To read the Blue Shield of California Foundation's letter on the proposed rule change, click here.
December 7, 2018
Chief, Regulatory Coordination Division Office of Policy and Strategy,
U.S Citizenship and Immigration Services Department of Homeland Security
20 Massachusetts Avenue NW Washington, DC 20529-2140
RE: Proposed Rule, Inadmissibility on Public Charge Grounds
Dear Ms. Deshommes:
Blue Shield of California (Blue Shield) writes in strong opposition to the Proposed Rule, Inadmissibility on Public Charge Grounds, published by the Department of Homeland Security (DHS) on October 10.1 If implemented, this policy will cause millions of residents, including non-immigrants and U.S. citizens, to abandon health care coverage and forego needed health care and other essential services—including food and housing. The rule as proposed will have a harmful effect on vulnerable communities across the country, with an outsized impact on pregnant women and children with health conditions. The proposed rule acknowledges this likely harm, saying the rule could lead to, “worse health outcomes, including increased prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants, or children.”2 This runs counter to important initiatives on social determinants of health—including access to food and housing—being championed by other parts of the Administration.3
Blue Shield is a nonprofit and one of the state’s largest health plans, with a mission to ensure all Californians have access to high-quality health care at an affordable price. We proudly serve four million Californians, including 400,000 Medicaid members through our affiliate Care1st Health Plan. We also support the independent Blue Shield of California Foundation (Foundation), funding work that advances the well-being of all Californians, particularly our state’s most vulnerable populations.
Informed in part through research supported by the Foundation, Blue Shield understands the Proposed Rule is antithetical to our mission and jeopardizes the health and well-being of entire communities—including immigrants, non-immigrants, and citizens. We urge DHS and other federal agencies with important expertise to take full measure of the potential damage that would result from this policy if enacted.
The Proposed Rule Significantly Understates the Number of Lives Impacted: DHS’ own preamble recognizes evidence of a “chilling effect,” in which qualified enrollees disenroll from public programs due to confusion, fear, and misinformation about perceived immigration consequences. This is not merely theoretical. Since the proposed rule’s release, public agencies in various parts of California have already reported a sharp rise in people refusing benefits, including pregnant women and young children who are not legally affected by the proposed changes.4
However, DHS gravely underestimates how much its proposed rule would deter enrollment in public programs (324,000 overall, 142,000 for Medicaid according to the proposed rule) by only counting populations directly subject to public charge review (such as foreign-born non-citizens seeking to adjust their status). These numbers are vastly outstripped when factoring in the chilling effects experienced by non-immigrants and U.S. citizens.
A recent analysis finds the policy would result in 2 to 5 million enrollees disenrolling or foregoing participation in Medicaid/CHIP nationwide.5 Among these are 700,000 to 1.6 million children, including hundreds of thousands with serious health conditions.6 In California alone, estimates show that between 317,000 and 740,000 eligible individuals would decline Medicaid coverage.
The Rule Would Reverse the Progress California has Made in Expanding Health Care Coverage: California has reduced the uninsured rate by more than half, from 17 percent to 7 percent. California has covered more people than any other state in the country. We are particularly proud that the uninsured rate for children decreased by 55 percent—more than any other state—and is now the lowest in the nation at less than 3 percent.
California provides health coverage for undocumented children using state funds. This improves health outcomes for the population and also avoids cost-shifting resulting from uncompensated care. The proposed federal rule would deter families of children eligible for health coverage under state law from accessing this coverage. This federal action would undermine a decision by a state government to address a public health concern using state dollars.This would certainly run counter to the principle of Federalism asserted by the Administration in other contexts.
The Proposed Rule Would Cause Significant Harm to Individual and Public Health: Bipartisan experts reviewing the evidence have concluded that health coverage increases access to care and improves a wide range of health outcomes.9 By targeting and discouraging Medicaid use, the proposed rule threatens to reverse these gains for thousands of working households. In fact, DHS’ preamble acknowledges the manifest harms associated with dropping public insurance coverage: reduced prescription adherence, increased emergency care due to delayed treatment, and greater prevalence of communicable diseases.10 It also would lead to an increase in uncompensated care, particularly for safety net hospitals and community health centers serving immigrants and non-immigrants alike.
