THE PROGNOSIS

Immigrants with an illness or insufficient savings to cover unforeseen medical costs could soon find it harder to gain admittance to the United States or stay here permanently.

Those circumstances are among a slew of new and tightened criteria immigration officials will soon start considering when they review applications for green cards or U.S. citizenship, under the Trump administration’s latest effort to limit immigration and discourage reliance on safety-net programs.

It’s no secret that cracking down on legal and illegal immigration through a variety of measures has become one of the administration’s hallmarks. It’s just the latest in a string of efforts to put more bureaucratic barriers in place, as my Washington Post colleagues Abigail Hauslohner, Nick Miroff, Maria Sacchetti and Tracy Jan report.

“The move is part of the Trump administration’s systematic effort to add new bureaucratic obstacles to the U.S. immigration system at the same time the president wants to put physical barriers along the Mexico border,” they write. “The administration has slashed the number of refugees admitted to the United States, tightened access to the asylum system and expanded the power of the government to detain and deport immigrants who lack legal status.”

But this new rule, which changes how an immigrant’s likelihood of becoming reliant on government benefits is evaluated, could have the most consequential and longest-term impacts, immigrant advocates charged yesterday.

“The Trump administration is enacting a hateful, invisible wall to keep immigrants out and public charge is the foundation of this,” Marielena Hincapié, executive director of the National Immigration Law Center, told reporters. “It would have the deepest, widest and most long-term impact on our country and our democracy.”

This all has to do with the idea of “public charge,” defined as someone who is judged likely to need public assistance for things like food, housing or health care. The concept has been around ever since the Immigration Act of 1882, which allowed federal officials to discriminate against people seeking to enter the United States if they were suspected of being likely to depend upon the government.

So, immigrants judged likely to become a public charge are already less likely to gain permanent status. But until now, officials could only use a very limited set of criteria in making the determination, including age, health, family status, finances and education or skills. They could also consider whether an individual had received cash benefits through the federal welfare program Temporary Assistance for Needy Families.

That list of criteria is about to grow much longer and much more specific, under the final rule announced yesterday by Ken Cuccinelli, acting director of U.S. Citizenship and Immigration Services.

“Through the public charge rule, President Trump’s administration is reinforcing the ideals of self-sufficiency and personal responsibility, ensuring that immigrants are able to support themselves and become successful here in America,” Cuccinelli said.

The rule defines the criteria more specifically than before, adds new criteria and weights such factors positively or negatively. Applicants will be especially in danger of being denied access to temporary or permanent citizenship if they’re judged to have no reasonable prospect of future employment, have received public benefits in the prior three years and lack health insurance or have medical need.

Here are specific factors that can now be counted against a green card applicant, according to the final rule:

— Having a household income of less than 125 percent of the federal poverty level.

— Having “a medical condition” that will interfere with work or school.

— Lacking enough money to cover any “reasonably foreseeable medical costs” related to the condition.

— Having “financial liabilities.”

— Having a low credit score.

— Lacking a college degree.

— Lacking English language skills “sufficient to enter the job market.”

— Having a sponsor “unlikely” to provide financial support.

And these are some factors that will be weighted positivily for the applicant:

— Having private, unsubsidized health insurance.

— Having income at least 250 percent of the federal poverty level.

Until the rule goes into effect two months from now, it’s unclear precisely how heavily immigration officials will weight these various criteria. But the rule holds major ramifications for the more than 1 million immigrants granted green cards every year. The new criteria make it likely that far fewer immigrants could receive approvals, experts say.

“It’s a wealth test,” said Elizabeth Lower-Basch, director of income and work supports at the Center for Law and Social Policy. “It creates space for them to apply it in a racially discriminatory fashion.”

Denials of immigrant visa applications could skyrocket back to highs of the late 1990s, when 13 percent of applicants were denied on public charge grounds, the libertarian Cato Institute wrote in an analysis of the final rule. That would have equated to just 115,000 green cards in 2018, wrote David Bier.

