Will Humble Federal Budget, Public Health, Public Health Law, Social Determinants, Wills Blog

White House Releases the Executive Budget Proposal

Big Cuts Proposed for Public Health & Social Determinants

The White House staff released the Executive Branch’s proposed budget for FY 21 last week.  I won’t spend a lot of time on it here because it will have little influence on what actually comes out of Congress because of the fact that different parties control the House and Senate. 

The basics of the proposal include a 9% cut to the HHS including a $693M cut to CDC and a $742 cut to HRSA. The overview of the 9% HHS cut says that it includes reductions on the Medicaid side of CMS. I couldn’t find any of those cuts in the CMS line items except for a general $3.6B cut to state budget authority (with no detail) a $24B cut to various federal hospital insurance trust funds. 

The proposed budget says that “$1 out of every $7 spent in Medicaid, were considered an improper payment”. I had never seen that statistic before. They also say that their budget cut to Medicaid is due to the fact that the Administration will “… strengthen CMS’ ability to address weaknesses in provider screening, enrollment, and identification, as well as beneficiary eligibility determinations in Medicaid“. Maybe they expect to capture the cuts there?  Ok, then.

They also propose an 8% cut to USDA programs (especially SNAP).  They book those savings due to “…  SNAP work requirements and apply them consistently to able-bodied adults ages 18 to 65, unless they qualify for specific exemptions. Under the proposal, adults would be required to work, participate in job training, or volunteer at least 20 hours a week in order to receive SNAP benefits“.

USDA will get big increases in other areas like farm subsidies. The proposed budget says: “To help farmers survive the market shocks (read tariffs), the Administration has provided $28 billion in trade mitigation assistance and $5.7 billion in supplemental and ad hoc disaster assistance to farmers.” 

In fact, a third of farm income last year came from Government payments and crop insurance last year, and they don’t expect that to change.  

New AzPHA Preventing Firearm Violence Evidence Resources

Will Humble Assurance & Licensure, Medical Marijuana, Public Health Law, Wills Blog

Member Action Items for this Week

HB 2784 Medical Marijuana Research – AzPHA Supports

This bill will make it explicit that the medical marijuana fund could be used for research regarding medical marijuana.  The bill is consistent with our Resolution on this topic and we encourage you to sign up in support of the bill.  It’ll be heard in the House Health Committee this Thursday.

HB 2550 ADHS Licensing Surveyors

Appropriates $3M & 44 staff positions in FY 2021 for additional (ADHS) long-term care facility surveyors.  Normally, these services would be paid for via a licensing fee.  In this case, the bill contemplates a general fund appropriation.  The genesis of this bill is as a result of the 2019 Auditor General’s Report that found the ADHS is not adequately following up on complaints at skilled nursing facilities in Arizona. This will be heard in House Health Committee Thursday and we encourage you to sign up in support of the bill.

HB1028   Public Health Surveillance –  AzPHA Supports

Adds “an emerging public health threat to the list of things that can trigger ADHS enhanced surveillance orders and compliance with mandatory public health interventions.  The idea is that the bill would provide enhanced surveillance authority for emerging public health threats that aren’t yet a full public health emergency- along the lines of doing enhanced surveillance when persons were getting severe lung illnesses from the bootleg vaping products that contained vitamin e acetate. This will be heard in the Senate Health Committee Thursday and we encourage you to sign up in support of the bill. 

Here’s a link to our weekly bill tracking spreadsheet thanks to our crack group of policy interns this year. Interesting to note that the bills that would further erode vaccination coverage haven’t been scheduled for a hearing next week. That doesn’t mean they’re kaput, but it’s a good sign.

Will Humble Disease Control, Wills Blog

Coronavirus Intervention Activities & Editorial Notes

Intervention Activities

As you know, Maricopa County Department of Public Health confirmed one case of 2019 Novel Coronavirus infection in a person from a couple of weeks ago. The person came to the Valley from Wuhan and had a mild illness that didn’t require hospitalization (a good sign). The person is still isolated at home with daily monitoring and regular testing to determine if the virus is still present in the nose and mouth.

