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It began with a few missed appointments last year. But soon, Kalihi Palama Health Center CEO and Executive Director Emmanuel Kintu noticed the patient no-shows beginning to pile up.

Last year, approximately 2,000 people who normally seek medical care at Kalihi Palama Health Center never arrived, the clinic reported to the national Health Resources and Services Administration. That is about 10% of the center’s total patient population — a significant blow.

Kintu believes it’s driven by fears about upcoming changes to national immigration policy that affect people who entered the U.S. legally and are currently in the process of obtaining green cards, or permanent residency status.

“They’re delaying seeking care because they think this is going to have an impact on their immigration status, or the immigration status of their extended families,” he said.

The shift in patient attendance began long before the policy rule change was finalized this month, and stems from its proposal last year, Kintu said. The new , which take effect on Oct. 15, would deny legal permanent residency, or green cards, to new applicants who use federal, state and local public benefit programs in health, nutrition and housing.

Immigration officers will soon weigh whether participating in those types of programs means an immigrant will pose a financial burden on the nation. The wording of the policy gives individual officers discretion to decide who might become a “public charge” in the future when they apply for a change in status or renewal.

In turn, state officials say the new rule could shift health care costs from the federal government to the state, at a higher price, as more people begin to rely on emergency services.

“This is especially significant for us since, on a per capita basis, there is a higher number of immigrants who call Hawaii home,” said Beth Giesting, director of the Hawaii Budget and Policy Center.

“It is likely that the punitive treatment of immigrants proposed would scare people away from programs for which they’re eligible,” she added. “That would certainly be bad for the families involved, bad for community health centers and hospitals that would be serving people without coverage, and bad for the economy.”

Revised Rules

Federal law has historically required green card applicants to prove they will not be a financial strain on the government. But in the past, determining whether someone was “ on the government for subsistence” was largely based on whether they received public cash assistance or were institutionalized for long-term care.

The new definition of a “public charge” includes anyone who is “more likely than not” to receive a wider array of public benefits for a cumulative 12 months within a 36 month period.

Programs that were previously excluded from consideration will now be analyzed, including non-emergency Medicaid for non-pregnant adults, the Supplemental Nutrition Assistance Program, or food stamps, and several housing programs.

“Along with the rules’ impact on food subsidies and housing support, this change will worsen existing health inequities and disparities, cause further harm to many underserved and vulnerable populations, and increase costs to the health care system overall, which will affect all patients,” the Association of American Medical Colleges President and CEO David Skorton said in a statement.

Although it has not taken effect, clinic directors say it has already altered patient behavior since the Homeland Security Department published its proposed rules in the fall of 2018.

“We’ve already been hearing from some community members that people are refusing to sign up for coverage or for these benefits, believing it’s going to have a negative impact on them in the future,” said Judy Mohr Peterson, the Med-QUEST Division Administrator for the Hawaii Department of Human Services.

After a whopping 266,000 public comments were submitted about the proposal, the rules were updated to exempt pregnant women, Medicare Part D recipients, active military members, refugees, asylum seekers and children under the age of 21. Anyone who submitted their application for a green card prior to the rule change will not be affected.

Still, the rules could lead to a significant drop in Medicaid participation for immigrant families and even their U.S. citizen children, and in turn, add more uninsured people to the health care market.

“The most significant effect is people will skip or forgo their primary care, and when they forgo their primary care, inevitably they are going to seek care either in the emergency room or end up with the hospitalization,” Kintu said.

The Chill Effect

The new rules — more than 800 pages long — are complex and unclear. They do not apply to everyone, only lawful immigrants who have not yet obtained green cards.

But confusion and miscommunication via word of mouth will broaden its impact, experts say.

The ramifications are potentially strong in Hawaii, which is home to the sixth-highest percentage of foreign-born residents in the country. Nearly  Hawaii residents is an immigrant, and more than half of all immigrants in Hawaii are naturalized U.S. citizens.

The rule change could lead to a “chilling effect” that would hit an estimated 212,000 noncitizens and their family members in Hawaii — about 15% of the state population, according to .

Mohr Peterson, the Med-QUEST administrator, is concerned about those who receive Hawaii’s Medicaid “lookalike” benefits, whether or not they meet federal citizenship requirements.

Those state funds cover care for people who are elderly, blind or disabled, she said.

“They live here legally, but they don’t meet the federal citizenship requirement, so we as a state have chosen to continue to provide benefits for them using state dollars,” she said. “It’s a concern to us that that will now be used against them with these new public charge rules.”

To become eligible for some federal public benefits, someone must already have established legal permanent residency. In general, migrants make up a small fraction of recipients of such benefits.

An by the Associated Press found that non-citizen low-income immigrants use Medicaid, Supplemental Security Income, and food or cash assistance at a lower rate than comparable low-income U.S. citizens. Overall, non-citizen immigrants represent 6.5% of Medicaid enrollees and 8.8% of food assistance recipients nationwide, the .

But even people who already have legal status are likely to dis-enroll from certain programs, erroneously fearing that it could hamper their ability to become a citizen one day.

Green cards are generally a step toward becoming a naturalized U.S. citizen. Those who hold green cards shouldn’t be affected, and neither should those who are applying for citizenship. Yet not everyone knows that.

“From our experience working with families, people don’t make that distinction, necessarily,” said Mohr Peterson, who also serves as the president of the National Association of Medicaid Directors. “If people are fearful, they will not sign up their kids for Medicaid and their kids won’t get the care.”

Claudia Hartz, a community health educator at the West Hawaii Community Health Center, has seen that up close.

Recently, immigrant parents consulted with her at the clinic and opted out of signing up their daughter for health insurance coverage, fearing it could interfere with their immigration status as parents in the future. The child was eligible for health insurance because she was born in Hawaii and is a U.S. citizen.

“Their child is needing medical insurance, but they’re waiting until they have legal status,” Hartz said. “If we offer insurance, they’ll say, ‘No, not yet, we’re in the process of getting our paperwork for legal status.’”

Fear Wave

Local health care providers are concerned that people will stop seeking medical care altogether if they believe it will jeopardize their chance for permanent residency or future citizenship.

Community health center officials like Kintu are alarmed, since their clinics serve a large portion of Medicaid patients and immigrants. If clinics lose too many patients, it could hamper their ability to keep offering services as the number of uninsured patients grows.

“If people don’t come in, we don’t get paid, and if we don’t get paid, we have to shrink,” Kintu said. “If we shrink, that means the folks who really need access to care don’t have the access which means need is going to grow. If you play it out it becomes a huge problem.”

More than half of all KPHC patients who are cared for at the Kalihi clinic rely on Medicaid for their health insurance.

Kintu estimates the new rules could potentially affect about 40% of Kalihi-Palama Health Center patients and the way they seek medical care, particularly those who could receive an adjustment in their immigration status in the future. Over the past year he has spoken to numerous pregnant women who decided not to come to their second and third trimester check-ups because of this fear.

“If the person chooses to forgo services and they have a bad outcome, by definition it’s impacting the whole family,” Kintu added. “The mental anguish is going to affect everybody.”