NAHC Releases Comments on Proposed Public Charge Changes

(December 13, 2018)—On Sept. 10, 2018, the Department of Homeland Security (DHS) proposed a changed in the application of the “public charge” in determining immigrant admission status in the Notice of Proposed Rulemaking (83 Fed. Reg. 51114), published to the Federal Register on Oct. 10. The U.S. Citizenship and Immigration Services website defines a public charge as “For purposes of determining inadmissibility, “public charge” means an individual who is likely to become primarily dependent on the government for subsistence, as demonstrated by either the receipt of public cash assistance for income maintenance or institutionalization for long-term care at government expense.”

There are concerns in the home health industry due to the proposed change, and the National Association for Home Care & Hospice has released comments on the proposed rule, below.

Dear Chief Deshommes:

The Department of Homeland Security (DHS) has recently proposed a change in the application of the “public charge” in determining immigrant admission status in the Notice of Proposed Rulemaking (NPRM). 83 Fed. Reg. 51114 (October 10, 2018). This change carries implications for home health and hospice agencies by impacting their ability to employ the necessary workforce to care for the millions of Americans receiving care in their home every year. Additionally, penalizing legal immigrants seeking needed health and social services will negatively impact on our nation’s health care system in general.

The National Association for Home Care & Hospice (NAHC) respectfully submits these comments regarding the proposals contained within the NPRM. NAHC is the largest trade association representing the interests of homecare and hospice agencies nationwide including nonprofit, proprietary, urban and rural based, hospital affiliated, public and private corporate entities, and government run providers of home health care and hospice since 1982.

This proposal will result in fewer eligible homecare workers, as immigrants tend to serve as a sizable proportion of the personal care and assistance aids workforce. These workers often qualify for public assistance through programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP). The typical annual income for these non-skilled workers falls below the guidelines for a two-member household as included in the proposed rule, and their eligibility for public assistance will also be counted as negative factors in determinations. Barring immigrants on the basis of public assistance will only exacerbate an already prevalent workforce shortage leaving many employers unable to care for patients in need. This will cause patients to seek out more costly institutional settings for the same care they could have received in their home.

According to PHI International’s research, in 2017 the median wage for homecare workers was $11.03 per hour, while the median annual income was $15,100. PHI also found that 16 percent of homecare workers are naturalized U.S. citizens, with an additional 14 percent listed as not an American citizen. In total, 30 percent of homecare workers are not natural born U.S. citizens. This is a strong indication that immigrants will play an important role in addressing the substantial workforce challenges homecare will face in the coming years. According to the U.S. Bureau of Labor Statistics, homecare workers rank in the top five fastest growing occupations. By 2026 the demand for homecare workers is projected to increase by over one million.

Many of these workers’ employers are providers of service in the Medicaid and Veterans Health Administration programs. These government-funded programs set reimbursement rates that effectively limit providers in the compensation they can offer to their staff. By virtue, these reimbursement rates limit wages resulting in an impoverished workforce. To that end, the majority of homecare workers qualify for some form of public assistance. Specifically, 30 percent qualify for Medicaid, and 30 percent qualify for SNAP. This means that the very programs that are considered in determining whether an immigrant is a “public charge” are the reason why these crucial homecare workers may qualify for that public support.

By adjusting a legal permanent resident’s (LPR) status on the basis of their need for public assistance, individuals will forego necessary care until such time that the condition requires emergency treatment, a situation that comes at a great cost to both the individual and our health care system. In addition, once coverage is lost, homecare providers of service are placed into the position of providing uncompensated care. In these scenarios, the uninsured individual may be discharged from a hospital or emergency department to a homecare agency. Without Medicaid or other assistance, homecare agencies will need to provide care on a charitable basis. Absent that charity, a return trip to the emergency department is the most likely outcome. This creates a cycle that is wholly avoidable by ensuring access to homecare.

Visit nahc.org for more information.