A new immigration rule from the Trump administration that will include Medicaid enrollment as a determining factor for allowing individuals to legally enter the U.S. or change their residency status could lead to a significant drop in Medicaid enrollment, according to healthcare experts.
The U.S. Department of Homeland Security will now use public benefits like Medicaid and food stamps to help determine if someone is a "public charge." This is the federal government's measure of an individual's reliance on government assistance. If an individual is determined to be a public charge, they can be barred from entry or not allowed to change residency status, according to the U.S. Citizenship and Immigration Services.
Medicaid has been used in the public charge determination in a limited way in the past, according to the Kaiser Family Foundation, a nonpartisan healthcare policy organization. But DHS is now expanding the definition of public benefit to include a broader use of the program, the dual state and federally run health insurance program that mainly covers people with low incomes.
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DHS said the rule, finalized Aug. 12, will ensure "self-sufficiency." However, healthcare experts and providers believe the changes could result in individuals and families losing their Medicaid.
An Aug. 12 joint statement from six hospital groups, including the American Hospital Association and the Federation of American Hospitals — which represents companies such as HCA Healthcare Inc. and Community Health Systems Inc. — said the policy could "lead to delays in care that would negatively impact the health of the communities we serve." The hospital groups asked the Trump administration to withdraw the rule.
A lawsuit led by Washington state challenging the rule asserts that private hospitals in the state will be forced to take on more expensive uncompensated care, which will ultimately impact the state treasury.
The Massachusetts Executive Office of Health and Human Services projects that hospitals in the state could lose about $457 million in Medicaid and Children's Health Insurance Program funding due to a "chilling effect" the rule will have on enrollment, according to the lawsuit.
Twelve other states have signed on to Washington's lawsuit, which alleges that DHS has no authority to make the changes outlined in the rule. California, Oregon, Maine, Pennsylvania and the District of Columbia have jointly filed a separate lawsuit as well.
Navigating rule's complexity
The public charge rule will take effect Oct. 15, and healthcare organizations and providers are working to prevent unnecessary coverage loss.
Seciah Aquino, a senior policy manager at the California Immigrant Policy Center, said the rule has a very narrow application. Yet people who are not subject to it are dropping their coverage because of "fear and anxiety" in the community.
"Families of mixed [immigration] status, individuals who are not applicable to the public charge rule ... are choosing to disenroll just to avoid having any type of problem with the federal government," Aquino said.
The California Immigrant Policy Center has been conducting training sessions across the state for healthcare and social workers about the specific provisions of the rule, and consulting with legal experts to help people successfully navigate the law.
"It takes immense amounts of energy to just fully digest every single detail," Aquino said.
One example of the rule's complexity regarding Medicaid use is that the DHS will not include state-funded programs that are not cash aid, according to Aquino. For instance, California's recent expansion of Medicaid to young adults who are undocumented is fully funded with state dollars, and therefore people using that program would not count as a public charge, according to Aquino.
Risk of Medicaid enrollment decline
Sara Rosenbaum, a professor of health law and policy at George Washington University, said in an Aug. 15 report that the rule will significantly reduce Medicaid enrollment.
Washington state's Medicaid agency projects that the rule will result in about 140,000 families in the state losing health insurance. Also, about $198 million in medical care will go unused by state residents annually, according to the state's lawsuit.
DHS in the final rule acknowledged the risk that people would be unable to access public benefits like Medicaid, but nevertheless said "self-sufficiency is the rule's ultimate aim."
Centers for Medicare and Medicaid Services Administrator Seema Verma told reporters Aug. 15 that it was premature to discuss the impact to Medicaid enrollment.
"I think at this point it is very speculative to say what will happen and what won't happen," Verma said.
The finalized rule exempted populations like children and pregnant mothers, who were not exempt in the proposed version of the rule, Verma said.

