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What you Need to Know about Public Charge and the Intersections with Health Centers

Tuesday, May 15, 2018   (0 Comments)
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Elizabeth Oseguera   

Elizabeth Oseguera

Senior Policy Analyst

California Primary Care Association

Elizabeth will be presenting on Monday, May 21, at the 2018 Spring Primary Care Conference.


The California Primary Care Association (CPCA) and our health center members have been immensely troubled by the tone of the national discussions on immigration, and we are particularly concerned about the rumors regarding public charge. Since his inauguration, the President has made restrictive immigration policies a cornerstone of his agenda and has implemented policies that are harmful to immigrants and their families. Currently the Trump Administration is reviewing changes to the public charge rules, yet another assault on our immigrant community, unfairly targeting them and creating an increased atmosphere of fear.


In response, the California Primary Care Association (CPCA) and CaliforniaHealth+ Advocates (the advocacy arm of CPCA), have been working closely with our immigrant-focused partners to create resources that assist health centers in advocating against changes that would negatively impact our immigrant patients and communities. CPCA and CaliforniaHealth+ Advocates represent over 1,300 community health centers and 6.5 million patients. For decades health centers have provided care to everyone, regardless of ability to pay, their immigration status, or their individual circumstances, while also advocating for their patients. To help health centers better understand the harm that could come from the proposed changes to the public charge rule, CPCA has taken a leadership role in helping to provide resources to other state health centers and PCAs in the hopes of increasing advocacy on the part of health centers on this issue.


If we want our communities to thrive, all of the families in those communities must be able to get the care and services they need. At this time of rising national division, CPCA and its member health centers are proud to stand with our immigrant communities and re-affirm our commitment to valuing and protecting the health care rights of our immigrant patients. We welcome your health center to stand with us in opposing any changes to the public charge rule.


Overview of the Public Charge Rule
The concept of 'public charge' has been in federal immigration law since the late 1800s. In 1996, the Illegal Immigration Reform and Immigrant Responsibility Act along with the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (Public Law 104-208) amended the public charge doctrine. This law expressly authorized consular agents to deny immigrant visas on the grounds that applicants were likely to become dependent on the government - and therefore be deemed a public charge - if they used 'federal public benefits'. However, PRWORA did not properly define what constituted a 'federal public benefit,' causing confusion and panic within the immigrant community and discouraging many from obtaining any public benefits, including seeking services at health centers, for fear of deportation.


To address this issue, many advocates worked hard to have the Immigration and Naturalization Service (INS) issue field guidance (64 FR 28689, May 26, 1999) clarifying that only cash assistance for income maintenance and institutionalization for long-term care at government expense could be considered in a public charge assessment. As a result, while Temporary Assistance for Needy Families (TANF) and Supplemental Security Income (SSI) could be considered, non-cash benefits other than long-term care could not. This meant that immigrants could again feel safe accessing other types of public benefit programs, such as Medicaid and services offered by community health centers, and that advocates and service providers could share a concrete, reassuring message about the 'safety' of using benefits such as Medicaid and SNAP. The field guidance became the purview of US Customs and Immigration Services (USCIS) when the Department of Homeland Security was created in 2002.


What Is Public Charge?
green cardPublic Charge is a term used in immigration law to describe an individual who is dependent on the government. The likelihood that a person will become a public charge is considered when the U.S. State Department Embassy or Consular officers abroad review visa applications for entrance or re-entrance into the United States, as well as when USCIS reviews applications for legal permanent resident (LPR) status in the US (i.e. applying for a green card). Public charge is NOT taken into consideration for people who have LPR status and are applying to become U.S. citizens. When determining if a person is likely to become a public charge, the Immigration and Nationality Act (INA) requires the government to consider a variety of factors, including the person's age, health, resources, family size, and education and skills.


The INA also allows a person to be deported on public charge grounds if the person has become a public charge within five years after coming to the US, for reasons that existed when the person came to the country. Deportation on public charge grounds is very rare.


Who can be considered a public charge?
All those applying to enter or re-enter the county, as well as those applying for LPR status in the U.S. are subject to the public charge test described above. Many individuals residing in the U.S., including DACA recipients and people with TPS, are not eligible to apply for LPR status, thus they would not be impacted by changes made to the public charge rule. However, these individuals may experience a change in circumstances, such as marrying a citizen, that makes them eligible for a green card, and therefore subject to the public charge rule.


Public charge does not apply to: Refugees, asylees, survivors of domestic violence, victims of trafficking or other serious crimes, special immigrant juveniles, temporary protected status (TPS) and certain other groups.


