Minnesota Hospital Association

Policy & Advocacy

rules, regulations and comments

The Minnesota Hospital Association continually monitors state and federal rules and regulations to keep members informed and advocates on behalf of members regarding the impact of regulations on the state’s hospitals and health systems. MHA submits comment letters to share recommendations and feedback with the appropriate government organizations and health care stakeholders. Examples of rules and regulations that MHA addresses include those implementing federal or state health care reform efforts, changing payment methodologies, establishing community benefit or other standards for tax-exempt organizations, or modifying government oversight of health care activities.

December 10, 2018

MHA comments on DHS proposed rule regarding inadmissibility on public charge grounds

Dec. 10, 2018   

Ms. Samantha Deshommes
Chief Regulatory Coordination Division
Office of Policy and Strategy
U.S. Citizenship and Immigration Services
Department of Homeland Security
20 Massachusetts Ave. NW
Washington, D.C. 20529-2140   

Submitted electronically through www.regulations.gov.   

RE: Notice of Proposed Rulemaking; Inadmissibility on Public Charge Grounds, DHS Docket No. USCIS-2010-0012, (Vol. 83, No. 196, October 10, 2018)   

Dear Ms. Deshommes:    

On behalf 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 line.   

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 jeopardy.    

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 proposed rule.[1]

MHA is 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 care.   

Thank you for your consideration of our concerns. If you have any questions, please feel free to contact me at 651-603-3498 or bnordparish@mnhospitals.org.   

Briana Nord Parish
Director of Policy 

[1]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.