Close contacts are being monitored daily for fever and symptoms, but so far there’s no evidence of community spread.  All the county health departments are set to contact travelers from China and provide them with monitoring instructions for 14 days after their last exposure (because Maricopa is the urban hub of the state they will be the primary spot where any action will be from travelers). Here are a few notes from Maricopa about some particulars: 

  • Maricopa County residents who have traveled to China recently and are concerned about 2019 Novel Coronavirus are supposed to call 602-747-7099;

  • Anyone with respiratory symptoms who is concerned about 2019 Novel Coronavirus should contact their healthcare provider BEFORE seeking care to avoid spread to others; and

  • Healthcare providers in Maricopa County who see patients with travel history to China in the 14 days before illness onset AND respiratory symptoms should contact Public Health at 602-747-7111

Anybody can go to the Maricopa.gov/Coronavirus website and look at their social media (Twitter @maricopahealth and @saludmaricopa, Facebook in English and in Spanish) for local updates including: Current case counts; FAQs in English, Spanish, and Mandarin;  Detailed healthcare provider guidance; Template letter for schools to inform families about the low risk; and Actions to prevent stigmatization and bullying.

MCDPH will also continue to work with healthcare providers to facilitate testing of people who meet CDC criteria, monitor those who are risk of developing illness, and isolate those who are potentially contagious.

Editorial Remarks

So far, the evidence suggests that this new virus is easily transmitted person to person.  While the symptoms can be severe in some folks, they’re commonly quite mild (like the single AZ case). It looks like the virus can be transmitted from asymptomatic persons, which means that standard practices like screening and isolation will be of limited effectiveness as interventions over the long run (the data are still a little unclear whether asymptomatic folks are infectious).

When you put these characteristics together along with the patterns for similar illnesses- it suggests that the number of undiagnosed and unreported cases (driven by a lot of people with truly mild infection) will turn out to be at least 10 times higher than what’s currently being reported in the Chinese surveillance data. 

While 2019-nCoV currently shows ~2% mortality the denominator is likely much much larger.  In reality, mortality is likely closer to something like 0.2% or even 0.02% (because the denominator is likely much larger than what is being reported by China). 

In other words, it looks like this new virus will be a high-incidence and fairly low virulence infection. 

So, as public health professionals, we need to keep our evidence hat squarely on our heads…  and as the virus spreads across the globe (as it will likely do in the coming weeks and months) frame our intervention plans consistent with what we do for similar viruses (e.g. influenza).

Right now, with just sporadic travel cases being reported and tracked and with some uncertainty still out there about the virulence of this virus, it makes sense to conduct the interventions that are underway at our county health departments and at other levels of government.

The CDC action is now quarantining repatriated citizens for 14 days – the first time they’ve used quarantine authority since smallpox.    Interventions like that when there are a handful of contacts is of course do-able and will have essentially no societal disruption.  It will also buy valuable time- time that we will use to better characterize the etiology of the new virus. 

However, when the wave eventually hits – as it will likely do in either weeks or months – we need to think carefully and make sure that our interventions are consistent with our standardized and existing public health practice principles.  By that, I mean the kinds of interventions we conduct and encourage for influenza type illnesses.

Encouraging actual suspect cases to self-isolate is a no-brainer.  But, when the wave comes, should we invoke public health authority beyond that?

Interventions like isolation and quarantine (once the wave hits) would cause major disruptions to society and place public health in the crosshairs of needing to justify why such dramatic interventions are needed – when we don’t implement them for things like influenza.  Also, there’s a real danger to future public health authority if you “cry wolf” too soon about a disease that may turn out to be a tragedy for a few, but no big deal for the vast majority.  

Just something for the back of your mind as we do what we need to do in the coming days.  Let’s continue be cautious at first, but not over-hype it, and be prepared to back off sooner than later if the data continues to suggest that this will indeed be a high-incidence and fairly low virulence infection. 

