The Health Impact Of The Proposed Public Charge Rules [from Health Affairs Blog]

by Wendy E. Parmet, Matthews Distinguished University Professor of Law and Faculty Director, Center for Health Policy and Law at Northeastern University School of Law; Professor of Public Policy and Urban Affairs, Northeastern University School of Public Policy and Urban Affairs 

This post was originally published on the Health Affairs blog (Sept. 27, 2018).

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On September 22, the Trump Administration announced it would soon publish in the Federal Register proposed new regulations defining when lawfully present immigrants should be considered a “public charge.” Although the draft regulations posted by the Department of Homeland Security (DHS) were not as far-sweeping as a version that was leaked last winter, if promulgated they would still have a dramatic impact on public health and the health care system.

For over a century, the Immigration and Nationalization Act has required most immigrants (not including refugees, asylees and certain other exempt groups) who seek to enter the United States, and most non-citizens within the United States who want to obtain permanent residency status, to show that they are “not likely to become a public charge.” The Act does not define “public charge,” but under a 1999 guidance, the term has only been applied to non-citizens who rely on cash benefits for most of their income, or to those who require public assistance for long-term care or institutionalization. The receipt of non-cash benefits, including publicly-funded health insurance, does not make one a public charge.

The Administration’s proposed regulations would end those exemptions and redefine “public charge” as including non-citizens who receive an amount greater than 15 % of the Federal Poverty Level (for a household of one) of certain listed monetizable benefits, including Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), the Supplemental Nutrition Assistance Program (SNAP) and federal housing support. In addition, except in limited circumstances, a non-citizen could be considered a public charge for receiving Medicaid or premium and cost-sharing subsidies under Medicare Part D for 12 out of 36 months. Immigrants who use these benefits for fewer months could also be found to be a public charge if they also receive monetizable benefits. The proposal posted by DHS also seeks comments as to whether participation in the Children’s Health Insurance Program (CHIP) could also cause a non-citizen to be found to be a “public charge.”

The draft regulations explain that the public charge determination is one that is future-oriented. The key question is whether the individual, looking at the totality of circumstances, is likely to use any of the covered benefits in the specified amounts in the future. However, use of any of the listed benefits within 36 months of filing for an adjustment of status (though not reaching back before the regulations go into effect) will be treated as heavily weighted negative factors in determining whether an individual is likely to become a public charge by using such benefits in the future.  As a result, an immigrant who was on Medicaid for several years as a child may find that that coverage is held against her if she seeks a green card once she becomes of age, even though her circumstances may have changed dramatically. DHS also proposes to consider whether an immigrant has “private insurance or the financial resources to pay for reasonably foreseeable medical costs related to a medical condition that is likely to require extensive medical treatment or institutionalization “ or will interfere with the immigrant’s ability to care for him or herself or work or attend school.

Negative Health Impacts

If promulgated these changes will almost certainly harm the health of immigrants and their families. Most obviously, the changes will create a significant disincentive for immigrants to enroll in publicly-funded health insurance programs. In its comments, DHS estimates that 2.5 % of the eligible population of immigrants and their family members who are otherwise eligible for Medicaid or Medicare Part D subsidies will either dis-enroll or forego participation in the programs. In reality, many more immigrants, including many who are not actually subject to the public charge requirement because they  have an exempt status, are likely to avoid coverage due to fear of negative immigration consequences. Even before the proposed regulations were posted by DHS, many immigrants chose not to enroll either themselves or their children in public programs because of fear of possible adverse immigration consequences.

The emphasis that DHS seeks to place on immigrants’ medical condition is likely to exacerbate the problem, creating a type of “pre-existing condition” bar for non-citizens. Under the proposal, the absence of private health insurance alongside the existence of a serious medical condition makes an individual more likely to be found to be a public charge. Hence immigrants, especially those without private health insurance, will have a strong incentive to avoid medical examinations and tests, even when offered free of charge, lest a potential health problem be discovered. As a result, treatable medical conditions will remain undiagnosed and untreated until they become emergencies. Ironically, the proposed regulations deal with that by not considering the receipt of so-called emergency Medicaid, which pays for emergency care, in determining whether an individual is a public charge. The regulations thus create a strong incentive for non-citizens to wait until their health problems become emergent.

The impact of the proposed regulations on health, however, extends far beyond the negative consequences that will follow from patients losing their health insurance or avoiding medical care. The inclusion of SNAP and housing subsidies in the list of benefits that can render one a public charge means that many immigrants will avoid critical programs that can improve the social determinants of health. Importantly, the loss of these benefits will inevitably extend beyond non-citizen immigrants to their entire family, including their citizen children. After all, a child will lose access to housing if her immigrant mother avoids housing support.

The proposal’s ripple effects will undoubtedly extend even wider. As DHS notes in its comments, the regulations may increase the financial woes of health care providers who serve immigrant communities, as their patients avoid public insurance and even, potentially, primary care. This financial hardship could well cause some providers to cut back on vital services for their entire community, not simply the non-citizens.

The False Promise Of Universal Self-Sufficiency

Indeed, what is perhaps the most striking about the proposed regulations is the fact DHS recognizes their potential harmful impact. In its comments, the department states that its proposal may lead to:

• Worse health outcomes, including increased prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants, or children, and reduced prescription adherence;

• Increased use of emergency rooms and emergent care as a method of primary health care due to delayed treatment;

• Increased prevalence of communicable diseases, including among members of the U.S. citizen population who are not vaccinated;

• Increases in uncompensated care in which a treatment or service is not paid for by an insurer or patient; and

• Increased rates of poverty and housing instability; and

• Reduced productivity and educational attainment.

Despite acknowledging these drawbacks, DHS claims that the regulations are, nevertheless, necessary to ensure “self-sufficiency” among immigrants. Yet, when it comes to health, the goal of complete self-sufficiency is unrealistic and quixotic. Look across the life span, and it’s easy to recognize that none of us is self-sufficient during our childhood, and few of us will be in the future if we live long enough. And that does not consider the fact that our health is significantly affected by social and environmental factors outside of our control. None of us can be self-sufficient in the face of a widespread epidemic, an environmental catastrophe, or even a motor vehicle accident caused by others. That is just as true for non-citizen immigrants as everyone else. As DHS notes, almost 20 % of American citizens rely on the programs affected.  The demand that immigrants achieve self-sufficiency is implausible. It is also cruelly demeaning to all Americans who rely on the programs that are targeted.

