Clinics struggle to resolve fears over Medicaid sign-ups and green cards

Last September, the Trump administration unveiled a controversial proposal — a policy that, if implemented, could jeopardize the legal status of many immigrants who sign up for some government-funded programs, including Medicaid. The Trump proposal is still working its way through the public comment and evaluation process, and could go into effect as early as this year, though some state attorneys general say they would challenge any such policy in the courts.

In the meantime, some doctors and clinics are torn: They want to keep patients informed about the risks that may be coming, but don't want to scare them into dropping health benefits or avoiding medical care right now.

"We are walking a fine line," says Tara McCollum Plese, chief external affairs officer at the Arizona Alliance for Community Health Centers, which represents 176 clinics in the state. "Until there is confirmation this indeed is going to be the policy, we don't want to add to the angst and the concern," she says.

However, if immigrants do come to a clinic asking whether using Medicaid now might affect their legal status down the road, trained staff members are ready to answer their questions, McCollum Plese says. (According to legal specialists, the rule would not be retroactive — meaning it wouldn't take into account a family's past reliance on Medicaid.)

Other providers prefer to take steps that are more proactive to prepare their patients, in case the proposal is adopted. At Asian Health Services, a clinic group that serves Alameda County, Calif., staff members pass out fact sheets about the proposed changes, provide updates via a newsletter aimed at patients, and host workshops where anyone with questions can speak to legal experts in several Asian languages. "We can't just sit back and watch," says CEO Sherry Hirota. "We allocate resources to this, because that's part of our job as a community health center — to be there not only when they're covered," she says, "but to be there always" — even when that coverage is in jeopardy. Currently, people are considered "public charges" if they rely on cash assistance (Temporary Assistance for Needy Families or Supplemental Security Income) or need federal help paying for long-term care. Trump's proposed change to that rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants' use of an expanded list of public benefit programs, including Medicaid, food stamps and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people.

If the proposed rule change goes into effect, it could force patients to choose between health care and their chance at a green card, McCollum Plese says. "And most people will probably not take the services."

Already, some immigrant patients are skipping medical appointments out of fear stoked by the proposed rule, according to providers and advocates. "For now, our focus has been on correcting misinformation, not necessarily raising awareness among those who haven't heard about the potential changes," says Erin Pak, CEO of KHEIR Center, a clinic group with three locations in Los Angeles. "This is a proposal that thrives on fear and misunderstanding," she says, "so we wanted to be thoughtful about how and when to engage patients on the issue, given that nothing has passed into law." The Department of Homeland Security is reviewing more than 200,000 comments from the public before it issues a final rule. And it's still possible the department won't adopt the rule at all, legal experts say.

At KHEIR Center, most patients are immigrants from Korea. Many are highly aware of the proposed rule because of the coverage it has received in Korean-language media, according to Kirby Van Amburgh, the center's director of external affairs.

Other groups served by the clinic, such as Latino and Bengali immigrants, have tended to ask few questions, Van Amburgh says.

Trained staff address patients' questions one-on-one, she says, and hand out a fact sheet when needed.

Last month, L.A. Care health plan, which covers more than 2 million Medicaid enrollees in Los Angeles County, hosted a webinar on the topic for about 180 providers. David Kane, an attorney at Neighborhood Legal Services of Los Angeles, led the webinar and urged doctors to tell concerned patients that nothing has changed yet — and that most immigrants would not be affected.

If the federal government adopts the rule, it would not be effective immediately, he notes; there would likely be a 60-day grace period before the changes take effect. After that, implementation could be further delayed or stopped in court.

John Baackes, CEO of L.A. Care, has been critical of the Trump administration's proposal, and says his organization offered the webinar because of the estimated 170,000 clients — legal immigrants — who could potentially be affected.

"I think we've got to let people know what could come, and try to give them more accurate information so that they don't act imprudently," Baackes says. To do that, "we have to stay current."

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente. Copyright 2019 Kaiser Health News. To see more, visit Kaiser Health News.