PHP Submits Public Comment Opposing Proposed Changes to Public Charge Regulation

In October 2018, Philadelphia Health Partnership submitted a public comment in opposition to proposed changes to public charge regulation. The rule would increase health disparities by making it harder for immigrants to obtain Lawful Permanent Residence status in the United States if they receive certain public benefits.

October 2018

Philadelphia Health Partnership (PHP) strongly opposes the Department of Homeland Security’s proposed changes to “public charge” regulation, which we believe would jeopardize access to care and services that are critical to the health and well-being of children, families, and communities. At PHP, we strive to advance health equity, rooted in our belief that factors such as national origin, ethnicity, race, and socio-economic status should not influence access to the supports and opportunities that people need to thrive. Over two decades, we have learned that improving health outcomes in Philadelphia County requires connecting people with health care and social services, including nutritious food and housing assistance.

The proposed rule would change the criteria that immigration officials use when deciding 1) whether certain immigrants legally in the United States can become Lawful Permanent Residents (i.e., obtain a green card) or can extend or change their temporary status and 2) whether certain individuals seeking lawful entry to the United States can be admitted. Currently, such requests can be denied if an individual is determined likely to become a public charge defined as someone primarily dependent on government for subsistence, for instance due to receiving cash assistance (e.g., Temporary Assistance for Needy Families, Supplemental Security Income, or General Assistance) or Medicaid long-term care benefits. We oppose the rule’s expansion of benefits used in public charge determinations to include participation in Medicaid, Medicare Part D, the Supplemental Nutrition Assistance Program (SNAP), and various housing assistance programs. We believe that the rule would discourage immigrants from enrolling in public benefits—not only harming affected individuals but also destabilizing families, endangering public health, and undermining our health care system.

Having health insurance is one of the most important determinants of whether people access health care. The proposed rule would force lawfully present immigrants in the United States who are eligible for Medicaid to choose between obtaining health coverage and pursuing a path to legal residency. For many of those without coverage, routine medical care would become out of reach financially. Since having a serious medical concern but no insurance is one of the negatively weighted factors that would make a public charge determination more likely, affected immigrants would face an additional disincentive to pursue treatment. As a result, many immigrants would rely on Emergency Medical Assistance, by which time many health issues may have progressed in severity, and in the worst cases, may no longer respond to treatment.  Moreover, emergency rooms and safety net medical providers would bear additional costs, straining their resources and capacity.

Health care providers and public health professionals alike increasingly recognize that health and well-being are influenced by social and environmental factors—including access to healthy food and stable housing—long before individuals enter a doctor’s office. In our grantmaking, Philadelphia Health Partnership has a long history of supporting organizations that promote food access, including the Metropolitan Area Neighborhood Nutrition Alliance whose “Food is Medicine” research has demonstrated the role of proper nutrition in improving overall health—particularly for those who are already medically vulnerable. A rich body of evidence exists on the negative health impacts of housing instability and homelessness, which programs like Section 8 Housing Assistance and Project-Based Rental Assistance are pivotal in averting. Including SNAP and Section 8 programs in public charge determinations would deprive individuals and families of access to critical supports that prevent chronic health conditions and/or make complying with treatment regimens possible.

We fear that reductions in eligible immigrants’ participation in Medicaid, SNAP, and housing assistance would have devastating consequences for children, starting at birth. The text of the rule itself acknowledges that dis-enrolling or foregoing enrollment in public benefits could lead to “worse health outcomes, including increased prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants, or children, and reduced prescription [medication] adherence.” We are concerned that if the proposed rule is implemented, lawfully present immigrant woman who are eligible for Medicaid when pregnant in Pennsylvania could forgo care in order to safeguard their ability to gain permanent residence, increasing the risks of maternal and child mortality as well as adverse birth outcomes. Extending risks beyond pregnancy, we are alarmed that parents would be discouraged from participating in SNAP and housing subsidies, harming both adults and children.

In response to requested comments on the Children’s Health Insurance Program (CHIP), we support the proposed rule’s exclusion of CHIP from the list of benefits considered in public charge determinations. Analysis of the 2016 National Health Interview Survey for the Philadelphia Health Partnership found that low-income (less than 200% of the federal poverty line), non-citizen children are already much less likely to have usual source of care and to use varied sources of health care. For instance, only 56% of low-income, non-citizen children had an annual well-child check-up compared to 84% of citizen children with citizen parents. Only 72% of low-income, non-citizen children had a usual source of care compared to 95% of citizen children with citizen parents. Discouraging parents from enrolling eligible children in health insurance would exacerbate current disparities. Moreover, any use of a child’s own receipt of benefits as an indicator of their future prospects as an adult directly contradicts our country’s commitment to economic mobility.

The historical record demonstrates that the current rule as proposed could have a broader effect on benefits enrollment for children than is intended. For instance, even though citizen children of immigrant parents retained eligibility for SNAP after welfare reform passed in 1996, the U.S. Department of Agriculture found that participation among children with at least one noncitizen parent declined by 37% in the year after welfare reform was implemented. According to the Center on Budget and Policy Priorities, by 1999, “only 40 percent of eligible citizen children living in households with immigrants participated in SNAP, compared to 70 percent of all eligible children.” Drawing on research on the “chilling effect” that welfare reform had on immigrant families’ enrollment in health coverage, the Kaiser Family Foundation estimates that if proposed public charge rule leads to Medicaid disenrollment rates ranging from 15% to 35% among Medicaid and CHIP enrollees living in a household with a noncitizen, between 2.1 to 4.9 million Medicaid/CHIP enrollees would dis-enroll nationally. According to PHP grantee Community Legal Services analysis, in Pennsylvania, a 20% reduction in immigrant family benefits enrollment would amount to over 30,000 SNAP recipients and over 54,000 Medicaid/CHIP recipients losing benefits.

According to the 2017 American Community Survey, 218,830 foreign-born residents live in Philadelphia County, of which 48% are non-citizens; 69,860 children in Philadelphia County have one or more foreign-born parent. In our over twenty-year history as a grantmaker, we have learned that immigrant individuals and families already face stark barriers to utilization of care and services. Lack of access and utilization harms us all, not only because it undermines American ideals of inclusion and opportunity but also because lack of preventive care and treatment increases public health risks, including the transmission of communicable diseases. We also know that many of the individuals who receive Medicaid, SNAP, and housing supports are low-wage workers who make critical contributions to our economy, such as working as nursing home or home health aides. We believe that providing eligible individuals with the supports they need to stay healthy benefits the well-being of our entire community. We urge the Administration to reconsider the proposed rule.