How a Possible Immigration Rule Change Might Harm Diabetes Care

By Craig Idlebrook/GluCraig

In this three-part series on the barriers undocumented immigrants with type 1 diabetes face in accessing medical care, a common theme came up in interviews – fear.

Sometimes the fear lies just below the surface. Tigist, an Ethiopian immigrant with type 1 diabetes, could calmly discuss her long struggle to gain asylum in the U.S. — except when she mentioned reports of authorities arresting immigrants at citizenship interviews.

Other times, fear creates a clinical unknown. Endocrinologists like Dr. Daniel DeSalvo at Texas Children’s in Houston ponder how to communicate with patients with type 1 diabetes who are scared to talk about their immigration status, and what hurdles they face to care that they aren’t discussing.

Now that fear may grow as the U.S. Department of Homeland Security (DHS) is proposing new rule revisions. If implemented, the rules could disqualify both legal and undocumented immigrants from obtaining citizenship or permanent residency if they used public benefit programs, including Medicaid and its Children’s Health Insurance Program (CHIP).

Health organizations and immigration rights advocates have warned that the proposed changes might cause immigrant families to forgo routine medical care, which could, in turn, cause a slow-churning medical crisis in emergency rooms across the United States.

“Our health centers are telling us that some people are dropping their insurance,” said  Dr. Robert Moore, the Chief Medical Officer of the Partnership HealthPlan of California, in a blogpost with Migrant Clinicians Network. “For some children who qualify for (public insurance), their parents are taking them off. For adults who qualify, they are discontinuing.”

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The proposed rules would expand what is commonly called the “public charge” barrier to gaining lawful immigrant status. It states, in essence, that an immigrant who may be a drain on public budgets should not be allowed to reside in the United States. The concept dates back to the late 19th century, when Congress began to define how to exclude “undesirable” immigrants, according to an overview by the Catholic Legal Immigration Network.

The original public charge focused on an immigrant’s financial self-sufficiency. In 1915, however, the Supreme Court expanded disqualifications to include medical considerations, saying the government could bar those who “by reason of poverty, insanity, disease or disability would become a charge upon the public.” Over the ensuing decades, the criteria proved vague and confusion persisted about how to implement the rules. In 1999, the Clinton Administration provided guidance, including the notion that health benefits should not be used to deny immigrants legal status.

The Trump Administration now proposes to expand the public charge criteria to include those who receive or are likely to receive Medicaid and CHIP programs, with some exceptions for asylum seekers and emergency medical situations. Under these rules, DHS estimates that 382,600 more green card applications would be subject to the new public charge test, and 517,500 more could be subjected to a similar test when applying for visa applications annually, according to a Vox report.

The Trump Administration argues that the proposed revisions are necessary because past presidential administrations did not clearly enforce the rules on the books.

This proposed rule will implement a law passed by Congress intended to promote immigrant self-sufficiency and protect finite resources by ensuring that they are not likely to become burdens on American taxpayers,” said DHS Secretary Kirstjen Nielsen in a statement.  

Several health organizations have released statements in opposition to it. They argue that many immigrants, even those who might qualify for benefits without a public charge penalty, might forgo services out of fear that it will invite scrutiny from immigration enforcement agencies. The American Academy of Pediatricians argued that the public charge could have a wide-ranging impact on children’s health, as one in four children live within a household that includes immigrants.

“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,” said AAP president Dr. Colleen Kraft.

Public comment for the rule change closed December 10th. As of late December, the DHS website has posted roughly 16,000 online comments, including 188 that included the word “diabetes.”

A review of the 188 comments found:

-Many listed “diabetes” among chronic conditions that can be better managed when low-income immigrants have access to public health benefits.

-A medical student sharing, as a warning, the story of a man with diabetes who was transported to the emergency room after he had not gone to regular medical visits in years.

-A statement by an official with the New York State School Board Association saying that public schools rely on Medicaid reimbursement to offset the costs of caring for immigrant children with diabetes at school.

Even among conservative circles, approval of the proposal is not universal. For example, the Cato Institute, a libertarian-leaning think tank, warned that the proposed rule-change fails to take into account that most immigrants actually contribute more money to government budgets over time than they might cost in benefits. The Institute also warns that the rules, which include a rubric for deciding an immigrant’s public charge “score,” might be confusing and implemented unevenly.

The proposal is being strongly backed by the Center for Immigration Studies (CIS), an ultraconservative think tank that works closely with the Trump administration on immigration policy. (It should be noted that the Southern Poverty Law Center warns that CIS has been known to share racist rhetoric and associate with white supremacists.) A CIS position paper echoed the Trump Administration’s reasoning, saying it was “a tool for keeping out or expelling unproductive immigrants who place a drain on society.”

No one knows whether the Trump Administration will follow through on the proposed rule change, or whether it will face a legal challenge from civil rights organizations and advocates for immigrant communities.

What is clear, however, is that this proposed rule change, along with other immigration-curbing moves made by the Trump Administration, is already having a chilling effect on immigrants’ access to healthcare. The Migrant Clinicians Network reported a rise in no-shows at medical appointments in immigrant communities since the 2016 election. In addition, many immigrants are opting out of essential benefits.

“There are reports of immigrants rejecting essential benefits such as food, housing, and medical care, for themselves and their children, out of fear even though the proposed rule has not yet come into effect,” said Tucson Mayor Jonathan Rothschild in public comment. “Even immigrants who would be exempt under this rule, such as refugees and asylum seekers, have been afraid to claim, or continue to claim, essential benefits to which they are entitled.”

Studies have shown that we won’t know the full effect of this proposed health policy change for several years, but from research about what we already know about diabetes outcomes and access to healthcare, we can make some educated guesses:

-It’s likely we will see a rise in emergency room visits and complications among immigrant families affected by diabetes.

-If more immigrants only seek healthcare in the direst conditions, there may also be a spike in rates of type 1 diabetes diagnosed while patients are in diabetic ketoacidosis (DKA), a potentially life-threatening condition.

-It’s possible we will even see a rise in deaths caused by delayed or missed diagnoses.

-In the end, it may prove that the cost of treating diabetes complications among undocumented immigrants could prove more expensive for the U.S. healthcare system in the long run than it would have been to have provided them with healthcare.

Time will tell, but one thing is clear: the Trump Administration is engaging in a demographic experiment in healthcare policy that may have a high human cost.

To read the rest of the “Undocumented with Type 1 Diabetes” series, please click here

The photo above was taken at a  December 5th press conference of New York City health advocates and advocates of immigrant communities against the proposed public charge rule change. Photo courtesy of NYC Health + Hospitals.  

T1D Exchange takes no stance on current or proposed immigration policies. This series is designed to profile the challenges of type 1 diabetes care for a group of people in the United States who are more likely than the average population to have uncertain access to medical care.


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