Public Charge Letter

December 10, 2018
Samantha Deshommes
Chief, Regulatory Coordination Division
Office of Policy and Strategy
US Citizenship and Immigration Services
U.S. Department of Homeland Security
20 Massachusetts Ave NW
Washington, D.C. 20529-2140
Re: DHS Docket No. USCIS-2010-0012
Dear Ms. Deshommes:
The District Hospital Leadership Forum (DHLF), on behalf of California’s 37 district and municipal public hospitals (DMPH), writes today to express serious concerns about the proposed rule entitled “Inadmissibility on Public Charge Grounds” published on October 10, 2018 in the Federal Register (83 FR 51114), and to urge the Department of Homeland Security (DHS), as a result, to withdraw the proposed rule.  The issue of most concern to us is the impact this policy could have on immigrants’ ability to access timely health care outside of the hospital emergency room. This proposed rule could create barriers to enrollment in Medicaid which would cause patients to skip preventive and other critical medical services. The proposed rule would also put an additional strain on an already fragile medical system by increasing the financial losses hospitals and health systems across the country face when the number of uninsured seeking care increases as a result.
California’s DMPHs are a diverse group of hospitals located throughout California from San Diego County to Modoc County.  Some are very small (three acute beds) but provide vital community services, including emergency and long-term care and are the sole provider in the community.  Other DMPHs are located in suburban/urban areas and are large (500 acute beds) but similarly provide necessary hospital services, such as teaching, trauma, and comprehensive inpatient and outpatient services.  Two-thirds of these hospitals are located in rural California and many are Critical Access Hospitals.  For several of these hospitals, they are the only source of health care in their communities and/or for residents within 100-mile radius.
Under current law, immigrants who are likely to become a burden on the government as demonstrated by receiving cash assistance can already be excluded from obtaining citizenship. This draft rule would expand the definition to include individuals who “use or receive one or more public benefits” including programs like Affordable Care Act subsidies, SNAP (formerly Food Stamps), subsidized benefits under Medicaid, and the Children’s Health Insurance Program. This is a substantial expansion of the definition of a public charge.
The proposed rule allows for determinations of public charge inadmissibility within the context of an immigrant’s overall situation — referred to as the “totality of circumstances” test. The rule proposes using a weighted evaluation system that compiles “positive factors” and “negative factors” to determine whether an immigrant is a public charge. Health Care would be a factor considered, and an individual would be expected to provide their past medical records in some cases. The proposed rule deems health conditions that require treatment to be among the heavily weighed factors. The proposal specifically states that “an alien is at high risk of becoming a public charge if he or she has a medical condition and is unable to show evidence of unsubsidized health insurance.”
We believe that this proposed rule will ultimately encourage immigrants to forgo medical care, both preventive and outpatient primary care services, out of fear that accessing services would make them deemed a burden on the government and could impact their immigration status. Commonly referred to as “care avoidance,” an individual will only seek medical care in emergent situations then as a result. Accessing care in the emergency room costs both the government and the provider more in the end. Additionally, not receiving preventative health care services such as vaccines and screenings also puts a burden on the emergency room as the patient instead shows up seeking treatment for illnesses that could have been prevented or treated earlier in a less expensive setting. Public hospitals like ours would also experience higher rates of uncompensated care which would impact our ability to provide healthcare to all patients in the community who need us, regardless of health insurance status.
The District Hospital Leadership Forum opposes any proposal that would create barriers to health care access. The significant impact on the health care system, including the increase in costs related to using the emergency room as the only place to receive health care, should be taken into consideration, as well as the burden put on the system by ultimately increasing the number of uninsured. For these reasons, the DHLF urges DHS to withdraw the proposed rule. Thank you for the opportunity to submit comments.
Sherreta Lane
Senior Vice President of Policy & Finance