Trump's immigrant healthcare rule could hurt low-income populations

Healthcare leaders warn that a pending Trump administration rule penalizing legal immigrants for using government benefits like Medicaid would hurt public health efforts and reduce their ability to serve millions of low-income children and families.

According to a revised draft of the 223-page rule leaked in March, the Trump administration will allow immigration officials to consider legal immigrants' use of public health insurance, nutrition and other programs as a strongly negative factor in their applications for legal permanent residency. The change also applies 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, known as Dreamers.

The Office of Management and Budget published a notice in July that the rule was under consideration, and an administration official said details of the rule were weeks away from being finalized, the New York Times reported last week. The OMB said it doesn't need to conduct an economic analysis of the rule because the impact would be less than $100 million, a claim that provider groups have challenged.

If the draft proposal is finalized, the Kaiser Family Foundation estimated that up to 2 million children who are U.S. citizens with immigrant parents could drop out of Medicaid and the Children's Health Insurance Program, and most would become uninsured. That's because the parents would worry that their children's use of those programs could jeopardize their legal status. Those concerns likely would spill over to children of undocumented immigrants, who are not covered by the proposed rule.

In 2016, there were 10.4 million citizen children with at least one parent who isn't a citizen, and 56% had Medicaid or CHIP coverage. An estimated 27 million immigrants and their children are part of families with at least one member receiving public benefits, according to the Migration Policy Institute.

Healthcare leaders and advocacy groups say the proposed changes would have a massive impact on health-related services for low-income children and families. They say it could drive up uncompensated care costs, increase use of emergency departments, endanger maternal and infant health and heighten the risk of infectious disease epidemics. It also could shift major costs from the federal government to state and local governments.

Dr. Benard Dreyer, director of pediatrics at Bellevue Hospital Center in New York, said rumors about the proposed rule already have chilled families from signing up for programs such as the Women, Infants and Children nutrition program and free school lunches.

He predicted that the population affected will be far broader than the groups singled out in the draft rule because all immigrant families in the U.S. will fear that their ability to remain in the country will be at risk if any member of the family used benefits they are legally entitled to.

"This is a major attack on the health of children in this country because 1 in 4 children live in an immigrant family," said Dreyer, a past president of the American Academy of Pediatrics. The AAP and other healthcare groups are gearing up a lobbying campaign to block the rule.

Currently, immigration officials can negatively weigh families' use of public cash benefits and Medicaid long-term-care benefits in evaluating applications for legal permanent residency and legal entry into the U.S. A 1999 rule clarification said noncash benefits like Medicaid could not be considered. Long-standing U.S. policy has discouraged immigration by people who would be "public charges" dependent on government benefits.

The leaked proposed rule would broaden those factors to include individuals' use of Medicaid health benefits, CHIP, Affordable Care Act premium subsidies, the Supplemental Nutrition Assistance Program, WIC, earned-income tax credits, housing assistance and other state and local benefit programs in the previous three years.

It also would give officials flexibility to deny legal residency for use of "any other federal, state or local public benefit program" except those specified as exempt, such as Medicare.

The changes would not apply to people granted refugee status or political asylum.

The rulemaking is part of the Trump administration's broader campaign to limit both legal and illegal immigration, including bigger border barriers and stepped-up detention and deportation of undocumented residents. It says the proposed measure simply seeks to enforce long-standing U.S. policy against immigrants using public benefits.

"More than half of all immigrant households use one or more welfare programs, driving the federal debt and deficit and unfairly taking benefits away from vulnerable U.S. citizens and communities," a Department of Homeland Security spokeswoman said. "Non-citizen public benefit usage is deeply unfair to U.S. taxpayers."

The leaked rule draft stated, however, that native-born Americans use non-cash public benefits like Medicaid at about the same rate as immigrants—22.1% compared with 22.7%.

Dreyer said he and his colleagues at Bellevue already are seeing a significant increase in hunger and food insecurity among their patients, who have heard about the proposed rule and are acutely aware of the Trump administration's broad efforts to reduce the number of immigrants in the U.S. He's worried about a possible increase in premature births if pregnant women decline to sign up for subsidized prenatal care.

Fear and confusion about the proposed rule, even among U.S. citizens in immigrant families, already have spread widely.

Cristian Mendoza, a 19-year-old college student who was born in the U.S. to Mexican immigrants, said his parents are nervous about the proposal because his father is seeking to renew his visa to stay in the U.S. The Mendozas, who live outside Los Angeles, have long received Medicaid.

That coverage enabled Cristian to receive successful treatment in 2014 for acute myeloid leukemia. And it's enabled his father, who owns a cellphone store, to receive treatment for his diabetes.

"My mother and father are concerned that he could be denied a green card because he uses Medi-Cal to stay healthy," Mendoza said.

Ken Janda, CEO of Community Health Choice, a managed-care plan serving Medicaid, CHIP and ACA exchange enrollees in the Houston area, said parents are afraid to enroll or re-enroll themselves and their children because of worries about the pending rule and the broader immigration crackdown.

He anticipates that the rule would shrink his plan's membership substantially. For the first time in a decade, the plan has seen seven consecutive months of decreased Medicaid enrollment, as well as a 20% decrease in CHIP perinatal program enrollment.

"This seems to be a purely punitive, anti-immigrant policy," Janda said. "It's so awful I can't imagine it. It's not who we should be as a country."

Paul Viviano, CEO of Children's Hospital Los Angeles, where 74% of patients are on Medicaid, said the rule could lead to children coming to his system sicker because of untreated conditions, with more arriving through the emergency department. It also could put additional administrative burdens on his hospital if immigration authorities require it to share patient records on use of public benefits.

"Our sense is this would have a chilling effect on families and children accessing healthcare services out of fear," Viviano said. "We think it's bad policy. Even the economic arguments don't hold water."

Maria Gomez, CEO of Mary's Center, a federally qualified community health center with clinics in Washington, D.C., and Maryland, said the rule will prompt many of her patients to drop Medicaid or other public coverage. That would squeeze her center's ability to serve the poor and uninsured.

She and her staff are pleading with their immigrant patients to stay on WIC and Medicaid, arguing that since they're already on those programs it's too late to drop out to protect their legal immigration status.

"We tell them, 'You were on it, it will be held against you. Stay on it because it's the best thing for you and your health,' " Gomez said.

Providers and advocacy groups say it will take a tremendous effort to educate the immigrant community about the rule and avoid misunderstandings that lead to people dropping or not seeking needed benefits.

Santiago, a 19-year college student in Houston who didn't want his real name used, said he and his parents are worried that his use of Medicaid will jeopardize his father's application for citizenship. Santiago has been on Medicaid since he was born in Texas with cerebral palsy. His parents are both permanent legal residents.

The leaked rule draft would not affect people who already have permanent legal status and are seeking citizenship, such as his father, who works two jobs. But Santiago and his parents are still nervous about his history of receiving Medicaid.

"My father is concerned that we might end up being separated," Santiago said. "I don't even want to think about it."