Fortunately, it isn’t too late to prevent the alarming prospects that DHS cites from coming to pass. Once the Regulations are published in the Federal Register, the public will have 60 days to comment. During this period, health care providers, health policy experts, and the public health community will have an opportunity to weigh in. The nation’s health may depend upon their doing so.  

Public Comment: HHS Proposed Revisions to Title X Funding Regulations

Yesterday, along with the George Consortium and in collaboration with the Center for Health Policy and Law at Northeastern University School of Law, we submitted public comments to the Dept. of Health and Human Services (HHS) regarding proposed revisions to Title X Regulations. We offer a reprint of the comments we submitted. 

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Office of the Assistant Secretary for Health
Office of Population Affairs
Attention: Family Planning
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room 716G
200 Independence Avenue SW
Washington, DC 20201

Re: Docket Number: HHS-OS-2018-0008, RIN: 0937-ZA00

Public Comment on Proposal to Revise Title X Regulations, Compliance with Statutory Program Integrity Requirements

Dear Assistant Secretary ADM Brett Giroir, MD:

The Center for Health Policy and Law at Northeastern University School of Law[1] and the Public Health Law Watch (PHLW)[2] appreciate the opportunity to make comments on the proposed Department of Health and Human Services (HHS) revisions to 45 CFR Part 59, “Compliance With Statutory Program Integrity Requirements.” The Center for Health Policy and Law is a university center of excellence focused on providing a rich context for students and researchers interested in myriad health-related topics, including public health law, health and human rights, health governance, bioethics, and drug policy. PHLW is a project of the George Consortium, a nationwide network of public health law scholars, academics, experts, and practitioners. It should be noted that these comments have been prepared by the Center for Health Policy and Law and PHLW, but do not represent the view of Northeastern University School of Law, Northeastern University, or individuals affiliated with either the Center or PHLW.

We offer comments on the proposed regulations’ failure to provide for exemptions or protections for providers whose conscience dictates that they counsel and provide medically-appropriate information about abortion and abortion-related services.

These proposed regulations seek, among other things, to eliminate the current requirement that Title X grantees “offer pregnant women the opportunity to be provided information and counseling regarding… pregnancy termination.”[3] On page 25506,[4] the “supplementary information” section invokes “conscience protections” as one justification for eliminating that provision. Specifically, it reasons that this provision conflicts with statutory “conscience protections” shielding health care personnel from engaging in practices conflicting with their moral and religious values. The commentary posits that eliminating the requirement to give women the opportunity to get information about abortion would solve any potential clashes between that provision and conscience provisions.

This reasoning, however, assumes that moral and religious conviction protections only apply when invoked against abortion. But that is simply not true. Dr. Willie Parker, for example, describes his mission to provide women with abortions as a Christian imperative.[5] Refusing to do so, he reasons, would be akin to the biblical Samaritan who refused to help a fallen traveler. An interfaith coalition blesses clinics that provide abortion for upholding the values of autonomy.[6] The late Dr. George Tiller, who was murdered in his church by an anti-abortion extremist, described his work of providing abortions as “a ministry.”[7] Others view providing abortions as a moral duty[8] to provide needed care to women who need help.[9] Some providers and health care workers believe their conscience requires adherence to professional and medical ethics, which require health professionals to provide all relevant, medically-appropriate information to patients, including when patients ask for a full range of family planning and/or abortion-related options and referrals, and when medically-appropriate even in the absence of explicit requests for such information or referrals by the patient.[10]

These proposed regulations change not only disregard the interests and rights of providers and patients whose consciences support ensuring transparency around and access to information related to abortion and abortion-related services, referrals, and counseling, they also ignore the fact that federal law protects the conscience of such providers. On page 25512,[11] the supplementary information section invokes the Church Amendments (codified at 42 U.S.C. 300a-7)[12] by describing its discrimination protections for health care professionals who refuse to perform abortions.  The notice for proposed rulemaking, however, fails to include, even in its footnoted quote of the law,[13] the provisions in the Church Amendments that explicitly also protect the professionals who do perform abortions, as well as those who counsel and/or refer patients to abortion services.[14] The law equally protects those with “reluctance or willingness to counsel, suggest, recommend, assist, or in any way participate in the performance of abortions or sterilizations contrary to or consistent with the applicant’s religious beliefs or moral convictions.”[15] The law recognizes that “religious beliefs or moral convictions” are not homogenous and do not operate solely in one direction. To be consistent with this provision of the law, as well as with the Department’s proposed conscience regulations[16], the Proposed Title X regulations should allow for health care providers whose conscience compels them to provide patients with full and medically-relevant information about their reproductive health options, including by providing them with clear and useful referrals to abortion services and providers, even in instances when patients do not explicitly request such referrals.

Sincerely,

Center for Health Policy and Law
Northeastern University School of Law
lawhealth@northeastern.edu  

Public Health Law Watch
phlawwatch@northeastern.edu  

[1] Center for Health Policy and Law, https://www.northeastern.edu/law/health.

[2] Public Health Law Watch, https://www.publichealthlawwatch.org/.

[3] 42 CFR § 59.5(a)(5)(C) (2017).

[4] Compliance with Statutory Program Integrity Requirements, 83 Fed. Reg. 25502 (proposed June 1, 2018) (to be codified at 42 C.F.R. pt. 59).

[5] Stephanie Russell-Kraft, Reclaiming the Moral Imperative for Reproductive Choice. A Q&A with Dr. Willie Parker., The Progressive (Apr. 11, 2017), http://progressive.org/dispatches/reclaiming-the-moral-imperative-for-reproductive-choice.

[6] Caroline Kent, The Religious Coalition Blessing Abortion Clinics Across America, Broadly (May 10, 2018, 10:15 AM), https://broadly.vice.com/en_us/article/a3azz4/religious-coalition-reproductive-choice-abortion-clinic-blessing.

[7] Carole Joffe, Working with Dr. Tiller: Staff Recollections of Women’s Health Care Services of Wichita, 43 Persp. On Sexual And Reprod. Health 199-204 (2011).

[8] Elizabeth Reiner Platt, Many Doctors are Motivated by Their Moral and Religious Beliefs to Provide Abortions. Why Doesn’t HHS Care About Their Consciences?, Public Rights/Private Conscience Project Blog (Mar. 29, 2018), , http://blogs.law.columbia.edu/publicrightsprivateconscience/2018/03/29/hhsconscience/.

