The use of public charge criteria in immigration policy has been largely restricted to the receipt of cash assistance. But a proposed rule by the U.S. Department of Homeland Security would disastrously expand the list of programs that would be considered in public charge determinations to include Medicaid, Supplemental Nutrition Assistance Program (SNAP), and housing. Recognizing the negative impact the proposed change would have on the health of New Yorkers and Americans across the nation, NYSHealth submitted the following comments urging that the proposed rule be withdrawn in its entirety:

December 7, 2018

The Honorable Kirstjen M. Nielsen
Secretary of Homeland Security
U.S. Department of Homeland Security
20 Massachusetts Avenue NW
Washington, DC  20529-2140

RE:  DHS Docket No. USCIS-2010-0012; Proposed Rule on Inadmissibility on Public Charge Grounds

Dear Secretary Nielsen:

The New York State Health Foundation appreciates the opportunity to respond to the Department of Homeland Security’s (DHS) Notice of Proposed Rulemaking to the changes regarding “public charge,” published in the Federal Register on October 10, 2018.

Recognizing the negative impact the proposed change would have on the health of New Yorkers and Americans across the nation, we urge that the proposed rule be withdrawn in its entirety.

The use of public charge criteria in immigration policy has been in place since the late 1800s. Its purpose has been to identify persons who would not be able to care for themselves. However, the application of public charge policy has been largely restricted to the receipt of cash assistance. The proposed rule would disastrously expand the list of programs that would be considered in public charge determinations to include Medicaid, Supplemental Nutrition Assistance Program (SNAP), and housing. The proposed rule directly undermines Health and Human Services Secretary Azar’s recent statement to prioritize these types of social determinants of health, acknowledging the vital role that adequate nutrition and stable housing play in ensuring health and wellness.[1]

The New York State Health Foundation is a private foundation that supports programs to improve the health of all New Yorkers, especially the most vulnerable. Many of the organizations we fund deliver critical services such as mental health treatment, opioid and other substance addiction treatment, and primary care to vulnerable populations, including immigrant New Yorkers. New York State is home to more than 4.5 million immigrants. 2.1 million of those live in a household with at least one non-citizen immigrant. 580,000 children under the age of 18 who are U.S. citizens live in a household with at least one non-citizen immigrant.[2],[3]

Given our history of support for the underserved, we have a deep understanding of the needs and challenges faced by immigrant communities. We are keenly aware of and alarmed about the deleterious impact the proposed rule change will have on their health.

Coverage Losses and Inefficiencies in Care
Under the proposed rule, health care coverage for millions of people who are lawfully present in the U.S. or seeking to lawfully enter the country (for example, to be unified with family members and to work) will be jeopardized. Millions will lose Medicaid insurance. While the Administration estimates 142,000 people will drop out of Medicaid as a result of the proposed rule, the figure does not account for the people who will disenroll out of fear and misunderstanding of the policy, meaning that the real figure could be 35 times larger.[4] The Kaiser Family Foundation estimates that as many as 4.9 million people nationally could drop out of Medicaid and SCHIP.[5]

Legal immigrants will continue to have health care needs. Without Medicaid, they will be more likely to seek care at hospital emergency departments, resulting in higher uncompensated care that shifts health care costs onto safety-net providers and state governments. The resulting steep rise in the number of uninsured immigrants will further strain an already stressed safety net system and lead to higher health care costs. The particular impact on safety-net providers and health care providers in communities with large immigrant populations will weaken not only their fiscal health but also their ability to serve the broader community. Executive leadership of New York City Health + Hospitals, the largest public health care system in the nation, has described the proposed rule as “antithetical to the sound practice of medicine.”[6]

Chilling Effect on Access to Services
New York and other states with large immigrant populations are already witnessing a chilling effect from the proposed rule. In a climate of fear, mistrust, and misinformation, legal immigrants are disenrolling themselves and their children (regardless of the child’s citizenship status) from health care and other public programs or declining benefits to which they are entitled.

