1. Public Health Implications of PRWORA’s Restrictions on Undocumented Immigrants’ Access to Care Jeff Kullgren, MPH, MSII Michigan State University College of Human Medicine

2. Overview  PRWORA’s restrictions  Texas situation  Public health implications  Policy and legal recommendations

3. 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA)  Enacted in 104 th U.S. Congress  “Ended welfare as we knew it”  Set new immigration policy  Specific language pertaining to undocumented immigrants

4. PRWORA: Undocumented Immigrants and Public Benefits Undocumented immigrants are ineligible for “any retirement, welfare, health, disability…or any other similar benefit for which payments or assistance are provided to an individual, household, or family eligibility unit by an agency of a State or local government or by appropriated funds of a State and or local government”

5. Exceptions to PRWORA’s Restrictions 1) “Assistance for health care items and services that are necessary for treatment of an emergency medical condition” 2)“Public health assistance for immunizations…and for testing and treatment of symptoms of communicable diseases whether or not such symptoms are caused by a communicable diseases” 3)States that enact legislation after August 22, 1996 affirmatively providing eligibility for undocumented immigrants 4)U.S. Attorney General declaration

6. Trouble in Texas (2000)…  Harris County Hospital District’s request regarding proposed payment policy changes  Attorney General John Cornyn’s opinion:  PRWORA prohibits hospital district’s provision of free or discounted non-emergency care  No state law affirmatively providing for undocumented immigrants’ eligibility  Penalties for violations related to misspending of state and federal funds

7. Responses to Cornyn’s Opinion  Criminal investigation of Harris County Hospital District and its leadership  Pressure from local advocates for investigations in other Texas jurisdictions  Mixed responses from health care providers:  Limitations on services in some areas  Alternative legal interpretations justifying continued service provision in others

8. Why Should the Public Health and Health Care Community Care?  Possibility for similar investigations in other jurisdictions both in Texas and elsewhere  Increased scrutiny of institutions particularly in areas with large undocumented populations  “Chilling effect” on both providers and undocumented patients  Broad-ranging public health implications…

9. Public Health and Health Care Implications of PRWORA’s Restrictions  Failure to respect states’ “police power”  Infringement on clinicians’ ethical obligations  Threatened access to care for undocumented immigrants’ children

10. Public Health and Health Care Implications of PRWORA’s Restrictions  Administrative complexities endangering access to care for all patients  Prevention of cost-effective use of public resources  Hindrance of infectious disease diagnosis and tracking

11. Law and Public Health Policy  Law presumably intending to revamp provision of public assistance has reshaped public health practice  Anti-immigrant sentiments of mid- 1990’s captured and controlled debate  Policy driven by rhetoric not evidence  Impractical constraints and unintended consequences

12. Macro-Level Strategies for Resolving this Conflict  State legislation affirmatively providing for undocumented immigrants’ eligibility  U.S. Attorney General exemptions  Federal legislation amending PRWORA  Formation of untraditional alliances

13. Micro-Level Strategies in the Absence of Broad Reform  Local agreements with district attorneys and law enforcement officials  Continued provision of services until judicial system addresses this issue  Public health leaders’ provision of expert knowledge and amicus curiae briefs if needed

14. Important Public Health Policy Research Questions  How have public health and health care institutions been affected?  Can the infectious disease and epidemiologic implications be quantified?  Case studies of public health consequences?  What are the “pull factors” driving illegal immigration?

15. Conclusion  PRWORA went much further than reforming welfare  Important public health implications related to undocumented immigrant restrictions  Utility of Harris County’s experience as a case study  Urgent need for macro and micro-level efforts to resolve this conflict