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

Advocacy Alert: US Senate Contacts

As you know, the Senate currently is working to try to pass a ACA repeal bill with the vote likely occurring when Congress returns from the Fourth of July recess. Both California Senators will oppose the legislation and are working with health care industry leaders in California on a strategy to reach out to our colleagues and friends/family in targeted states to encourage Senator’s from those states to vote against the bill. This advocacy alert is in line with an alert you will receive from CHA today that encourages you to make contact with colleagues and family in key states to ask them to weigh in with their Senators. Contact information is below. Also attached is a summary of the Senate bill that came from Senators Feinstein and Harris’s office.

Yesterday, as you heard, Congressional Budget Office (CBO) released their score of the Senate bill. The Senate Republicans’ACA repeal-and-replace bill would result in 22 million more uninsured people over 10 years and a $321 billion budget deficit over the same period, according to the score.  The analysis is seen as a hurdle for Republicans as they look to pass their bill next month.

Contact info for target Senators:

Email contact pages to Senators may not let you submit if you’re from outside the state, but if you know anyone in the target states (including perhaps staff of hospitals in neighboring states with whom you coordinate), pass the link along. You can make phone calls and tweet targeted Senators.

Senator Susan Collins (Maine)



Phone: 202-224-2523


Senator Dean Heller (Nevada)



Phone: 202-224-6244


Senator Lisa Murkowski (Alaska)



Phone: 202-224-6665


Senator Rob Portman (Ohio)



Phone: 202-224-3353


Senator Jeff Flake (Arizona)



Phone: 202-224-4521


Senator Shelly Moore Capito (West Virginia)



Phone: 202-224-6472


Additional resources:


Real stories from Covered California:

Georgetown Center for Children and Families

  • Report: Medicaid in Small Towns and Rural America

Commonwealth Fund

  • Report : Medicaid Cuts and Hospital Finances

Kaiser Family Foundation:

  • State by state Medicaid numbers and fact sheets for each state: Link
  • Interactive state-by-state map – what’s at stake with ACA repeal: Link
  • Overall comparison of Senate bill, House bill, and ACA: Link
  • Breakdown of current federal vs. state spending under Medicaid: Link


If you have any questions, please let me know.  And thank you for your ongoing grassroots advocacy.



SB 538 (Monning) – OPPOSE

Dear Senator Lara:

The District Hospital Leadership Forum (DHLF), on behalf of California’s district and municipal public hospitals (DMPHs), is opposed to SB 538 (Monning).

The contract provisions this bill seeks to prohibit are tools used to negotiate fair contracts on behalf of California patients served by these hospitals.   By preventing health plans and hospitals from reaching certainty in how their contractual relationships are governed, the unintended consequences of this bill would disrupt healthcare services and increase costs for patients served at all California hospitals, including district and municipal hospitals.

This bill provides an unfair contracting advantage to large, sophisticated health plans. California’s district and municipal hospitals range in size; some serve urban populations and others offer access to acute and long-term care in rural communities. California’s district and municipal hospitals are primarily stand-alone hospitals, more than two-thirds are rural and half have a critical access hospital (CAH) designation. Imposing additional onerous administrative requirements diverts resources away from the provision of health care. Many DMPHs do not have staff dedicated to contract negotiations while California’s large health plans have significant resources for this purpose.

The California market is dominated by a handful of insurance companies. Allowing market dominant health plans to negotiate with small, independent hospitals in a manner that disrupts their healthcare delivery systems will harm consumers and compromise access to care. The inequitable advantage given to health plans under this bill, especially in negotiations with non-system, often rural hospitals will result in the loss of critical healthcare services in underserved communities; the discontinuation of new healthcare services; increased healthcare costs; and a new surge in out-of-pocket expenses for patients.

