Proposed Changes Make Some Say ‘No’

Dave A. Chokshi, MD, is an internal medicine doctor at Bellevue Hospital in New York City. It’s a public hospital where, more and more, Chokshi said he’s had to have a new kind of risk-benefit conversation with his predominantly immigrant patient population: Should patients come in to get their blood pressure checked? Or should they stay home for fear that their use of health care might be used against them when they go to renew their visas or green cards?

At the same time, as chief population health officer at New York City Health and Hospitals, Chokshi has been keeping tabs of what you might call qualitative data: reports from the city’s public health system, the largest in the country, that patients are canceling their Women Infants and Children benefits. Or dis-enrolling from food stamps. Or canceling their Medicaid.

“It makes me very worried, frankly,” he says. “Sad and worried. It puts clinicians in challenging positions ... . And it makes me very worried about downstream impacts of this.”

But Chokshi isn’t just worrying to himself. Instead, Chokshi is one of a number of physicians and physician groups using their positions as health authorities to lead the charge against a Trump administration move to expand immigration criteria called the “public charge rule” to include use of health care.

From ‘Poor Laws’ To ‘Public Charge’

The public charge rule has been in place since 1882, when Congress passed its first immigration law. The law was aimed at reducing the number of poor immigrants in the United States, a move borrowed from earlier British “poor laws,” historian Hidetaka Hirota said on the Public Radio International program The World in December.

Initially, it was used to keep poor Irish immigrants out of the United States, Hirota told The World. Over time, it has been used to exclude gays and lesbians, disabled people and, more recently, immigrants from Latin America.

Before the Department of Homeland Security issued its proposed changes to the public charge rule in September, the rule mainly meant immigrants couldn’t access cash assistance — Supplemental Security Income or Temporary Assistance to Needy Families — if they wanted to work their way toward being a U.S. citizen. It also made it a disqualifying event for immigrants to receive long-term care in nursing homes paid for by the federal government.

But under the new proposal, the rule wouldn’t just apply to poverty. It would apply to health use, too. The Department of Homeland Security proposed to add into the calculus use of the Children’s Health Insurance Program, Supplemental Nutrition Assistance Program, Section 8 housing assistance, Medicare Part D Low Income subsidies, as well as nonemergency Medicaid use.

The new rule would apply to people seeking to renew their green cards or receive green cards, and might also apply to people seeking to naturalize as U.S. citizens. It does not apply to refugees or asylum seekers or to immigrants serving in the U.S. military or their spouses.

In some cases, DHS could allow immigrants who do use public benefits to adjust their status if they pay a “public charge bond.”

‘A Bizarre Paradox’

Not long after the proposed change came out, the New England Journal of Medicine published a perspective that called the proposed changes “a new threat to immigrants’ health.”

Article author Breanne Grace, of the University of South Carolina College of Social Work, told NEJM in an interview that some health care organizations have responded to the political rhetoric against immigrants by declaring themselves “sanctuary institutions.” Much like sanctuary cities, where the local governments and police do not work with the U.S. Citizenship and Immigration Services to detain and deport immigrants, sanctuary hospitals are intended as places where immigration enforcement is not welcomed.

Still, Grace said, “individual hospitals can’t do enough. They are always going to be inadequate to address larger policies at any given point.”

This was soon followed by a joint statement by the country’s largest physician groups, including the American College of Obstetricians and Gynecologists, the American College of Physicians, the American Academy of Family Physicians and the American Psychiatric Association, arguing against the rule.

The joint statement says the rule “would make it much more likely that lawfully present immigrants could be denied green cards or U.S. visas, or even be deported, merely on the basis of seeking needed health services for them and their family, including those for which they are eligible.”

The statement was emblematic of leadership within the physician community, Chokshi says.

“How often is it that pediatricians and OB-GYNs and family physicians agree on anything?” Chokshi asks. “The fact that people came together so quickly and vociferously in opposition to this proposal tells you how straightforwardly negative it would be for the health of the patients we all serve.”

In October, Chokshi coauthored a viewpoint in the Journal of the American Medical Association on the danger the public charge rule poses to immigrants and their health. In an interview with the Physician Leadership Journal, he lays out the “bizarre paradox” of the proposed rule.

Quoting from the proposed rule itself, Chokshi and coauthor Mitchell Katz, MD, president and CEO of NYC H+H, run through the effects of the law: 382,600 green card applications would be denied and more than a half-million other kinds of immigration visas would be denied on the basis of the expanded public charge rule.

It also anticipates “worse health outcomes, such as an increased prevalence of obesity and malnutrition and reduced prescription adherence; increased prevalence of communicable diseases; increased rates of poverty and housing instability; and reduced educational attainment.”

“Avoiding needed health care, such as immunizations,” the article states, “could increase the chance of outbreaks of transmissible pathogens.”

This is the madness of the proposal, Chokshi tells the PLJ. “You look at the text of the proposed rule itself, and it anticipates these pernicious effects,” he says. “There’s even risk of greater housing instability — all these things that we know affect health outcomes.”

For physicians, it’s also likely to increase use of the emergency department, because emergency Medicaid would still be admissible. And it could increase costs, as people appear in the ED with more complicated acute cases.

A Chilling Effect

And while the proposed rule has not yet gone into effect and the administration hasn’t responded to any of the comments, what is true, says Chokshi and others, is that the proposal already is having a chilling effect.

At the National Association of State and Territorial AIDS Directors, where physicians and leaders administer services for HIV and hepatitis care, and who work in public health, it’s clear that the proposed rule doesn’t single out the largest public health programs administered by NASTAD members: the Ryan White Care Act or the AIDS Drug Assistance Program.

Still, says Amy Killelea, an attorney and director of Health Systems Integration with NASTAD: “We’re hearing from our members that there’s been a drop in utilization of HIV and hepatitis treatment and prevention as a result of this rhetoric.”

Then there are the reports Chokshi has received about people disenrolling from WIC, even though it’s also not subject to the public charge rule change.

And in the joint statement from ACOG, APA and AAFP, the group states that rather than risk putting themselves or their immigrant family members in danger, many patients will just avoid care.

“As a result, the proposed regulation not only threatens our patients’ health but as this deferred care leads to more complex medical and public health challenges, will also significantly increase costs to the health care system and U.S. taxpayer,” the statement reads. “Most importantly, the order puts a governmental barrier between health care providers and patients and stands in stark contrast to the mission each of our organizations share: ensuring meaningful access to health care for patients in need.”

Indeed, NASTAD’s Killelea says she wonders if the purpose of the rhetoric in the proposed rule is to do exactly that.

As a physician and a public health expert, Chokshi says he should never have to counsel patients on whether to receive needed food, housing or medical care. But since he does, he says he doesn’t hesitate to speak publicly and be among the health care leaders fighting the rule.

NYC H+H’s was among the 210,000 comments DHS received on the rule during the 60-day comments period.

“It’s very clear we have a responsibility to speak out,” he says. “But it’s not necessarily obvious that opposition will have a direct impact on the decision-makers, given that this is something the Trump administration can enact through executive powers.”

Still, he adds again, “I think we have a responsibility to speak.”