[9] Holly Fernandez Lynch & Ronit Y. Stahl, Protecting Conscientious Providers of Health Care, N.Y. Times, (Jan. 26, 2018), https://www.nytimes.com/2018/01/26/opinion/protecting-conscientious-providers-of-health-care.html.

[10] See American Medical Association, Physician Exercise of Conscience, AMA Principles of Medical Ethics, I, II, IV, VI, VIII, IX (2016), https://www.ama-assn.org/delivering-care/ama-principles-medical-ethics. See also American Academy of Physician Assistants, Guidelines for Ethical Conduct for the PA Profession (2013), https://www.aapa.org/wp-content/uploads/2017/02/16-EthicalConduct.pdf .

[11] Compliance with Statutory Program Integrity Requirements, supra note 4.

[12] See 42 U.S.C. §300a-7 (2016).

[13] Compliance with Statutory Program Integrity Requirements, supra note 4.

[14] See 42 U.S.C. §300a-7(c) and (e). See supra note 12.

[15] Id.

[16] Protecting Statutory Conscience Rights in Health Care; Delegations of Authority, 83 Fed. Reg. 3880 (proposed Jan. 26, 2018) (to be codified at 45 C.F.R. pt. 88).

Medicare is Not Going Broke [from philly.com]

By Robert I. Field

Have you heard the news? Medicare will run out of money in just four years. Can the program survive?

Four years is the time until the Trust Fund that provides financial support for Medicare will become insolvent – that is, according to a prediction that the Fund’s Trustees made in 1997. Then in 1998, they upped the timeframe to ten years and in 1999 to 16. They shrank it back to 12 years in 2006 and to eight in 2009.

The Trustees first projected an insolvency date for the Trust Fund in 1970, when they predicted that it was just two years away. Since then, the timeframe has varied wildly, reaching a high of 28 years under projections made in 2001 and 2002.

This year, the projection is for eight years, falling from 12 a year ago. That has led to dire predictions that Medicare as we know it is unsustainable. But after almost 50 years of fluctuating projections, the program has not gone under yet – and it is not likely to do so anytime soon.

The Medicare Trust Fund contains the proceeds of the payroll tax that all working Americans pay. It supports the cost of Part A of the program, which covers hospital care. It has no role in supporting Part B, which covers physician services, and Part D, which covers prescription drugs. While there is a separate trust fund for Part B, it is continually replenished with general tax revenue, so it can never become insolvent.

Even were the Trust Fund to become insolvent, Medicare is still projected to have enough money to pay 91% of claims. The shortfall could be remedied in a number of ways, like raising the payroll tax or reducing provider payment rates. Medicare would not be broke, and hospital coverage would continue.

And as past projections demonstrate, predicted dates for insolvency do not mean that it is inevitable. The projections are the Trustees’ best guess as to the date on which the Trust Fund will run out of funds based on current trends in medical spending and tax revenue. Those factors change every year, as the past gyrations in insolvency projections make clear.

This year’s tighter timeframe primarily reflects factors that would be easy to change – the Trump administration’s health care policies as implemented by Congress. Those policies weakened the Affordable Care Act, which had significantly strengthened the Trust Fund’s finances. The year after the ACA took effect, the insolvency timeframe shot up from eight years to 19. In particular, Congress’s repeal of the ACA’s individual insurance mandate set to take effect in 2019 will increase the number of uninsured, forcing Medicare to raise hospital payments to account for their care. The ACA also established an independent advisory board to cut costs, which Congress also repealed.

So, if you find the shorter Medicare timeframe concerning, the main culprit is clear. It is not the structure of the program or the ACA. It is the Trump administration’s policies, which are undermining the financial stability of much of our health care system.

Certainly, Medicare faces other long-term financial challenges as medical costs continue to rise and the number of beneficiaries grows. Policies to address those concerns are urgently needed.  But the most recent Trust Fund financial projection is a diversion from those more serious issues. The Trust Fund could be as solid as ever, if Congress were to put the ACA back on track.

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Robert I. Field, JD, MPH, PhD, is professor of law and public health at Drexel University and is the founder and editor of the Health Cents blog.

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This blog post first appeared in the Health Cents blog of Philly.com.

The latest strategy to undermine Obamacare: challenge the constitutionality of a mandate that doesn’t exist [from Philly.com]

By Robert I. Field

Can a law be unconstitutional if it doesn’t exist? That may sound like an abstract riddle, like the proverbial tree falling in a forest, but it is central to a lawsuit challenging the constitutionality of the Affordable Care Act. The suit, brought by 20 Republican attorneys general, seeks to have the entire law thrown out, and the Trump administration recently announced its support.

The challengers’ argument goes like this. In 2012, the Supreme Court upheld the ACA’s mandate requiring all Americans to maintain health insurance or pay a penalty. The Court characterized the penalty as a tax, but one that is waived for the those who have coverage. Under this reasoning, the mandate is a tax penalty that comes under Congress’s broad power over taxation.

In the huge tax bill enacted late last year, the amount of the penalty was reduced to zero starting in 2019. The challengers assert that since no amount will be assessed for going without insurance, the mandate can no longer be characterized as a tax, thereby eliminating its constitutional underpinning.

They claim this invalidates all of the ACA, even provisions that have nothing to do with the mandate. The Trump administration’s position doesn’t go quite this far. It only wants the consumer protections for sick and injured insurance buyers to be eliminated.

This argument amounts to nonsense. With the penalty reduced to zero, the mandate no longer exists. The law contains no other penalty for choosing to be uninsured. It doesn’t matter whether you call the mandate a tax or anything else, as of 2019, it will no longer be in force. By what stretch of logic can a law that that is not in effect be considered unconstitutional?

The argument makes even less sense, if that is possible, when you consider that Congress’s power to re-impose the penalty in the future remains on the books. There is ample precedent for a tax to be suspended and then re-imposed. If Congress were to resurrect the penalty at some point, would the mandate become constitutional again? Or is it only unconstitutional when it isn’t in effect?

Even if the challengers could overcome this void of logic, they would face a second one in their request to have the entire law invalidated. They argue that the mandate can’t be severed from the rest of a law, so if it is declared unconstitutional, everything must go.

The guiding legal principle when a court strikes down part of a law is to look to Congress’s intent concerning the other parts. Congress did not declare its intent in the text of the ACA, but the intent of its recent actions is crystal clear. A few months before repealing the mandate penalty, it defeated a bill to repeal all of the ACA. If it had intended that the end of mandate would eliminate the law’s other provisions, it would not have voted to keep them.