Will Humble State Legislature, Wills Blog

Member Action Items for this Week

HB2423, SB1170 & HB2727 Dental for Pregnant Women

SB 1170 is scheduled for a hearing before the Senate Appropriations Committee Tuesday 02/11/2020 at 2 PM and the mirror bill HB2727 will be heard in the House Health and Human Services Committee the next day (Thursday 2/13 at 9AM).  Please sign on in support of both bills and come to the hearing rooms at the Capitol to show your support.   

Please email appropriations committee members, letting them know how you feel about SB1170, which will provide comprehensive dental care to pregnant adults. See their email addresses: [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]; [email protected]

These bills would expand oral health coverage for pregnant women enrolled in AHCCCS to include preventive and other services.  This is a terrific bill for public health because a mom’s oral health status is directly linked to birth outcomes.  A new systematic review found a clear relationship between periodontal disease and pre-term birth, and low birth weight.

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SB1493 Pharmacists; Dispensing Hormonal Contraceptives

This good bill (SB1493) is scheduled to be heard in the Senate Health and Human Services Committee on Wednesday morning at 9 am. Please go into the AZLEG system and express your support for this bill.  It would allow a pharmacist to dispense a self-administered hormonal contraceptive to a person 18 or over pursuant to a standing order.

There are checks and balances in this statute to ensure that best practices are used.  This is a net public health benefit as teen births are the number one cause of inter-generational poverty and the bad health outcomes that result.

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HB 2549 Adult Protective Services Audit

HB 2549 is scheduled to be heard will be heard in the House Health and Human Services Committee on Thursday 2/13 at 9 am.  Please sign on in support of this bill and come to the hearing rooms at the Capitol to show your support.

A recent report from the Developmental Disabilities Planning Council has identified several critical shortcomings in the performance of the Adult Protective Services program at the Arizona Department of Economic Security. This bill would charge the Auditor General’s Office with contracting for an independent evaluation of APS’ performance- an evaluation that is sorely needed.  It includes a $300K appropriation to do the review.

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HB2486  Immunization Requirements – AzPHA Opposes

While HB2486 isn’t scheduled for a hearing next week, we’re asking our members to go into the AZLEG system and express their opposition to this bad bill.  It would basically do away with the FDA vaccine approval process and replace it with criteria set by this law for the purposes of implementing vaccination requirements.  

This bill adds a series of additional requirements that, unless met, mean that a vaccine is eliminated from any vaccination requirement. It’s basically an IED to get completely rid of all vaccination requirements.  Bad bill.

Will Humble State Legislature, Wills Blog

Here’s a Summary of Last Week’s Committees Hearings

Bills that Passed House Health Committee this week:

HB 2608  Overdose Prevention & Harm Reduction – AzPHA Supports

This bill would facilitate evidence best practices that slow the spread of blood-borne pathogens and engage injection drug users in treatment.  It’s currently a felony to provide syringes to injection drug users via a syringe access program even though these programs are evidence-based programs that reduce the spread of Hepatitis C, HIV and other blood-borne pathogens and engage injection drug users in treatment. 

We have supported bills like this for the last several years, but they have yet to be successful.  This Bill got a pass recommendation from the House Health Committee (8-0). On to the Rules Committee then the House floor.

HB2670 Doulas; Voluntary Certification – AzPHA Supports

This bill would establish a voluntary certification process for a person to “practice as a certified community doula.” The ADHS would write the rules and run the program.  There’s good evidence that doulas can improve birth outcomes while reducing delivery costs. Here’s an Issue Brief that provides documentation. This Bill passed the House Health Committee 9-0 on 2/6.

SB1397 Health Insurance; Pre-existing conditions – Neutral 

This bill provides a partial backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre- existing conditions from coverage.

It is silent on whether people with pre-existing conditions could be charged higher premiums, which is why we’re neutral on the bill.  We’d like to see it amended so that it includes Community Pricing.  The bill got a pass recommendation from the Senate Finance Committee last week (9-0). Hopefully it’ll eventually be amended to include community pricing.

