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The UCLA Center for Health Policy Research’s Public Comment on proposed changes to the federal "public charge" immigration test

December 13, 2018

      Ninez Ponce, MPP, PhD
      Director, UCLA Center for Health Policy Research
      Professor, UCLA Fielding School of Public Health
      Department of Health Policy and Management
       
      December 10, 2018
       
      Samantha Deshommes, Chief
      Regulatory Coordination Division, Office of Policy and Strategy
      U.S. Citizenship and Immigration Services Department of 
      Homeland Security
      20 Massachusetts Avenue NW 
      Washington, DC 20529-2140

      Re: DHS Docket No. USCIS-2010-0012, RIN 1615-AA22, Inadmissibility on Public Charge Grounds
       
      Dear Ms. Deshommes:
       
      The Center for Health Policy Research at the University of California, Los Angeles (UCLA) strongly opposes the changes proposed by the Department of Homeland Security (DHS) regarding “public charge,” published in the federal register on October 10, 2018.
       
      As part of the university’s Fielding School of Public Health, we conduct the California Health Interview Survey, which provides information on the state of all Californians to help legislators, county health departments, and advocates make decisions and take action on what kind of health issues need attention, with the ultimate goal being to improve the health of all Californians.
       
      How it will affect our university/Center communities
      California is built upon – and thrives upon – the contributions of immigrants. As one of the world’s leading public universities, UCLA both cultivates and benefits from those contributions in terms of the faculty we recruit, the staff we hire, and the students and communities surrounding the university who give back as much as we give.
       
      The proposed changes to public charge would potentially affect a portion of our faculty, staff and students and their families who hold visas they are attempting to renew, or new hires attempting to get a new visa. Our UCLA Center for Health Policy Research projects are staffed by many public health professionals, methodologists and policy analysts who immigrated to the United States.

      How it will affect the immigrant community in California regarding health
      Beyond the university’s faculty, staff and students, the proposed changes to public charge are complex and will lead to misinformation, confusion, and fear about enrollment in public programs, including nutrition assistance, health care coverage, and housing assistance. Recent analysis of the Supplemental Nutrition Assistance Program (SNAP, known as CalFresh in California) and Medicaid (known as Medi-Cal in California) indicates that this “chilling effect” could impact up to 2.2 million immigrant families in California alone.i If just 35 percent of these Californians in immigrant families disenroll from SNAP and Medicaid, 765,000 people across the state would lose access to critical resources for nutritious food and health care services.ii
       
      Research shows there was significant disenrollment in public benefits after the enactment of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) among immigrants who remained eligible for public benefits post- PRWORA. A prominent and highly cited piece of research by Fix et al. (1999)iii examined immigrant disenrollment over the 1994-1997 period and found that while PRWORA changed immigrant eligibility requirements (i.e., public benefits eligible only to immigrants who have had green cards for at least 5 years), there was still significant disenrollment in public benefits due to fear and confusion among immigrants who had no change in eligibility and were fully eligible. This prior research indicates a 35 percent disenrollment rates is reasonable. This scenario has been used in recent analyses on the proposed public charge rule published by the Kaiser Family Foundation,iv California Health Care Foundation,v and the Fiscal Policy Institute.vi
       
      Page 51266 of the proposed rule states that the “chilling effect” of this rule would not be comparable to that which was observed following the enactment of PRWORA because that law changed eligibility requirements, whereas this rule would change enrollment incentives. However, this assertion does not explain why refugee Food Stamp use dropped 60 percent between 1994 and 1997, despite their eligibility remaining unchanged by PRWORA.vii The assumption of a 2.5 percent rate of disenrollment is a gross underestimate of this proposal’s potential chilling effect. If DHS were to calculate the costs and consequences of this policy using a more accurate, evidence-based rate of disenrollment, the projected negative impacts on public health and the economy would be significantly worse.
       
      Disenrollment from SNAP and Medicaid would increase poverty, hunger, and poor health in communities statewide by reducing the resources that California residents have for health care, food, and other basic necessities. Among California’s immigrant adults potentially impacted by the proposed rule, Medi-Cal enrollees are 1.8 times more likely to have a usual place to get health care and are 1.5 times more likely to have had a preventive care visit in the past year, compared with people who are uninsured.viii More than 400,000 of California’s immigrant adults are food insecure, which means that they lacked consistent access to enough food at some point in the past year.ix Disenrollment from CalFresh could increase food insecurity in California for these adults and others in their households, including children.x
       
      SNAP mitigates hunger and is associated with better health. Nationwide, SNAP decreases food insecurity by up to 30 percent, with the largest effects among households with children and households with very low food security.xi Exposure to SNAP is also associated with positive birth outcomes (healthier birth weights), increased likelihood of reporting excellent or very good health, decreased risk of chronic diseases in adulthood, and increased likelihood of adhering to prescription medicines among seniors.xii
       
      The effects of Medi-Cal are also seen throughout the life course of participants. For instance, children with Medi-Cal are more likely than uninsured children to graduate from high school and college and as adults, earn more and pay more taxes.xiii Children with Medi-Cal are twice as likely to receive routine preventive medical and dental care than uninsured children.xiv Adults with Medi-Cal are 40 percent more likely to receive routine check-ups than uninsured adults.xv Medi-Cal saves thousands of lives every year.xvi
       
