HAP Resource Center

Lawmaker Letter: Joint Letter, PA Congressional Delegation, Proposed Public Charge Rule

December 10, 2018

Dear Members of the Pennsylvania Congressional Delegation:

The undersigned organizations are writing to express significant concern regarding the potential health consequences of newly proposed immigration policy set out in the “public charge” rule.

The new policy proposed by the U.S. Department of Homeland Security (DHS) could impact the ability of legal immigrants to get a green card or become a citizen, based on the extent to which they access and rely upon public benefits. Of concern, this proposal could increase the number of uninsured and impact public health because immigrant families lawfully present in the United States may disenroll or forgo health care and food benefits for fear of jeopardizing their immigration status.

The adverse health consequences for children and families include forgoing health care coverage, failing to pursue preventative and routine care, and losing access to nutritious foods out of concern for the scrutiny they may face under the policy. Ultimately, this leads to sicker patients relying upon hospital emergency departments, an increase in uncompensated care, and higher costs for all purchasers of care.

Under the new DHS proposal, when conducting a “public charge” determination, where the government considers if a legal immigrant is primarily dependent upon the government, the types of programs that the government considers would be expanded to include Medicaid, the Medicare Part D low-income subsidy, Supplemental Nutrition Assistance Program (food stamps or SNAP), and select housing programs. The public charge analysis would review the amount and length of time an individual received public assistance, and consider personal characteristics such as age and health status.

An analysis of the proposed rule by Manatt Health estimates that 4.4 million non-citizen adults and children who receive Medicaid or Children’s Health Insurance Program (CHIP) coverage, as well as 8.8 million citizen adults and children with Medicaid or CHIP coverage who are the family members of a noncitizen, are potentially affected, based on 2016 data.

That population of 13.2 million Medicaid and CHIP enrollees accounted for an estimated $68 billion, including $1.2 billion in Pennsylvania, in Medicaid and CHIP health care services during 2016. Of particular significance for Pennsylvania, the Manatt study indicates that 39 percent of the Medicaid and CHIP funding in jeopardy is attributable to health care services provided to children.

Under the Manatt analysis, based on 2016 data, an estimated $17 billion in hospital payments could be at risk under the public charge proposed rule. Hospital payments to Pennsylvania could be reduced by as much as $216 million and the Philadelphia/Camden/Wilmington core-based statistical area, including 85 hospitals, would be disproportionately impacted facing a $232 million impact.

Foreshadowing similar impacts, the Milken Institute School of Public Health conducted an analysis of the impact of the proposed rule upon patients and communities served by health centers.

That study suggests, that of 13.3 million Medicaid beneficiaries who are served by community health centers during 2017, the chilling effect of the proposed policy could affect 2.6 million patients.

Based on conservative assumptions of the impact upon legal non-citizen immigrants, the consequences of the proposed policy include:

  • 354,000 legal immigrant health center Medicaid patients disenrolling from their coverage, including 8,000 Pennsylvania patients
  • $346 million loss in Medicaid revenue, including a $7.6 million loss for Pennsylvania health centers
  • 295,000 fewer patients served by Community Health Centers overall, including nearly 8,000 Pennsylvania patients
  • 3,400 full-time equivalent medical staff impacted by staff reductions, including 83 physicians and nurses serving communities in Pennsylvania

A more inclusive analysis that includes the impact to family members of legal non-citizens cautions the following impacts for Pennsylvania: 13,000 Medicaid patients disenrolling; a $12.3 million revenue impact; nearly 13,000 fewer patients served; and 135 medical professionals impacted by staff reductions.

The financial impact of a significant loss of Medicaid payments and an increase in uncompensated care will place a significant strain upon hospitals and other providers already managing tight margins. Safety net providers and health care providers in communities with large immigrant populations will be particularly hard-hit, affecting not only their fiscal health but their ability to serve the broader community.

Moreover, the proposed policy will also chill access to food assistance programs that play a key role in stemming food insecurity. Families that face food insecurity are sicker, need more health care and ultimately generate more health care spending. Food insecurity is reduced by one- fifth overall and one-third for children when families have access to SNAP. Compared to food insecure adults without SNAP, those who receive SNAP experience 25 percent less in health care utilization and expenditures.

Turning back progress in addressing food insecurity will set back population health efforts by health care providers who are improving health outcomes and reducing health care expenditures.

The co-signed organizations represent health care providers that offer care to Pennsylvania patients through the full continuum of care. Collectively, we are committed to improving the health of Pennsylvania and we recognize that access to health care coverage and food assistance programs are crucial to health care outcomes. We urge federal policymakers to reconsider this shortsighted policy that will have direct consequences for the health of millions of lawfully present families and, in turn, impact the health of all citizens and communities.


Health Federation of Philadelphia
Healthcare Council of Western Pennsylvania
Pennsylvania Association of Community Health Centers
Pennsylvania Athletic Trainers’ Society, Inc.
Pennsylvania Coalition for Oral Health
Pennsylvania College of Emergency Physicians
Pennsylvania Homecare Association
Pennsylvania Psychiatric Society
Pennsylvania Rural Health Association
Pennsylvania Section of American College of Obstetricians and Gynecologists
Pennsylvania Society of Physician Assistants
Rehabilitation & Community Providers Association
Safety-Net Association of Pennsylvania
The Hospital and Healthsystem Association of Pennsylvania
The Urban Health Care Coalition of Pennsylvania


Topics: Access to Care, Federal Advocacy, Health Care Reform, Population Health

Revision Date: 12/10/2018

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