Legacy Submits Official Comments to DHS on Public Charge

December 7, 2018

The Honorable Samantha Deshommes
Chief, Regulatory Coordination Division, Office of Policy and Strategy
U.S. Citizenship and Immigration Services
Department of Homeland Security
20 Massachusetts Avenue NW, Washington, DC 20529-2140

Re: DHS Docket No. USCIS-2010-0012; Inadmissibility on Public Charge Grounds

Dear Hon. Deshommes:

On behalf of Legacy Community Health, the largest community health center in the state of Texas, we appreciate the opportunity to express our opposition to DHS’ proposed rule Docket No. USCIS-2010-0012; Inadmissibility on Public Charge Grounds. The proposed rule seeks to expand the definition of “public charge” for individuals who seek adjustment of status or a visa, or who are applicants for admission and “proposes to require all aliens seeking an extension of stay or change of status to demonstrate that they have not received, are not currently receiving, nor are likely to receive, public benefits as defined in the proposed rule.” [1]

 With 34 locations across Southeast Texas, Legacy served nearly 170,000 patients in 2018. With the majority of our patient population depending on the state’s Medicaid and Children’s Health Insurance Program (CHIP), Legacy is on the front lines of treating patients that would be directly affected by this proposed rule.

 The proposed rule seeks to add the use of non-emergency Medicaid, Medicare Part D prescription drug benefits, Supplemental Nutrition Assistance Program (SNAP), Section 8 housing assistance and potentially the Children’s Health Insurance Program (CHIP) to the definition of public charge. As the rule itself points out, the expanded definition of public charge could result in “worse health outcomes,” “increased use of emergency rooms,” “increased prevalence of communicable diseases,” “increases in uncompensated care,” and “increased rates of poverty and housing instability”.[2]

 If finalized, the impact of this rule on safety-net providers in Texas would be significant. This proposed rule will drive individuals to seek care in the emergency room setting rather than the preventative care setting, resulting in an increase in uncompensated care costs. A recent study conducted by Manatt concluded payments to hospitals impacted by the public charge proposed rule total an estimated $17 billion for the United States, with Texas being one of the most financially impacted states. [3] The destabilizing impact of this rule will threaten the ability of safety-net providers to serve their communities. 

 According to census data, 4.6 million Texans are foreign born.[4] Harris County, where Legacy is located, is one the most populous counties of foreign born residents in the nation.[5] The Manatt study estimates the proposed rule will impact 22% of Texas Medicaid and CHIP populations, one of the highest impacts in the nation, due to the chilling effect on enrollment due to this proposed rule.[6]

 At Legacy, we are already witnessing the chilling effects of this proposed rule on our immigrant patient populations. Some of our immigrant patients have asked to dis-enroll from public assistance programs, even when the proposed rule does not apply them, out of fear that their use of the programs will be “counted against them.” 

 We have also heard concern from our eligibility staff about how to provide services to patients applying for their green card. At Legacy, patients without insurance are directed to our eligibility staff to review programs or insurance options available to them. Our eligibility staff assists patients with health care coverage, but now they are put in a position of being asked sensitive immigration questions. The federal government should encourage patients to seek preventative care, not limit access, causing the immigrant population to seek care only in emergencies.

 The proposed rule requests comments on whether the CHIP program should be included in the determination of public charge. Legacy opposes including CHIP because its inclusion will likely result in deterring women from seeking high-quality prenatal care and lead to preventable high-risk pregnancies. With Harris County experiencing some of the highest rates of maternal mortality and morbidity in the nation, including CHIP will likely exacerbate an already dire situation, and further threaten access to care for unborn children and their high-risk mothers.

 We have taken an active role in communicating with our state’s congressional delegation regarding the harmful impacts of this rule. We hope that you will reconsider your efforts, and we respectfully request the Department of Homeland Security not finalize this proposed rule.

 Thank you for your consideration of these comments.

 Sincerely,

Katy Caldwell

CEO


[1] Inadmissibility on Public Charge Grounds, 83 Fed. Reg. 51114 (Oct. 10, 2018), https://www.gpo.gov/fdsys/pkg/FR-2018-10-10/ pdf/2018-21106.pdf.

[2] Inadmissibility on Public Charge Grounds, 83 Fed. Reg. 51114 (Oct. 10, 2018), https://www.gpo.gov/fdsys/pkg/FR-2018-10-10/ pdf/2018-21106.pdf.

[3] Mann, Cindy, et al. Medicaid Payments at Risk for Hospitals Under the Public Charge Proposed Rule. Nov. 2018, www.manatt.com/Manatt/media/Media/PDF/White%20Papers/Medicaid-Payments-at-Risk-for-Hospitals-Under-the-Public-Charge-Proposed-Rule_Manatt-Health_Nov-2018-1.pdf.

[4] American Community Survey (ACS) . “United States Census Bureau- 2013-2017 American Community Survey 5-Year Estimates.” American FactFinder - Results, factfinder.census.gov/faces/nav/jsf/pages/community_facts.xhtml.

[5] U.S. Census Bureau QuickFacts: Harris County, Texas; Texas.” Census Bureau QuickFacts, United States Census Bureau, www.census.gov/quickfacts/fact/table/harriscountytexas,tx/PST045217.

[6] Mann, Cindy, et al. Medicaid Payments at Risk for Hospitals Under the Public Charge Proposed Rule. Nov. 2018, www.manatt.com/Manatt/media/Media/PDF/White%20Papers/Medicaid-Payments-at-Risk-for-Hospitals-Under-the-Public-Charge-Proposed-Rule_Manatt-Health_Nov-2018-1.pdf.