Originally published by The NY Times
Scrolling down the list of my primary care patients, I wondered who might be affected. A pregnant woman from Cameroon. An elderly woman with brittle bones from the Dominican Republic. A man with cancer from Ecuador. The Trump administration’s proposal to deny green card status to people who use services like food assistance and Medicaid threaten several of my patients with a harrowing choice: their health, or their immigration status.
A “public charge” is someone that the United States deems likely to be primarily dependent on the federal government for subsistence. The government can prevent public charges from adjusting their status from a visa category (such as work visa) to a legal permanent resident (green card holders). Immigrants thus have strong incentives to avoid this designation.
Historically, the government has designated as public charges only those immigrants who receive cash assistance from programs like Temporary Assistance for Needy Families in amounts that represent more than half of their personal income.
But the new rule proposed by the Department of Homeland Security — which is expected to be published in the Federal Register on Wednesday and opened to a 60-day public comment period — significantly broadens that set of programs.
If the proposed rule is adopted, programs that are crucial for my patients’ health, including Medicaid, the Supplemental Nutrition Assistance Program (once known as food stamps), housing assistance and Medicare Part D (the prescription drug benefit), would all count toward the designation of a public charge.
Accordingly, my pregnant patient from Cameroon may have to decide whether becoming a permanent resident is more important than providing her unborn child with the nutrients required to live a long life. My patient from the Dominican Republic may have to decide whether becoming a permanent resident is more important than taking the medication that will strengthen her bones and prevent a hip fracture.
Even if my patient from Ecuador decides the unthinkable, forgoing Medicaid and chemotherapy to let his cancer slowly consume his body, the federal government could identify his cancer as a reason for denying him legal permanent resident status. This is because health conditions, in and of themselves, would also become heavily weighted factors in a public charge designation under this rule.
Among the stated reasons for the proposed change is that it will inspire an increase in “self-sufficiency,” feeding into the larger narrative that those who use these programs become dependent on the government. This notion is both factually baseless and harmful to my patients and their families. These public assistance programs often provide the gateway not only to health but also to economic self-sufficiency.
Research published in 2012 found that access to food stamps during childhood led to a significant reduction in obesity, high blood pressure and diabetes in adulthood.
Housing assistance via the federal Housing Choice Voucher, formerly known as Section 8, makes rent affordable and helps families avoid homelessness, putting parents in a better position to secure permanent employment.
Low-income subsidies for Medicare Part D make medication more affordable, and studies have demonstrated that reduced medication costs are associated with better adherence to treatment and improved health outcomes. It should come as no surprise, then, that people who take their prescribed medicines also have fewer missed days of work and less reliance on short-term disability.
Medicaid itself has been associated with a reduction in mortality, with a recent estimate predicting one life saved annually for every 239 to 316 adults gaining insurance.
While the benefits of these public assistance programs seem clear, even if one rejected this research we have a moral obligation to provide basic human services to legal immigrants. We shouldn’t shroud the truth: The regulation will physically harm immigrants. It will also inflict pain on their children, who may have the most to lose as their parents are pushed to partly forfeit health care, nutrition and shelter assistance. One in four children (19 million in all) in this country has immigrant parents, and nearly nine in 10 of these children are citizens.
Even without the rule going into effect, the fear surrounding it has magnified the calamity. In 18 states, nearly two-thirds of licensed providers for the federal Women, Infants and Children nutrition program have reported already seeing a decline in caseloads, some by as much as 20 percent. If this rule is put into effect, one million immigrants are expected to drop Medicaid.
To be clear, no immigrant should remove himself from public assistance programs, at least until the rule is made final, and we still have several steps before that would become a reality. And immigrants, even with the rule, would still be allowed a paltry 12 months of Medicaid in a three-year period before being labeled public charges. But this fear, stoked by our president and carried out by brutal regulations, may cause immigrants like my patients to shy away from the government’s helping hand for decades to come.
During the health care debates in 2010, opponents of expanding coverage frequently spoke about reform getting in the way of the doctor-patient relationship. What they don’t seem to understand is that my relationship with my patients is predicated on their ability to get insurance coverage like Medicaid. My ability to prescribe medications to treat diseases for the elderly is dependent on Medicare Part D. And my counsel about healthy food will fall on deaf ears if nutritional assistance is forgone.
Our government should not torture our nation’s must vulnerable immigrants by forcing them to choose between their citizenship status and their health. Immigrants should not have to give up food, shelter and health care to pursue the American dream.