The Community Health Care Association of New York State, the State’s primary care association for federally qualified health centers, recently surveyed its members and found that more than half have already seen an increase in the number of individuals who are eligible for but not enrolling in Medicaid, SNAP, Section 8 Housing, and the Women, Infants and Children (WIC) program because of concerns over deportation, inability to attain a green card, or inability to sponsor a loved one to attain legal permanent status. Some parents have even refused benefits for their citizen children, fearing their own or their other children’s ability to gain legal permanent status. Additionally, New York State health centers have reported that since the beginning of 2018, immigrants’ concerns about accessing Medicaid benefits have resulted in decreases in early access to prenatal care among expecting mothers as well as decreased medication adherence rates, including among high-need patients. The fear of using public benefits has also led to increased behavioral health needs, poor school performance, food insecurity, and housing instability.[7]

Similarly, the president and chief executive officer of the Mount Sinai Health System, which provides health care to more than 110,000 children recently pointed to the devastating consequences when children go without care because of their family members’ fear that seeking care could disqualify them from receiving a green card:

“Some children will not receive necessary vaccines, making them susceptible to preventable diseases, such as measles, mumps, Hepatitis A and B, and polio. Illnesses will not be addressed when they are easily treatable. Without proper prenatal and perinatal care, there will be an increase in birth complications. 

What inevitably happens when someone goes without proper care is that minor health issues are ignored until they become so serious that the patient shows up at the emergency department with a severe condition that is costly to treat. We see it happen every day at our hospitals.” [8]

Negative Economic Impact
The negative economic impact of the proposed rule change would be sizable, with a total estimated cost of $164.4 billion.[9] On a national level, economists estimate that the effect of the proposed rule would extend to 24 million people in the United States, including 9 million children under the age of 18.[10] The total annual income of workers affected by the public charge rule is estimated to be more than $96.4 billion. Should those workers leave the United States, the negative indirect economic impact would total more than $68 billion.[11]

As a result of Medicaid disenrollment, estimates are that New York State could lose as much as $7.6 billion in federal funding and economic ripple effects from, for example, reduced revenues at grocery stores as fewer SNAP dollars flow and at hospitals as families lose health insurance. These ripple effects could also lead to the loss of up to 34,000 jobs in New York State.[12]

The Need to Strengthen Health and Economic Security
The proposed rule on public charge will harm individuals’ health and the viability of the social safety net in the short-term. It will also have permanent consequences for our nation’s health and economy. We should honor our history as nation of immigrants by preserving the ability to grow up healthy, work, and be productive. We respectfully urge the Department of Homeland Security to withdraw the proposed rule in its entirety and fulfill America’s promise of opportunity.

Respectfully submitted,

David Sandman, Ph.D.
President and CEO
New York State Health Foundation

cc:   Ms. Samantha Deshommes, Chief Regulatory Coordination Division, Office of Policy and Strategy, U.S. Citizenship and Immigration Services

[1] The Root of the Problem: America’s Social Determinants of Health, Azar, A.M., Hatch Foundation for Civility and Solutions, November 14, 2018.

[2] State Profiles, Migration Policy Institute, 2016.

[3] Only Wealthy Immigrants Need Apply: How a Trump Rule’s Chilling Effect Will Harm New York, Fiscal Policy Institute, October 10, 2018 .

[4] Public charge rule keeps immigrants away from health programs, advocates say, Goldberg, D., Colliver, V., and Rayasam R. Politico, November 20, 2018.

[5] Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid, Artiga, S., Garfield, R., and Damico, A. Kaiser Family Foundation. October 11, 2018.

[6] The “Public Charge” Proposal and Public Health Implications for Patients and Clinicians. Katz, M.H. and Choski, D.A. JAMA, November 27, 2018.

[7]Testimony from the Community Health Care Association of New York State, Rose Duhan, president & CEO, before the New York City Council Committee on General Welfare, Committee on Immigration, and the Committee on Health

Oversight Hearing: The Impact of the Proposed “Public Charge” Rule on NYC, November 15, 2018

[8] One sick immigration rule: The ‘public charge’ regulation will make America less healthy, Davis, K.L., New York Daily News, October 10, 2018.

[9] Economic Impact of Proposed Rule Change: Inadmissibility on Public Charge Grounds, New American Economy Research Fund, October 2018.

[10] FPI Estimates Human & Economic Impacts of Public Charge Rule: 24 Million Would Experience Chilling Effects, Fiscal Policy Institute, October 18, 2018.

[11] Economic Impact of Proposed Rule Change: Inadmissibility on Public Charge Grounds, New American Economy Research Fund, October 2018.

[12] Only Wealthy Immigrants Need Apply: How a Trump Rule’s Chilling Effect Will Harm New York, Fiscal Policy Institute, October 10, 2018

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