Public Health Alarms Raised Over Possible Change in Immigration Policy

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Public health advocates are alarmed by a possible shift in long-standing policy about penalizing legal immigrants for accepting healthcare services, food stamps, heating assistance, and other noncash assistance as their applications to become permanent residents are pending.

This story has been updated.

A draft rule from the Department of Homeland Security would expand the definition of any immigrant who falls under the category known as “public charge.” Under current guidelines, people labeled as public charges can be denied legal entry to the United States, but under current policy, only the use of cash assistance like Temporary Assistance for Needy Families or Supplemental Social Security Income is counted.

Use of noncash benefits by dependents—US-born children of immigrants using healthcare services or food assistance—has not been not counted. The proposed rule would change all that and count nonemergency use of Medicaid, food assistance like the Supplemental Nutrition Assistance Program (SNAP) and the Women, Infants, and Children Program, housing and heating assistance programs, the Children’s Health Insurance Program (CHIP) and subsidized health insurance through the Affordable Care Act (ACA).

The draft rule would allow the government to revoke legal status from immigrants using services for which they are eligible. Immigrants who are undocumented are already ineligible for most benefits.

A recent column in The New England Journal of Medicine said the change, if enacted, would have dire consequences, such as higher rates of low infant birth weight, infant mortality, and maternal morbidity.

One estimate suggests that nearly one-third of US-born residents could have their use of public benefits considered when the government is deciding about the immigration status of a family member. This would include 10.4 million children who are citizens, legal immigrants, and households made up of people of mixed immigration status, and people living abroad who wish to come to the United States.

In 2016, an estimated 19% of noncitizen adults and 38% of noncitizen children were enrolled in Medicaid or CHIP. Disenrolling from public benefit programs from which they are eligible could mean an additional 1 million people uninsured and 1 million could lose food assistance, and lead to rising rates of poverty, a primary risk factor for illness and mortality.

“This is about people already here,” said Georges C. Benjamin, MD, executive director of the American Public Health Association (APHA), in an interview with The American Journal of Managed Care^® (AJMC^®). Driving people underground and scaring them away from interacting with the healthcare system has negative repercussions for education, the workforce, hospital emergency rooms, and other places, he said.

As one example, he said, “kids won’t get immunized. We’ll be treating people at a later stage of disease.”

For instance, the 2018-2019 flu season is about to start in a matter of weeks, and last year’s flu season was deemed high-severity by the CDC, with record-breaking levels of flu-like illness and hospitalizations, and 171 pediatric deaths.

Herd immunity for communities will be lost, Benjamin said.

In addition, there will be consequences for employers, as individuals lose the ability to manage chronic conditions, like diabetes, and cannot stay healthy enough to work, he said.

Without Medicaid, CHIP, or subsidized insurance bought through ACA exchanges, people will wait to get treated at emergency rooms, leaving hospitals or federally qualified health centers (FQHCs) to pick up the slack.

“There will be a cost shift to all of us in terms of uncompensated care,” Benjamin said. “This will kill people.”

A spokeswoman for the National Association of Community Health Centers noted that FQHCS are required to provide services to all people regardless of income, insurance or immigration status. Commenting about the prospect of a policy change, Amy Simmons said in an email to AJMC^®, "We would be concerned about any policy that would deny anyone, including legal immigrants, access to basic health care services. Not only would health centers that already have fragile operating budgets be hit hard financially, but anytime health care access to primary and preventive services is denied, people will usually seek more costly care at hospital emergency rooms."

"Even rumors about the potential changes may cause people to not seek care when they need it—which again will have major impacts in terms of outcome and costs," she said.

Children who are US citizens, who may have 1 or both parents who are immigrants, are likely to be the most impacted by any policy change. Despite the fact that their children might be eligible for meals at school or families might be eligible for SNAP, parents may decide to not enroll the whole family, running the risk that children will be hungry in school instead.

“People are going to have to make terrible decisions,” Benjamin said.

“We will continue to fight this,” said Benjamin. “I suspect there may be some lawsuits,” adding that his organization has not yet talked to an attorney.

One study published earlier this year found that household immigration status did have an impact on Medicaid enrollment in some states. States that did not expand Medicaid appeared to have a chilling effect on the participation of eligible adults who could have enrolled in the program, but did not, because of undocumented immigrants living in the same household.

Reference

Perreira KM, Yoshikawa H, Oberander J. A new threat to immigrants’ health—the public-charge rule. [pubished online August 1, 2018]. NEJM. doi: 10.1056/NEJMp1808020.