Several states and immigration groups said they plan to sue the administration over the new rule.

Zoe Tillman, a courts and justice reporter for BuzzFeed News:

California Attorney General Xavier Becerra:

There’s another potential effect here — and it’s one that some immigrant advocates are even more worried about. In making their public charge determination, officials may also start taking into consideration whether an immigrant has availed themselves of Medicaid or other safety-net programs, including food stamps and housing subsidies.

These programs already have strict restrictions on enrollment by immigrants. In most cases, an immigrant would need to have gained permanent status and lived in the United States for a minimum of five years before they could enroll. So technically speaking, these new criteria don’t signal a huge shift.

But there could be a widespread chilling effect, given President Trump's broad anti-immigration rhetoric. Advocates fear that immigrants will choose not to enroll in such programs even when they’re eligible, for fear it could jeopardize their prospects or those of a family member.

“Our concern is people are going to be leery of reading the fine print and are just going to stay out of it,” said Eliot Fishman, senior director of health policy for Families USA.

Democrats in Congress also lambasted the rule, calling it xenophobic. “The Trump administration’s callous crusade to demonize immigrant families continues,” Sen. Ron Wyden (Ore.), the ranking Democrat on the Finance Committee, said in a statement.

Rep. Adriano Espaillat (D-N.Y.), the first formerly undocumented immigrant to serve in Congress:

Rep. Betty McCollum (D-Minn.):

The Department of Homeland Security acknowledged it received mostly negative comments about the rule it initially proposed last year. Commenters worried the new, specific criteria would lead to a merit-based system allowing the agency to discriminate against the poor, less-educated and less-healthy.

DHS did exclude several programs, such as the "WIC" nutrition program for women, infants and children and the Children's Health Insurance Program, from the public charge consideration. The agency also stressed that it won't consider the participation of childen or pregnant women in any safety-net programs.

"DHS notes that it did not codify this final rule to discriminate against aliens based on age, race, gender, income, health, and social status, or to create an 'ageist' system that selectively favors wealthy, healthy, and highly educated individuals," the rule says. "Rather, this rule is intended to better ensure that aliens subject to this rule are self-sufficient."

AHH, OOF and OUCH

AHH: Two experimental Ebola treatments will now be offered to all patients in Congo. They're expected to markedly increase survival rates for those infected with the disease, our Post colleague Claire Parker reports. The current Ebola outbreak has infected about 2,800 and killed more than 1,800 since it started about a year ago.

“From now on, we will no longer say that Ebola is incurable,” Congolese doctor Jean-Jacques Muyembe Tamfum said on a conference call.

“The drugs, tested in a nearly nine-month clinical trial, have performed so well that health professionals will now administer them to every patient in Congo,” Claire writes. “…The new therapies were tested in a multi-drug, randomized, controlled trial conducted on the front lines of the Ebola outbreak since November. Researchers administered one of four drugs to the 681 patients who had participated in the study as of Friday. When a monitoring group determined that two of those drugs were vastly outperforming the others based on data from 499 patients, scientists called off the study and said they would exclusively treat Ebola patients with the more effective drugs going forward.”

OOF:  For several years, the Obamacare marketplaces have seen declining enrollments among consumers who earn too much for subsidies. Centers for Medicare and Medicaid Services Administrator Seema Verma is arguing that proves the health-care law is failing a lot of people.

New data out from CMS found that between 2017 and 2018, insurance enrollment decreased among people who were not eligible to receive subsidies under the Affordable Care Act. There was a decline of about 1.2 million unsubsidized enrollees, or 24 percent, among the unsubsidized population. And from 2016 to 2018, enrollment for unsubsidized people dropped 40 percent.

“While data from the Effectuated Enrollment report shows stability in Exchange enrollment and premium trends, affordability remains a significant challenge for people who do not qualify for Exchange subsidies,” the agency said.

