Health Care

Proposed change to immigration rule may push Florida kids out of safety net

Caring for Miami’s uninsured residents is hard enough for Dr. Fred Anderson without his also having to worry about placing immigrant patients in jeopardy of being separated from their families and losing their access to free and low-cost healthcare.

But with the Trump administration’s posting of a proposed rule Wednesday that would deny citizenship to immigrants who use certain public benefits, such as food stamps, housing assistance and Medicaid, Anderson said it has become much more difficult for him to do his job.

Fewer patients are seeking care, Anderson said, and those who do are increasingly reluctant to follow up with additional care when needed — raising the likelihood that their medical conditions will worsen.

“Many of us consider this an effort to weaponize the safety net,” he said.

Legal experts and patient advocates say the proposed rule, also known as “public charge,” affects immigrants seeking lawful status and not their children and dependents. But confusion and fear over the policy is likely to lead to fewer children in immigrant households receiving healthcare, food stamps and other benefits that are key to healthy development, said Miriam Harmatz, a healthcare attorney and co-executive director of the Florida Health Justice Project, a nonprofit that advocates for increased access to healthcare.

“People are confused and afraid,” she said.

The Justice Project estimates that more than 107,000 kids in Florida — about half of whom live in Miami-Dade, Broward and Palm Beach counties — are likely to lose their government-sponsored health insurance coverage as a result of the chilling effect the proposed rule will have on so-called mixed-status families whose children are U.S. citizens but one or both of the parents are not.

Miami-Dade is home to more immigrants than any other part of Florida, with almost 60 percent of residents born in another country and 28 percent identified as non-citizens, according to the U.S. Census. Of the 400,000 citizen children in Florida who receive Medicaid or CHIP and live with a non-citizen parent, 27 percent or about 109,000 reside in Miami-Dade.

A rise in uninsured children, Harmatz said, is likely to strain the county’s taxpayer-owned Jackson Health System, which receives more than $400 million a year in local funds to fulfill a mandate to provide healthcare to all Miami-Dade residents, regardless of immigration status or ability to pay.

“Those costs are going to be shifted right back to the Miami-Dade taxpayers,” she said.

More than 400,000 U.S. citizen children in Florida are enrolled in Medicaid or CHIP with a non-citizen parent, according to the 2016 American Community Survey. Half of those children live in Miami-Dade, Broward, and Palm Beach Counties. Florida Health Justice Project

Immigrants who live in Miami-Dade and rely on safety net programs were reluctant to speak with the Miami Herald for fear that they would attract the scrutiny of federal immigration officials. But those who work with them said their jobs have become more difficult due to recent events, such as the separation of children from their parents at the Mexican border, and a rising anti-immigrant tone.

Anderson, a family physician working with Florida International University’s fleet of mobile clinics that serve mostly uninsured and low-income residents of Miami-Dade, said he recently tried to persuade a woman in her 50s to get additional tests and a biopsy at Jackson Memorial Hospital after she received a free mammogram screening.

But the woman refused because of her status as an undocumented immigrant and fear that seeking help would bring her to the attention of immigration officials — even though under Miami-Dade ordinance all county residents are eligible to receive free or discounted healthcare through the public hospital system at Jackson.

Anderson said he feels as though the tools he uses to help uninsured and low-income Miami-Dade residents improve their lives are now being used against them through Trump administration policies, such as the proposed changes to the so-called public charge immigration rules that govern how the use of public benefits affect an immigrant’s legal status.

“It really erodes the trust that we have worked years if not over a decade to build with our local communities that we are on their side,” Anderson said. “We are trying to help them become healthier and even self sufficient.”

Anderson, an assistant professor for FIU’s Wertheim College of Medicine, oversees a fleet of mobile clinics through the university’s NeighborhoodHELP program, which provides low-income Miami-Dade residents free visits with a family doctor, a psychiatrist and social service counselors in exchange for patients’ allowing students to work with them.

Beatrice Farnsworth, a clinical instructor with FIU’s school of social work, said the NeighborhoodHELP program sees patients from a variety of backgrounds, including undocumented immigrants, others with temporary protected status (TPS) and permanent legal residents with green cards.