It would be hard to imagine a more frivolous lawsuit. Yet the Trump administration has taken the highly unusual step of siding with the challengers and refusing to defend it. That role will be filled by 17 Democratic attorneys general.

With such a flimsy legal claim, why would the Trump administration pick up the challengers’ cause? The reason most likely has less to do with legal reasoning than with finding a new opportunity to sabotage Obamacare by disrupting the insurance marketplaces.

Regardless of which way the trial judge rules, an appeal is virtually certain. The case could well go all the way to the Supreme Court, a process that could take years. In the meantime, the litigation will inject an added element of uncertainty for insurers that participate in the marketplaces. That uncertainty, coupled with other Trump administration actions, like permitting the sale of barebones policies outside the marketplaces, could lead some of them to impose additional price hikes or to withdraw from the market altogether. It seems more than coincidental that the administration’s announcement came just as insurers are reaching decisions on prices and participation for next year.

By the time the case is finally resolved, it will have cost millions of dollars in legal expenses, not to mention additional millions that consumers will have to pay in higher prices for insurance. That money would be much better spent expanding coverage for sick patients than litigating a frivolous claim that seeks to take away their health care, instead.

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Robert I. Field, JD, MPH, PhD, is professor of law and public health at Drexel University and is the founder and editor of the Health Cents blog.

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This blog post first appeared in the Health Cents blog of Philly.com.

New Dangers For Immigrants and the Health Care System [from Health Affairs Blog]

PHLW's Wendy E. Parmet and Elisabeth J. Ryan co-authored an article posted on the Health Affairs Blog about the potential changes to the definition of "public charge" and how that will negatively impact health care and the health care system. 

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New Dangers For Immigrants And The Health Care System

By Wendy E. Parmet and Elisabeth Ryan

The Trump administration’s crackdown on immigrants may soon create new perils for the health care system if a set of proposed regulations by the Department of Homeland Security (DHS), leaked last month to the Washington Post, are promulgated. The regulations would dramatically expand the definition of “public charge,” a criteria used in immigration law to determine both admissibility to and deportability from the United States. As a result, many immigrants, including many low wage health care workers, may be deterred from using publicly-funded health care benefits to which they and their dependents, including their citizen children, are legally entitled.

The Immigration and Nationalization Act requires most non-nationals (other than refugees, asylees, and certain other protected classes) who seek a visa to show that they are not likely to become a “public charge,” that is, someone dependent on public benefits. Once they are in the United States, most immigrants must make a similar showing if they seek a change in status, for example, if they apply for a green card. In limited circumstances, even green card holders may be deported for becoming a public charge.

An Expanded Definition Of ‘Public Charge’

Under long-standing policy, the use of publicly funded health care benefits (other than long term care) did not render an immigrant a public charge. In January however, the State Department issued a revised Foreign Affairs Manual, used by the consular offices in reviewing visa requests, which expanded the definition of public charge to include consideration of health benefits. The proposed DHS regulations would apply that approach within the United States, treating the use of Medicaid, the Children’s Health Insurance Program (CHIP), the Affordable Care Act (ACA) subsidies, and even benefits wholly funded by the states—but not Medicare—as a factor in determining whether an immigrant had been or would become a public charge. An immigrant could also be found to be a public charge if his or her dependents, including citizen children, used Medicaid or CHIP.

The implications of this potential change for patient care are significant. Non-citizen immigrants are already far less likely than citizens to have health insurance. In part, this is due to the fact that undocumented immigrants are ineligible to participate in the ACA’s exchanges or to receive federally funded health insurance (except for emergency Medicaid). Current law also denies most lawfully present immigrants from receiving Medicaid or CHIP for the first five years they have that status. With less access to insurance, it’s not surprising that immigrants are less likely than citizens to have a usual source of care, or preventive services.

Since the Trump administration took office, there have been widespread anecdotal reports that many immigrants have stopped showing up for their medical appointments. Undoubtedly some of this is due to the general climate of fear created by enhanced enforcement actions, which is especially frightening to those who are undocumented, as well as their families. But advocates also believe that a draft leaked in February 2017 of a proposed executive order expanding the definition of public charge led many immigrants to stay away from the health care system. In response, advocates and providers have tried to reassure immigrants that they should continue getting needed care.

Potential Consequences

If enacted, the proposed regulations will undermine that message, causing more immigrants to forgo needed care, meaning that easily treatable health conditions will go untreated until they become worse, and pregnant women will lack prenatal care. In addition, with immigrants afraid to access coverage for which they are eligible, hospitals and other safety net providers will be forced to bear more unreimbursed costs. The regulations may also create troubling new tensions between immigrant patients and their providers. For example, consider the possible predicament of a legal immigrant who gives birth to a child who needs neo-natal intensive care. By virtue of her birth, the child would be an American citizen and eligible for Medicaid, even if the mother was not eligible, as a result of her immigration status. Today, the hospital would likely work with the mother to enroll the child in Medicaid, so that the hospital could be paid for the child’s treatment. But with the new regulations in place, the mother might fear that enrolling her child in Medicaid would adversely affect her ability to get a green card and stay in the United States with her child. As a result, the mother’s interest and the hospital’s would be in conflict. Situations like this will likely arise every day, as patients fear enrolling in insurance to which they are entitled.

The regulations may also cause problems for many health care workers. While immigrants make up about 8 percent of the overall American workforce, they constitute 16 percent of the health care work force. Most non-citizen physicians and registered nurses receive health insurance through work, and will not be significantly affected by the proposed regulations. However, 22 percent of low skilled jobs in the health care sector, including nursing home workers and personal attendants, are filled by immigrants, many of whom lack access to employer-provided insurance.

For example, 25 percent of the home health aide workforce is non-United States born and one-third of home health aides rely on publicly-funded programs, including Medicaid and the ACA’s premium tax credits for insurance. If they avoid such programs for fear of becoming a public charge, they are likely to be uninsured, and unable to receive necessary care. That is likely to affect their ability to stay healthy and be productive workers. Making matters worse, the expanded definition of public charge will likely make it harder for low-skilled immigrants, including those who would otherwise work in the health care sector, to enter or stay in the country.  