The data also found an increase of 4 percent in enrollment among people who were eligible for ACA subsidies. The agency noted that the average monthly enrollment for subsidized individuals has grown substantially larger than for unsubsidized individuals.

“As President Trump predicted, people are fleeing the individual market. Obamacare is failing the American people, and the ongoing exodus of the unsubsidized population from the market proves that Obamacare’s sky-high premiums are unaffordable,” Verma said in a statement.

From Larry Levitt, Kaiser Family Foundation executive vice president for health policy:

OUCH: Tennessee state lawmakers are considering a measure this week that will effectively ban abortion as soon as a woman knows she is pregnant.

The bill — like laws that have recently passed in states such as Alabama and Georgia that ban abortions once a fetal heartbeat an be detected, bills that have been blocked in court — is “probably unconstitutional. But at least one Republican backer says that’s the point,” our Post colleague Kayla Epstein reports. The proposed amendment to a stalled Senate bill would bar abortions as soon as a "a viable pregnancy is presumed to exist or has been confirmed." 

“We want a vehicle to lead the Supreme Court to consider, I hope, overturning or at least chipping away at Roe v. Wade,” state Sen. Kerry Roberts (R) told CBS News. A legislative assistant to Roberts told Kayla his position has not changed. State Sen. Mark Pody (R) also acknowledged the measure would probably be challenged in court.

“A new amendment would give a fetus the same constitutional rights as a person under state law and bar abortion in all cases unless the life of the pregnant woman was at risk,” Kayla writes. “The bill also would bar terminations of pregnancies confirmed by the presence of the human chorionic gonadotropin (HCG) hormone.”

HEALTH ON THE HILL

— Amid signs his campaign has lost ground, Sen. Bernie Sanders (I-Vt.) has sought to make health care his defining issue, pushing Medicare-for-all more aggressively, our Post colleague Sean Sullivan reports.

Meanwhile, as part of the risky strategy, Sanders’s aides and allies have become more combative in criticizing policy ideas that compete with his own universal health-care plan. He has delivered recent speeches on Medicare-for-all and put a personal spin on his pitch. He has traveled by bus with diabetes patients to purchase cheaper insulin in Canada. Sanders has also pushed his rivals to refuse campaign donations from top members and lobbyists of health insurance and pharmaceutical companies.

“But it’s not clear if the emboldened approach will help Sanders or compound his troubles,” Sean writes. For one, there is the usual criticism over ending private insurance and raising taxes in order to pay for the plan.

“Another challenge, some Democrats say, is that Sanders is no longer the only major candidate supporting Medicare-for-all, potentially making him a victim of his own success,” he writes. “After a breakout campaign against Clinton in 2016 and a strong start to his 2020 effort, the Vermont independent has struggled to win over new voters. Many of his supporters say they are drawn to other candidates, such as Sen. Elizabeth Warren (D-Mass.), who has moved ahead of Sanders in some recent surveys.”

While some question whether the strategy will work, top Sanders officials, including Ben Tulchin, Sanders’s pollster and strategist, say the issue is “where Bernie is seen as the most credible.”

OPIOID OPTICS

— From 2006 to 2012, 15 percent of the pharmacies in the country handled nearly half the opioid prescription pills in the nation, according to The Post’s analysis of a federal database maintained by the Drug Enforcement Administration.

That includes Shearer Drug, a small family-run pharmacy in Clinton County in Kentucky. In that time frame, the pharmacy purchased nearly 6.8 million pills containing hydrocodone and oxycodone, our Post colleagues Jenn Abelson, Andrew Ba Tran, Beth Reinhard and Aaron C. Davis report. This is the latest in a series of investigative pieces from our colleagues on the DEA database on the ongoing opioid crisis in the United States.