Why are we Concerned about Changes to the Public Charge Rule?
The Office of Management and Budget (OMB) has officially received draft regulations on public charge indicating that the Trump administration is planning to make changes very soon. In the Notice of Proposed Rule Making that OMB released late last year, it indicated that the proposed public charge rules would be available on the federal registry by July 2018.


On March 29 the Washington Post released a new version of the leaked rules that would make unprecedented changes to long-standing policy around public charge:

  • It would significantly broaden the scope of the benefits that could be considered in the public charge analysis to include non-cash benefits, including Medicaid, Children's Health Insurance Program (CHIP), Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the Earned Income Tax Credit, and housing assistance programs. Under this leaked version of the rules, the Trump administration would consider virtually all means-tested benefits in the public charge determination.
  • It attempts to expand the definition of "public charge" from being primarily dependent on cash assistance or government-funded long-term care to simply applying for or receiving one or more public benefits.
  • It would count a dependent's receipt of benefits as a negative factor in the public charge assessment, and significantly expand the definition of "dependents" to include any individual who lives with and "benefits from but does not contribute to" the immigrant's financial resources.
  • It would apply an analysis similar to the public charge test to applications to extend non-immigrant visas, or to change from one category of non-immigrant visa to another.

Under this leaked version of the rules, the Trump administration would consider virtually all federal, state, and local public benefit programs in the public charge determination if the benefits were means-tested or supported day to day living expenses. Within the drafts leaked to date, it is unclear how programs that were not listed as either included in or excluded from the public charge test would be treated. Unfortunately, the health center sliding fee scale was not explicitly exempt, meaning that at this point in time we are unsure if the Trump administration will consider its use as a negative factor in the public charge analysis.


Workers who come to the US on migrant and agricultural worker visas would be impacted by the leaked proposed rule when they apply to enter the US and any time that they apply to extend their visa or change to another nonimmigrant visa category. This could have a drastic impact on California businesses, especially if they employ immigrants.


How will Patients be impacted by Changes to Public Charge?
If the leaked proposal were implemented as drafted, these changes could deny immigrants permanent residency if they, or their family members, including citizen children enrolled in Medicaid, CHIP, WIC, and other health and nutrition programs. Even subsidies received from health care exchanges and refundable tax credits like the Earned Income Tax Credit would be considered. The chilling effect will drive eligible families away from enrolling in programs that help them stay healthy and pay for medical care at community health centers. This will cause many immigrant families to avoid seeking needed healthcare until their condition deteriorates, which could increase avoidable emergency room visits. We strongly believe that any change to the public charge rule will discourage many immigrants and migrant workers from accessing healthcare services.


As an organization that represents healthcare providers, we know that it is crucial that ALL communities have access to healthcare services. This allows for healthy and thriving communities that help contribute to our nation's workforce and economy.


How will Health Centers be Impacted by Changes to the Public Charge Rule?
Health centers will need to retrain staff, in particular enrollment staff, to ensure they can answer questions from immigrant patients who may qualify for Medicaid, the sliding fee scale, or other public benefit programs offered at the federal, state or local level. If the proposed policy changes go into effect, it will no longer be possible to assure patients that using Medicaid or other health benefits won't affect their immigration status. Each Clinic will need to decide how to talk to immigration patients about the possibility that receiving essential benefits could affect their ability to adjust their immigration status.


Community Health Centers are also likely to experience a reduction in the immigrant patients seeking care. Last year after the release of a leaked executive order concerning public charge, health centers in California already had immigrant patients asking to be dis-enrolled from public benefit programs, such as Medicaid, and in some cases, asking to have their information deleted from the health center's system, including their electronic health records.


Since health centers may no longer be able to enroll all their immigrant patients into public benefit programs, or offer them the sliding fee scale, it could raise the cost of providing services to patients. This is a great concern for health centers in states with significant immigrant populations.


How can my Health Center get Involved?


Inform Yourself and Your Communities
It is very important that health center leadership and staff are aware of the public charge threat and how the proposed changes could impact their patients and health centers. As with the events of the 1990's, it is likely that changes to the public charge rule will again discourage many immigrants from seeking healthcare services for fear of immigration consequences. To help ensure that our immigrant patients have access to public benefit programs, including Medicaid, we encourage health centers to become advocates against the public charge rule.


