HAP Resource Center

Comment Letter: Dept of Homeland Security, Proposed Public Charge Rule

December 10, 2018

Kirsten M. Nielson Secretary
Department of Homeland Security
20 Massachusetts Avenue, NW
Washington, DC 20429-2140

RE: Inadmissibility on Public Charge Grounds, DHS Docket No. USCIS‒2010‒0012

Dear Secretary Nielson:

On behalf of The Hospital and Healthsystem Association of Pennsylvania (HAP), which represents approximately 240 member institutions, we appreciate the opportunity to offer comments regarding the proposed rule, Inadmissibility on Public Charge Grounds. Given the significant health consequences of the proposed policy for millions of individuals and families and the negative impacts for hospitals and health systems throughout the country and in Pennsylvania, we urge the Department of Homeland Security (DHS) not to finalize the proposed rule.

The anticipated immediate impact of broadening the definition of public benefits that are considered in the public charge determination and the scope of the review is that legal non- citizen immigrants and their family members will disenroll or forgo health care and food benefits. This will increase the number of uninsured and result in adverse public health consequences.

As patients forgo needed medical care, a significant burden is placed on the future use of medical services, and the risk of harm to the broader community if diseases and conditions are not treated and managed properly. Ultimately, this will result in sicker patients that are costlier to treat, reliance on hospital emergency departments, an increase of uncompensated care, and higher costs for all purchasers of care.

A wide range of studies have been conducted evaluating the impact of the proposed policy. Collectively, the studies demonstrate that the proposed rule will:

  • Increase the number of uninsured by virtue of patients disenrolling from coverage
  • Lead to poorer health outcomes as patients do not seek needed health care
  • Reduce revenue and resources relied upon by health care providers, including significant reductions in Medicaid payments

Specifically, an analysis of the proposed rule by Manatt Health estimates that 4.4 million noncitizen 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.

The impacted population of Medicaid and CHIP enrollees accounted for $1.2 billion 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.

An analysis by the Milken Institute School of Public Health speaks to similar dynamics impacting patients and communities served by health centers.

Based on conservative assumptions of the impact on legal noncitizen immigrants, the consequences for Pennsylvania specifically include:

  • 8,000 legal immigrant health center Medicaid patients disenrolling from their coverage
  • $7.6 million loss in Medicaid revenue for Pennsylvania health centers
  • Nearly 8,000 fewer Pennsylvania patients served by Community Health Centers
  • 83 full-time equivalent medical staff at Pennsylvania health centers impacted by staff reductions

A more inclusive analysis that includes the impact to family members of legal noncitizens 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.

HAP joined a coalition of organizations representing health care providers in Pennsylvania expressing the collective concerns of hospitals, health systems, community health centers, physicians, behavioral health providers, and physician assistants in a recent letter (attached for the record). That group spoke with a unified voice in stating:

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

Finally, beyond the direct impact to health care coverage and access to services, the proposed rule also will impact health outcomes by chilling 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. Pennsylvania hospitals are working to break that cycle through population health-driven initiatives that are improving health outcomes and reducing health care expenditures.

The anticipated impact to access to the Supplemental Nutrition Assistance Program (SNAP) resulting from the proposed rule will undermine those efforts.

Given all of the concerns outlined above, HAP urges DHS to reconsider this shortsighted policy. The proposal will have direct consequences on the health of millions of lawfully present families and, in turn, impact the health of all citizens and communities.

In the event DHS moves forward in finalizing the proposed rule in some form, notwithstanding serious concerns raised through the public comment period, HAP urges DHS to consider the following targeted comments:

  • The Children’s Health Insurance Program (CHIP) should not be included as a public benefit that is used to determine if an individual is likely to become a public charge
  • DHS should be clear that at the time of a visa application, graduate students, medical residents, physicians, scientists, and researchers with a signed employment letter from a sponsoring institution stating that the individual will meet federal income and insurance requirements will be considered sufficient proof to be admitted to the United States without delay, as these individuals are unlikely to become “public charges”

Thank you for your consideration and review of the concerns and perspectives of the Pennsylvania hospital community. Any questions regarding the comments may be directed to me or my colleague, Laura Stevens Kent, vice president, federal advocacy.


Jeffrey Bechtel
Senior Vice President, Health Economics and Policy 


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

Revision Date: 12/10/2018

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