SB 538 allows “cherry-picking” by monopolistic health plans of healthcare services. Many DMPHs have invested in creating integrated systems to best serve their communities. These “systems” (not to be confused with the large hospital systems that are prevalent in California’s urban areas) include the hospital, outpatient clinics, medical groups and other providers to ensure the patients are able to have the full spectrum of their care coordinated. Prohibiting DMPHs from negotiating on behalf of clinics and other healthcare providers making up this system that serves a community will result in costly, confusing care for patients. This would have the unintended consequence of uncoordinated care rather than the coordinated care all healthcare stakeholders agree is the goal.

Supporters of SB 538 paint the bill as a solution to reducing healthcare costs and dismantling what they perceive as “market dominant” providers. DMPHs are the opposite of “market dominant” providers and would be seriously harmed in negotiations with “market dominant” health plans.

For these reasons, we respectfully ask for your “NO” vote on SB 538. For further information, please contact the DHLF legislative advocates, Kathryn Scott at or 916-812-4706 or Meghan Loper at or 916-446-7843.




Sherreta Lane

Vice President, Finance Policy


cc:          The Honorable Bill Monning

Honorable Members of the Senate Appropriations Committee

Brendan McCarthy, Consultant, Senate Appropriations Committee




Advocacy Trip to Washington D.C.

A group of DHLF members traveled to Washington, D.C. the week of 5/22/17 to advocate on issues related to the ACA repeal/AHCA on behalf of California’s district and municipal hospitals.  The members were successful in communicating the district/municipal hospital concerns with the AHCA.  Additionally, they were able to hear representatives’ input regarding the discussions and decisions that led to the vote in the House.  

It was a busy two days of meetings as this group met with approximately 30 Congressional Representatives and/or their staff and the staff of the two U.S. Senators.  Each of the hospital members were able to meet with representatives and/or staff from their local areas.  Additionally, meetings were held with Republican Representatives with district/municipal hospitals in the district as well as Congressional Representatives who serve on key committees.  Your colleagues did an excellent job outlining concerns and describing district/municipal hospitals’ challenges for both those in attendance and those unable to make the trip. 

A giant thank you to the DHLF delegation pictured below:  Elly Garner, Govt Affairs Director, Palomar Health; Gary Herbst, CFO, Kaweah Delta Healthcare District; John McCormick, CEO, Oak Valley District Hospital; Donna Hefner, CEO, Sierra View Medical Center; Harry Weis, CEO, Tahoe Forest Health System; Steve Clark, DHLF staff; Ted Owens, Govt Affairs Director, Tahoe Forest Health System; and Melanie Van Winkle, CFO, Mammoth Hospital.  And a huge thank you to Charity Bracy, DHLF federal advocate who coordinated the trip (constant schedule changes and all). 

As we heard in DC, it is critical for Representatives (especially the Republicans) to hear directly from their constituents.  They will be in their districts in August so we encourage you to invite them to your hospital during that month.  DHLF staff stands ready to assist with this.  And for future advocacy trips (both to DC and Sacramento), it is important that our elected officials hear directly from those of you on the front lines of providing health care to community members. 

As references (and for the tours in the district), I’m attaching the key documents we used in Washington.






Letter to California Congressional Delegation

Attached is a letter the DHLF sent on February 1 to the California Congressional Delegation outlining California’s district and municipal hospitals’ concerns with efforts in DC to repeal the Affordable Care Act.

On behalf of the patients served by these hospitals the top priority is protecting Medicaid expansion. California stands to lose an estimated $15 billion annually in federal funding for Medicaid expansion and insurance subsidies — more than any other state. Based on the expansion of the Medi‑Cal program, caseloads have increased from 7.9 million in 2012‑13 to a projected 14.3 million in 2017‑18.  California’s district/municipal hospitals are projected to lose approximately $400 million annually if the Medicaid expansion population is eliminated. Without coverage, the Medicaid expansion population will resort back to obtaining access to health care in emergency rooms where care is more expensive or they will forego care, especially preventative services.  Elimination of Medicaid expansion will increase demands for uncompensated care and reduce revenues, which ultimately will impact access to care for any person trying to obtain access to health care at that facility.   Today, these individuals are receiving the appropriate healthcare services at the right time and in the right setting.  Revoking coverage will negatively impact many Californians’ health status.