In September 2018, U.S. Citizenship and Immigration Services proposed a change in the rule for “public charges” – people who depend primarily on the government for assistance. The about-face would limit access to green cards and temporary visas for most immigrants who receive Medicaid and other public benefits.
Almost immediately, the news instilled fear among immigrant communities along the Texas-Mexico border, and rumors started spreading about what the change meant for their access to health care, says Jake Margo, MD, a family medicine specialist at Starr County Memorial Hospital in Rio Grande City.
“There’s been all kinds of things out there even on the Mexican side that [immigrants] will have their green cards torn up if they have a receipt from a hospital showing that they’ve paid [for medical services with Medicaid],” Dr. Margo said.
As it turned out, the enacted policy may not apply as extensively as once thought. But the unfounded rumors about the law have done a lot of damage, and now physicians and other advocates are struggling to undo the repercussions.
Between August when the final policy came out, and Oct. 15, when it took effect, misconceptions intensified and exacerbated already limited health care opportunities for many immigrants and their families, Dr. Margo says. Because immigrants now are afraid to use Medicaid, or any other public health service, they ignore health problems until they become a crisis.
“I’ve been working here 14 years now and [the emergency department] has never been this busy before,” he said. “A lot of these people have kids who should have seen a doctor somewhere else, outside of the emergency room. They should have some type of Medicaid that allows them to get care, but we’re not seeing it.”
The rule change also has delivered a financial gut punch to rural hospitals like Starr County Memorial Hospital, as well as to regional clinics, Dr. Margo says. While most other medical facilities have a payer base made up mostly of insured patients with a small minority of Medicaid patients, those in rural and border areas have just the opposite, he says. Because immigrants are declining to use even Medicaid, many cannot pay for services at all.
“When other [medical facilities] talk about uninsured, they usually mean Medicaid patients,” he said. “When we talk about uninsured, we really mean uninsured. We have a social worker to make sure [patients] do apply for emergency Medicaid at least, but a lot of them are not. They’re declining because of this [rule change].”
The new policy, which the Texas Medical Association and most other medical organizations strongly opposed, will directly affect millions of visa and green card holders and applicants, according to the most recent data from the Department of Homeland Security (DHS) and Pew Research Center.
However, the nationwide consulting firm Manatt says the regulation’s impact will spread to tens of millions more by deterring immigrants and their American-born children from using health care and other services for which they are eligible.
Many immigrants with green cards can legally use Medicaid for their children who are U.S. citizens, but they are afraid to do so, says Troy Fiesinger, MD, a Sugar Land family physician who sits on the TMA Council on Legislation. They fear that the use of any government service by their family will cost them their green card or a shot at citizenship.
This is expected to have an outsized impact in Texas. About 1.8 million children in the state, or about 1 out of 4, have at last one parent who is not a citizen, according to the Austin-based Center for Public Policy Priorities.
“This fear could have a much more powerful effect than the actual change in federal rules,” Dr. Fiesinger said. “In essence, [the problem is] not what the rule has done, it’s what people think it will do.”
Opposition mounts
The public charge rule has been part of immigration law since 1882, but the 837-page revision broadens the parameters to include visa and green card recipients who receive health care, nutrition, and housing services.
While there has not been enough time for scientific studies showing how many immigrants have been affected by the rule change, “experience suggests such policy changes can have broad ‘chilling effects’ that lead to immigrant families opting out of public benefits and avoiding interactions with government authorities,” according to a December 2018 Urban Institute report.
In August 2019, the U.S. Immigration Policy Center at the University of California San Diego conducted a survey of undocumented immigrants that showed “changes to the public charge rule will negatively and significantly affect the participation of undocumented families, including families with U.S. citizen children, across a broad range of public programs, including programs that are not directly implicated in the new policy.” (See “Impact on the Undocumented,” below.)
Anecdotal evidence from Texas physicians confirms that immigrants are indeed staying away from health services. That is a problem for both patients and physicians in a state with the highest rate of uninsured patients in the country, says Lucia Williams, MD, a Jacksonville obstetrician-gynecologist on TMA’s Committee on Rural Health.
“Texas already has nearly 5 million uninsured people,” she said. “If [those patients can’t or won’t enroll in] Medicaid, then they’re not going to get care, including prenatal care. If they drop Medicaid or [the Children’s Health Insurance Program], their kids aren’t going to get vaccinated. They won’t qualify for the school lunch or breakfast programs for the children, and children who go to school hungry don’t do as well in school. Texas specifically has made this big push to lower maternal mortality and morbidity, and not getting prenatal care is not going to help those numbers.”
For these and other reasons, TMA opposed the rule from the start. In December 2018, then-TMA President Doug Curran, MD, submitted a letter urging U.S. immigration officials to withdraw the proposed rule. Virtually all other major medical organizations joined TMA – along with other individuals and organizations – in pointing out that the new rule will hurt patient health and undermine physician finances.
Unfortunately, the numerous exceptions in the revised rule have made it even more confusing and spread greater fear among immigrants, says Cheasty Anderson, a senior policy associate at the Children’s Defense Fund-Texas. The best way to address that uncertainty is for physicians, social workers, nonprofits, and others who deliver health care to immigrants to educate them about what the new rule does and does not do.
“The new regulations sound scary, but they actually affect very few people,” she said. “[Physicians should tell each patient] you should definitely keep your children enrolled in the programs for which they’re eligible because that has no impact on your [citizenship] applications. We’re just going to have to say it again and again and again. People aren’t going to trust it until they’ve heard it from different sources.”
“In extremis”
Not every Texas physician will feel the direct impact of the revised rule. But the repercussions are likely to be far-reaching – though maybe not immediately obvious, Dr. Williams says.
“I don’t think [many physicians] will see much of an impact except when they have to cover the emergency room and they see more people dropping in sicker and in extremis because they waited until the last minute to come in so that they didn’t end up with a big bill,” she said.
But rural physicians, especially those in areas with a high immigrant population, and physicians working in low-income areas already have seen a direct impact from the rule change and are likely to see more, Dr. Williams says.
“I imagine we’ll go back to taking cash payments,” she said. “When I was in private practice, you’d get about $800 for a Medicaid [obstetrics visit], and every time they’d see us they’d pay a little bit on it – because you don’t want them to not get the care. It’s like a step back in time though. And those [patients] who have jobs and can do it, will. Those who don’t, won’t.”
Rural hospitals in Texas, already struggling because of policy changes to Medicaid and the state’s refusal to expand Medicaid eligibility, are having to cut services. Since 2013, more than 20 rural Texas hospitals have closed, and many have had to scale back services, according to the Texas Hospital Association.
Starr County Memorial Hospital, for instance, may have to reassess how best to provide pre-birth and birth-related services as a direct result of the public charge rule, Dr. Margo says.
“It looks like we’re working up something temporarily to keep them going a little bit longer,” he said. “But this has been a constant struggle for us.”
There are efforts to stop the rule. Congress has taken steps to defund it, and 16 states have filed suit against it. However, the outcome of those actions were still pending at press time.
Meanwhile, TMA is coordinating with the Texas Health and Human Services Commission, legislators, and other stakeholders to ensure that all eligible Texas children who need Medicaid or CHIP and other services can get them, Dr. Williams says.
“We’re working with those groups and people in the legislature to say this could be catastrophic for the overall health of Texans,” she said.
Tex Med. 2019;115(11):35-39
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