Pregnant and Without Health Care: Dr. Adrian Billings on New Public Charge Rule

[Editor’s Note: On Friday, a US district court blocked the Department of Homeland Security from implementing the proposed public charge rule. As a result, the rule will not go into effect this week. Nonetheless, the proposal of the rule has, for many months, caused a “chilling effect” among immigrant patients with legal status, and threatens to continue to prompt legal immigrants to discontinue the health coverage for which they are eligible. Here, we speak with one physician about the chilling effect he has seen at his health center. Read MCN’s previous statements on public charge, here and here.]

This summer, a woman who was four months pregnant discontinued her Medicaid health care, despite being legally eligible for the coverage, and planned to pay out of pocket for prenatal care, childbirth, and postpartum care -- thousands of dollars in total. Her clinician, Adrian Billings, MD, PhD, FAAFP, a cradle-to-grave doctor and Chief Medical Officer at Preventative Health Care Services, a community health center in bordertown Presidio, Texas, was rattled.

“She was being advised by an immigration attorney...to not accept any public [assistance], for fear of public charge, that will penalize immigrants if they accept any form of public assistance,” he recalled. According to Protecting Immigrant Families, federal public charge determinations seek to identify people who may depend on the government as their main source of support. If the government determines that a person is likely to become a “public charge,” it can deny that person admission to the US or lawful permanent residence. In other words, a legal alien resident may decide to disenroll from Medicaid health care coverage, even if she is eligible for the benefit, out of fear of jeopardizing her ability to get a green card later on.

The Trump Administration threatened a change in the rule early in 2019, which caused many patients, like Dr. Billings’ pregnant patient, to drop coverage before the final rule language was even announced. When the final text of the rule was released in August, it was clarified that prenatal care will be an exception; a legal resident utilizing Medicaid for prenatal services would not jeopardize her immigration status under the new public charge rule. But fear, confusion, and uncertainty are driving pregnant patients to disenroll anyway. “Women are still going to avoid Medicaid, despite assurances by the government that this will not affect their immigration status. The fear has been spread,” Dr. Billings believes.

Today, October 15, the new final rule on public charge was supposed to take effect. The court injunction holds off the implementation until the court battle is settled -- but providers have already witnessed dangerous repercussions across the country, and last week’s injunction does not reinstate the health insurance of hundreds of legal immigrants who are eligible for coverage, who, out of fear or caution, have terminated their coverage.

“Immigrants may have all the right documentation, and the new public charge rule may be held up in court, but immigrants’ concerns over possible future ramifications will prevent them from seeking care in a timely way,” said Laszlo Madaras, MD, MPH, Chief Medical Officer of Migrant Clinicians Network, who works in an emergency room as a family doctor in Pennsylvania. He fears that patients will avoid getting preventative or early care, leading to less effective and more expensive emergency room visits further down the road. Discouraging immigrants with legal status from utilizing their health care is “an inhumane way to treat people,” he added.

By mid-summer, months before the final rule language was released, two of Dr. Billings’ pregnant patients, who could have been covered by Medicaid, had dropped out of insurance coverage on the advice of their two separate attorneys.

“The big concerns for me as a physician are: for the health of my patient, who legally has the right to apply for Medicaid; for her unborn child, who can’t make the decision for their own health; and for her other children, who wouldn’t be able to access Medicaid [either],” Dr. Billings said. “I’m worried about the direct consequences, of not getting the health care they need, and not being able to afford the health care they need.”

But, should the rule make its way out of the courts, he’s also concerned about the indirect consequences, like the financial strain it puts on systems like Federally Qualified Health Centers, rural clinics, and critical access hospitals that already have a narrow profit margin. “If [the new rule on public charge] reduces the number of patients that have coverage, that may tip the balance of financial viability,” he noted.

“It also produces stress and strain on providers like me, who are taking care of this population but who can’t get the labs they need,” because patients paying out of pocket may choose to forgo labs that don’t appear essential, Dr. Billings said. “For those two pregnant women, a patient panel is several hundred dollars; an ultrasound is several hundred dollars,” he said, and other tests and labs pile on more bills, all which leads patients to ask providers which are the most important. “There’s a standard of care in obstetrics where, for a prenatal panel, they’re all important.” When a patient forgoes certain tests or labs, “this puts stress on the provider, because they’re taking care of a patient that doesn’t have adequate care,” Dr. Billings emphasized. He also added that it may increase liability concerns of providers who are wary of caring for a patient without a full understanding of their health needs. “That’ll make providers who are risk-averse think, ‘I’m going to move away from the border,’ or ‘I’m not going to deliver babies anymore,’” he worried. “It makes it even harder to recruit and retain providers.”

Fortunately, Dr. Billings’ system was able to absorb the costs of care for the two women, paying for the needed prenatal care, including labs. “But it’s just two patients. If two were to become 200, we couldn’t afford to do that,” he said. For health systems with high immigrant patient populations, the new public charge rule “will exacerbate the financial strain. The costs are going to be borne by the patient, or the local health systems that take care of the patient.”  Even before its implementation, the rule had already had significant implications in the health coverage of many immigrants -- and that is sure to continue, despite not coming into effect this week.

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