Will Humble Affordable Care Act, Assurance & Licensure, Family Planning, Health Insurance, Medicaid, Nutrition, Opioids, Public Health, State Legislature, Wills Blog

Here’s the List of Bills that We’re For and Against

Below is a summary of the short list of bills that we’re following closely. Our public health policy interns from the UA College of Public Health (Dylan Miller, Caitlin Tillis & Desiree Jones) have also put together a tracking tool in spreadhseet format that you can download. 

Tobacco Control

HB2636 & SB1400  Tobacco Retail Licensing – AzPHA Supports

This bill (sponsored by Representative Blackman) would facilitate a licensing system for stores that wish to sell tobacco products including e-cigarettes.  It also references the amendment to federal FDA law that raises the tobacco sale age to 21.  This bill would be helpful to ensure compliance with the new federal age standard. The licensing system would be coordinated by the ADHS and begin on January 1, 2022.

HB2637   Tobacco Definition –  AzPHA Supports

This bill (sponsored by Representative Blackman) will define electronic cigarettes as a tobacco product for the all purposes of state law (although I don’t think that this would extend for tax purposes although I’m not sure yet).

HB2173   Smoke Free AZ Act Amendments –  AzPHA Supports

This bill sponsored by Representative Kavanagh would amend the voter approved Smoke Free Arizona Act to include electronic cigarettes.  Because this amends a voter approved initiative it will need a supermajority vote in the legislature.

Immunizations

HB2050 Immunizations; Parental Control – AzPHA Opposes

This (Fillmore) bill would essentially get rid of the current system by which schools track whether students are vaccinated or not.  Currently, parents decide whether to vaccinate their children and schools can’t require students to receive the recommended immunizations OR refuse to admit or otherwise penalize a student because the student has not received the recommended immunizations as long as the parent signs a personal exemption. Bad bill.

HB2486  Immunization Requirements – AzPHA Opposes

This bill would basically do away with the FDA vaccine approval process and replace it with criteria set by this law for the purposes of implementing vaccination requirements.  The FDA has a rigorous approval protocol that includes all the core elements to determine whether they are safe and effective.  The data are reviewed by independent panels and approved using rigorous protocols.

This bill adds a series of additional requirements that, unless met, mean that a vaccine is eliminated from any vaccination requirement. It’s basically an IED to get completely rid of all vaccination requirements.  Bad bill.

SB 1267  School Immunization Rate Reporting – AzPHA Supports

This common-sense Carter bill would require schools to post the immunization rates on their school website.

Oral Health

HB 2244 Dental; Native Americans –  AzPHA Supports

This bill would require AHCCCS to seek federal authorization to reimburse IHS and tribal facilities to cover the cost of adult dental services that are eligible for a federal medical assistance percentage of 100%.  Authorizes AHCCCS to seek CMS approval to reimburse Indian health care dental providers that receive 100% FMAP for the cost of dental services. Passed House Health 9-0 in late January.

HB2423, SB1170 & HB2727  AHCCCS Dental for Pregnant Women –  AzPHA Supports

These bills from Rep. Butler & Sen Carter would expand oral health coverage for pregnant women enrolled in AHCCCS to include preventive and other services.  This is a terrific bill for public health because a mom’s oral health status is directly linked to birth outcomes.  A new systematic review found a clear relationship between periodontal disease and pre-term birth, and low birth weight.

HB2535 Preventive Dental Care (AHCCCS) – AzPHA Supports

This bill from Representative Shah would boost the adult oral health coverage for Medicaid members to include two regular cleanings, fluoride 15 treatment, and one set of X-rays annually.  We are in support of this common-sense bill.

Maternal & Child Health

SB1472   Maternal Health; Postpartum Visits – AzPHA Supports

This is a terrific bill from Senator Carter that would direct AHCCCS to require their contracted health plans to increase post-partum visits by new moms and increases the appropriation that would be required to pay for this important initiative.  There are a ton of important physical and behavioral health reasons to implement this important initiative.