The Administration defends the proposed regulations on the theory that they will advance self-sufficiency among immigrants. Self-sufficiency is an articulated goal in our immigration laws. But immigration law also establishes that many classes of immigrants are qualified for and entitled to federally-funded health benefits. So do many of our health laws, including the ACA and the laws authorizing CHIP. These laws reflect the realization that self-sufficiency with respect to health care is unrealistic. When it comes to health care, very few people are truly self-sufficient. Almost everyone needs insurance, and even the forms of insurance that the regulations favor depend upon public’s support. For example, employer-provided insurance receives preferential tax treatment, and Medicare is financed in part from general tax funds. And all but the very wealthy can find themselves relying on Medicaid or other public programs if a serious accident or disability befalls them.

Not only is self-sufficiency in health care unrealistic, it makes for bad health policy. The proposed regulations may be aimed primarily at keeping out unskilled workers, but by deterring taxpaying immigrants from accessing necessary care, they will spread costs throughout the health care system, add to health-related work losses, and harm the health of children and families.

There are still many steps before some version of the proposed regulations become law. The proposal is currently before the Office of Management and Budget, which could demand changes. It would then need to be published in the Federal Register for public comment. Should that happen, it is imperative that those who care about patients and the health care system weigh in, lest the Administration’s war against immigrants becomes a war against the American health care system.

Public Health Law Watch Comments on HHS Regulation Proposal: Protecting Statutory Conscience Rights

Public Health Law Watch, joined by our friends at the Public Health Law Center, submitted official comments to the U.S. Department of Health and Human Services proposed amendments to 45 CFR 88, "Protecting Statutory Conscience Rights; Delegations of Authority." Based on our combined expertise in public health law and policy, we offered comments on five main issues: (1) the lack of evidence that these rule revisions are necessary; (2) the absence of consideration for patients who face refusal of care; (3) the potentially dangerous expansion of existing definitions around “conscience protections;” (4) the potential harm these rules will cause for the LGBTQ population; and (5) the detriment these proposals would cause to reproductive health and rights.

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U.S. Department of Health and Human Services

Office for Civil Rights

RIN 0945-ZA03Docket

HHS-OCR-2018-0002

Public Health Law Watch (PHLW) and the Public Health Law Center appreciate the opportunity to make comments on the proposed Department of Health and Human Services (HHS) revisions to 45 CFR Part 88, “Protecting Statutory Conscience Rights; Delegations of Authority.” PHLW is a project of the George Consortium, a nationwide network of public health law scholars, experts, and practitioners.  The Public Health Law Center is nonprofit affiliate of the Mitchell Hamline School of Law, and a leading center of expertise in the use of law to prevent chronic disease.  The Center’s team of lawyers, law students, policy analysts and graduate students helps health leaders nationwide create communities where everyone can be healthy, with a focus on promoting healthy eating, encouraging physical activity, reducing the use of tobacco products, supporting health equity, and addressing cross-cutting legal issues that affect the nation’s health. Based on our combined expertise in public health law and policy, we offer the following comments on five main issues: (1) the lack of evidence that these rule revisions are necessary; (2) the absence of consideration for patients who face refusal of care; (3) the potentially dangerous expansion of existing definitions around “conscience protections;” (4) the potential harm these rules will cause for the LGBTQ population; and (5) the detriment these proposals would cause to reproductive health and rights.

First, we question the need for these regulatory revisions. As laid out in the Supplementary Information accompanying the proposed regulations, federal law already contains a plethora of provisions that protect individuals who invoke a religious objection to providing certain types of care, including abortion and assisted suicide. Yet, that information contained scant evidence that a pervasive discriminatory environment towards individuals and institutions who invoke these protections actually exists.  Rather, while the evidence provided describes an uptick in “conscience” complaints since the election of President Trump in late 2016, a total of only 44 complaints have been made since 2008. That represents less than 0.2% of the estimated 25,000 complaints that the HHS Office of Civil Rights (OCR) receives every year. Most of the remaining claimed support in the accompanying information is based solely on anecdotal commentary rather quantifiable data. Expanding these existing protections also risks directly conflicting with numerous professional standards, including the American Medical Association acknowledgement that conscience protections are not unlimited and that physicians “are expected to provide care in emergencies, honor patients’ informed decisions to refuse life-sustaining treatment, and respect basic civil liberties and not discriminate against individuals in deciding whether to enter into a professional relationship with a new patient.”  The current version of 45 CFR Part 88 is fully adequate to properly address existing and potential complaints about conscience protection violations. HHS can also fully institute its stated goals of ensuring “knowledge, compliance, and enforcement” of existing conscience protections via administrative means that do not require revising and expanding the current regulations.

Second, we are concerned that the regulations contain no protections for patients who face denial of care when health care providers and entities invoke these “conscience protections.”  By leaving patient consideration out, these regulations not only devalue those patients as individuals, but also potentially put their lives at risk. We have no way to know exactly how many times such “conscience protections” have been invoked or the extent of harm caused, but we do know that providers have, for example, refused to inseminate a woman because of her sexual orientation, refused to help a profusely bleeding pregnant woman because the fetus would not survive the procedure necessary to save her life, and refused to transport a pregnant woman by ambulance to a clinic that provided abortions. As the American Academy of Family Physicians has emphasized, “There is a distinct difference between declining to participate in a procedure versus denying access to care to an individual patient. The former is a protected right, the latter is an unacceptable shirking of our basic responsibility to care for our patients and contrary to the key underpinnings of the Code of Medical Ethics.”  Even if OCR prioritizes “conscience protections” of the health care providers and entities, the regulations also need to adequately protect the health and lives of the patients affected when such conscience protections are invoked. Further, the regulations are focused solely on health care providers and entities that refuse to provide certain types of care, yet fail to protect health care workers who view providing services like abortion as moral imperatives and yet face constant barriers and little consideration for their views.

Third, though the regulations are intended to enforce the “conscience protection” provisions in federal law, several of the proposed definitions in section 88.2 are so wide as to significantly expand existing law. We are particularly alarmed about the broad proposed definition of the term “referral or refer for.” While some of the existing provisions include a right for health care workers not to provide a “referral” for a service they have a religious or moral objection to, this definition of referral includes “the provision of any information…by any method… that could provide any assistance in a person obtaining….a particular health care service, activity, or procedure[.]” (emphasis added). This expansive definition conceivably allows a health care provider to not only refuse to provide a direct referral for care, but also to present the health care services he or she is willing to perform as the only medical options available to the patient. This could deprive a patient of the ability to make a decision with informed consent and leave them unaware that they can seek alternative and appropriate care from another provider. Again, these regulations provide no recourse to a patient harmed by this situation; rather, the regulations consider only the provider.

