In a rare moment of consensus, healthcare industry groups uniformly blasted the Trump administration’s proposal to penalize legal immigrants for using Medicaid and other public benefit programs, warning it would have broad negative effects on the healthcare system, government budgets and public health.

The Department of Homeland Security received 210,889 comments on its proposed “inadmissibility on public charge grounds” rule, issued in October, when the comment period ended Monday. Healthcare stakeholder groups, including hospitals, physicians, insurers and public health advocates, urged DHS to withdraw the rule entirely.

“The policies proposed by this rule are contrary to (the) hospital mission of service to vulnerable members of society,” the American Hospital Association wrote, warning it would lead to millions of people losing Medicaid and other public coverage. “This loss of coverage would inevitably lead to poor health outcomes for legal immigrant communities and greater financial strain for the hospitals that serve them.”

The public charge rule would allow federal immigration officials to consider legal immigrants’ use of public health insurance, nutrition, housing and other programs as a strongly negative factor in their applications for legal permanent residency.



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The changes also would apply to citizens’ and legal residents’ requests to bring family members into the U.S., as well as to young people who have legal status under the Deferred Action for Childhood Arrivals program, who are known as “Dreamers.” The rule would not apply to people granted refugee status or political asylum.

The public benefits covered by the proposed rule include Medicaid, Medicare Part D subsidies, the Supplemental Nutrition Assistance Program and Section 8 housing vouchers. The agency asked for public comment on whether the Children’s Health Insurance Program also should be included. Healthcare groups strongly urged DHS not to consider including CHIP.

Immigration officials currently are only allowed to consider families’ use of public cash benefits and Medicaid long-term care benefits in evaluating applications for legal permanent residency and legal entry into the United States. A 1999 rule clarification said benefits other than cash, like Medicaid, cannot be considered.

DHS Secretary Kirstjen Nielsen previously said the proposed rule is consistent with long-standing U.S. policy requiring immigrants to show they can support themselves financially. It’s part of the administration’s broader campaign to limit both legal and illegal immigration.

DHS estimated the regulation would affect about 382,000 people a year. But experts predict far more people—including immigrants who are citizens or permanent legal residents—would be affected because of massive fear and confusion about the rule. The Kaiser Family foundation estimated that 2.1 million to 4.9 million Medicaid and CHIP beneficiaries would disenroll due to fear of family members losing legal status in the U.S.

Manatt Health estimated that as many 4.4 million adults and children who aren’t citizens and have Medicaid or CHIP coverage and 8.8 million citizen adults and children on those programs could drop coverage because of the proposed rule’s chilling effect.

Providers and plans say they’ve already seen immigrant families choosing not to sign up for public benefit programs, or dropping out, due to fear about how their participation could affect their ability to stay in this country. Medicaid Health Plans of America wrote that the rule would cause people to forgo enrolling in Medicaid plans and to likely become uninsured.

Alex Shekhdar, vice president of federal and state policy at Medicaid Health Plans of America, said his organization’s member plans are getting a lot of worried inquiries from immigrant families about the impact of using public benefits like the Supplemental Nutrition Assistance program and the Women, Infants and Children Food and Nutrition Service. “It’s having a chilling effect across all social services,” he said.

In its comments, the AHA said the loss of covered people would put about $68 billion in government healthcare funding at risk, which would translate to an estimated $17 billion annually in hospitals payments. That doesn’t include the potential increase in uncompensated care costs.

In Florida and Texas, two states with large immigrant populations, the potential loss in Medicaid and CHIP payments to hospitals would total an estimated $785 million and $1.9 billion, respectively, the AHA wrote.

America’s Health Insurance Plans cautioned that the proposed rule would have a significant negative effect on the already-short supply of long-term care workers, including home health aides, personal care aides and nursing assistants.

That’s because 25% of the estimated 4 million direct care workers in the U.S. are immigrants, with nearly half of those immigrant workers using Medicaid or other public benefits because of their low wages.

This would “exacerbate the impending direct care shortage, making it more likely that older Americans and people with disabilities will have to receive care in nursing facilities instead of remaining in their homes with personal supports,” AHIP wrote. The result would be higher state and federal long-term care spending, the group added.

NYC Health & Hospitals, New York City’s public hospital system, said it could face an annual financial hit as high as $362 million from immigrant families dropping Medicaid and CHIP, with up to 350,000 patients potentially affected by the rule.

University of California Health predicted the rule would cause many patients to delay or forgo care, ultimately leading to greater prevalence of communicable diseases, reduced prescription adherence and increased use of emergency departments.

The five-hospital academic system also said the rule could further discourage international student enrollment, partly by hampering access to Medicaid for foreign students and researchers.

The American Academy of Family Physicians said the proposal “puts a government barrier between healthcare providers and patients and does not ensure meaningful access to healthcare for patients in need.”

“The fear generated by this rule would put families in impossible situations where they are forced to choose between keeping their families together or enrolling in programs to keep their families healthy,” wrote Dr. Georges Benjamin, executive director of the American Public Health Association.

In addition, parents may opt not to vaccinate their children, communicable and sexually transmitted diseases may go undiagnosed, and pregnant women may choose not to seek medical attention for themselves and their unborn children, Benjamin said.

“At a time when our nation faces a declining life expectancy for the third year in a row, we cannot afford to promote policies that encourage people to abstain from basic health services and limit access to adequate nutrition and housing options,” he wrote.

There also were many critical comments from individual healthcare providers. Michelle Homer, a veteran nurse in Waltham, Mass., who works with immigrant families, urged the administration to drop the proposed rule.

“In my experience, most immigrants have always been afraid to use (public services) … because they don’t want to jeopardize getting a green card,” she wrote. “The one exception to this has been utilizing WIC services for their children. Since the election of President Trump, families are now afraid to even leave their homes to obtain WIC. Young children are not getting the nutrition they need.”

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Healthcare groups rip Trump proposal penalizing legal immigrants for using Medicaid –