Regulatory Coordination Division
Policy and Strategy
Citizenship and Immigration Services
of Homeland Security
Massachusetts Ave. NW
electronically through www.regulations.gov.
of Proposed Rulemaking; Inadmissibility on Public Charge Grounds, DHS Docket
No. USCIS-2010-0012, (Vol. 83, No. 196, October 10, 2018)
of our 142 member hospitals and health systems, the Minnesota Hospital
Association (MHA) offers the following comments regarding the Department of
Homeland Security (DHS) proposed rule regarding inadmissibility on public
charge grounds. MHA
is concerned by DHS’ proposed broadening the factors
used in public charge determinations, which would lower the threshold for
public charge determinations from “primarily dependent” to “likely to receive a
public benefit,” expand the list of public benefits considered and apply a
specific income rule.
The proposed rule is a
significant departure from the current criteria used in public charge
determinations, which considers whether an individual is “primarily dependent”
on cash assistance or receiving long-term care at the government’s expense. The
proposed rule would broaden the criteria in public charge determinations to
include receipt of even modest amounts of benefits from Medicaid, the Medicare
Part D Low-Income Subsidy Program, the Supplemental Nutrition Assistance
Program (SNAP) and housing assistance. It would also give weight to criteria
related to income, health status and age, among others. The proposed income
criteria could limit future immigration status for low- and moderate-income
legal immigrants, whose incomes are below 250 percent of the federal poverty
In the preamble to its
proposed rule, DHS acknowledges that the rule could decrease the disposable
income and increase the poverty of families and children – including U.S.
citizen children – and that immigrants forgoing benefits could experience lost
productivity, negative health effects, increased medical expenses due to
delayed health care and increased disability claims.
These foreseeable and
likely outcomes from the proposed rule could jeopardize access to health
services for legal immigrants across Minnesota, threatening the health of
individuals and public health. Increasing barriers to accessing health care,
such as prenatal care, well-child visits and immunizations, increases the risk
of poor health outcomes, such as preventable disease outbreaks. In 2017,
Minnesota experienced a preventable measles outbreak endangering public health,
stressing the health care system and costing the state more than $1 million.
Minnesota’s hospitals and health systems have already experienced a chilling
effect as legal immigrants decide to forgo health benefits, including Medicaid
and Children’s Health Insurance Program (CHIP) benefits, out of fear that
receiving public assistance may affect their future immigration status.
While the proposed rule
does not recommend eligibility changes to Medicaid, legally present immigrants,
as well as their citizen family members, choosing to either unenroll from or
not apply for Medicaid coverage could put millions of individuals and their
families at risk for loss of coverage, which could result in a delay accessing
care. Delayed care often exacerbates medical conditions, leading to sicker
patients and higher reliance on hospital emergency departments. Delayed care
also increases health care costs, consequently putting hospital payments in
Under the proposed
rule, hospitals are likely to experience increases in uncompensated care and
bad debt costs, leading to greater financial strain for the hospitals and
making it difficult for them to maintain current services. This would
negatively affect access to health care for the whole community, not just
immigrants targeted by the new rule.
An analysis prepared by
Manatt Health examines the implications of the chilling effect for state
Medicaid and CHIP programs as well as Medicaid hospital payments. Overall, the
analysis shows that as many as 13.2 million people could be affected by the
rule’s chilling effect in one year. This loss of coverage translates, for the
Medicaid and CHIP programs, to an estimated $68 billion in health care services
that would be at risk. For hospitals nationwide, this loss of coverage puts an
estimated $17 billion in hospital payments at risk.
Based on this analysis,
Minnesota’s hospitals and health systems could see a reduction of $157 million
in payments. The estimated loss in Medicaid and CHIP payments would
disproportionately fall on Minnesota’s hospitals and health systems that
provide care for the largest number of vulnerable patient populations. Minnesota’s
state Medicaid and CHIP funding would be reduced by $812 million under the
concerned that the likely loss of coverage resulting from these policies could
have a significant, detrimental impact on the vulnerable populations across
Minnesota as well as on the state’s Medicaid and CHIP programs.
Medicaid, Medicare Part
D Low-Income Subsidy Program, SNAP and housing assistance are programs that
have improved participants’ health, well-being, school success and economic
security. MHA believes immigrant families should
not feel they must choose between future immigration status and their ability
to meet basic needs by accessing healthy food, adequate housing and health
you for your consideration of our concerns. If you have any questions, please feel free to
contact me at 651-603-3498 or email@example.com.
Director of Policy
Cindy Mann, et al.,
Medicaid Payments at Risk for Hospitals Under the Public Charge Proposed Rule,
Manatt Health (November 2018) available at https://www.manatt.com/Manatt/media/Media/PDF/White%20Papers/Medicaid-Payments-at-Risk-for-Hospitals.pdf.