Compounding the concern about the broad definition of “refer,” the terms “workforce” and “assist” also have definitions that include activities, omissions, and persons far beyond the scope of those already protected under federal law. “Workforce” includes not only health care entity employees and contractors but also includes unpaid volunteers. “Assist in the performance” means “to participate in any program or activity with an articulable connection to a…” procedure, activity, or program. This explicitly includes, but is not limited to, “counseling, referral, training, and other arrangements….” These exceptionally broad definitions expand the scope of those who can invoke “conscience protections” beyond those originally envisioned in many of the federal provisions at issue. By allowing such a broad population of individuals to invoke “conscience protections” in such a wide range of situations, the care of patients is further diminished. This particularly puts at risk the health of patients in areas with few existing resources; low-income U.S. residents are already more likely to live in areas with fewer physicians and fewer hospitals and to have significantly poorer health overall. Residents in rural and farm communities also face similar barriers to access and health disparities.  The regulations should ensure adherence to the federal laws so that they apply narrowly and therefore minimize the impact on patient care.

Fourth, we are deeply concerned that these regulations particularly imperil care of the LGBTQ population. Health care already has a long history of anti-LGBTQ discrimination, such as classification of homosexuality as a psychiatric disorder and “treatment” that included electroshocks and “conversion” therapy. Partially as a result of this harm, LGBTQ populations have numerous health disparities, including higher rates of HIV, suicidal ideation and attempts, and violence victimization. They face frequent discrimination in health care contexts and these regulations would only enhance that discrimination by allowing a health care worker to raise a “moral objection” to, for example, homosexuality in general or to same-sex marriage. The objection could conceivably even be invoked to refuse treatment to children who have same-sex parents. Within the LGBTQ community, the transgender population is particularly at risk under these regulations. Absolutely no evidence exists that health care providers are being forced, for example, “to perform gender-affirming surgeries against their will…but what is happening every day, is transgender patients are being denied every kind of medical care you can think of.” A full 22% of transgender people in America already avoid doctors and medical care due to fear of discrimination and 31% have no access to regular health care at all. Those numbers are already alarming in the context of public health; these regulations risk leading to even wider denial of care, which would only increase that crisis.

Finally, the health care services explicitly targeted most often by these regulations (and by existing federal law) are those involving reproduction. In fact, the regulations often seem to be directly intended to “undermine existing legal and ethical protections for patients’ access to sexual and reproductive health information and services, and other critical care.” Many of the existing federal provisions explicitly allow providers and entities to invoke conscience protections in relation to directly providing abortions. But conscience protections have also been invoked to refuse access to emergency contraception for rape victims and to refuse to perform medically necessary procedures to save a woman’s life. The United States already has the worst rate of maternal deaths in the developed world, and this issue is further compounded by significant disparities: black mothers die at a rate 3-4 times more often than white mothers. To allow health care providers to invoke conscience protections to lifesaving reproductive health care even as a woman dies will escalate already unacceptably high rates. Further, these regulations also target – according to the supplementary information provided - laws requiring insurance coverage of reproductive health services, public notice requirements for “crisis pregnancy centers,” and attempts to require hospitals and healthcare professionals to provide abortion care when a woman’s life is endangered. These provisions go well beyond what the federal law currently covers, dangerously encroaching not only on a constitutionally protected right to reproductive health care but also on the very lives of women as patients. 

While protecting religious convictions has indeed been a long-respected – though never unlimited - right in the United States, HHS’s proposed regulations prioritize expansion provider protections without adequate consideration for how they endanger the health and lives of already vulnerable patient populations. We urge HHS not to adopt these proposed regulations.

Sincerely,

PHLW and PHLC

Public Health Law Watch

A project of the George Consortium

Publichealthlawwatch.org

Public Health Law Center

Publichealthlawcenter.org

Immigration and Health Care Under the Trump Administration [from Health Affairs Blog]

PHLW is back with this post by our own Wendy E. Parmet on the Health Affairs Blog.  The piece about the current state of immigration and health care comes out of her recent presentation at the Harvard Law School Petrie-Flom Center Sixth Annual Health Law Year in P/Review in December 2016.

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Immigration and Health Care Under the Trump Administration

by Wendy E. Parmet

Non-citizen immigrants are the canaries in the health care coal mine. Disproportionately poor, non-white, and non-English speaking, and without access to the franchise, they are among the most vulnerable groups in the United States. Consequently, they are often the first to experience the gaps, inefficiencies, and conflicts in our health care system. Meanwhile, anti-immigrant sentiment often spills into health policy debates, as was evident in 2009 when opponents of the bill that became the Affordable Care Act(ACA) focused their opposition on the erroneous claim that it would cover undocumented immigrants. It is therefore not surprising that the first year of the Trump administration, which has focused its domestic agenda on restricting immigration and repealing the ACA, has proven especially perilous for immigrants who need health care.

As a group, immigrants tend to be healthier than the native-born population. They are also far less likely to have insurance. In 2015, for example, 18 percent of lawfully present nonelderly adult immigrants, and 42 percent of undocumented immigrants were uninsured, compared to only 11 percent of United States citizens. Immigrants’ low insurance rate is partly due to the fact that they disproportionately work in sectors of the economy in which employer-sponsored insurance is uncommon. But the law also plays a significant role. Even before the Trump administration took office, immigrants faced an array of legal barriers to obtaining health insurance. Most importantly, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PROWRA) prohibited undocumented immigrants from accessing most federally-funded insurance programs (including Medicaid, Medicare and Children’s Health Insurance Program (CHIP)). PRWORA also barred most authorized immigrants (except refugees) from benefiting from federally-funded programs for five years after obtaining legal status. And although the ACA made it easier for many documented immigrants to gain coverage, it left PROWRA in place. The ACA also limited participation in the exchanges to immigrants who are “lawfully present,” a category that the Obama administration decided did not include the approximately 800,000 young adults who participated in the Deferred Action for Childhood Arrivals (DACA) program. 

The Trump administration’s policies threaten to swell the number of uninsured immigrants, and deter those who have insurance from accessing needed care. For example, several of last year’s Republican proposals to repeal and replace the ACA included specific provisions to bar further classes of immigrants from purchasing insurance on the exchanges, even when they used their own money. Other proposals would have allowed states to deny Medicaid reimbursement for services rendered to eligible non-citizens prior to documentation of their immigration status. In addition, because immigrants tend to have lower incomes than the native-born population and are less likely to have employer-provided health insurance, they would have been disproportionately harmed by efforts to repeal the Medicaid expansion.

