PCDC: ‘Public Charge’ Rule Changes Threaten Health Systems and Public Health

Categories: Policy
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PCDC strongly opposes proposed changes by the U.S. Department of Homeland Security (DHS) to the “public charge” rule and urges DHS to withdraw the proposed rule in its entirety.

“The proposed changes target families who have immigrated lawfully — as well as their U.S. citizen relatives — by undermining their access to basic needs, including food, shelter, and health care,” writes Patrick Kwan, Senior Director of Advocacy and Communications, in PCDC’s official comments to DHS.

“PCDC has profound concerns about how the proposed changes as well as the chilling effects will distress and disrupt the health care workforce and provider pipeline,” Kwan writes.

Read the full comment below, or download the PDF.

December 7, 2018

The Honorable Kirstjen M. Nielsen
Secretary of Homeland Security
U.S. Department of Homeland Security
20 Massachusetts Avenue NW
Washington, DC  20529-2140

RE: DHS Docket No. USCIS-2010-0012, RIN 1615-AA22, Comments in Response to Proposed Rulemaking: Inadmissibility on Public Charge Grounds


Dear Secretary Nielsen,

The Primary Care Development Corporation (PCDC) appreciates the opportunity to respond to the Department of Homeland Security’s (DHS) Notice of Proposed Rulemaking to the changes regarding “public charge,” published in the Federal Register on October 10, 2018.

PCDC is a national nonprofit organization and Community Development Financial Institution dedicated to building equity and excellence in primary care. We have advocated for primary care for 25 years and assisted over 1,000 primary care practices in more than 40 states and territories. Our mission is to create healthier, more equitable communities by building, expanding, and strengthening the national primary care infrastructure.  

Since our founding in 1993, PCDC has improved primary care access for more than 1 million patients by leveraging more than $1 billion to finance over 130 primary care projects. Our strategic community investments have built the capacity to provide 3.5 million medical visits annually, created or preserved more than 10,000 jobs in low-income communities, and transformed 1.8 million square feet of space into fully functioning primary care practices. Through our capacity building programs, PCDC has trained and coached more than 7,000 health workers to deliver superior patient-centered care. We have also assisted more than 450 primary care practices — encompassing some 2,250 providers — to achieve patient-centered medical home recognition, improving care for more than 5 million patients nationwide.

We strongly oppose the proposed changes to the public charge rule and urge DHS to withdraw the proposed rule in its entirety. Not only does the proposed rule create additional inhumane challenges and barriers for immigrant families who are struggling to make ends meet, the proposed changes also threaten health care systems across the country and public health for all Americans. The proposed rule would dramatically reinterpret requirements for certain immigrants to enter the United States and/or become permanent residents. The proposed changes also target families who have immigrated lawfully — as well as their U.S. citizen relatives — by undermining their access to basic needs, including food, shelter, and health care.

DHS proposes to drastically change the long-standing definition of “public charge” as someone “primarily dependent on the government for subsistence” to anyone who uses — or is deemed likely at any time in the future to receive — any government benefits from a vastly expanded list of vital programs that address the social determinants of health. The availability and accessibility of such programs — Medicaid, the Supplemental Nutrition Assistance Program (SNAP), federal housing and rental assistance, and Medicare’s Part D premium assistance and Low-Income Subsidy — is central to the success of primary care and larger health care sector, helping patients address the critical needs of health care coverage, food, and housing. The proposed rule not only hurts patients and their families but also the health providers who serve them.

In addition to the individuals and families who are directly targeted and affected, we are deeply concerned about those who, worried about potentially being classified as public charges, could proactively disenroll or forego benefits for which they are eligible. This effect is not theoretical. Subsequent to the enactment of welfare reform in 1996, legal immigrant uptake of health and social services declined sharply, far beyond the actual restrictions put in place, in part due to fear and confusion about whether use of benefits would hurt their immigration status. These declines occurred even among groups with eligibility not changed by the law, such as refugees and the citizen children of noncitizens. In fact, when the INS clarified public charge policy in 1999, it did so precisely “to reduce the negative public health consequences generated by the existing confusion.” The proposed rule would recreate these negative public health consequences for all immigrants, including the many who are essential members of the health care workforce nationwide as well as the families of these workers.

