HHS’ PRWORA Notice – What it Means for Community Health Centers
HHS’ move to label the community health center program as a “federal public benefit” under PRWORA marks a sharp departure in federal policy.
Authors: Alex Somodevilla and Julian Polaris
Editors: Patti Boozang and Amanda Eisenberg
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tl;dr
On July 14, the Trump administration announced broad policy changes that will significantly restrict immigrant access to a variety of federal programs (including federal health, nutrition, and education programs), reversing settled policy that had been in place for over 25 years. In particular, several federal agencies, including the Department of Health and Human Services (HHS), issued notices expanding the types of federal programs under their purview that will be considered “federal public benefits,” which are subject to eligibility restrictions based on immigration status pursuant to the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA).
As a result of HHS’ policy reversal, which went into effect the day it was issued, PRWORA’s immigrant eligibility restrictions now apply to more than a dozen additional programs, including mental health and substance use disorder programs administered by the Substance Abuse and Mental Health Services Administration, Title X family planning services, Head Start programs, and the Community Health Center Program.
HHS’ extension of “federal public benefit” status to the health center program arguably conflicts with the community-wide nature of the program (as outlined in statute), and we expect this issue to make its way through the courts in the coming months.
For the time being, because community health centers are non-profit entities, they will generally not be required under PRWORA to conduct immigration-status checks for their patients, although we expect the administration to attempt to revisit this policy in the near future.
The 80 Million Impact
Community health centers receive grant funding under Section 330 of the Public Health Service Act to provide primary and other health care services to all patients in medically underserved communities, regardless of their ability to pay. Today, 32.5 million patients, many of them with low incomes who suffer from chronic diseases, rely on community health centers for primary, preventive, behavioral health, and other health care and related services.
Federal statute does not establish eligibility criteria for individuals to receive services at a community health center. Quite the opposite: Community health centers are required to provide services “for all residents of the area served by the center” and to “assure that no patient will be denied health care services due to an individual’s inability to pay for such services.” Since PRWORA was enacted, the community-wide nature of the Section 330 health center program meant that it has not been considered a “federal public benefit” subject to PRWORA’s immigrant eligibility restrictions.
With this policy reversal, however, HHS has now reclassified the Section 330 health center program (as well as other programs health centers often participate in) as a “federal public benefit” subject to immigration eligibility restrictions. This restriction could devastate health care access for many immigrant groups, including legally residing noncitizens, who have historically come to rely on health centers for these important services.
Because most health centers are non-profit organizations, they are generally exempt from a requirement to verify the immigration status of any patients who come to their doors seeking care. [1] As we’ve previously noted, PRWORA exempts non-profit organizations from any requirement to “determine, verify, or otherwise require proof” of an individual’s immigration status when seeking or applying for federal public benefits. HHS states that it is not formally revising aspects of PRWORA’s verification requirements at this time. The agency ominously notes that “pending further regulation and/or guidance on the situations in which verification is required, all entities that are part of HHS’ administration of public benefits should pay heed to the clear expressions of national policy” concerning access to services for noncitizens. However, this admonition does not constitute any new, legal requirement for non-profit entities.
As such, (and notwithstanding HHS’ policy change), health centers remain under no obligation to conduct immigration status checks with respect to care provided under the Section 330 program (or any federal program for which health centers are the direct recipient of grant funding from the federal government), nor are they required to turn patients away from their doors because of their immigration status.
PRWORA provides the Department of Justice (DOJ) with some say in interpreting the non-profit verification exemption. We expect that the administration will seek to revisit the scope of the exemption in future guidance or rulemaking. We will continue to monitor and report on DOJ guidance in this area.
It is also important to note that PRWORA exempts certain benefits and services from the scope of immigrant eligibility restrictions, including vital public health programs that health centers administer like public health assistance for immunization and treatment for communicable diseases. These exemptions are clearly outlined in statute and are likely to remain in place.
The Bottom Line
HHS’ recent notice upends decades-long policy by dramatically expanding the list of programs that the agency considers to be “federal public benefits” under PRWORA — including the health center program, which has become a pillar for community health in underserved communities. However, because PRWORA exempts non-profit entities from having to verify the immigration status of the patients they serve, the HHS notice does not have any immediate impact on the ability of health centers to serve all patients in their communities (as is required by statute).
It is important for health centers to clearly convey this point to their communities, as such a monumental policy change (along with the rhetoric surrounding it) risks creating a “chilling effect” deterring individuals from seeking needed care due to fear of government reprisal or perceived consequences under PRWORA. Indeed, this chilling effect is an intended consequence of such guidance.
Moving forward, the administration and stakeholders will also have to grapple with what appears to be a fundamental conflict between HHS’ expanded interpretation of federal public benefits under PRWORA, and health centers’ statutory obligation to provide services “for all residents of the area served by the center.” We expect this tension to play out in the courts in the coming months.
[1] We note that our discussion focuses on programs for which health centers are the primary recipient of federal funds – like the Section 330 program. The implications may be different for federal grants that flow through other entities, such as state or local governments (and for which a health center is a sub-grantee), as well as programs that have independent immigration-related eligibility criteria separate from PRWORA.
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