Re: Notice: Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA); Interpretation of “Federal Public Benefit”
Children’s HealthWatch writes in strong opposition to the new interpretation of “Federal public benefit” in the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 recently released by the US Department of Health and Human Services (HHS). This reinterpretation will strip qualified, lawfully present immigrants and their children of access to health-promoting programs funded by HHS, including Head Start, health centers, and block grants like the Community Services Block Grant and Community Mental Health Block Grant. It will also impose burdensome administrative requirements on state and local governments, impacting all families who interact with HHS programs. The health and wellbeing of millions of lawfully present children and families will undoubtedly be harmed by these changes. We urge you to withdraw this notice.
Children’s HealthWatch is a non-partisan network of pediatricians, public health researchers, and child health policy experts who examine how policy decisions affect the health and well-being of young children. Founded in the wake of PRWORA to monitor the legislation’s impact on the health of young children and their families, we seek to achieve optimal health for this population by advancing research to transform policy. We accomplish this mission by interviewing caregivers of young children in emergency departments and primary care clinics in four cities: Boston, Minneapolis, Little Rock, and Philadelphia. Since 1998, we have interviewed more than 80,000 caregivers and analyzed those data to determine the impact of public policies on the health and development of young children. More than 25 percent of the young children in this dataset have immigrant mothers, mirroring national statistics that nearly one in four children age 0-5 in the US has at least one immigrant parent.
The reinterpretation of the definition of ‘Federal public benefit’ contravenes nearly three decades of established policy and will cause harm to lawfully present immigrants as well those not directly barred, including children in mixed status families and broader communities. Although HHS claims these changes are being made to prevent undocumented immigrants from accessing public benefits, undocumented immigrants have never been eligible. Instead, lawfully residing immigrants—including those with Temporary Protected Status, nonimmigrant visas (such as work or student visas), and children with a pending application for adjustment of status, asylum, withholding of removal or for protection under the Convention Against Torture—will be barred from evidence-driven, health-promoting, community services and programs.
This Reinterpretation Will Create a Chilling Effect, Harming the Health of All Children and Families
The new rule will harm the health and wellbeing of young children and have consequences for children beyond those newly excluded. Existing restrictions in PRWORA and accompanying regulations already create a chilling effect that deters eligible family members from participating. For example, data show that in 2016-2019, participation among US citizen children in mixed status families in programs like Medicaid, the Children’s Health Insurance Program (CHIP), and the Supplemental Nutrition Assistance Program (SNAP) decreased nearly twice as fast as children with US citizen parents due to feelings of fear and uncertainty caused by changes to immigration policy. Similarly, research from Children’s HealthWatch during this time showed a significant decrease in well-child visits among children of immigrant mothers compared to those in US citizen families. Well-child visits are vitally important for ensuring that children receive the developmental and health screenings they require in order to identify and address problems early on and receive necessary vaccinations to prevent serious disease, disability, and risk of contagion to other children. Additionally, parents can receive guidance and connections to resources they need to provide optimal care for their children. The HHS rule reinterpreting the definition of federal public benefits will only exacerbate these chilling effects, causing harmful ripple effects to families and children, including US citizens, across the country.
Access to Head Start is Critical for Child Well-being and Workforce Participation
The inclusion of Head Start in the reinterpretation is especially damaging, as children enrolled in the program are in a crucial period of brain development. Cutting them off the program will jeopardize their cognitive, academic, socioemotional, and motor development. Head Start is an evidence-based school readiness program that provides high quality and comprehensive services for families in need. Participation in the program has transformed the lives of countless families by providing access to early childhood education — since its inception, Head Start has served 40 million infants and preschoolers in every community in every state across the country. The effects of Head Start are well-documented; Head Start significantly improves the educational outcomes and financial prospects of participating families. Children attending Head Start have a higher likelihood of graduating high school and attending college, and earn higher wages as adults than non-Head Start children. They are also more likely to raise strong families, underscoring the long-term and multi-generational benefits of the program. As medical educators at each of our institutions, we have had the privilege of training many future physicians who tell us proudly that they are Head Start graduates. We’ve seen in our Medical Schools how the first steps on the educational path to future success often begin with this program.
Children’s HealthWatch research documents the multiple, harmful consequences of the inability to access and afford quality early childhood education and care. We found that when caregivers are unable to work or pursue education due to challenges accessing child care (child care constraints) they are worse off financially, experiencing difficulty affording their families’ basic needs, such as food, housing, and utilities. Increasing child care constraints for immigrant parents will further reduce the hours they are able to work, lowering their household income and making it harder to afford necessities. Ultimately, the financial impacts of child care constraints manifest in poorer health for children and their parents. Compared to those in families without child care constraints, young children in households that have experienced child care constraints are 43% more likely to be in fair or poor health, 60% more likely to be at risk of developmental delays, and twice as likely to be child food insecure (one of the most severe levels of food insecurity). Their parents are also 57% more likely to be in fair or poor health and 84% more likely to experience maternal depressive symptoms.
