2018 letter.

The rule also exempts children adopted by US citizens; individuals enlisted in the US Armed Forces, serving in active duty or in the Ready Reserve, or their spouses or children; and people Congress has previously exempted, such as asylum seekers and refugees.

The rule — due to take effect October 15 — is not expected to go unchallenged. Rep. Judy Chu (D-CA) has introduced "The No Federal Funds for Public Charge Act," which would prevent federal funds from being used to implement the rule.

The National Immigration Law Center said it will soon sue to stop its implementation.

Millions could lose housing or healthcare in the future. The Kaiser Family Foundation estimates that currently 13.5 million Medicaid and CHIP enrollees, including 7.6 million children, live in a household with at least one noncitizen or are noncitizens themselves and may be at risk for decreased enrollment.

An Urban Institute study conducted in December 2018 — just after the public charge proposal was issued — found that it was already having a chilling effect.

About one in seven adults in immigrant families (13.7%) reported that they or a family member did not participate in a noncash government benefit program in 2018 for fear of risking a future green card. In low-income families, 21% of adults said they avoided public benefits.  

Del Monte of the AAP said that pediatricians were urging the administration to reverse the rule. "We must support the health of all children if we are to reach our full potential as a nation," he said.

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