      The proposed changes to public charge will predominately affect children and people of color. Nearly 70 percent of California residents projected to disenroll from health care and nutrition assistance benefits as result of the proposed rule would be children.xvii Throughout the state, disenrollment from CalFresh and Medi-Cal would most significantly impact Latinos (88 percent) and Asians (8 percent).xviii
       
      How it will affect the economy of the state
      The harm of the proposed changes to public charge extends beyond immigrants and immigrant families. Analysis shows that if just 35 percent of Californians in immigrant families disenroll from Medi-Cal and CalFresh, the state would lose up to $2.8 billion in economic output.xix For every lost dollar in federal benefits, the state would lose approximately $1.60 in economic activity.xx Up to 17,700 jobs would be eliminated statewide. An estimated 57 percent of the job losses would come from California’s health care sector (8,400 jobs) and food-related industries (1,800 jobs).xxi These anticipated economic losses show that deterring immigrants from accessing much-need public programs will hurt individuals, families, and entire communities, regardless of immigration status. The evidence provided by UCLA researchers and their esteemed colleagues across that country makes clear that the proposed changes to public charge will leave us a sicker, hungrier, poorer nation.
       
      The proposed rule is an affront to our country’s core values, our social contract, and our history as a nation of immigrants. In driving immigrants from resources that support health, well-being, education, and upward economic mobility, this policy will force us to forego the many contributions immigrants make to the economy and our society.
       
      For all of these reasons, we ask that DHS immediately withdraw this proposed rule.
       
       
      Ninez A. Ponce, MPP, PhD
      Professor, Fielding School of Public Health Director
      UCLA Center for Health Policy Research, 
      UCLA Fielding School of Public Health
       
      i Ponce NA, Lucia L, Shimada T. December 2018. Proposed changes to immigration rules could cost California jobs, harm public health. Los Angeles, CA: UCLA Center for Health Policy Research, UC Berkeley Labor Center & California Food Policy Advocates.
      ii ibid
      iii Fix M.E., Passel J.S. (1999). Trends in Noncitizens’ and Citizens’ Use of Public Benefits Following Welfare Reform: 1994 – 1997. Washington, D.C.: The Urban Institute. Available at https://www.urban.org/research/publication/trends-noncitizens-and-citizens-use-public-benefits- following-welfare-reform
      iv Artiga, S., Damico, A., Garfield, R. Potential Effects of Public Charge Changes on Health Coverage for Citizen Children. Kaiser Family Foundation. May 18, 2018. Available at: https://www.kff.org/disparities-policy/issue-brief/potential-effects-of-public-charge-changes-on- health-coverage-for-citizen-children/
      v Zallman, L., Finnega, K. Changing Public Charge Immigration Rules: The Potential Impact on Children Who Need Care. California Health Care Foundation. October 23, 2018. Available at: https://www.chcf.org/publication/changing-public-charge-immigration-rules/
      vi Fiscal Policy Institute. “Only Wealthy Immigrants Need Apply” How a Trump Rule’s Chilling Effect will Harm the U.S. October 2018. Available at: http://fiscalpolicy.org/wp-content/uploads/2018/10/US-Impact-of-Public-Charge.pdf
      vii United States Department of Agriculture Food and Nutrition Service, Office of Analysis, Nutrition, and Evaluation. (1999) Who is Leaving the Food Stamp Program? An Analysis of Caseload Changes from 1994 to 1997. Available at https://fns-prod.azureedge.net/sites/default/files/cdr.pdf
      viii Ponce NA, Lucia L, Shimada T. December 2018. Proposed changes to immigration rules could cost California jobs, harm public health. Los Angeles, CA: UCLA Center for Health Policy Research, UC Berkeley Labor Center & California Food Policy Advocates.
      ix ibid
      x ibid
      xi James Mabli et al. (2013). Measuring the Effect of Supplemental Nutrition Assistance Program (SNAP)
      Participation on Food Security. Food and Nutrition Service, USDA. Available at: https://www.fns.usda.gov/measuring-effect-snap-participation-food-security-0
      xii Carlson, S., Keith-Jennings, SNAP Is Linked with Improved Nutritional Outcomes and Lower Health Care Costs, Center on Budget and Policy Priorities, 2018. Available at: https://www.cbpp.org/research/food-assistance/snap-is-linked-with-improved-nutritional- outcomes-and-lower-health-care
      xiii Harbage Consulting, “Medi-Cal Matters: A Snapshot of How Medi-Cal Coverage Benefits Californians, California Health Care Foundation September 2017.
      xiv ibid xv ibid xvi ibid
      xvii Ponce NA, Lucia L, Shimada T. December 2018. Proposed changes to immigration rules could cost California jobs, harm public health. Los Angeles, CA: UCLA Center for Health Policy Research, UC Berkeley Labor Center & California Food Policy Advocates.
      xviii ibid
      xix Ponce NA, Lucia L, Shimada T. December 2018. Proposed changes to immigration rules could cost California jobs, harm public health. Los Angeles, CA: UCLA Center for Health Policy Research, UC Berkeley Labor Center & California Food Policy Advocates.
      xx ibid
      xxi ibid