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Dr. Fred Anderson, right, consults with his patient, Sharma Boboolal in a mobile clinic in Miami Gardens. Anderson is a family doctor who said his job caring for uninsured and low-income patients, including many immigrants, has become more difficult due to proposed changes to a federal citizenship rule called public charge and a rise in anti-immigrant rhetoric. Miami Herald file, 2015

Lately, Farnsworth said, the program has seen a drop-off in visits and an increasing reluctance to seek specialty care, even among immigrants who have nothing to fear because the proposed rule does not affect them, such as those with green cards or TPS. She says the rise in anti-immigrant rhetoric and confusion over the proposed rule has caused a chilling effect among the program’s patients.

Farnsworth said the program has been working with one family that includes a father who is a naturalized citizen, a mother who is undocumented and their three children, who were born in the United States.

“They qualify for food stamps and Medicaid for their children,” she said. But they won’t apply.

“They’re afraid if they apply for that, they won’t get citizenship for the mother,” Farnsworth said. “Thankfully the children are healthy, but God forbid something happens.”

Anderson said the social workers and physicians with the NeighborhoodHELP program would like to tell their immigrant patients that they have no reason to worry. But they’re not immigration law experts, he said, and they fear giving out bad advice to their patients.

“We don’t want to alarm them,” he said.

Immigration policy currently defines a public charge as someone who is primarily dependent on the government for subsistence. The policy only allows the government to consider whether the person applying for legal entry or lawful permanent status (green card) receives, or is likely to receive cash assistance, such as Supplemental Security Income or Temporary Assistance for Needy Families, or government sponsored long-term care in a nursing home or other institution.

The expanded list posted on Wednesday adds Medicaid, the Medicare Part D Low Income Subsidy Program, Supplemental Nutrition Assistance Program or SNAP, public housing assistance — including Section 8 Housing Voucher Program and Section 8 Rental Assistance.

More than 233,000 children in Florida who are enrolled in the Supplemental Nutritional Assistance Program are U.S. citizens who live in “mixed-status” families where one or more parent is not a citizen. About half of them live in Miami-Dade, Broward and Palm Beach counties. Florida Health Justice Project

Anyone interested in the proposed rule will have 60 days from Wednesday to post a public comment through the Federal Register. Federal officials with DHS will then review the public comments and make any changes to the rule before posting a final version and providing an additional 60 days before enactment, said Matt Childers, a political scientist and researcher with the Florida Health Justice Project.

Childers studied an unpublished version of the 434-page rule and said the latest draft appears to be much less restrictive than the original version, which proposed denying citizenship to immigrants who used a larger set of public benefits, including subsidies to buy health insurance on the Affordable Care Act Exchange and even state and local assistance.

While that’s no longer the case, Childers said, he expects the chilling effect will lead to parents removing their kids or refusing to sign them up for public healthcare benefits that American citizens are entitled to, such as the Children’s Health Insurance Program and Medicaid.

He pointed to the bad advice that some immigration attorneys provided on Miami’s Spanish-language radio stations in August when the proposed rule received a rash of media attention. Childers also cited similar confusion among immigrants after welfare reform in the 1990s, when their participation in programs like Medicaid and SNAP dropped sharply.

“There’s going to be a large faction of legal immigrants who already have a green card who are going to mistakenly think this is going to affect their application to be citizens,” he said. “It won’t.”

By analyzing U.S. Census data, Childers said many Florida children also are likely to lose SNAP benefits. With more than 233,000 Florida children in mixed-status families enrolled in SNAP, Childers estimates that between 15 to 35 percent, or 35,000 to 82,000 kids could lose their government food benefits if the proposed rule goes forward and immigrant families decide not to participate in safety net programs.

“Short of an incredibly well-funded public information campaign,” he said, “there’s still going to be a chilling effect.”

Follow Daniel Chang on Twitter @dchangmiami

This story has been updated to clarify that the proposed rule applies to immigrants applying for legal entry or lawful permanent status in the United States.