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Voices Speaking

September 25, 2018

What is Public Charge?

Karen Siegel, M.P.H.

“Public charge” is a term used by immigration officials to determine that a person seeking to enter the United States, immigrate, or apply to become a Legal Permanent Resident or “green card” holder is or is likely to be dependent on public services.

To date, this determination has included only cash assistance (such as SSI and TANF) and publicly funded long-term institutional care. On Saturday, the Department of Homeland Security issued a press release and text of proposed changes to the “public charge” rule.


It is important to note that these changes are not yet in practice. Before changes can be implemented, the administration must give the public 60 days to comment on the proposed rule, consider those comments, and then wait at least 60 days after posting the final rule before implementing changes.


What changes have been proposed?

If undertaken, proposed changes would expand the benefits included in a determination of “public charge” to include:

  • Non-emergency Medicaid (with limited exceptions)
  • The Supplemental Nutrition Assistance Program (SNAP)
  • Housing assistance such as Section 8 housing vouchers
  • Low-income subsidy for prescription drug costs under Medicare part D

The draft also asks whether or not the Children’s Health Insurance Program (CHIP) should be included. Additional details about changes to how the rule is applied and to whom are available here.


Who would these changes impact?

These changes would affect individuals seeking a change in immigration status, though it does not apply when “green card” holders apply to become citizens.

The public charge statute requires immigration officials to consider overall circumstances, not just the use of services, in making an immigration status decision.  Finally, these changes would not be retroactive; so, they will only apply to enrollment in the specified services after the final rule takes effect.

In Connecticut, many lawfully present “qualified non-citizens” (see definition here) are eligible for enrollment in the state’s Medicaid and SNAP programs.


Who is exempt from a public charge determination?

Some groups—such as refugees, asylees, and other protected groups—are not subject to “public charge.”

Further, the determination will consider use of benefits by the individual applicant – not by family members.

Click here for more details about which groups are exempt and a detailed list of relevant programs.


Why do the changes to this rule matter?

The primary cause of concern is that fear of a potential rule change and confusion about what has not been changed will lead to lower rates of enrollment in programs that help families meet their basic needs—including SNAP and Medicaid. This “chilling effect” is already taking place according to some reports.

Should the draft rule take effect, lawfully present immigrants who work in low-paying jobs will be forced to choose between obtaining vital services and their immigration status. Many will likely stop using or fail to enroll in health insurance or nutrition programs for themselves or their families for fear that the rules may change again. Such uncertainty adds to the daily stress of living in an immigrant family in today’s political climate.

In Connecticut, 81,000 citizen children who have at least one non-citizen parent are enrolled in Medicaid or CHIP. Children make up 40% of the national Medicaid population and account for just 19% of Medicaid spending. Yet, the services they receive can have lifelong benefits. Further, when parents are uninsured, eligible children are less likely to be insured or see a doctor. Thus, this rule change jeopardizes the health and wellbeing of thousands of Connecticut’s families.

Providing access to health care and nutritional support for non-citizens is an investment in our state’s future and enables families to continue to work and contribute to the economic and social wellbeing of our state.


What can you do?

1.    Prepare to comment on the proposed rule change once it is posted—sign up for alerts here.

2.    Help to correct confusion about what the current rule is and who the changes would affect.

3.    Contact Senator Blumenthal, who serves on the Immigration Subcommittee of the Judiciary Committee, to thank him for his defense of our nation’s tradition of welcoming immigrants.

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September 7, 2018

Connecticut Strives for Primacy of Health Equity in Primary Care

Karen Siegel, M.P.H. and Tekisha Dwan Everette, Ph.D., Executive Director, Health Equity Solutions; Eva Marie Stahl, Ph.D., Project Director, Community Catalyst

Connecticut’s federally funded effort to introduce primary care innovations (through the State Innovation Model or SIM grant) is entering its final years of implementation. In the coming months, the state will present and finalize its proposals (to review and comment on proposals as they are released, see here). Right now is an opportune time to ensure these proposals can transform Connecticut’s health system to promote equity by investing in prevention and addressing social and economic factors that make some in our state far less healthy than others.

As a reminder, many states applied for the federal SIM grant funds to advance health reform. Connecticut has used this funding as an opportunity to explore new models of primary care delivery with a focus on health disparities. Specifically, SIM piloted a primary care health home model that incorporated community health workers into the care team for some patients. As with any pilot or model, there continue to be bumps that need smoothing and culture that needs shifting. The premise, however, is solid: the current system does not do enough to reduce the deep disparities in both individual and population health that reverberate through communities of color. Specifically, the current system does not do enough to connect families with community-based services where they live. 

Commitments to any one payment model can serve as a barrier to improving health outcomes. The fee-for-service approach of the Medicaid payment system is limited in flexibility and for too long some have safeguarded it as the only viable path. This is not an “us” against “them” situation but rather a recognition that, in its current form, fee-for-service is a barrier to scaling up efforts to connect primary care with community-based services in long-term and meaningful ways. With an innovative approach, Connecticut can adapt the state’s health systems to the needs of all of our residents while simultaneously safeguarding access to quality health care and vital services.

As advocates and stakeholders disagree about what payment or delivery system approach will meet the triple aim of lower cost, high quality care while maximizing access – the question is: what do consumers want? What do consumers need? And how do consumers define success? And if the goal is to center on health equity in this work, what systematic and systemic changes are needed? Connecticut’s approach of focusing on primary care to meet these needs is admirable. Primary care is the first touch point for many people when they interact with the health care system and a venue of frequent contact with parents and young children. It is also a space ripe for culture change given the right supports. A whole-family and integrated care approach is, without a doubt, the future of health care delivery and what is needed to advance health equity in Connecticut.

How we get there while ensuring that any system reflects the needs and wants of consumers themselves is less clear. Listening to consumers is hard work; it requires patience, resources and time to build trust. Specifically, it is essential to build trust with communities of color and those communities left out of economic progress; it also demands a long-term commitment from key stakeholders and decision makers. Finally, it requires advocates and stakeholders to be listeners and innovators.

As Connecticut’s decision makers contemplate next steps regarding how to implement some of the learnings from their SIM work over the next six or so months, those advocating for better care and health equity should consider what mechanisms would support needed changes that reflect consumer feedback. Reconsidering the pathways – the “how” – as we forge ahead with advocacy in a financially scarce environment will be important to meeting our goals for health equity and readying the system for more ambitious work around social determinants of health. Let’s get to work together.


Tekisha Dwan Everette, PhD*, Executive Director, Health Equity Solutions and Karen Siegel, M.P.H., Health Policy Fellow, Connecticut Voices for Children contributed to this blog as guest bloggers.
*Dr. Everette is a subcontractor with the Consumer Advisory Board but the opinions written here are wholly her own and do not represent any other entities.

Click here to see the original blog post on Community Catalyst's website.

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