Read the entire piece on Health Affairs here: Immigration and Health Care Under the Trump Administration

Why is Congress not prioritizing health care for children and other vulnerable populations?

By Jennifer Lea Huer

Back in September of this year, Congress was faced with the decision of whether or not to renew funding for both the Children’s Health Insurance Program (CHIP) and the Community Health Center Fund. Both sources of funding expired on October 1, 2017. As of the date of this post, 68 days have passed since Congress failed to renew funding for these crucial programs. Much has been written about the imminent need to reauthorize CHIP funding; states are already warning their residents that funding is running low and decisions about cutting coverage may soon follow. In addition to the estimated 9 million children in danger of losing coverage if CHIP funding is not renewed, recent studies estimate that millions more people could lose access to care if Congress does not take concrete steps to reauthorize funding for community health centers.

The federal government formalized its commitment to community health centers (CHCs) back in 1965, when it established the Health Center Program – a program that champions the development and capacity of CHCs, especially in the provision of care for millions of our country’s most vulnerable patients. The Patient Protection and Affordable Care Act (ACA) reiterated the US commitment to CHC growth and funding by establishing the Community Health Center Fund. The ACA authorized five years of funding, a total of about $7 billion, for CHCs. This funding meant that every state in the United States, including the District of Columbia, could have at least one CHC.  Federal funding also led to implementation of primary care programs, as well as behavioral health programs, and specific programs focused on special populations (e.g., veterans, children, chronically ill, homeless). Upon its expiration in 2015, Congress extended community health center funding for an additional two years, which, as mentioned, expired on October 1st.

Congress’ inaction is of the utmost concern, because community health centers are essential components of the American health care system, providing primary care services to more than 27 million people each year. One in 12 patients are served by a federally-funded CHC. Twenty-five percent of rural Americans receive their primary care from a CHC. An overwhelming percentage of CHC patients represent racial and ethnic minority groups. As other settings within the health care system continue to grow and cost more money, CHCs find themselves struggling to provide care to increasingly larger volume of patients, particularly for patients who would otherwise not have access to appropriate and cost-effective primary and ambulatory care services.

CHCs are known to provide high quality care and have a low per patient cost, but because the majority of their patients are under- or uninsured, CHCs heavily rely on federal support to maintain financial stability. Federal support for CHCs comes in the form of grants – which account for 70% of CHC funding. And end to the health center program means that CHCs will lose 70% of their funding, which will result in what experts have termed a “funding cliff.” This situation is especially dire for states that chose not to expand Medicaid; CHCs have even higher numbers of uninsured patients in these states (when CHCs cannot rely on Medicaid payments for otherwise reimbursable services, they must utilize more of their federal grant dollars to provide direct care, rather than using that grant funding to expand capacity for care delivery and specialized programs).  Experts are also forecasting that beyond stress to the health care system, this significant loss of funding will have detrimental effects in other sectors of our economy, including employment and state tax revenue.

Interestingly, both the House and the Senate have introduced bills that would extend funding for CHCs. But while both chambers have referred the Community Health Investment, Modernization, and Excellence Act of 2017 to sub-committees for review, the bills have stalled, with no further action occurring since September.

Here in Massachusetts, CHCs are trying not to panic, but many are worried that they will need to cut staff, clinic hours, and in the worst cases, shut down their facilities. The CHC funding cliff would result in Massachusetts CHCs losing $196 million in funding, which would impact hiring of new staff, continuation of much needed expansions (facility and programmatic), and, most importantly, it would mean that more than 141,000 residents could go without health care.

As the Trump Administration continues to aggressively degrade the integrity of the ACA and health care in the United States, CHCs will find themselves pressured to rise to the challenge of filling gaps in care delivery and cost containment. The CHIME Act indicates bipartisan recognition and support for solving the impending funding crisis, but Congress has not stopped internal squabbling long enough to focus on acting in the best interest of its constituents. It’s time members of Congress prioritize serving those who need them most and move to immediately reauthorize funding for the Community Health Center Fund.

Of Mosquitoes and “Moral Convictions”: How Rolling Back the Affordable Care Act’s Contraceptive Mandate Jeopardizes Women’s and Children’s Health

By Linda C. Fentiman

December 5 is the deadline to submit comments on the Trump Administration's recent action to gut the Affordable Care Act’s contraceptive mandate, which requires employer-sponsored health plans to ensure women's access to free, effective contraception.  This decision, announced in October in two Interim Final Rules, threatens serious harm to American children, because of the risk that women who lack access to contraception will become pregnant, contract Zika, and unwittingly transmit the virus to their developing fetus.  Since 2015, as an exponentially expanding Zika epidemic swept across Latin America, the United States, and its territories, thousands of children around the globe have been born with microcephaly.  On the U.S. mainland alone, almost 100 children have been diagnosed with microcephaly or other Zika-associated birth defects.   In Florida, the Department of Health has recently reported a new, sexually transmitted, case of Zika in Miami-Dade County.  In 2017 alone, 225 cases of Zika infection were confirmed in Florida; 119 are pregnant women, and three infants have been born with congenital Zika syndrome.  New York City, more than 400 pregnant women have been diagnosed with Zika since January 2016 and at least 20 infants have been born with microcephaly or other Zika-associated birth defects.

             The World Health Organization, Centers for Disease Control (CDC), and other health agencies have scrambled to reduce Zika’s threat by controlling the mosquito population and minimizing the risk of sexual transmission of Zika.  The CDC have been particularly outspoken, urging women of reproductive age to consider Zika’s risks to a developing fetus when deciding whether to travel to a Zika-affected area and, indeed, whether to become pregnant at all.

    In the face of such a dangerous disease, the Trump Administration’s drastic action to limit contraceptive access is both short-sighted and flawed legally.  The Administration announced two new regulations in October authorizing expanded exemptions and accommodations for employers, universities, and other health plan sponsors who wished to deny women free access to FDA-approved contraception, based on the plan sponsor’s religious beliefs or “moral convictions” (82 Fed. Reg.47658 and 82 Fed. Reg. 47838).   No exemption or accommodation was provided for plan sponsors seeking to opt out of any other health care service.  These new rules make it quite likely that many, especially poor and middle-income, women, will be denied access to effective contraception.  While the Fact Sheet accompanying the regulations states that low-income women whose employers opt out may seek contraceptive care through community health centers it conveniently ignores the fact that pending Republican legislation seeks to dramatically reduce federal funding for family planning services, including contraception, and that Republican efforts to repeal the Affordable Care Act would have authorized states to deny Medicaid recipients coverage for such services.

