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A mother from El Salvador has been to the emergency room three times for dangerously high blood pressure and missed every primary care visit in the last year because her MassHealth has expired. She is afraid if she renews, then the government may find and deport her, or, worse, block her sons’ green card applications.
As primary care physicians in Greater Boston, we know our immigrant patients and their families forgo vital nutrition, health and housing services every day for fear of consequences for their status as non-citizens. We are concerned that the Trump administration’s recently proposed rule, which expands the designation of a “public charge,” further endangers the health and well-being of our immigrant patients and the community at large.
Current guidelines define a public charge as someone who is primarily reliant on the government as their main source of support. (An immigrant can be denied legal permanent residence or a visa if they are designated a “public charge.”) While currently the only benefits considered in determination of public charge are cash assistance and government-paid institutional care, a Trump administration proposal would expand the designation to consider additional benefits, including non-emergency Medicaid, Medicare Part D prescription drug assistance, Supplemental Nutrition Assistance Program (SNAP, i.e. food stamps) and certain federal housing vouchers. It will, as Dara Lind for Vox wrote, “make it extremely difficult for many immigrants to come to the U.S. or receive green cards” if it appears they are likely to seek access to public benefits.
This proposal is doubly harmful. First, it forces immigrants who qualify for public benefits — a small but vulnerable group, including low-income pregnant women — to make a false choice between a chance at legal permanent residence and essential needs. Second, because of the rule’s complexity and ambiguous language, many immigrants may disenroll themselves and their U.S. citizen children from benefit programs, even if the proposed rule doesn’t actually apply to them. For example, the rule does not apply to refugees or asylum seekers, but we know asylum seekers who refuse to apply for MassHealth for fear of jeopardizing their legal cases with U.S. immigration officials.
Nobody should have to choose between staying in this country or visiting the doctor.
Patients may also disenroll from programs that are not covered by the changes, such as the Children’s Health Insurance Program (CHIP) or the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Some might argue that American taxpayers should not be bearing the cost of medical care for immigrants; however, immigrants pay billions of dollars in taxes each year and actually subsidize the care of American-born patients. We know that access to health insurance and programs like SNAP and WIC promote healthy families and reduce health care costs.
Without health insurance, many patients wouldn’t be able to access preventive care — blood pressure and diabetes screening, contraception, and vaccinations — so they would be more likely to visit urgent care and emergency rooms with advanced chronic disease, leading to increased healthcare costs and mortality rates.
The proposed rule change would also be devastating to the public health system. Massachusetts, alone, stands to lose $2.1 billion in Medicaid and CHIP spending, because people who would normally access those services, may opt to be uninsured instead. This could result in an increase in uncompensated care, which may force community health centers and hospitals in underserved communities to cut services that benefit U.S. citizens and immigrants alike. Lack of vaccinations and treatment for communicable diseases could cause outbreaks that threaten the broader public health.
For all these reasons, we joined colleagues in five our country’s largest medical associations in opposing the proposed changes to the public charge rule.
Although the public comment period is now over, the battle to protect access to health care for immigrants is only beginning. We must continue to reassure our patients — like the immigrant mother nervous to renew her MassHealth and the asylum seeker too anxious to enroll — that nothing has changed, yet, and they should keep their benefits.
We hope this rule never takes effect. But if it does, it may only do so after the administration addresses over 200,000 public comments (far more than any regulatory proposal typically receives). We stand with our immigrant patients, co-workers and communities. Nobody should have to choose between staying in this country or visiting the doctor.
The writers are members of the Health and Law Immigrant Solidarity Network (HLISN). Drs. Jasrasaria and Henderson-Frost are internal medicine residents at Massachusetts General Hospital; Dr. Jirmanus is at family physician at Cambridge Health Alliance; Dr. Kimball is a primary care physician at Boston Medical Center; and Dr. Zeidman is a primary care physician at Massachusetts General Hospital.
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