By Leah Zallman, M.D., M.P.H.; Karen E. Finnegan, Ph.D.; David U. Himmelstein, M.D.; Sharon Touw, M.P.H.; Steffie Woolhandler, M.D., M.P.H.
JAMA Pediatrics, July 1, 2019
Abstract
Importance: In October 2018, the Trump administration published a proposed rule change that would increase the chance of an immigrant being deemed a “public charge” and thereby denied legal permanent residency or entry to the United States. The proposed changes are expected to cause many immigrant parents to disenroll their families from safety-net programs, in large part because of fear and confusion about the rule, even among families to whom the rule does not technically apply.
Objective: To simulate the potential harms of the rule change by estimating the number, medical conditions, and care needs of children who are at risk of losing their current benefits, including Medicaid and Children’s Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program (SNAP).
Design, Setting, and Participants: A cross-sectional study used nationally representative data from 4007 children 17 years of age or younger who participated in the 2015 Medical Expenditure Panel Survey to assess their potential risk of losing benefits because they live with a noncitizen adult. Statistical analysis was conducted from January 3 to April 8, 2019.
Main Outcomes and Measures: The number of children at risk of losing benefits; the number of children with medical need, defined as having a potentially serious medical diagnosis; being disabled (or functionally limited); or having received any specific treatment in the past year. The numbers of children who would be disenrolled under likely disenrollment scenarios drawn from research on immigrants before and after the 1996 welfare reform were estimated.
Results: A total of 8.3 million children who are currently enrolled in Medicaid and CHIP or receiving SNAP benefits are potentially at risk of disenrollment, of whom 5.5 million have specific medical needs, including 615 842 children with asthma, 53 728 children with epilepsy, 3658 children with cancer, and 583 700 children with disabilities or functional limitations. Nonetheless, among the population potentially at risk of disenrollment, medical need was less common than among other children receiving Medicaid and CHIP or SNAP (64.5%; 95% CI, 61.5%-67.4%; vs 76.0%; 95% CI, 73.9%-78.4%; P < .001). The proposed rule is likely to cause parents to disenroll between 0.8 million and 1.9 million children with specific medical needs from health and nutrition benefits.
Conclusions and Relevance: The proposed public charge rule would likely cause millions of children to lose health and nutrition benefits, including many with specific medical needs that, if left untreated, may contribute to child deaths and future disability.
Conclusions
Most children who lose Medicaid and CHIP become uninsured. Without coverage, they are likely to forego or delay needed care, and some, such as children with epilepsy or asthma, as well as newborns who require immunizations, are likely to incur higher long-term health care costs. In addition, undertreatment of illness increases school absenteeism and parental work absence, which, in the case of asthma, led to a loss of parental productivity of $719.1 million in 1996 alone.
However, our main concerns are not economic but ethical. We believe that denial of needed health care and nutrition to anyone, but particularly to children, violates human rights. We call on the medical community to speak out against this unjust and unethical proposal to change the public charge rule.
Comment:
By Don McCanne, M.D.
As we struggle to teach the policymakers, the politicians, and our nation at large about the unequivocal practical and fiscal advantages of the single payer model of Medicare for All, we seem to assume that everyone would understand and support the ethics and moral imperative of this model. Sadly, the politicians currently in control apparently do not share this view of health care ethics as they intend to modify the “public charge” rule in a manner that would result in the disenrollment of millions of resident children from the Medicaid and CHIP programs, which will surely expose many of them to adverse health consequences.
Some would frame this as an immigration issue rather than a health care issue. There is no question but that we should have rational and humane immigration policies in place, but when our immigration policies create health problems, then we need to modify the policies. Health should never be a bargaining chip as we address other socioeconomic and political problems.
How often have you heard “zero tolerance” during discussions of immigration? Yet why do we not hear “zero tolerance” during discussions of reform models of health care financing? Except for the single payer model of Medicare for All, all other models would leave tens of millions without adequate coverage, access or affordability.
We need to sort out our values. Instead of using “public charge” as a hammer to deprive people of health care, we need to first make sure that everyone does have essential health care without having to suffer financial hardship. After we declare that as an inviolate right, we can work on our other issues, but we should never, ever consider trading away health care.
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