On October 10, the US Department of Homeland Security issued a proposed change in federal immigration policy that would have a major impact on the health and well-being of millions of legal residents – hundreds of thousands here in Massachusetts. These new “public charge” rules would make using Medicaid, the Supplemental Nutrition Assistance Program (SNAP), or the Children’s Health Insurance Program (CHIP) a reason for denying immigrants permanent residency in the country. As Douglas Jacobs, MD, internal medicine resident at Brigham and Women’s Hospital put it in a recent New York Times editorial, this new policy threatens patients with “a harrowing choice: their health, or their immigration status.” Not only would this policy harm thousands of lower-income immigrants and their families, it could also have a chilling effect that would prevent many legal residents from seeking the care they need – and to which they’re legally entitled.

At Partners, we see fostering the health of our community as our primary mission. That’s why we feel compelled to take action to prevent the implementation of this cruel and unhealthful change in immigration policy. On December 10, David Torchiana, MD, President and CEO of Partners HealthCare, and the presidents of eight Partners hospitals submitted a formal response in opposition to the proposed public charge rules – a stance based not on politics, but on our deeply held values and our expertise in matters of public health. The full text is included below:


Dear Secretary Kirstjen Nielsen:

Thank you for the opportunity to comment on the proposed rule entitled “Inadmissibility on Public Charge Grounds,” 83 Fed. Reg. 51114 (October 10, 2018), issued by the Department of Homeland Security (DHS or the Department). (1)

Partners HealthCare (Partners) is an integrated health care system founded by Brigham and Women’s Hospital and Massachusetts General Hospital. In addition to its two academic medical centers, the Partners system includes community and specialty hospitals, a managed care organization, community health centers, a physician network, home health and long‐term care services, and other health care entities. Partners HealthCare is committed to patient care, research, teaching, and service to the community.

Partners strongly opposes DHS’ proposal to broaden the grounds for which an applicant for lawful permanent residency would be deemed a “public charge.”

Specifically, we are concerned with how the proposed rule will impact the health and well‐being of the patients and the communities we serve and the financial consequences that patients and hospitals and community health centers will face if the rule is finalized

Health Impact

The DHS proposed rule expands the benefits that could be used to determine whether a person is likely to become a public charge to include non‐emergency Medicaid, Supplemental Nutrition Assistance Program (SNAP), Medicare Part D Low Income Subsidy, and housing assistance. If the rule is finalized, our patients may choose to forgo these vital coverage programs and supports critical to their health and well‐being, at a time where we, as an organization, are focused on the social determinants of health.

The proposed rule would deter immigrants from participating in two important health programs: the Medicare Part D Low Income Subsidy, which helps Medicare recipients afford their prescription coverage; and MassHealth, the Massachusetts Medicaid Program, which provides health coverage to Massachusetts residents who would otherwise go uncovered. If this proposed rule were to go into effect, many of our residents would forgo prescription coverage and health insurance as they would fear participation would impact their ability to stay in the United States. Research has shown that individuals without health insurance are less likely to receive preventative care and manage their chronic conditions, which negatively impacts clinical outcomes. Partners HealthCare’s Medicaid Accountable Care Organization (ACO), Partners HealthCare Choice, manages over 100,000 Medicaid patients, many of whom would be at risk of disenrolling from benefits due this proposed rule.

In addition to access to care and prescriptions, a growing body of evidence has shown that social and economic factors, including food security and housing, can affect the risk of disease and health outcomes. Our Medicaid ACO provides programs that focus on connecting our patients with programs to improve these social determinants, including community health workers and community resource specialists, as well as social determinants screenings for all our ACO members. These factors, combined with health behaviors, have been estimated to account for eighty percent of a person’s health outcomes.

It is vital for the long-term health and security of our patients to have access to benefits that both SNAP and housing assistance offer, two programs that improve the social determinants of health.

DHS recognizes that the proposed rule could lead to worse health outcomes, increased prevalence of communicable diseases and increased rates of poverty and housing instability. As an organization dedicated to improving the health and welfare of our patients and communities, Partners strongly opposes the inclusion of health, nutritional, and housing benefits as factors in making public charge determinations.

Chilling Effect

If finalized, the impact of the proposed rule described above will be far reaching, impacting immigrants and immigrant families whether the rule applies to them directly or not. DHS estimates that the proposed rule will result in a 2.5 percent rate of disenrollment, or forgone enrollment, across all of the public benefit programs included in the rule. This rate of disenrollment does not consider the additional individuals who would disenroll out of confusion, uncertainty or fear, despite acknowledging this “chilling effect” in the rule’s preamble. Though the rule has not been finalized, our providers have seen qualified immigrants attempting to and disenrolling from benefits for which they are entitled and need to survive.

