The Trump administration's "public charge" rule, which would require legal immigrants to submit 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 in New York.
The amicus 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. It 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 use certain public benefits, including many forms of Medicaid, certain types of federal housing assistance or Supplemental Nutrition Assistance Program benefits.
Immigrants also can be labeled as a public charge if they have medical conditions requiring "extensive" healthcare, a term that opponents say the rule doesn't clearly 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 healthcare 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.
Supporters of the public charge rule say it will require aliens to prove they will strengthen American society rather than burderning it. They point to support from President Bill Clinton in 1996, when he argued that aliens be self-reliant in accordance with federal immigration policy.
President Barack Obama also voiced support for a public charge rule before a joint session of Congress, promising that the Affordable Care Act would not cover illegal immigrants, although some of them eventually utilized ACA programs.
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 charge.
Scholars state that the administration ignored or dismissed more than 266,000 comments from public health officials and others who warned that the rule jeopardized healthcare, 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.
Defenders of the rule counter that it only affects immigrants seeking new status, in an effort to apply for more time to remain in the U.S. They also point to exemptions, such as the fact that welfare-dependent immigrants are exempt from the policy during a prolonged grace period. It also does not affect immigrants' use of private charity.
WHAT'S THE IMPACT
A drop in Medicaid enrollment such as the one predicted by the rule's detractors would likely result in falling Medicaid revenue, which could affect the ability of healthcare 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 also says 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 contend 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 healthcare and would lead to serious health problems. As a result, Ku said, there could be as many as 1,300 to 4,000 excess premature deaths per year.
THE LARGER TREND
While the public charge rule was not mentioned during Thursday night's Democratic primary debate in Houston, the evening was dominated by healthcare. At issue for much of the night was Medicare for All, which would essentially create a single-payer health system in the U.S.
Senators Bernie Sanders and Elizabeth Warren are proponents of Medicare for All, while former vice president and front-runner Joe Biden opposes it, instead advocating for strengthening the ACA in part by adding a public option.