Effect of the Public Charge Rule

Ever since a copy of the Trump Administration’s proposed change to the public charge policy, was leaked to the media, there has been an ongoing political debate about the Whitehouse’s efforts to limit public benefit access for immigrants.  This paper aims to address the effect public charge will have on healthcare coverage and healthcare spending for Lawfully Present Residents (LPRs) in the United States.

Under the current coverage policies, LPRs may qualify for Federal Medicaid/Medicare and Children’s Insurance Protection Coverage (CHIP) of the Affordable Care Act (ACA), and be awarded coverage after five years with a qualified immigration status.  Individual states have the authority to wave this time restriction, for children and pregnant women only, by extending coverage without the necessity for a qualified status set forth by the federal government.  Prior to the enactment of the ACA, LPRs who did not qualify for Medicaid/Medicare, or any of the 31 Health and Human Services programs, couldn’t afford to buy their own private health coverage.1 Most LPRs, if employed, earn low-income wages from employers that do not provide health insurance benefits.  LPRs in this category are forced to rely on other means, either seeking free services through community clinics, choosing to delay care for critical services, or not to go to the doctor at all.2   The ACA may fail to provide full healthcare coverage ‘for all’ however, despite failing to provide full protections to all LPRs it offers this frequently forgotten group an opportunity to participate in a health exchange that was not previously accessible. The ACA also awards non-qualified LPRs with the opportunity to purchase health insurance through the insurance exchange at affordable rates.3,4  It’s important to point out that most, nonelderly, LPRs pay into taxes and public programs at the local, state, and federal levels.5  In addition to providing immediate gains to families by expanding access to preventative care and shielding them from the alternative of having to pay otherwise high out-of-pocket medical expenses without coverage, ACA participation also has long-term payoffs for health later in life – payoffs which have an economic and public health effect on society as a whole.  Factors that affect an LPR’s current access to quality healthcare can be far and wide. Immigrants, as a collective, are often considered a vulnerable population – socioeconomic background, limited English proficiency, immigration status, geographical presence, and marginalization all play a role in their healthcare disparity. 

There are three types of major stakeholders involved – politicians, hospitals, and advocates for LPRs. Politicians who decide federal policy on LPRs’ access to healthcare coverage, and more broadly to public charge accessibility, have significant stake in this policy decision specifically on its fiscal impact on federal and state budgeting. On average an LPR’s costs to State and local governments is approximately $1,600 dollars.  If you take into account the number of new persons obtaining LPR qualified status in 2016 for New York City-Newark-Jersey City, totaling 195,593 persons that means approximately $313 million is spent on supporting this migrant population.4,6  Many politicians, including the Trump Administration, argue that this expense is an inefficient way of spending taxpayers’ money.

Serviced patients seeking healthcare specifically in safety net hospitals led to decreased hospital spending overall. This was partly due to the fact that the care covered by the ACA led to a measurable increase in receipt of preventative care which in turn minimized charitable service spending provided by hospitals. The public charge coverage loss effects caused by the proposed policy change would be rippling and widespread especially throughout a small number of key states that service large LPR populations such as California, New York, New Jersey, and Florida (states that already support the largest share of illegal immigrants). In the wake of already imposed budget cuts for Medicaid and other programs, these hospital centers will face the additional burden of supporting and providing uncompensated care to patients in need that would otherwise be covered.10-12  

Efforts to address the impact of public charge have played out in the political arena, often times leaving States and local advocacy groups to bear the financial burden of providing aid.7 8  The long standing criticism for welfare reform, especially for public healthcare benefits, has been that the LPR community already faces indirect exclusion from the programs that are supported by the taxes they pay.  With the Trump administration’s new proposed public charge policy and the increased attention paid to immigration enforcement, the forecast is that there will be a demotivating effect on a non-citizen’s decision to relocate to the United States to take advantage of public services.  But this model doesn’t take into account the already present, already qualified residents and their citizen family members who will be faced with the decision to weigh their health up against the fear of possible deportation.9, 5 LPRs are expected to disenroll in coverage as their participation, and their family members’ participation, now lends itself to increased scrutiny for becoming a public charge.  For the same reason, immigrants pursuing residency status are not likely to enroll in any healthcare plans; losses that will absolutely lead to worsening health outcomes overtime for families who are already at a disadvantage.

If policy makers decide that public charge changes are required to lower fiscal spending, then hospital systems, specifically in key states as addressed above, will need to be provided with capital to support the increased number of critical ‘free’ services that will be provided to LPRs without appropriate healthcare coverage.

References:

1. Health Coverage for Lawfully Present Immigrants. U.S. Centers for Medicare & Medicaid Services. (www.healthcare.gov/immigrants/lawfully-present-immigrants/)
2. Bettigole, C. An Uninsured Immigrant Delays Needed Care. Health Affairs. December 2015. DOI: 10.1377/HLTHAFF.2014.1162.

1. Broder T, Moussavian A, Blazer J. Overview of Immigrant Eligibility for Federal Programs. National Immigration Law Center. December 2015.
2. Kaiser Family Foundation. Health Coverage of Immigrants. December 2017. (www.kff.org/disparities-policy/fact-sheet/health-coverage-of-immigrants/)
3. Andrapalliyal V. “Healthcare for All”? : The Gap between Rhetoric and Reality in the Affordable Care Act. UCLA Law Review. 2013. V. 61 A. 58. (www.uclalawreview.org/health-care-for-all-the-gap-between-rhetoric-and-reality-in-the-affordable-care-act/)
4. Public Charge. U.S. Citizenship and Immigration Services. 2017 June 26. (www.uscis.gov/greencard/public-charge/)
5. Derose K, Escarce J, Lurie N. Immigrants and Healthcare: Sources of Vulnerability. Health Affairs. September/October 20017. Volume 26, number 5. DOI: 10.1377/HLTHAFF.26.5.1258
6. Lawful Permanent Resident 2016 Data Tables. Homeland Security. Table: fy2016_table5 (www. https://www.dhs.gov/immigration-statistics/lawful-permanent-residents/)
7. Field Guidance on Deportability and Inadmissibility on Public Charge Grounds. Immigration and Naturalization Services, Department of Justice. March 26, 1999. Vol. 64, No. 101 Federal Register pages 28689-28693.
8. Kaiser Family Foundation. Proposed Changes to “Public Charge” Policies for Immigrants: Implications for Health Coverage. February 13, 2018. (https://www.kff.org/racial-equity-and-health-policy/fact-sheet/public-charge-policies-for-immigrants-implications-for-health-coverage/)
9. Health Care Coverage Maps. National Immigration Law Center. January 2018.
10. Medical Assistance Programs for Immigrants in Various States. National Immigration Law Center. January 2018.