Further, family members of immigrants will also lose access to fundamental benefits. U.S. born citizen children of immigrants, for example, would not be able to access SNAP or housing benefits if their immigrant parent was concerned with being at risk for being considered a public charge. This is no small threat- in 2016, one in four children in the United States has at least one immigrant parent. (2)

Anyone with a non-citizen family member may second-guess enrolling in these critical public programs. Manatt Health estimates the Medicaid/CHIP population that could be subject to the chilling effect is approximately 13.2 million nationwide. (3) As many as 500,000 Massachusetts residents, including 160,000 children could withdraw from needed housing, health and food benefits alone. (4) The implementation of this rule would lead to profound consequences on the well-being and likelihood of long-term success for our communities.

Financial Impact

If the proposed rule is finalized as drafted, it is likely that Partners and other health care providers will see a decrease in Medicaid payments and an increase in uninsured patients and uncompensated care. According to a recent analysis by Manatt Health, an estimated $68 billion of Medicaid/CHIP spending nationwide will be at risk due to the proposed rule and the chilling effect. Massachusetts alone could see a $2 billion reduction, which includes $457 million in hospital payments. (5)

Because Medicaid is mostly a means-tested program, those who drop Medicaid will be unlikely to afford commercial insurance and become uninsured. The uninsured are more likely to forgo preventative care, leading to delayed diagnosis of treatable conditions, and would still need hospital services for emergency and inpatient procedures. These newly uninsured patients will have worse health outcomes, but increased medical debt. The burden will then fall on hospitals that will incur increased bad debt when low-income patients are unable to afford the resulting bills. This rule will likely increase Partners uncompensated care losses. The increased cost of providing uncompensated care to those who forgo Medicaid coverage over time will ultimately result in higher health care costs for all consumers.

Children’s Health Insurance Program (CHIP)

The DHS draft regulations request comments regarding DHS’ potential inclusion of the Children’s Health Insurance Plan (CHIP). For many of the reasons stated above, CHIP should not be a factor included in the public charge determination. In 2017, over 220,000 children in Massachusetts rely on CHIP for their health coverage. (6) These children rely on CHIP for access to check-ups, preventative care and vaccinations.

The proposed rule notes the purpose is to promote self-sufficiency among immigrants. As children are not expected to be self-sufficient in the United States, CHIP benefits should not be a factor in the public charge determination.

Families should not be deterred from seeking health coverage for their eligible children.

Since the rule was released, providers across our system field daily questions from their patients about their ability to keep seeing their doctors and access programs that preserve their health, nutrition and housing. It is clear that, if implemented, families and children will not seek critical health care services and supports on which they rely, undermining our efforts to create strong, healthy communities. It is our view that the Department’s proposed public charge rule will have a far-reaching impact on the health of the communities we serve and the stability of the health care system itself. For the reasons stated above, we urge DHS to withdraw the current proposal.

Sincerely,

David F. Torchiana, MD, President and CEO, Partners HealthCare

Peter Slavin, MD, President, Massachusetts General Hospital

Elizabeth G. Nabel, MD, President, Brigham Health

Scott L. Rauch, MD, President, McLean Hospital

Denise M. Schepici, MPH, President, Martha’s Vineyard Hospital

David E. Storto, President, Spaulding Rehabilitation Hospital and Partners Continuing Care

David O. McCready, President, Brigham and Women’s Faulkner Hospital

Margot Hartmann, MD, PhD, President and CEO, Nantucket Cottage Hospital

Joanne Marqusee, President and CEO, Cooley Dickinson Health Care


Read more about Massachusetts leaders’ opposition to the “public charge” rules in the Boston Globe.

Notes

(1) 83 Fed. Reg. 51114, 51270 (Oct. 11, 2018­)

(2) Samantha Artiga et al., Kaiser Family Foundation, Nearly 20 Million Children Live in Immigrant Families that Could Be Affected by Evolving Immigration Policies (April 2018), https://www.kff.org/disparities-policy/issue-brief/nearly-20-million-children-live-in-immigrant-families-that-could-be-affected-by-evolving-immigration-policies/

(3) Cindy Mann et al., Manatt Health, Medicaid Payments at Risk for Hospitals Under the Public Charge Proposed Rule (November 2018), https://www.manatt.com/Insights/White-Papers/2018/Medicaid-Payments-at-Risk-for-Hospitals-Under-Publ

(4) Wagman, Nancy. MassBudget. A Chilly Reception: Proposed Immigration Rule Creates Chilling Effect for New Immigrants and Current Citizens, http://www.massbudget.org/report_window.php?loc=A-Chilly-Reception-Proposed-Immigration-Rule.html

(5) Cindy Mann et al., Manatt Health, Medicaid Payments at Risk for Hospitals Under the Public Charge Proposed Rule (November 2018), https://www.manatt.com/Insights/White-Papers/2018/Medicaid-Payments-at-Risk-for-Hospitals-Under-Publ

(6) Centers for Medicare & Medicaid Services, 2017 CHIP Annual Enrollment Report, https://www.medicaid.gov/chip/...


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