PCDC has profound concerns about how the proposed changes as well as the chilling effects will distress and disrupt the health care workforce and provider pipeline. Immigrants constitute 15.7 percent of the health care workforce nationally and more than twice that in the District of Columbia (37 percent), New York (37 percent), California (33 percent), and New Jersey (32 percent). Other states with high shares of immigrant health care workers include Florida (28 percent), Maryland (24 percent), and Massachusetts (21 percent).

The proposed rule would establish income levels that could penalize many health care professionals and their families in public charge determinations. Under the proposed changes, immigrants seeking to avoid designation as a public charge must demonstrate a household income level above 250 percent of the federal poverty guidelines — currently, $41,150 for a couple with no children or $63,000 for a family of four.

While immigrant health care professionals in higher-paid professions, such as physicians and registered nurses, will unlikely be affected by the proposed changes, the many lower-paid health professionals who care for patients — as well as those in critical and vital support functions — could be threatened by the proposed rule.

In PCDC and 1199SEIU Healthcare Workers East’s 2015 report, Who’ Going to Care?: Analysis and Recommendations for Building New York’s Care Coordination and Care Management Workforce, we found patient outreach and engagement staff earn between $26,000 and $40,000 annually and care management staff earn between $31,000 and $50,000. Earlier this year, a Health Affairs Blog article found “22 percent of low-skilled jobs in the health care sector, including nursing home workers and personal attendants, are filled by immigrants, many of whom lack access to employer-provided insurance… [and] 25 percent of the home health aide workforce is non-United States born and one-third of home health aides rely on publicly funded programs, including Medicaid and the ACA’s premium tax credits for insurance.”

The proposed rule could have severe impacts on these health care professionals who serve crucial roles in providing direct care, care coordination, patient engagement, health navigation, and more.

Proposed changes by DHS could create dire public health problems and harm the long-term health and well-being of millions of children and families. As DHS acknowledges in the proposed rule:

“Disenrollment or foregoing enrollment in public benefits program by aliens otherwise eligible for these programs could lead to:

  • Worse health outcomes, including increased prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants, or children, and reduced prescription adherence;
  • Increased use of emergency rooms and emergent care as a method of primary health care due to delayed treatment;
  • Increased prevalence of communicable diseases, including among members of the U.S. citizen population who are not vaccinated;
  • Increases in uncompensated care in which a treatment or service is not paid for by an insurer or patient;
  • Increased rates of poverty and housing instability; and
  • Reduced productivity and educational attainment.”

Projected Medicaid disenrollment rates of up to 35 percent could result in up to 2 million citizen children without Medicaid (or CHIP, if included) benefits. In turn, medical issues — particularly those that would otherwise have otherwise been addressed in primary care settings covered by the public benefits program — would instead be treated by expensive emergency departments and safety net care. As families lose these and other critical benefits named in the proposed rule, the potential for adverse health impacts would increase. Individuals lacking proper nutrition, health care coverage, home energy assistance, and preventive services would be at increased risk of obesity, malnutrition, communicable and non-communicable diseases, poverty, housing instability, and reduced ability to address these issues. Without health care coverage, individuals and families would access primary care and preventive services less frequently, turning instead to emergency departments for non-urgent and avoidable urgent cases. This shift would strain limited resources and dramatically increase uncompensated care costs.

PCDC strongly believes no child or family should be penalized for or frightened from accessing health care, public health, or safety net services. We urge the Administration to reconsider this dangerous and cruel proposal to reinterpret public charge determinations.


Patrick Kwan, Senior Director of Advocacy and Communications
Primary Care Development Corporation (PCDC)
Office: (212) 437-3927      l    Email:   pkwan@pcdc.org