with Paulina Firozi


The White House is seriously considering a new policy that would penalize legal immigrants seeking permanent status for accepting health-care services paid for by the government.

The rule, which is expected to be officially announced soon per NBC News, would change the definition of when a legal immigrant is considered a "public charge" to the government, and impact the decision over whether they qualify for permanent resident status.

The mere suggestion of the expanded policy has already had a "real chilling effect" on immigrants using health-care services, Alberto Gonzalez of the advocacy group Community Catalyst told me. Doctors have "witnessed examples on the ground of people not wanting to access their local providers because they’re afraid if they take their kids for a checkup it will be communicated to the federal government." 

Since the beginning of the Trump administration, officials have been working on a plan to broaden a long-standing immigration law that takes into account an immigrant's current and possible dependence on the government when considering whether to grant them legal status. For decades, the U.S. government has calculated an immigrant to be a "public charge" if they rely or are expected to depend on the government for more than half of their income.

The current calculation considers whether the immigrant uses welfare or long-term care benefits, such as accessing a nursing home through Medicaid. The Trump administration is thinking about expanding the definition of "public charge" to include more public benefits -- such as other Medicaid services, subsidies to help pay for health insurance under Obamacare, food stamps and public housing, according to a draft plan obtained by our Post colleague Nick Miroff. Medicare services would not be included.

The proposal is by no means a done deal. Once finalized, the rule would then be opened for public comments. But immigration advocates are already organizing a massive pushback campaign.

If implemented, the implications for health care would be sweeping. A new report published in the New England Journal of Medicine this month determined that the number of immigrants who wouldn't access  Medicaid and the Children's Health Insurance Program (CHIP) because of the policy would result in at least one million people becoming uninsured. Gonzalez said mental illnesses may go untreated, kids will miss pediatric visits, and families will forgo preventive care, like cancer screenings. 

"It will be a public health crisis," Gonzalez said. 

For some seeking asylum, family separations were worth the risk: 'Whatever it took, we had to get to this country’ (Zoeann Murphy, Jorge Ribas/The Washington Post)

Advocates say another effect of such a policy would be that legal immigrants may also refuse social services like health care because they think it will negatively impact their hope of bringing their kids,  or other relatives, across the border to join them. The draft policy suggests an immigration caseworker could deny a visa based on the use of public benefits by anyone in the immigrant sponsor's household.

Democrats are pouncing on this possibility following the uproar over now-ended separations of thousands of migrant families at the border under Trump's "zero tolerance" immigration policy.

"The proposal of such a rule is a back-door attempt to circumvent Congress and unilaterally restrict family reunification," Democratic U.S. House members wrote in a May 7 letter to the administration. "Expanding the definition of 'public charge' under this rule would in essence create a new authority to bar immigrants from obtaining legal entry or permanent resident status in the country by virtue of caring for their family through the use of social services that they are legally entitled to use while under their current status." 

Even the possibility of change is already affecting behavior of legal immigrants.

An organization in Denver, called the Mile High Health Alliance, surveyed health providers to see whether they'd noticed a dropoff in their immigrant patients. Of those who responded, 87 percent said there had been a decrease in appointments made by immigrants since the beginning of the Trump administration and 66 percent said there'd been an increase in "patients expressing concern about having their personal information shared with other agencies that might jeopardize their continued residency in the country or legal status." 

In June, Minnesota Gov. Mark Dayton (D) sent a letter to the White House Office of Management and Budget echoing those findings. "Sadly the rule is already having an effect, regardless of the fact that it has yet to be released, social service providers in Minnesota report that just the prospect of this draft rule has begun causing children and adults to fear accessing safety net programs," he wrote.

Dr. Benard Dreyer, a past president of the American Academy of Pediatrics, told me that many of his patients aren't signing up for food stamps or for infant formula through the Women, Infants, and Children (WIC) program out of fear that it will hurt their chances of staying in America. 

Dreyer, who works at Bellevue Hospital in New York City, estimated about 90 percent of his patients are immigrants. He and the other pediatricians are currently discussing how to best communicate to their patients that no policy has changed yet and there's more potential damage if they don't get, for instance, proper nutrition for their children or routine immunizations.

"I have patients who say I won’t sign my kid up to preschool even though universal pre-K is not a means-tested program, but the fear is pervasive," Dreyer told me. "Already a huge amount of damage has been done because of the fear in the immigrant community."

The rule is being written at the Department of Homeland Security, but this won't be the first time a Trump immigration policy change overlapped with the responsibilities of the Department of Health and Human Services. Readers will recall that HHS has been responsible for reunifying parents with their children who were separated at the border.

Asked for HHS's reaction to the impact this policy could have on immigrants' health, a spokesperson responded in an email: “As a matter of policy, HHS and CMS do not comment on alleged, leaked documents."

Most of the anti-immigration rhetoric from the Trump administration has focused on undocumented immigrants, so what makes this proposal different is it exclusively affects people lawfully admitted or seeking lawful admittance into the country.