 As advocates, health centers can help inform their elected officials of the threats to the public charge rule, while also helping their communities understand what public charge is and who would be impacted by the proposed changes. This will help eliminate misinformation, and hopefully some of the fears caused by misunderstanding who will be impacted by changes to the public charge rule. To do this we've provided links to resources down below.


The goal is to educate lawmakers and the general public through social media, op-eds, letters to the editor, and direct advocacy about the impact changes to public charge will have on the health care system and immigrant communities as a whole, and to prepare the public to submit comments to USCIS once the Notice of Proposed Rulemaking with the draft regulations is published in the Federal Register.


Join the National Health Center Immigration Workgroup
CPCA, in coordination with the Association of Asian Pacific Community Health Organizations (AAPCHO) and NACHC, has created the National Health Center Immigration Workgroup to help inform other state PCAs and community health centers about immigrant issues, such as public charge. Through this workgroup, we hope to align the health center voice on immigrant issues, in particular public charge, while also providing a platform for information and resource sharing. We would also like to use this workgroup to help compliment the efforts of the Protecting Immigrant Families (PIF) Campaign, a coalition led by our immigrant and anti-poverty partners to advance nationwide advocacy efforts against the public charge rule, and the experts on this issue.


If you are interested in learning more, or joining the National Health Center Immigration Workgroup, please complete the registration form at https://www.surveymonkey.com/r/NHCIWG_2018.


Submit Public Comments & Encourage Others to do the same
Once the proposed rules are officially released through publication in the Federal Register, we will all have an opportunity to submit public comments. It is our hope to have a massive number of public comments submitted to USCIS to help delay the rule's implementation date, and perhaps avoid the release of the rule all together. To be successful in this endeavor, it is CRUCIAL that we not only have individuals and health centers submitting public comments, but that we encourage state entities and representatives to do the same, since they could help provide economic impact analysis that could derail the implementation of the rules.


Through the National Health Center Immigration Workgroup, we will be developing template letters that health centers can use to submit their public comments. We will also discuss resources and tools that could help health centers encourage their elected officials to submit public comments against changes to the public charge rule.


Refugees welcomeJoin the Protecting Immigrant Families (PIF) Campaign
If you are interested in learning more about public charge, are would like to take a more active role in advocating against changes to the public charge rule, please join the Protecting Immigrant Families (PIF) Campaign by going to http://bit.ly/PIFCampaign.


PIF has created a sign on letter to oppose changes to the public charge rule. PIF is asking organizations to sign on now, to allow the letter to be released at the moment the rules are officially released. If you're interested in adding your organization please click HERE.


Also, the National Immigration Law Center (NILC) and FWD.US are creating a portal to help people submit public comments once the Notice of Proposed Rulemaking is published. Sign up for the PIF campaign to receive updates on its availability.


What are some Helpful Resources for Health Centers?
Below please find resources created by CPCA, CaliforniaHealth+ Advocates and our immigrant partners.


Resources Created by CPCA & CaliforniaHealth+ Advocates

  • Public Charge Factsheet and Talking Points
    In coordination with the Protecting Immigrant Families (PIF) coalition, CPCA staff created high-level talking points and a fact sheet that give background on the public charge law and discuss possible high-level ramifications if the Administration expands the definition of public charge. CPCA has been using these documents to discuss public charge while we await the Office of Management and Budget to release the official rules.
  • CPCA's Immigration Resource Page
    CPCA has developed the Immigration Resource Page to help create a centralized library of the documents available around immigration that can help our health centers educate themselves and patients on immigrant issues. In our website you will find sample policies and procedures that can help health centers protect patients and prepare staff for the possibility of an immigration raid, talking points to help frontline staff answer questions by their immigrant patients, and resources concerning public charge. You may access our immigration resource page by clicking HERE.
  • Public Charge Webinar
    CPCA, in partnership with AAPCHO and NACHC, hosted a webinar on May 9th to help health centers and other state PCAs better understand the public charge rule. During the webinar Gabrielle Lessard from NILC provided an in depth overview of the public charge rule, and the proposed changes. Thu Quach from Asian Health Services, a health center in California, provided an overview of their advocacy efforts around public charge while also sharing best practices with challenges they've encountered in their work. To watch the free recording please go to CPCA's website.


Resources Created By Immigrant Partners




NWRPCA welcomes and regularly publishes white papers and articles submitted by members, partners and associates with subject matter expertise. The appearance of any guest publication in our Health Center News database represents the views of the author and does not constitute endorsement by NWRPCA of the stated opinions or perspectives, nor does it suggest endorsement of the contributor's products or services.

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