SB1493 Pharmacists; Dispensing Hormonal Contraceptives – AzPHA Supports

This is a bill we support from Sen. Ugenti Rita which would allow a pharmacist to dispense a self-administered hormonal contraceptive to a person 18 or over pursuant to a standing order.  There are checks and balances in this statute to ensure that best practices are used.  This is a net public health benefit as teen births are the number one cause of inter-generational poverty and the bad health outcomes that result. 

HB2670 Doulas; Voluntary Certification – AzPHA Supports

This bill would establish a voluntary certification process for a person to “practice as a certified community doula.” The Department of Health Services would write the rules and run the program.   There is good evidence that doulas can improve birth outcomes while reducing delivery costs. Here’s an Issue Brief that provides documentation. This Bill passed the House Health Committee 9-0 on 2/6.

Social Determinants

HB2104 Child Care Assistance and Training –  AzPHA Supports

This bill would let ADES waive work requirements for people enrolled full time in an accredited educational institution in order to continue to provide supplemental child care assistance subsidies for the dependent child. 

Disease Control

SB 1028   Public Health Surveillance –  AzPHA Supports

Adds “an emerging public health threat to the list of things that can trigger ADHS enhanced surveillance orders and compliance with mandatory public health interventions.  The idea is that the bill would provide enhanced surveillance authority for emerging public health threats that aren’t yet a full public health emergency- along the lines of doing enhanced surveillance when persons were getting severe lung illnesses from the bootleg vaping products that contained vitamin e acetate.

Workforce

SB 1167 Graduate Medical Education – AzPHA Supports

This important bill from Sen Carter would set up a program to reimburse primary care residency programs and qualifying Community Health Centers.  This bill is important because it addresses the shortages that we face in rural and under-served areas by setting up residency programs that will have a long-term positive impact on access to care (especially primary care) in these areas. 

HB 2296 Native American AHEC – AzPHA Supports

This bill would create a sixth Area Health Education Center (AHEC) that will focus on the Indian Health System. AHECs are committed to expanding the health care workforce, while maximizing diversity and facilitating distribution, especially in rural and under-served communities and offer creative, hands-on and innovative health career curriculum for pre-college level students.

Vulnerable Populations

HB 2608  Overdose Prevention & Harm Reduction – AzPHA Supports

This bill would facilitate evidence best best practices that slow the spread of blood-borne pathogens and engage injection drug users in treatment.  It’s currently a felony to provide syringes to injection drug users via a syringe access program even though these programs are evidence-based programs that reduce the spread of Hepatitis C, HIV and other blood-borne pathogens and engage injection drug users in treatment.  We have supported bills like this for the last several years, but they have yet to be successful.

HB 2549 Adult Protective Services Audit – AzPHA Supports

A recent report from the Developmental Disabilities Planning Council has identified several critical shortcomings in the performance of the Adult Protective Services program at the Arizona Department of Economic Security. This bill would charge the Auditor General’s Office with contracting for an independent evaluation of APS’ performance- an evaluation that is sorely needed.  It includes a $300K appropriation to conduct the review.

SB 1086 Licensing Surveyors –  AzPHA Supports

Appropriates $3M & 44 staff positions in FY 2021 for additional (ADHS) long-term care facility surveyors.  Normally, these services would be paid for via a licensing fee.  In this case, the bill contemplates a general fund appropriation.  The genesis of this bill is as a result of the 2019 Auditor General’s Report that found the ADHS is not adequately following up on complaints at skilled nursing facilities in Arizona. Passed Senate Health 8-0 in late January.

HB 2031   School Marshals – AzPHA Opposes

Lawmakers just introduced a new bill that would bring guns into Arizona schools.  HB 2031 would create a school marshal program that would allow school employees across Arizona to carry concealed firearms on school grounds, during school hours.  There is no evidence in the literature that we could find to demonstrate that this is an evidence-based intervention to prevent violence and injury in schools so we are opposing the measure.