It would even affect children who are U.S. citizens if their parents are not and thus afraid to take advantage of benefits. Immigration advocates accuse Trump officials of seeking to enact a policy that targets low-income, Latino or black immigrant communities where there are already deep disparities in health care.

In a call with reporters Tuesday afternoon, Marielena Hincapié, executive director of the National Immigration Law Center, said such a rule sets up an impossible choice for all but the richest immigrants. She said it would have the broadest impact of any immigration proposal in recent memory, with the potential to affect tens of millions of people.

"A common thread is [Trump is] attacking families at their core,"  she said. "This proposed regulation is at the top of their anti-immigrant wish list.

DHS spokeswoman Kate Waldman told the Post in March that proposed changes are "intended to protect the American taxpayer by ensuring that foreign nationals seeking to enter or remain in the U.S. are self-sufficient."

It's notable then that a study published in the International Journal of Health Services released Wednesday morning found immigrants pay more into the health-care system than they receive. Immigrants account for 12 percent of the population but only account for 8.6 percent of total U.S. health-care expenditures while U.S.-born individuals account for 90 percent of the population but 93 percent of expenditures, the researchers wrote.

Most of the data they analyzed was from before the ACA was implemented. But Wesley Boyd, a Harvard psychiatry professor who participated in the study told me he believed the findings would now be more robust because "there would be more immigrants subsidizing health insurance for native born Americans than we found in our study, and that therefore the contribution that immigrants make to the bottom line of the US healthcare system would be even greater."

"It is unlikely that restrictions on immigration into the United States would result in a meaningful decrease in health care spending. To the contrary, restricting immigration would financially destabilize some parts of the health care economy," the researchers concluded. 

Until there's a final rule, immigration advocates' greatest concern is that immigrants don't seek health-care services that they need now.

"We’re hearing stories about families worried that they want to sponsor a family member but counseled to get family off of benefits as to not jeopardize that family member’s visa," said Jackie Vimo, policy analyst at National Immigration Law Center. "Immigration law is extremely complicated. A big piece of how this works is the chilling effect, The families who don’t understand the nuances are going to play it safe."


AHH: The Centers for Medicare and Medicaid Services announced yesterday that for the first time it would allow Medicare Advantage plans to impose “step therapy” under "Part B" drugs. The change essentially allows patients to try out less expensive or generic versions of drugs before turning to more expensive ones. It's part of the latest move by the Trump administration to implement its blueprint to lower drug prices. 

The announcement by CMS will grant private insurers more power to negotiate the prices of drugs administered at doctors offices and hospitals, Bloomberg’s Anna Edney reports. “The change will bring what Medicare pays closer in line to what the private sector gets," per the report. “In the commercial market, health insurers negotiate discounts of 15 percent to 20 percent or more on the same drugs for which Part B has paid full price. Half of the savings will be required to go back to patients. In future years, the savings will be used to reduce premiums. But because 2019 rates are already set, patients may receive a gift card instead.”

“For the first time ever, we’re going to unleash these plans, which are so good at negotiating, to try to get discounts on Part B drugs,” HHS Secretary Alex Azar told Anna in an interview. “This is a very important change in terms of drug pricing as well as just in managing and modernizing how Medicare functions.”

OOF: Large employers in the United States will have to pay more for health coverage next year, according to a new report from the National Business Group on Health, marking the sixth straight year that such benefit costs have increased. Employers are expected to shell out $14,800 per employee, up 5 percent from $14,099 in 2018, Modern Healthcare’s Shelby Livingston reports.

“This is consistent with the last five years, but consistent doesn't mean good,” Brian Marcotte, president and CEO of the National Business Group on Health said ... “Top-line medical trend is still running two times wage increases and three times general inflation, which continues to threaten affordability for all Americans.” And Shelby notes the costs will go up for employees, too. “Employers pick up about 70% of the tab for health coverage, while their workers pick up 30%, or $4,400, through premium and out-of-pocket expenses, such as copayments or coinsurance,” she reports.

As a way to save on spending, the report also found employers are using high-deductible health plans less frequently. “About 91% of employers offer at least one high-deductible plan. But for the first time in four years, the number of employers offering those plans as the only option is projected to decrease from 39% this year to 30% in 2019,” Shelby adds.

OUCH: A new report from the Centers for Disease Control and Prevention has found one in seven babies who were exposed to the Zika virus during pregnancy have “significant, ongoing health issues,” our Post colleague Ariana Eunjung Cha reports.

The report found 6 percent of the babies had birth defects such as small head size, or brain and eye damage; 9 percent had at least one neurodevelopment issue like seizures or difficulty swallowing; and 1 percent of the babies had neurodevelopment issues as well as birth defects, Ariana writes. The findings are based on an analysis of 1,450 children born in Puerto Rico and the U.S. Virgin Islands whose mothers had confirmed cases of Zika while pregnant.

“I think the bottom line is that the Zika story is not over,” Margaret Honein, director of the CDC’s Division of Congenital and Developmental Disorders told Ariana. “People may feel like it's behind us. For these children, it's not over, and we need to know as much as possible so that we can be prepared.”


— A Palm Beach doctor, a lawyer and the chairman of Marvel Entertainment make up a trio that are reportedly pulling the puppet strings at the Department of Veterans Affairs from the president’s private Mar-a-Lago Club, according to a report by ProPublica’s Isaac Arnsdorf.

“[F]rom a thousand miles away, they have leaned on VA officials and steered policies affecting millions of Americans,” Isaac writes. “They have remained hidden except to a few VA insiders, who have come to call them ‘the Mar-a-Lago Crowd.’”

“At all times, we offered our help and advice on a voluntary basis, seeking nothing at all in return,” Bruce Moskowitz,  Marc Sherman and Ike Perlmutter said in a statement, Isaac reports, after fielding questions through a crisis communicator. “While we were always willing to share our thoughts, we did not make or implement any type of policy, possess any authority over agency decisions, or direct government officials to take any actions.”

A spokesman for VA told Isaac that a “broad range of input from individuals both inside and outside VA has helped us immensely over the last year and a half." White House spokeswoman Lindsay Walters said Perlmutter, Sherman and Moskowitz “have no direct influence over the Department of Veterans Affairs.”


— The Food and Drug Administration announced an expansion to its recall of valsartan, a commonly used treatment for high blood pressure and heart failure, because of a potential contamination of a cancer-causing chemical, N-nitrosodimethylamine. The agency initially issued a voluntary recall last month, but has since expanded it twice, “to include additional products from more drug companies, as well as some tablets with valsartan and hydrochlorothisazide,” USA Today’s Mike Snider reports


— Express Scripts said it plans to drop dozens of drugs next year from its list of covered treatments, a move that comes as pharmacy benefit managers are increasingly becoming targets in the debate over high drug prices. Citing a lack of movement from drugmakers to lower their prices directly, the top PBM said it would drop 48 drugs and “emphasized that it wasn’t just focusing on rebates and will be excluding numerous brand-name drugs from coverage because there are generic drugs or other brands with lower list prices that make them a better overall deal,” Bloomberg’s Robert Langreth reports.

The report adds the changes will affect Express Scripts’s main formulary — PBMs like Express Scripts negotiate rebates from pharmaceutical companies in exchange for including that company’s drugs on these formularies, or lists of drugs covered by insurers. “For example, Express Scripts said that next year it will cover Symfi, a new HIV combo pill from Mylan NV that the benefit manager said has a 40 percent lower list price than Atripla. Express Scripts will also cover Merck & Co.’s lower-cost hepatitis C medicine Zepatier,” Robert writes.

— Billionaire activist Carl Icahn penned an open letter published yesterday to fellow shareholders of Cigna to publicly oppose the $54 billion deal to acquire Express Scripts.

“Cigna is dramatically overpaying for a highly challenged Express Scripts that is facing existential risks on several fronts,” Icahn wrote in the letter, the Wall Street Journal’s Cara Lombardo reports. “Mr. Icahn and his affiliates own about 0.56% of Cigna, a stake worth more than $250 million as of Monday’s market close,” Cara writes. “But the odds are against him, some observers say, in part because he has limited time to rally other shareholders. What’s more, it isn’t known how much of the stake he can actually vote, because the record date has already passed. Mr. Icahn said in the letter he also holds a short position in Express Scripts, which means he is betting its share price will decrease.”


— The World Health Organization said vaccinations could begin in Congo as soon as today in the fight against the latest outbreak of Ebola. A genetic analysis has confirmed that the strain of Ebola connected with the latest outbreak is the Zaire strain, which can be treated with a vaccine, the Associated Press reports. The strain is the same as the most recent outbreak in Congo that was just declared over on July 24, but the outbreaks are not connected, according to WHO’s emergency preparedness chief, Peter Salama.


— Health officials in Ohio say that 624 people got sick after eating at a Chipotle restaurant outside of Columbus last month, our Post colleague Eli Rosenberg reports. The individuals reported eating at the Chipotle between July 26 and 30 and suffering from gastrointestinal symptoms, according to the surrounding county’s Delaware General Health District.

The chain voluntarily closed that specific restaurant last week for 24 hours after the illnesses were reported, Eli writes, to replace the food and sanitize the restaurant. Since reopening, there have been no reported illnesses.

A lawyer Ron Simon says “his firm had been contacted by more than 100 people who had been sickened, including some who were hospitalized, and he expected to be filing more lawsuits soon,” Eli writes.

— And here are a few more good reads: 



  • The FDA holds a meeting of its antimicrobial drugs advisory committee.
  • The CATO Institute holds an event on short-term health plans

Coming Up

  • FDA Commissioner Scott Gottlieb speaks at an event hosted by the National Health Council on Friday.

West Hollywood city council passes measure calling for removal of Trump’s Walk of Fame star

The West Hollywood City Council on Aug. 6, unanimously voted on a proposal to remove the star. However, the move is only symbolic. (Amber Ferguson/The Washington Post)