Health & Medicine

California’s family doctors say Trump’s proposed immigration rule threatens public health

The public can make comments on the proposed immigration rule at
The public can make comments on the proposed immigration rule at Cathie Anderson

California’s family physicians are warning federal officials that a proposed change in immigration rules will put public health at risk because it weakens “herd” immunity, especially in the Golden State where one in every two children has a foreign-born parent.

The Trump administration on Wednesday proposed changes to a federal rule that, immigration experts say, creates ambiguity about what it means to be an immigrant who depends on the government for their support. In the parlance of immigration, such a person is called a “public charge,” and getting saddled with that label can ruin a shot at permanent U.S. residency for many immigrants.

“The new rule would make it difficult for any temporary visitor to adjust his or her status to get a green card if he or she had lawfully or otherwise used health and other public benefits,” said Kevin Johnson, the dean of the King Hall law school at UC Davis. “Immigrant rights advocates fear that it will discourage all non-citizens from using public benefits, even ones they are lawfully entitled to.”

Comments from two Sacramento-area congressional leaders reflected the wide ideological divide separating Democrats and Republicans. U.S. Congresswoman Doris Matsui, a Democrat representing Sacramento, called the proposal another example of the Trump administration’s cruelty. U.S. Rep. Tom McClintock, a Republican, represents voters in a district that stretches from Placer County down to Fresno County. He said the proposed rule is welcome and long overdue.

The 10,000-member California Academy of Family Physicians released a statement earlier this week saying that it opposed the proposed rule, saying that illness does not discriminate based upon immigration status.

“The flu season is just upon us, and we are seeing that we are having difficulty getting our immigrant children and adults in for flu shots,” said Dr. Lisa Ward, president of the board of the California Academy of Family Physicians. “It is quite likely that one of the reasons is that they are too afraid not only to get health care for the adult parents but for their U.S.-born children as well, and that’s just one tiny bit of health care.”

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Since proposed language for this rule surfaced in the media, Ward and another family physician, Dr. Erika Roshanravan, said their clinics have seen declines in the number of parents seeking routine exams for their children. One week earlier this month, Ward said, two of three immigrant parents canceled well-baby visits.

“These are children I’ve seen for years, families I know well,” said Ward, the medical director at Santa Rosa Community Health Centers. “I delivered a couple of those children.”

Roshanravan, a family physician at CommuniCare Health Centers in Woodland, said: “I was scheduled to see a 6-month-old in my clinic, and the child we are talking about was born a native U.S. citizen. But the child was not signed up for the California Health Insurance Program for fear that, if any household member participates in any of these programs, that it would affect other members of the household.”

Among her concerns: Flu season is upon us. If large numbers of people don’t get shots, the contagion could spread quickly.

Although U.S. residents have come to think of the flu as rather innocuous, complications from the disease kill thousands of U.S. residents annually. The U.S. Centers for Disease Control and Prevention estimates that 80,000 Americans died during the last flu season from influenza and its complications, making it the deadliest flu season since 1976.

“This proposal is nothing more than a further attempt to restrict current and future immigrants from citizenship by holding basic human needs – health care, food, housing, and education – away from reach,” Matsui said. “These actions will disproportionately hurt children, including those who are U.S. citizens, by forcing their families to choose between putting food on the table and legal status.”

In a media briefing last week, immigration experts stressed that, under the proposed rule, immigration officials would be able to consider the record of only the individual applying for permanent residence and it would not take into account any history prior to when it goes into effect.

In addition, they said, many immigrants do not have to worry about this area of immigration law. They include refugees, asylum seekers, crime survivors, human trafficking survivors, survivors of abuse or battery by a U.S. citizen spouse or permanent resident spouse and individuals renewing DACA status.

However, the new language proposed by the U.S. Department of Homeland Security does upend the settled definition of who is a public charge.

“For about the last 20 years, we’ve had federal guidance that defines a public charge as a person who depends on cash assistance or is in long-term care that is being paid for by the government,” said Gabrielle Lessard, a senior policy attorney with the National Immigration Law Center. The proposed change would “treat a person as a public charge if they use essential health, nutrition and housing benefits as well as cash and long-term care.”

If the rule change goes into effect, investigators would consider whether an applicant for permanent legal resident could at some point in their future become a public charge. Then, their history of past access to programs such as Medi-Cal, CalFresh (formerly known as food stamps) and subsidized housing such as Section 8 would be weighed.

The rule also makes it tougher for some applicants to attain permanent residency, Lessard said. They include children, people over age 62, individuals with large families, those who have an income below 125 percent of the federal poverty level (about $40,000 for a family of four), those who speak limited English, and those who are uninsured and without the resources to buy insurance or cover the cost of care.

“A bedrock principle of American immigration...has been that immigrants admitted to our country should support themselves and not demand to be supported by others,” McClintock said. “As recently as 1996, bipartisan majorities in Congress affirmed this principle in law. The public charge rule proposed by the Department of Homeland Security establishes clear standards for implementing this law.”

It makes it easier, though, for applicants with income over 250 percent of the federal poverty level, almost $63,000 for a family of four, and above the U.S. median income, Lessard said.

No single factor could rule out an applicant, Lessard said, but because the rule adds so many new factors, it becomes harder for individuals to know whether they would pass muster. Right now, she said, it’s easy for people to know their public charge status.

The ambiguity is breeding fear among immigrants from around the world, regardless of whether they are from Mexico or El Salvador or Russia or Eritrea, Ward said. Patients are telling the medical team at Santa Rosa Community Health Centers that they feel frightened about the uncertainty this throws into their future immigration status.

“Out of fear and out of just trying to be cautious and protect themselves, people will avoid seeking services and enrolling in these programs without the full picture of what might impact them and what might not,” said Sarah Dar, health policy manager with the California Immigrant Policy Center.

Now that the proposed rule has been published in the Federal Register, Dar said, the public will have 60 days to make comments about the implications of the new law and whether they oppose or favor it. When the comment period is over, officials from Homeland Security will review all statements before issuing a final rule that will be published in the Federal Register. Along with the final rule, they will publish a preamble in which the agency addresses the public comments.

“The opportunity that we have before us (is) to really weigh in and to raise all kinds of arguments on what we think the impact of this will be,” Dar said.

What’s next?

What happened? For about the last 20 years, federal guidance has defined a public charge as an immigrant who depends on cash assistance or is in long-term care that is being paid for by the government. The Department of Homeland Security proposed a rule in the Federal Register on Oct. 10 that will redefine how that’s determined. When an immigrant applies for permanent U.S. residence, officials will be able to consider whether the applicant accessed essential health, nutrition and housing benefits as well as cash and long-term care.

Can I provide an opinion or evidence? Yes, you can make a comment at by clicking on the comment icon to the left side of the proposed rule.

What’s the process like for approval of a rule? It does not take an act of Congress to pass a rule. Rather, the rule is published on the Federal Register for 60 days. During that period, the public may comment. Once that comment period has concluded, federal officials will review all comments and, if necessary, make changes to the proposed rule. A final rule will then be posted to the Federal Register. In a preamble to the rule, officials will address any comments. Once the final rule is published, it will then go into effect.

Where can immigrants go for help? Immigration experts advise immigrants to discuss their situation with a trusted immigration attorney.

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