December 18 , 2019
The Phantom Menace: Job Losses Follow Medicaid Drop-off among Fearful Immigrants
By Barbara Caress
In November, Montefiore Hospital’s Care Management Organization, which provides services to private and public health insurers, announced 149 job layoffs due to declining enrollment, mostly of Medicaid recipients. That made Montefiore the first hospital system in the New York City area to publicly acknowledge the effects of a sharp and ongoing Medicaid enrollment drop-off. Because Medicaid provides about one-quarter of income for New York City hospitals, similar repercussions at other hospital systems may not be far behind.
That’s because the falling numbers are indisputable. Since the summer of 2017, the number of New York City residents enrolled in Medicaid managed care (the form of Medicaid which includes nearly all enrollees except those receiving long-term care) has declined by 180,000. A similar trend was picked up in the American Community Survey, an annual report by the US Census Bureau. There were 130,000 fewer people in the city covered by Medicaid in 2018 than had been in 2017.
The downturn accelerated in early 2018 following reports that the Trump Administration intended to change the way the Department of Homeland Security evaluates immigrant applications for permanent legal resident status – a key step in the process of becoming a citizen. Primarily affected would be immediate relatives of US citizens who either already live here or who are seeking to come. In 2016, 1.2 million people, including a half-million living in the US, applied to become legal permanent residents.
In October 2018, the Trump Administration formally released proposals that would greatly increase the list of factors that could predict that someone would become a “public charge” and therefore ineligible to enter the country or receive the “Green Card” that demonstrates permanent legal resident status and permits the holder to live and work here.
Source: NYS Department of Health Medicaid Managed Care Reports
These new factors included: being younger or older than working age; having an income below 125 percent of the Federal poverty level; being disabled, unemployed, or without private health insurance; and having limited English proficiency.
What seems clearly to be driving the decline in Medicaid enrollment is another proposed new factor for not issuing Green Cards: having received or being approved to receive non-cash public benefits, including housing assistance, SNAP (food stamps), and Medicaid.
These proposed new standards, while widely publicized, have yet to be implemented. Although they were finalized in August 2019 with the intent that they’d become effective two months later, implementation has been suspended pending the outcome of a number of lawsuits challenging them, including one initiated by New York State Attorney General Leticia James.
Even without a rule change in place, however, expectation alone has spread confusion and fear among many immigrant families, creating a chilling effect on Medicaid and SNAP enrollment across the country. One in five adults in poor immigrant families reported avoidance of noncash public benefits during 2018, according to an Urban Institute study published this year. In fact, the fear was so pervasive that one in 10 poor immigrants from families where every member was a US citizen did not seek to enroll in one of these public programs.
Nationwide, 13.5 million Medicaid enrollees live in families with a least one noncitizen. While we don’t have an equivalent count for New York City immigrant Medicaid recipients, the city’s liberal eligibility rules have enabled tens of thousands to receive benefits. There are 1.5 million poor and working-class immigrant New Yorkers potentially impacted by the proposed rule change.
“Nearly half (47%) of community health centers report that many or some immigrant patients declined to enroll themselves in Medicaid in the past year,” according to an October 2019 Kaiser Family Foundation study focused on New York and three other states. It further reported that Medicaid recipients at about one-third of the centers surveyed asked to be removed from the rolls.
SNAP enrollment in New York City has taken a similar downturn. Between January 2017 and January 2019, according to the City’s Human Resources Administration, the agency that oversees SNAP, noncitizen drop-off (-6.2% in 2017-2018 and -10.9% in 2018-2019) was more than twice that of citizens (-3.2% and -2.8%). While the increase in the State’s minimum wage and a somewhat improved economy might have accounted for some of the decline, it doesn’t explain why non-citizens were less likely to participate than citizens. Even the drop in citizen enrollment might be caused by fear of being labeled a public charge. Families with immigrant members worry that use of public benefits by any family member, citizen or not, might imperil their status. The fact that there was no decline in the number of people served by food pantries in the city between 2017 and the first two quarters of 2019 shows a continuing need.
The Mayor’s Office of Immigrant Affairs (MOIA) has created an extremely comprehensive program to inform immigrants about the proposed rule change. It stresses that: first, nothing has yet happened, and won’t until the courts rule; second, that the proposed public charge rule applies to a limited class of immigrants – and specifically not those who already have Green Cards, or who are refugees or have been granted asylum; and, third, that even under the proposed Trump rule, many non-cash benefits, such as Medicaid coverage for pregnant women, would remain untouched. MOIA has led a robust effort by multiple City agencies to get the word out and to connect people with legal services.
Yet the evidence of sharply declining Medicaid enrollment is a stark reminder that such good-intentioned efforts are not enough. Even without the enactment of a new public charge rule, frightened New Yorkers have retreated into the shadows. To combat the terrifying effect of Trump’s war on immigrants might require the City and State to re-calibrate the way they enable life-saving services. Letting people know their rights and advising them how to deal with Homeland Security is clearly insufficient to alleviate the fear. Perhaps a better course is for the City to say, "We can't fix the Trump administration's policy. We are fighting it. In the meantime, we will do everything in our power to make sure you and your kids get what you need and that we can provide. Come in. Tell us if you need food or health care. No documents, no questions."