SB 1164    Severe Threat Order of Protection – AzPHA Supports

This bill would create a new kind of severe threat order of protection (with judicial review) and place new requirements for persons for who the orders have been issued including prohibiting the person from buying or having a firearm during the order’s duration.

SB 1169 School Health Program – AzPHA Supports

This bill from Sen Carter would support the costs of placing nurses and psychologists in Arizona public schools. The bill includes a detailed list of application standards for schools.

SB1397 Health Insurance; Pre-existing conditions _AzPHA Neutral

This bill provides a partial backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre- existing conditions from coverage. It is silent on whether people with pre-existing conditions could be charged higher premiums, which is why we’re neutral on the bill.  We’d like to see it amended so that it includes Community Pricing.

HB 2788 Pre-existing Conditions; Essential Benefits

This bill from Rep. Butler would provide a backstop in case the US Supreme Court strikes down the Affordable Care Act. It would prohibit health insurers from offering health insurance plans that exclude people with pre-existing conditions from coverage and would not allow insurers to charge more for people with pre-existing conditions. It would also require coverage for the 10 essential health benefits outlined in the ACA.

Nutrition

SB1221   SNAP; benefit match – AzPHA Supports

This bill would direct an appropriation of $800K to the ADES to develop the infrastructure to create a produce incentive program within SNAP (food stamps) and to help enrollees to buy Arizona grown fruits and vegetables. 

Will Humble Medicaid, Public Health Law, State Legislature, Wills Blog

CMS Puts Medicaid Block Grants on the Table

A couple of days ago CMS released guidance encouraging states to ask for Medicaid waivers that would block grant the services “able bodied adults”.  The block grant would come with increased flexibility about how to spend those federal dollars and what services to provide- but would cap federal funding for that portion of the program. They’re branding the initiative the Medicaid Healthy Adult Initiative.

Here’s the letter that CMS sent to the State Medicaid Directors and their ”Fact Sheet”.

It’s an optional program, so governors will have a choice whether to take the bait or not. I haven’t seen any media responses from our governor about whether he’s interested in such a new block grant waiver. The Oklahoma governor already directed his state health department to begin the waiver application work.

Also, as is standard operating procedure these days it seems, it’s likely that a state or group of states will sue CMS in federal court challenging their authority to approve such waivers – likely arguing that CMS doesn’t possess the authority to do this under the existing law.

Will Humble Medicaid, Public Health Law, State Legislature, Wills Blog

CMS’ New Medicaid Fiscal Accountability Rule Expected this Spring

The new regulation could blow a $2B hole in the AHCCCS Budget & undo Medicaid expansion

CMS is proposing a set of new wide-ranging regulations that would change the way states can pay for their share of Medicaid costs including supplemental payments. The proposed “Medicaid Fiscal Accountability Rule” will have profound implications for the ways in which States finance Medicaid programs and pay for Medicaid services.  It basically changes the ways states can finance the state share of Medicaid costs (including provider taxes like our hospital assessment that pays for Medicaid expansion).

AHCCCS put together a Summary Document that details how the proposed new regulations could impact Arizona’s Medicaid program. Their comment letter is 4 pages long and outlines the challenges the new rule would pose in Arizona.

CMS says that they’re proposing the new rule to “address states’ increasing reliance on donations, taxes, or other financing strategies that CMS perceives mask or circumvent current Medicaid rules regarding how states are permitted to generate the state portion of the Medicaid match.”  

In my opinion, CMS (Seema Verma) wants to force states to finance their match with unpopular taxes so states can’t raise that match and instead cut eligibility and/or services.

One thing is certain with the proposed new Rules…  it’ll be a game changer in terms of how states are able to finance their portion of Medicaid programs (likely including our hospital provider assessment which pays for the state match for our Medicaid expansion). CMS even concedes that they don’t know how the new Rule will play out in states or how it will affect the real people that rely on Medicaid services.