The proposed rule further erodes individual and public health by discouraging access to SNAP and housing assistance. Penalizing the receipt of food and housing security will upend efforts to address social determinants of health, including innovations spurred by the Department of Health and Human Services.
Moreover, this proposed rule exacerbates a hostile policy environment that has induced fear and toxic stress among immigrant families. Research supported by the Blue Shield of California Foundation has documented these stressors’ toll on children’s physical and mental health—and their opportunities to succeed—across the lifespan.11
Conclusion: The weight of evidence is clear: the proposed rule would inflict devastating consequences, both immediate and long-term, for the health and wellness of our communities. We ask for DHS to withdraw this harmful policy.
Andy Chasin Policy Director
Blue Shield of California
1 As proposed in the Federal Register Volume 83, pages 51114-51296: https://www.gpo.gov/fdsys/pkg/FR-2018-10-10/pdf/2018-21106.pdf
2 See Proposed Rule at page 51270.
3 See speech by U.S. Secretary of Health and Human Services, “The Root of the Problem: America’s Social Determinants of Health,” November 14, 2018 (citing, for example, the importance of nutrition services because, “HHS found that Americans with malnutrition are twice as costly to treat at the hospital as those who come in well-nourished. In fact, malnutrition is involved in 12 percent of non-maternal, non- neonatal hospital stays—$42 billion each year in healthcare spending.” Available at: https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/the-root-of-the-problem- americas-social-determinants-of-health.html
4 See Politico, “'Public charge' rule keeps immigrants away from health programs, advocates say,” November 20, 2018 (“[S]ocial workers and public health officials in states with large immigrant populations say the rule's effects already appear widespread, scaring potential applicants away from health or nutrition programs aimed at children, poor families, people with HIV and other vulnerable populations.”); California Health Line, “Report, Researchers Warn that ‘Public Charge’ Rule Changes Would Lead to Hardship, Economic Losses in California,” November 8, 2018 (“Even though the rule changes would affect a relatively narrow group of people, experts predict hundreds of thousands more Californians could drop out of government programs because of confusion and fear. This so-called chilling effect would disproportionately affect children and Latinos, increasing poverty, hunger and poor health in communities across the state, researchers said.”).
5 Kaiser Family Foundation, “Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid,” October 2018 Issue Brief. Available at: http://files.kff.org/attachment/Issue-Brief-Estimated- Impacts-of-the-Proposed-Public-Charge-Rule-on-Immigrants-and-Medicaid.
6 California Health Care Foundation, “Changing Public Charge Immigration Rules: The Potential Impact on Children Who Need Care,” October 2018. Available at:
7 See UCLA Center for Health Policy Research, “How Proposed Changes to the ‘Public Charge’ Rule Will Affect Health, Hunger and the Economy in California,” November 7, 2018. Available at: https://healthpolicy.ucla.edu/newsroom/Documents/2018/public-charge-seminar-slides-nov2018.pdf
8 See Sacramento Bee, “California’s Uninsured Rate Drops to New Low,” November 21, 2017; Georgetown University Center for Children and Families, “Child Uninsured Rate in California Ranks Lowest in Nation,” November 21, 2016.
9 Sommers B, Gawande A, Baicker K. “Health Insurance Coverage and Health – What the Recent Evidence Tells Us.” N Engl J Med. 2017;377(6):586-93. Available at: https://www.nejm.org/doi/pdf/10.1056/NEJMsb1706645
10 Specifically, the rule cites the risk of “Worse health outcomes, including increased prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants, or children, and reduced prescription adherence.”
11 Kaiser Family Foundation, “Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, and Health,” December 13, 2017. Available at: https://www.kff.org/disparities-policy/issue-brief/living-in-an-immigrant-family-in-america-how-fear- and-toxic-stress-are-affecting-daily-life-well-being-health/