In 2012, the pharmacy had bought more than 1.1 million pain pills, up 55 percent from 2006. The amount of pills Shearer Drug handled in that time was enough to dole out 96 pills a year to every person in the county of about 10,000. “It’s a lot of pain medication for this little town,” county coroner Steve Talbott told The Post.

“Shearer Drug is among thousands of small, independent pharmacies — from Smith County Drug Center in Carthage, Tenn., to Zion Pharmacy in Kanab, Utah — that handled large volumes of hydrocodone and oxycodone from 2006 through 2012 and until now have largely avoided publicity for their roles in the epidemic,” our colleagues write. “…To study the pharmacies, The Post examined the total number of pills that contained oxycodone and hydrocodone sold to each pharmacy over the seven years, and other metrics, such as year-over-year orders and overdose death rates in the counties where the pharmacies are located. The review excluded some small cities that are designated as counties, which inflates the per capita calculations."

— How many pain pills went to your local pharmacy? Our colleagues Andrew, Armand Emamdjomeh, Aaron Williams, Danielle Rindler and Tim Meko put together an interactive graphic as part of the investigative series, analyzing and mapping pharmacy data. “It provides a first-ever, granular look at the number and type of pills that flowed into pharmacies and their local communities during a period in which nearly 100,000 people died nationwide from overdoses,” they write. Click here to see the map that details how many pills were handled by retail and chain pharmacies and how many pills were sent to pharmacies near a specific location.

— And here are a few more good reads: 

We have received hundreds of messages from local journalists, educators, researchers, federal and local government workers, health-care professionals, volunteers, advocates and citizens interested in diving into the pain pills database.
María Sánchez Díez
TRUMP TEMPERATURE
There are various ways Canadians could thwart President Trump’s plan to import drugs from the north — and drug makers might just thwart it for them.
Stat
The U.S. government's deficit widened to $120 billion in July, fueled by in...
Reuters
Labor leaders dispute candidates’ claims that single-payer will leave their members worse off.
Politico
AGENCY ALERT
National
Washington Post journalists were given access to the McAllen, Tex., facility that has brought accusations of “kids in cages.”
Arelis Hernández
MEDICAL MISSIVES
Business
The study's authors say police violence is a "public health issue" with profound consequences for democracy.
Christopher Ingraham
National
In Omaha, where few remember the mass shooting that killed eight here in 2007, the gun conversation feels stuck.
Greg Jaffe
INDUSTRY RX
Deals between drugmakers and hospital systems to mine the genetic profiles of hospital patients are triggering concerns over the control of valuable genetic data.
Wall Street Journal
STATE SCAN
Pennsylvania’s governor says at least four children from his state were recently separated from their parents by U.S. Immigration and Customs Enforcement and wrote Monday to demand the agency halt the practice until it has a plan to ensure the welfare of children.
Associated Press
Stacks of potentially deadly fentanyl-laced pills sealed inside plastic tubs were displayed Monday on a table in a Salt Lake City courtroom, a haul that prosecutors say amounted to a tiny portion of the opioids shipped all over the U.S. as part of a multi-million dollar operation accused in at least one fatal overdose.
Associated Press
By The Way
Public health investigators are trying to identify the source of a bacterial outbreak that has been linked to the death of one woman who stayed at the Sheraton hotel in Atlanta this summer. Another 11 cases of Legionnaires' disease among hotel guests have been confirmed, and officials say there are another 61 probable cases.
Hannah Sampson
Morning Mix
The victims ranged in age from 8 months to about 8 years old. Four of them were siblings, officials said.
Allyson Chiu
SECOND OPINION
That’s why, as president, I will push to ban them again.
Joe Biden via New York Times
DAYBOOK

Today

  • Sen. Chuck Grassley (R-Iowa) speaks at a discussion on rural health hosted by at the Bipartisan Policy Center.

Coming Up

  • The House Financial Services Committee holds a hearing in Los Angeles on the homelessness crisis on Wednesday. 
SUGAR RUSH

The president has topped 12,000 in our database of false and misleading claims: