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The "Public Charge" Inadmissibility Rule and its' Potential Impact on Hospitals

By Lucia Buffaloe, Senior Manager, NP KA Medicaid and Marilyn Burgos, Marketing Associate

Recently, five federal judges issued temporary injunctions against the proposed “Public Charge” Inadmissibility Rule.  Under the new “Public Charge” Inadmissibility Rule that was expected to go into effect October 15th, stricter measures would be put in place to penalize individuals who the government deemed to have the potential to exploit public assistance.  The rule would make it more difficult for immigrants to obtain a green card and renew other immigrant statuses.  In August 2019, when the administration announced the proposed change, it rang alarms with many of our client hospitals and other healthcare facilities across the United States.  Concerns over loss of health coverage, loss of patients, increased ED use, and increased bad debt began to transpire.

While the Public Charge Inadmissibility Rule has been in effect for over a decade, the proposed changes to the rule have reignited past uncertainty discussions.  Who is truly deemed a public charge? What does it mean to those who are responsible for providing care to mixed-immigrant communities?  A key change is the broadening of rules on programs that the federal government will consider public charge determinations, which can potentially create negative factors against obtaining a green card or immigrating to the U.S. if not fully understood.  Not only would this impact immigrants and their families, but it will also impact hospitals financially.


The General Immigration Act of 1891 was enacted to allow for the federal government to assume control of processing of all immigrants seeking admission to the United States under The Office of the Superintendent of Immigration. This was the cornerstone for what we know today as the U.S. Citizenship and Immigration Services (USCIS).  For several decades, there have been revisions in the immigration laws and regulations, yet none included an exact standard for determining which aliens should be deemed LPC (Liable to become Public Charge).

In 1996, the Illegal Immigration Reform and Immigrant Responsibility Act was signed into law.  One of the provisions of this law required immigrants to demonstrate their capability to maintain an income above the poverty level.  A category for “Public Charge” was created to establish rules in determining LPC inadmissibility.  The category was created to help clarify laws, policies and regulations.  In 1999, the Immigration and Naturalization Services (INS) reissued a Field Guidance for Deportability and Inadmissibility on Public Charge grounds.


According to the AHA, in 2017 hospitals provided $38.4 billion in uncompensated care to uninsured and low-income individuals.  The new proposed rule has the potential to increase the amount of uncompensated care costs, putting a strain on hospital resources.  This situation is likely to occur because legal immigrants seeking citizenship would be discouraged from using public benefits they are entitled to for fear of it being used against them.  One of our managers in the field recently encountered this fear.  A patient was entitled to Medicaid benefits as she was a legal permanent resident for over five years.  She was undergoing treatment for a chronic condition and declined to proceed with the Medicaid application under the direction of her attorney.  In certain states, LPRs (green card holders) are eligible for full Medicaid benefits after five years of active LPR status.  However, this patient decided to remain self-pay for all of her visits creating an out-of-pocket expense she could not afford.

Clients have also started expressing concerns about WHERE they would incur the most uncompensated care costs.  They all agree it would be in the emergency room setting; the fear is that many patients will delay treating their conditions until it becomes life-threatening.  Emergency rooms aren’t designed to treat and manage conditions that would otherwise be directed to a primary care setting.  In addition, the delay in preventive care will force hospital emergency rooms to treat high-level and in some cases life-threatening conditions that will ultimately become a much more expensive treatment.

Many of our clients provide care for immigrants and lower-income communities.  The increase of uncompensated costs could potentially place our clients in very difficult financial positions.  It could also force them to make operational changes such as reducing services, thereby forcing patients to seek specialized services elsewhere.

Our teams are having ongoing conversations with our clients to come up with solutions that address their concerns while still providing their patients with the support and counseling they need to make informed decisions.

In the next article, as part of our three-part series, we will explore in depth the open dialogues we’ve had with our clients and their patients.  We will also review real life experiences and the impact public charge has on Medicaid and Charity care.

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