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AAP, members speak out against ‘public charge’ proposal :

October 16, 2018

After nearly a year of indicating it would do so, the Department of Homeland Security (DHS) issued a proposed regulation in mid-October that could threaten the health and well-being of immigrant families.

The proposal expands the “public charge” test, which is used to identify people who may depend primarily on the government for subsistence. Someone who is found to be a public charge could be denied a visa or green card. In short, the proposal makes it harder for immigrants, especially those in low-income households with children, to enter the country and advance through the immigration process.

The public has until Dec. 10 to submit comments on the proposal. After that deadline, DHS must consider the comments. Eventually, it will publish a final rule, and the changes will take effect.

While the public charge proposal threatens immigrant child health, it is technical in nature and may not grab headlines like the issue of family separation. The Academy is undertaking an extensive advocacy strategy to speak out against the proposed regulation and is empowering members with tools to do the same.

Following is an explanation of what changes to public charge would mean for child health, how the Academy is speaking out and how AAP members can add their voice to the advocacy efforts.

Proposal details

The more than 400-page proposed regulation expands the public charge test to consider whether an immigrant has used or is likely to use certain government programs, such as Medicaid, the Supplemental Nutrition Assistance Program (SNAP) and housing assistance. The proposal adopts an income threshold, under which households would be subject to the public charge test; a family of four would need to earn nearly $63,000 annually to be exempt from the test.

“The public charge proposal presents immigrant families with an impossible choice: keep yourself or your children healthy but risk being separated, or forgo vital services like preventive care and food assistance so your family can remain together in this country,” AAP President Colleen A. Kraft, M.D., M.B.A., FAAP, said in a news release.

In addition, the proposal discriminates against those with pre-existing conditions. For example, a low-income immigrant who is unable to cover the cost of an extensive treatment needed for a medical condition could be denied permanent legal status.

Child health impact

Based on the numbers alone, the potential child health impact of the proposed regulation is massive: one in every four children in the United States lives in an immigrant family, meaning the child or at least one parent is foreign-born. A recent analysis by the Fiscal Policy Institute finds that the effect of the proposal would extend to 24 million people in the U.S., including 9 million children.

After the proposal was leaked, many pediatricians across the country witnessed a chilling effect in their practices, with families disenrolling from programs or avoiding health services for which they are eligible. Although there was no change in policy, parents were afraid that by using the programs, they could jeopardize their ability to continue through the immigration process and remain in the United States.

During a recent radio interview with PRI’s “The World,” Lanre Falusi, M.D., FAAP, of Washington, D.C., explained how parents in her practice were asking if it is safe to access programs such as SNAP and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

“Parents are choosing to play it safe and remove themselves from programs that they qualify for,” Dr. Falusi said in the interview. “It is a very confusing and scary time for the families I see.”

As a result of this fear and confusion, children are not receiving the health care and nutrition services they rely on and are missing out on lifelong benefits of these programs. For example, children enrolled in Medicaid are twice as likely to have routine checkups and vaccinations than uninsured children.

In addition, if parents disenroll from their health coverage or choose not to enroll at all due to fear of being deemed a “public charge,” their children's health could suffer.

Recent studies looking at Medicaid expansion to low-income adults found that children were more likely to have an annual well-child checkup if their parents were insured.

AAP advocacy

Ever since initial reports of the proposal surfaced, the Academy had been preparing for its likely publication. In fact, the Academy was among the first to voice its opposition to the harmful effects of the proposal at the White House Office of Management and Budget when it was first under consideration last spring.

DHS finally announced its plan to issue the proposal over a weekend in September. The following day, Dr. Kraft joined a press call with partners to respond to the news. The Academy strongly opposed the proposal and called on the Trump administration to rescind it immediately.

Since the policy is not final until after the administration publishes the final rule, the Academy is ramping up efforts to submit comments on the proposed regulation and is urging members to speak out against it.

The AAP recently created a Public Charge Advocacy Toolkit, which can be found at The toolkit includes background information on the proposal and information on how AAP members can oppose the rule by submitting comments, posting on social media and writing letters to their local newspapers.

Over the past several months, pediatrician experts have been featured in local and national news outlets, explaining the consequences of changes to public charge on children's health.

In addition to individual pediatrician advocacy, the AAP has joined with other leading physician organizations to oppose the public charge proposal. Since last year, the AAP has served as a health care sector lead for the Protecting Immigrant Families, Advancing Our Future campaign, which brings together leading advocates for immigrants, children, education, health, anti-hunger and anti-poverty groups, and faith leaders.

In advance of the December public comment deadline, the Academy will continue to emphasize the proposal’s child health consequences and how families already are experiencing its dangerous chilling effect.

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