The comment period ended yesterday (we turned in comments) and the final rule will be announced in the coming months.

Will Humble Immigration Policy, Social Determinants, Wills Blog

US Supreme Court Temporarily Allows Homeland Security to Enforce their New ‘Public Charge” Rule

Last week the US Supreme Court granted the president’s request to immediately begin enforcing the Department of Homeland Security’s new “public charge” rule which overhauls how DHS makes decisions about granting legal permanent resident applications. The final rules block legal immigrants from extending their temporary visas or gaining permanent residency if DHS decides the applicant is “likely to rely on designated public benefits in the future”.

The implementation of the new public charge” final rule now has the green light while it’s under judicial review in the lower courts. The SCOTUS issued this Order (which is different from a full on opinion). The Order stayed the temporary injunction issued by the district court.  If DHS gets the result they want in the lower courts, then the Plaintiffs (NY etc.) will appeal to the supreme court.  As is often the case these days, it was a 5-4 decision with the usual cast of characters on each side of the issue.

DHS will now begin considering whether applicants for legal permanent status have received Medicaid (AHCCCS), the Supplemental Nutrition Assistance Program (food stamps), or Section 8 Housing assistance in the past.  The definition of a “public charge” in the new Rule is: “an individual who receives one or more designated public benefits for more than 12 months in the aggregate within any 36-month period”. 

Medicaid limits eligibility (for immigrants) to qualified legal immigrants with refugee status, veterans, and people lawfully present in the US for 5 years or more. State Medicaid programs can elect to provide coverage to legally present immigrants before the 5-year waiting period ends (Arizona does not). 

States get matching funds from CMS when they choose to provide Medicaid coverage to legally present immigrants who are children or pregnant before the end of the 5-year waiting period.  33 states have elected to cover lawfully residing immigrant children and 25 states cover legally present pregnant women – Arizona does not.

Fortunately, the new Rule doesn’t consider whether benefits were used by an applicant’s kids. So, lawfully present kids that are receiving benefits (e.g. Medicaid) won’t have that used against them if the child later applies for legal permanent residency (a “green card”).  The public charge rule will use a “totality of the circumstances” test for applicants, which means that DHS will use the statutory factors and now the new factors laid out in the final rule.

Here are some things to remember about this new Rule

  • This is an issue of legal immigration- unauthorized migrants are largely ineligible for public assistance;

  • This doesn’t directly impact current legal permanent residents (current green card holders). The public charge test won’t be applied to legal current residents (green card holders) applying for citizenship;

  • The new rule isn’t retroactive – meaning public benefits received before 10/15/19 won’t be counted as a public charge; and

  • The new rules don’t apply to refugees. Existing statute prevents DHS from using these criteria for refugees and a couple of smaller exempt groups.

However, this issue is still not resolved. A group of states are still challenging the new DHS regulations arguing that the new rules are inconsistent with the law passed by congress a couple of decades ago (on which the new rules rest).  The district court ruling from a few months ago agreed with the challengers that they were likely to win, and temporarily blocked DHS from implementing the new regulations.

Public health note: 

Even though the final Rule excludes benefits received by children, this policy will still have a significant impact on children’s health as well as the health of their families and our communities.

We know from both national reports and from assistors and community organizations working in Arizona, that families are afraid and withdrawing from or reluctant to participate in benefits for which they or their children are legally eligible. Nationally, nearly one in four children have an immigrant parent, and almost 90% of them are US citizens.  Missing out on safety net programs for which folks are entitled can result in bad health outcomes because of social determinants that won’t be addressed and missed doctor’s appointments which could result in missed developmental screenings and interventions.

The fate of the new regulations are in the hands of the Judicial branch and to some extent in the hands of the voters this fall.

What we can do is to get the word out to families in this category that signing up their kids for safety net benefits to which they’re entitled won’t count against them when they apply for legal permanent status- nor will it count against their kids if they eventually apply for a green card. We can minimize the public health impact of this decision if the public health system is effective in ensuring that families know this important information! 

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