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The Health 202: The clock is ticking on stricter 'public charge' rules for immigrants

with Paulina Firozi


If an immigrant has enrolled in Medicaid or accepted food stamps, it could soon be harder for them to stay in the United States permanently under a new regulation the Trump administration will formally propose today.

In a strange reversal from the way new regulations are usually put forward, the Department of Homeland Security released a draft of the rule a few weeks ago but hadn’t yet posted it in the federal register. When that happens today, it will kick off a 60-day public comment period where you can bet doctors and other health advocates will be pushing for DHS to back away from the changes the agency is seeking.

“Sweeping in its effect, the rule discounts the contribution of working families,” says a letter obtained by The Health 202 that was signed by more than 1,500 groups including the American Academy of Pediatrics, the ACLU and the National Immigration Law Center.  “It would chill access to critical programs that help taxpaying immigrants and their families access health care, food and other essential needs.”

The changes these advocates are protesting have to do with the “public charge” determination made by immigration officials when someone from another country applies for a green card allowing them to live and work in the United States on a permanent basis. If officials determine the applicant is likely to be heavily dependent on government assistance — thus, a “public charge” — they could now be less likely to greenlight the application.

The way things stand right now, immigration officials consider whether an applicant received federal, state and local welfare assistance in making a public charge determination. But under the proposed rule, whether an immigrant enrolled in Medicaid, collected food stamps or participated in public-housing programs would also become factors for the first time — and they’d be weighted heavily in the determination of whether to award legal status.

And that could discourage legal immigrants from availing themselves of government help for which they’re eligible, for fear it could jeopardize their prospects of staying in the United States for the long term.

“This public charge proposal is presenting immigrant families with an impossible and truly unfair dilemma, which is to keep their families healthy and utilize bread-and-butter services or risk being separated and forego vital services,” Julie Linton, a pediatrician practicing in North Carolina who co-chairs the American Academy of Pediatrics Immigrant Health Special Interest Group, told me.

Linton and other doctors are most concerned about immigrant families living in the United States in which one or both parents are seeking permanent residency. Of the approximately 1 million immigrants who are annually granted green cards, more than half live in the United States on temporary visas. These legally present individuals and families are eligible for public programs in most states, but could become afraid to participate in them under the new rules.

Various drafts of the new rule had been circulating for months, and The Health 202 wrote about the issue back in April and again in August. There was speculation that it would go even further, including a review of Obamacare insurance subsidies and whether an individual’s family members used government benefits.

The proposal we’ll see today doesn’t include those elements. Nor does it give a definitive answer on whether enrollment in the Children’s Health Insurance Program could jeopardize green-card applications for kids, instead soliciting specific feedback on that question. So in a few ways, the proposed rule is somewhat less stringent than what the administration was contemplating, perhaps reflecting the strong pushback from health providers.

(We should also note that immigrants who already have green cards who are seeking citizenship aren’t subject to a public charge determination, nor are refugees or those granted asylum.)

But the proposed rule does contain something else advocates dislike — it suggests factoring in income of applicants for the first time. Earning less than 125 percent of federal poverty level ($25,975 for a family of three) would count against applicants, while earning more than 250 percent of the federal poverty level ($51,950 for a family of three) would give them a boost.

“This proposed rule change would mark a fundamental change from our nation’s historic commitment to welcoming immigrants,” the letter from AAP and others says. “It would radically reshape our legal immigration system, putting the wealthy at the front of the line, ahead of hard-working families who have waited years to reunite.”

Ask administration officials for their interpretation, however, and they speak of encouraging self-sufficiency among immigrants and preserving public funds — arguments similar to those made by Seema Verma, administrator of the Centers for Medicare and Medicaid Services, for the new Medicaid requirements her agency is allowing.

DHS Secretary Kirstjen Nielsen said long-standing federal law requires would-be immigrants to “show they can support themselves financially,” in an announcement of the proposed rule a few weeks ago.

Hans von Spakovsky, a senior fellow with the conservative Heritage Foundation, told Politico that “we can be choosy about who we allow into the country.”

Keeping up with the news in President Trump’s Washington is exhausting — whether you live here, work in the nation’s capital, or are just watching from afar. That’s why we’re launching Power Up. This new newsletter by author Jacqueline Alemany will land in your inbox before you reach for that first cup of coffee. It will bring you Washington, fast.

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— During his rally in Council Bluffs, Iowa last night, Trump reupped his claim that Republicans want to ensure protections for preexisting conditions.

“We will always protect Americans with preexisting conditions. We are going to protect Americans with preexisting conditions,” he said.

He called on his supporters to vote for Republicans in the midterm elections, specifically naming Iowa Republicans  Reps. Rod Blum and David Young. Young, who is in a tight race in his district, is one of a handful of Republican lawmakers who have recently introduced measures related to protecting preexisting conditions. He introduced a nonbinding resolution expressing support for such protections last month.

The fight over preexisting conditions has continued to rage on the campaign trail. Democrats argue Republicans want to get rid of protections, pointing to the GOP-led lawsuit states have brought against the Affordable Care Act and Republicans contend they have always wanted to preserve protections for sick individuals.

— The president also once again chided what he called a "socialist health care plan" from Democrats in an op-ed for USA Today out this morning. Our colleague Colby Itkowitz explained the significant flaws in Trump's argument here, which essentially amounts to a slam on the Democratic "Medicare for all" message that the president says will result in fewer benefits to those are currently covered by the health-care program for seniors (that is not correct).

"A majority of House Democrats have already signed up for a socialist health care plan that would obliterate Medicare and eliminate Medicare Advantage for 20 million seniors," Trump said during the rally, referring to "Medicare for all." "Republicans want to protect Medicare. We're protecting it for our great seniors who have earned it and paid for it all of their lives."

Trump said that as a candidate, he had promised protections not only for patients with preexisting conditions but for seniors covered under Medicare.

"That is why I am fighting so hard against the Democrats' plan that would eviscerate Medicare," Trump wrote. "Democrats have already harmed seniors by slashing Medicare by more than $800 billion over 10 years to pay for Obamacare. Likewise, Democrats would gut Medicare with their planned government takeover of American health care."

"The truth is that the centrist Democratic Party is dead. The new Democrats are radical socialists who want to model America’s economy after Venezuela," he continued. "If Democrats win control of Congress this November, we will come dangerously closer to socialism in America. Government-run health care is just the beginning."

Our Post colleague David Weigel has a good primer on how Republicans have shifted away from demanding reforms to entitlement programs in his new campaign newsletter.

Journalists were already pointing out the problems with Trump's argument in the op-ed. From the Post's Fact Checker:


AHH: As of the end of last month, health-care companies across the nation had acquired $23.4 billion in venture capital funding this year, and Modern Healthcare’s Tara Bannow reports that figure surpassed the amount of funding the sector gained in all of last year.

It also makes up about 28 percent of total U.S. venture capital funding so far this year, Tara reports, citing Pitchbook’s quarterly report on venture capital spending.

“Last year, healthcare services and systems, healthcare devices and supplies and pharma and biotech amassed $20.5 billion in venture capital funding, with pharma and biotech capturing far and away the largest share of those dollars,” she writes.

OOF: The number of migrant families being kept in detention facilities in Arizona has been so overwhelming that the federal government released hundreds of parents and children to shelters and other locations in the past several days, our Post colleague Nick Miroff reports.

A spokeswoman for U.S. Immigration and Customs Enforcement explained to The Post that the agency was at risk of exceeding the court-imposed limit for how long children can be kept in immigration jails. “As a result, ICE has been dropping off busloads of families at church shelters and charities, some with ankle monitoring bracelets, others with little more than a notice to appear in court,” Nick writes.

There has been such an influx of Central American families that necessary resources are running low. Teresa Cavendish, director of Casa Alitas, which is housing 200 migrants at a church gymnasium in Tucson, told Nick the facilities have run out of ankle bracelets for the detainees.

“The U.S. Border Patrol has arrested soaring numbers of Central American families in the three months since President Trump halted the practice of separating migrant parents and children who enter the United States illegally,” Nick adds. “Since the beginning of October, at least 395 family members have been taken into custody in Arizona’s Tucson sector, according to the latest Border Patrol statistics, exceeding the number that agents typically register during an entire month.”

OUCH: Sen. Amy Klobuchar (D-Minn.) has called on the Centers for Disease Control and Prevention to investigate the outbreak of acute flaccid myelitis that has emerged in Minnesota. The condition, which has been compared to polio, can lead to facial muscle weakness, droopy eyelids, issues swallowing or slurred speech, our Post colleague Lindsey Bever described.

There have been six cases of AFM reported in children across the state in the past several weeks.

“Since AFM can develop as a result of a viral infection, the Minnesota Department of Health has issued recommendations that parents and children take measures to avoid the spread of germs and contact a healthcare provider at the first sign of illness,” Klobuchar wrote in a letter to the agency. “But as the causes of AFM are unknown, I urge the CDC to provide more information immediately about preventive measures and treatments.”

She called on the CDC to provide more information on what efforts are underway to track AFM infections, research the causes of the illness and to describe any additional resources needed for that work.


— The Trump administration is planning to take offline for regularly scheduled maintenance for several hours for most Sundays during open enrollment in the Affordable Care Act exchanges.

The site will be down from midnight until noon on Sundays starting on Nov. 4, though it will not be down on Dec. 9. The open enrollment period for 2019 begins Nov. 1 and continues through Dec. 15. 

Like last year, CMS said the downtime is planned for a total of 60 hours. Last year, however, the site only ended up being offline for 21.5 hours, the agency said. 

“Maintenance windows are regularly scheduled on every year during Open Enrollment,” a CMS spokesperson said. “This year’s potential planned maintenance schedule is the same as  last year’s. Similar to last year, we are sharing the maximum potential maintenance windows to allow agents, brokers, and assisters to plan in advance of Open Enrollment.”

The agency said maintenance is scheduled for low-traffic periods, which include Sunday mornings.


— Are you mixing up all the iterations of "Medicare-for-all" bills introduced by Democrats this year? The Health 202 is, too. Thankfully, the Kaiser Family Foundation will release a new interactive tool today comparing side-by-side the various plans for expanding Medicare. The tool includes eight bills that range from creating a broad national health insurance program to more incremental measures that would create a new public plan option to supplement private coverage and existing public programs. Kaiser has an accompanying issue brief here.


— Staff reviewers at the Food and Drug Administration have expressed concern that patients can abuse and potentially overdose from an opioid injection from Trevana Inc.

The treatment, oliceridine, is in the same class of opioids as morphine and fentanyl, and “aims to manage moderate-to-severe acute pain in adult patients for whom an intravenous opioid is necessary and the injection should be administered in hospitals and ambulatory surgery centers,” Reuter reports.

The FDA’s expert panel will vote on the safety and efficacy of the treatment later this week. The agency usually follows the panel’s advice on treatment, though it is not required to do so, per the report. 

—And here are a few more good reads from The Post and beyond: 

Tom Cotton’s fact-free theory on the leaks of Ford’s letter (Salvador Rizzo)

Democrats Are Ignoring One Key Voting Group: Veterans (The New York Times)

This is not what a pro-Kavanaugh electoral backlash looks like (Philip Bump)

Poll: Kavanaugh confirmation energizes Democrats more than GOP (Poiltico)


Former Planned Parenthood head leaves door open to elected office (Politico)


Bipartisan group of senators ask Trump to increase focus on maternal deaths (The Hill )

AP FACT CHECK: Trump distorts Democrats' health care ideas (Associated Press )

Juul boosts lobbying amid FDA scrutiny (The Hill )

800,000 people kill themselves every year. What can we do? | Lady Gaga and Tedros Adhanom (Lady Gaga and Tedros Adhanom via The Guardian)



  • The FDA holds a meeting of the Oncologic Drugs Advisory Committee.
  • The FDA holds a meeting of the Anesthetic and Analgesic Drug Products Advisory Committee.
  • The Alliance for Health Policy holds an event on aging in America.

Coming Up

  • The American Enterprise Institute holds an event on “Nurse practitioners and America’s primary care shortage” on Oct. 15.
  • The Brookings Institution holds an event on “Crafting public policy to address the nation’s opioid epidemic” on Oct. 15.

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President Trump that Nikki Haley will resign from her position as U.N. ambassador by the end of the year. Here's a look back at her time in the White House

President Trump announced on Oct. 9 that Nikki Haley will resign from her position as U.N. ambassador by the end of the year. (Video: Blair Guild/The Washington Post)