Trump administration's 'public charge' rule jeopardizes health care

Reviewed by James Ives, M.Psych. (Editor)Sep 12 2019

The Trump administration's "public charge" rule, which would subject legal immigrants to a public charge determination if they use public health, nutrition and housing benefits for which they are eligible, represents a major threat to health, according to a "friend of the court" brief filed Sept. 10. The brief is signed by the American Public Health Association, American Academy of Nursing, and more than 60 deans and scholars from 27 schools of public health, public policy, nursing and medicine. The amicus brief has been presented to courts in multiple legal challenges to the rule now pending in federal courts in New York and California. The deans and scholars are urging the courts to block the rule from taking effect.

The rule, finalized by the U.S. Department of Homeland Security in August, allows immigration officials to designate immigrants as a "public charge" if they utilize certain "public benefits," including many forms of Medicaid, certain types of federal housing assistance or Supplemental Nutrition Assistance Program (SNAP) benefits. Immigrants also can be labeled as a public charge if they have medical conditions requiring "extensive" health care - a term that the rule fails to define. Being designated as a public charge can disqualify immigrants from permission to enter the country or to achieve "green card" status as permanent legal residents. The amicus brief argues that the rule threatens the health of immigrants, their families, the health care safety net and entire communities in which they live. Half the U.S. population lives in communities where at least one in 10 residents is an immigrant.

"In the name of 'self-sufficiency,' this rule threatens dire consequences for millions of hard-working immigrants and their families and the nation's public health," said Lynn R. Goldman, MD, MS, MPH, the Michael and Lori Milken Dean of the George Washington University Milken Institute School of Public Health (Milken Institute SPH) and one of the amici who signed the brief. "If allowed to stand, this rule will cause immigrants to forgo services for which they are eligible and to avoid seeking necessary health care, especially preventive care. This rule will result in a spike of preventable illness and death."

The brief argues that the Trump administration acted arbitrarily, capriciously and contrary to law when it finalized this rule, which bars lawful permanent residence to people determined likely to become so-called public charges.

Scholars state that the administration ignored or dismissed more than 266,000 comments from public health officials and others who warned that the rule was a threat to the public health.

The rule jeopardizes health care, with immigrants and their families opting to forgo critical benefits related to basic health needs, including immunizations that can keep an entire community healthy. The scholars state the rule will cause a substantial drop in enrollment in Medicaid and other essential health programs, leading to poor health outcomes and an increase in death rates.

Such a drop in Medicaid enrollment not only un-insures patients but results in falling Medicaid revenue that will affect the ability of health care safety net providers such as community health centers to serve all residents of their communities. An analysis prepared by the Geiger Gibson/RCHN Community Health Foundation Research Collaborative, concludes that as a result of declining Medicaid revenue, health centers across the nation could serve between 136,000 and 407,000 fewer patients annually. The brief further points out that patients may simply cease to obtain care they need, insured or otherwise, since having a medical condition that requires care can jeopardize the ability to remain in the U.S. Immigrants simply may forgo care for themselves and their families entirely, fearing the consequences.

The scholars also argue that the rule's impact on the Medicaid program will lead to higher death rates, not just among immigrants but U.S. citizens as well. In a declaration filed in the U.S. District Court for the Northern District of California, Leighton Ku, PhD, a professor of health policy and management at Milken Institute SPH, concluded the "public charge" rule will cause between one and three million members of immigrant families, including U.S. citizens, to disenroll from or forgo Medicaid benefits each year, even if eligible. The loss would substantially reduce the ability of many racial and ethnic minority groups, especially Hispanic and Asian families, to afford health care and would lead to serious health problems. As a result, Ku states, there could be as many as 1,300 to 4,000 excess premature deaths per year.

The brief, which can be accessed here, was filed in the U.S. District Court for the Southern District of New York on Sept. 10. The deans and scholars, American Public Health Association, representing 25,000 public health professionals, and American Academy of Nursing, representing 20,000 nursing professionals, were represented by Ted Waters, Phillip A. Escoriaza and Christopher J. Frisina, of Feldesman Tucker Leifer Fidell, LLP of Washington, D.C.

The brief was produced with support from the Robert Wood Johnson Foundation (RWJF). The public health scholars who signed the brief did so in their individual capacities; views expressed are their own and do not represent affiliated universities or RWJF.