            With infectious diseases like Zika, citizens expect government to take direct steps to minimize the chance of disease transmission and to advise them about how to protect themselves.  Those most at risk for contracting the Zika virus are, as usual, the poor, who live in substandard housing that fails to protect them from mosquitoes and lack financial and other resources to access effective healthcare, including contraception and abortion.  Further, in states like Florida and Texas, even women and girls with financial means are frequently prevented from obtaining the full range of reproductive health care by restrictive federal and state laws governing access to contraception and abortion.

Recent natural disasters compound the problem. Puerto Rico provides a striking example of the intersection of legal and economic barriers; similar problems exist in Florida and Texas.  In Puerto Rico, two-thirds of all pregnancies are unintended; recent rates in Florida and Texas were 58% and 56%, respectively. Like their counterparts on the mainland, many Puerto Rican women, both married and single, want effective contraception, especially long-acting reversible contraception (LARC), such as IUDS and hormonal implants, which prevent pregnancy most effectively.  However, until the ACA contraceptive mandate became law, LARC was out of reach for almost all middle-class and poor women because of its higher upfront costs. 

Today, Puerto Rican women of all economic strata face significant hurdles in controlling mosquitoes and accessing healthcare, due to Hurricane Maria’s massive destruction of island infrastructure.  Yet even before the hurricane struck, women living in Puerto Rico were at high risk of contracting Zika and of being unable to plan for the birth of a healthy child.  Since December 2015 more than 34,000 people have been infected with Zika in Puerto Rico, more than 3,300 of them pregnant women. Nearly 150 infants have been diagnosed with serious Zika-associated birth defects.

  Officials from the CDC and Puerto Rico's Department of Health have worked over the last two years to increase public awareness of the risks posed by Zika, expand access to effective contraception, and minimize Zika transmission to pregnant women.  However, since Hurricane Maria, efforts to combat Zika have largely stalled, as both federal and Puerto Rican government officials have focused on other pressing needs - food, safe drinking water, electricity, and other infrastructure repair.

In the face of recent natural disasters, the Trump Administration’s decision to gut access to contraceptive coverage threatens a public health emergency of immense proportion, risking the health of vulnerable women and children. At the very moment that women in Florida, Texas, Puerto Rico, and the U.S. Virgin Islands are in the greatest need of government assistance due to devastating hurricanes, the Administration has erected major barriers to contraception and effective family planning, limiting the ability of women and their families to make informed decisions about the risks of bringing a potentially disabled child into the world.  This directly contravenes the Affordable Care Act’s command that “the Secretary of Health and Human Services shall not promulgate any regulation that-- (1) creates any unreasonable barriers to the ability of individuals to obtain appropriate medical care; or (2) impedes timely access to health care services….” (42 U.S.C.A. § 18114).

While the Administration asserts that its new contraceptive coverage policy is necessary to preserve the religious freedom and moral convictions of employers and other health plan sponsors, its promulgation of two Interim Final Rules that limit only women’s healthcare access displays an utter disregard for the constitutional guarantees of equal protection, due process, and personal privacy.  Finally, the decision to publish these controversial regulations as Interim Final Rules, with no opportunity for public notice and comment before they go into effect, contravenes the essential requirements of agency rule-making in a democracy. 

Everyone committed to gender equity, access to preventative health care, and protecting the public from infectious diseases should consider commenting on the Interim Final Rules before the December 5 deadline.  Here is the link:  https://www.regulations.gov/comment?D=CMS-2014-0115-13773

GOP Tax Bill Would Inflict Real Pain on Nonprofit Hospitals [From Philly.com]

By Robert I. Field

Nonprofit hospitals have had much to fear from Congress recently. The Senate came within one vote of repealing much of the Affordable Care Act, which would have left millions of patients uninsured and unable to pay for hospital care. And Congress may soon consider major cuts to Medicare and Medicaid, which could slash reimbursement for many hospital services.

Now, nonprofit hospitals face a new threat in the tax reform plan unveiled recently by House Republicans. Nonprofit hospitals include most of the largest and most prestigious ones in the Philadelphia area.

Like all major tax changes, the Republican proposal would create winners and losers.  Some of those winners and losers had been expected, but the changes that put nonprofit hospitals in the loser’s column came as a surprise. They would be in for significant hits in at least two ways.

First, they would lose an important source of financing for expansion. Nonprofit hospitals raise money for construction projects by issuing tax-exempt bonds that allow investors to avoid paying tax on the interest. This reduces the interest rates they have to pay to attract investors, which saves them large amounts in project costs. The tax plan would eliminate the exemption for interest on many of these bonds, which would force the hospitals to pay prevailing market rates. For many of them, major new construction could become unaffordable.

Second, they stand to lose many of their donations. Donors to nonprofit hospitals receive a tax deduction for their contributions but only if they itemize deductions on their tax returns. Itemization is worthwhile only if deductible expenses add up to more than a standardized amount. The tax plan would raise that amount to almost double its present size —  $12,200 for individuals and $24,400 for couples — which would take away the benefit of itemizing for many. Without itemizing, the tax incentive for making smaller donations would disappear.

Tax-exemptions for bonds and donations are benefits that for-profit hospitals do not enjoy. In that regard, the changes would put nonprofits and for-profit facilities on a more equal footing. But for-profit hospitals can raise money by issuing stock to private investors, a funding source they rely on extensively. Nonprofits have no stock to sell, so the proposed changes would put them at a significant disadvantage.

On top of these threats, some in Congress, as well as President Trump, would like to add a provision to the tax plan repealing the individual mandate under the Affordable Care Act. The Congressional Budget Office estimates that this would cause 13 million Americans to lose coverage over the next 10 years. Without insurance, these people would lack the means to pay for hospital care.

And if a tax bill were followed by cuts to Medicare and Medicaid, the financial losses for many hospitals would be substantial.

Tax reform has been billed as a way to stimulate economic growth. But for one major industry that serves as a major source of employment, not to mention its role as a guardian of our lives and health, it would do just the opposite.