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Doctors: Trump's 'Public Charge' Immigration Rule Makes America Less Healthy

Dr. Bhuyan, a family physician and member of American Academy of Family Physicians, one of the organizational signatories of the joint statement opposing the final public charge rule.
Dr. Bhuyan, a family physician and member of American Academy of Family Physicians, one of the organizational signatories of the joint statement opposing the final public charge rule.
Dr. Natasha Bhuyan
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Doctors across the country are voicing their concerns that the Trump administration's new rule targeting legal immigrants who use public benefits will cost the nation dearly in the long run.

On Monday, the Trump administration announced another aggressive change to the U.S. immigration system — this time, a "public charge" rule that would affect immigrants seeking a path to citizenship.

Under the new regulation, poor immigrants who are in the United States legally will be denied green cards, also known as permanent legal status, if they are deemed to be a burden on taxpayers.

The Trump administration said the rule is part of its ongoing effort to encourage “merit-based” immigration into the country, by ensuring “the availability of public benefits [don't] constitute an incentive for immigration to the United States.”

But some physicians and medical professionals are decrying the rule — saying that it instead guarantees a public health crisis, and ensures the very high taxes it’s trying to mitigate.

Starting in October, the United States government will implement a rigorous wealth test to determine this “burden.” Immigrants who use — or are found likely to use — government benefit programs such as Medicaid, food stamps, and subsidized housing will not be granted green cards.

“This final rule amends DHS regulations by prescribing how DHS will determine whether an alien applying for admission or adjustment of status is inadmissible to the United States,” the final text says, “because he or she is likely at any time to become a public charge.”

The United States has had a public charge law since the 1880s, but it was defined narrowly — immigrants could be deemed a public charge and denied a green card if they relied on two federal programs for their source of income, like supplemental security income (SSI) or long-term institutional care.

In other words, immigrants seeking green cards and applying for citizenship already have had to prove they will not become a public charge, or burden, on the United States. But the new rule dramatically expands the definition of a public charge, extending it to programs like federally funded health care, SNAP, and public housing.

Immigrants who are undocumented already cannot receive public benefits. The rule is directly aimed at the hundreds of thousands of immigrants who are here legally under some form of visa.

During the announcement of the rule Monday, U.S. Citizenship and Immigration Services (USCIS) Director Ken Cuccinelli said it was part of a broader effort to foster “self-reliance." The regulation states its goal is that “aliens within the Nation’s borders not depend on public resources to meet their needs.”

There are some exceptions: The regulation will not apply to refugees, immigrants who already hold green cards, or children under the age of 21. Parents will be able to sign their children up for public benefit services without it penalizing their chances of legal permanent status, or counting against their children's in the future.

But immigration advocates have opposed the rule since it was first proposed in October 2018, warning that even immigrants who are not subject to the regulation may forgo needed services out of fear of retaliation from immigration authorities.

"In terms of public health, the bad thing is that the word may not get out, or the word will get out and people won't believe it," said Will Humble, executive director of the Arizona Public Health Association.

Humble worked as director of the Arizona Department of Health Services, which facilitates the state's Women, Infants, and Children (WIC) public benefit program, when SB 1070 was passed. Even though the anti-immigration legislation did not mention public benefits, the agency witnessed a sharp decline in enrollment.

"We lost a whole bunch of members in our WIC program, because parents got scared of the bill, even though it had nothing to do with WIC," he said.

The medical community has begun to speak out with a new concern: This chilling effect could have long-term health consequences for the entire United States population.

When it comes to public health care services alone, over 13.5 million people enrolled in Medicaid and Children’s Health Insurance Program (CHIP), including almost 8 million children, currently live in a household with at least one noncitizen, or are noncitizens themselves. According to a Kaiser Permanente study published on Monday, all of them are at risk for decreased enrollment due to fear or confusion about the rule. A study by JAMA Pediatrics published in July, which specifically looked at the rule’s impact on children, had similar findings.

Humble said this may particularly affect children who are supposed to be exempt from the regulation. "Adults may choose not to sign their kids up because they don't trust the government with that information, or they're worried the Trump administration is going to change the rules in the future and make them retroactive."

Children will miss out on preventative health measures, like developmental screenings and vaccines, Humble said, and they may not have access to nutritional foods that are critical for early development.

The new rule will "become a public health crisis,” predicted Dr. Natasha Bhuyan, a family physician and regional medical director at One Medical who works with many immigrant clients in greater Phoenix. “The way that these rules are written, people will be forced to delay getting care.”

“In the United States, we know that when people delay getting care, ultimately they end up in the emergency room,” Bhuyan said. “And that’s an extremely expensive way for people to access care in our health care system. The intent of these proposals is to decrease reliance on taxpayer benefits, but it might actually end up driving up what taxpayers are putting into the system.”

As immigrants with serious chronic medical conditions like diabetes, asthma, and high blood pressure avoid seeking physician care for checkups or more minor concerns, their health problems could become more complex, and more difficult to treat. According to Bhuyan, if physicians are not given the opportunity to care for patients before they are in crisis, emergency room treatment becomes the standard for low-income immigrants who are here legally, significantly increasing costs to the overall United States health care system.

The rule will likely create a cyclical problem, she added, in which immigrants and their citizen children who must first forgo health care (and social determinants of long-term health like stable housing and healthy food) are eventually forced to use it more regularly, and at higher costs to the federal government.

The day after it was announced, doctors from six national provider organizations, representing almost 600,000 physicians and medical students, signed a joint statement opposing the final public charge rule. The doctors, who were from the American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American College of Obstetricians and Gynecologists, American Osteopathic Association, and the American Psychiatric Association, expressed many of these concerns.

“Many of our members have already witnessed this chilling effect among their own patient populations, with patients avoiding health services and programs out of fear,” the statement said. “Most important, the order puts a governmental barrier between physicians and patients and stands in stark contrast to the mission our organizations share: ensuring meaningful access to health care for patients in need.”

One in seven adults in immigrant families reported avoiding public benefit programs for fear of risking future green card status, according to the Urban Institute’s annual Well-Being and Basic Needs Survey conducted in December 2018, just months after the rule was announced as a proposal.

"These pages target families who have immigrated lawfully," Bhuyan said. "And they're just trapped in this impossible dilemma, because they're forced to choose between giving up lifesaving services related to health, nutrition, or housing, or they have to forgo a chance at keeping their families together."

The public charge rule is scheduled to go into effect 60 days after its issuance on Monday.

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