The Head Start program should not be defined as a public benefit and must remain statutorily exempt. Head Start ensures that children are prepared for K-12 education, and the sudden recategorization would plunge millions of families and children into uncertainty. Restricting eligibility for Head Start will increase the prevalence of child care constraints and jeopardize children’s development for both immigrant and citizen families by reducing workforce capacity and increasing administrative burden (the learning, compliance, and psychological costs associated with navigating the processes to access assistance). This change will harm entire families’ mental and physical health regardless of citizenship status and increase downstream health care costs while weakening the workforce as a whole.
Limiting Access to Health Programs Will Harm Health and Health Care Delivery
Expanding the definition of “Federal public benefit” to include essential health programs, such as Title X and the Health Center Program, threatens public health, delivery systems, and the broader economy. Title X is the only federal program dedicated to providing individuals with low-incomes access to affordable family planning care. In many areas, it is the only available source of essential health care. Restricting these services will significantly reduce access to prenatal care, which is essential for healthy birth outcomes and early child development.
Similarly, Federally Qualified Health Centers (FQHCs) provide primary and preventive care services, which are crucial for managing chronic conditions and promoting overall health, especially for perinatal parents and infants. Children’s HealthWatch research demonstrates that young children who do not receive the health care they need are more likely to be hospitalized, be in fair or poor health, and be at risk for developmental delays. Again, confusion about eligibility and fear of immigration consequences may discourage even eligible individuals, including US citizen children, from accessing needed care.
Denying access to preventive care does not eliminate family members’ need for services, it shifts the burden to individual families to pay out of pocket. When individuals cannot pay out of pocket, this financial burden shifts to hospital emergency departments and state systems, leading ultimately to increased insurance premiums to cover these rising costs. Furthermore, people who are unable to access preventive health care inevitably enter the health care system at more complex and expensive points. Delayed treatment leads to worse health outcomes and poor maternal and infant health, all of which require more intensive, costly interventions. Children’s HealthWatch research showed longer and more costly hospitalizations among infants whose families were food insecure, a sign of economic hardship. Similarly, we have shown that early hardship is predictive of later need for acute health care, such as emergency department visits.
Consequently, hospitals, especially in rural and underserved areas, will absorb more uncompensated care, threatening their financial viability. This is in addition to lost productivity, as people with advanced health issues are less likely to be able to continue working and supporting their families. This will have broader impacts on communities, given immigrants’ essential role in the workforce. Restricting access to critical health care programs not only contradicts the agency’s commitment to health and public safety but also threatens to destabilize the health care system and the broader economy.
This Reinterpretation Will Increase Administrative Costs, Burden State and Local Governments
The HHS notice correctly notes that the process of stricter eligibility verification established by the new rule will create millions of dollars in new administrative costs. The process will increase administrative burden and costs for state and local governments that already spend significant resources on verifying eligibility for restricted programs like Medicaid and SNAP. Any new requirements for state and local governments to verify eligibility for programs newly deemed to be Federal public benefits would be an unfunded mandate and force them to develop costly new policies, technology, and training procedures for each one. Prior to the enactment of H.R.1, state budgets were already facing increasing fiscal stressors. The significant cut in federal funds and cost shift to states for Medicaid and SNAP make new requirements under the HHS rule even more unaffordable.
Red tape is already a major barrier to effective utilization for federally funded programs to all who want to participate. Low-income families utilizing the programs targeted by HHS already face “time poverty” driven by excessive paperwork requirements that stem from federal regulations like the ones that this notice may create. Federal paperwork already costs 10 billion hours and $276.6 billion annually. Instituting even more requirements without increasing funding for these programs will lead to less time and money for their core missions.
The increased time and money required for this system may lead to otherwise eligible families dropping out of programs, delays with application processing, and state agencies further limiting these programs in order to keep up. In addition to the impact on families with immigrant members, US citizens may see their benefits delayed or reduced in order to pay for increased administrative costs, or be deterred from applying for programs they are eligible for due to fear and uncertainty. When families are unable to access the benefits they are eligible for, their health suffers. Our prior work has shown that access barriers in safety-net programs are associated with concrete and measurable harm to maternal and child health.
Children’s HealthWatch research underscores this. We found that among families with young children, enrollment gaps (non-participation in 1 or more of the benefits for which they were eligible) in key safety-net programs were associated with administrative burden, especially learning about and complying with program rules. The generosity of state safety-net program policies also played a role in families’ participation in the maximum number of benefits for which they were eligible; more generous policies were associated with lower odds of an enrollment gap. In interviews across five states with state employees, families, and non-profits assisting families with benefit applications, we found complex administrative rules created barriers to efficient, effective state processes and caused frustration and anger for state workers, non-profit service providers, and families, whether immigrant or US-born. Thus, rather than increasing complexity we must drive investments in streamlined, inclusive processes to decrease the red tape and regulations surrounding these programs, increasing efficiency and saving money overall.
Conclusion
HHS is abolishing a 30-year precedent that community-serving programs are exempted from PRWORA restrictions in order to promote the well-being of children, their families, and their communities. This reinterpretation, combined with a host of anti-immigrant policies and actions from the Administration, Congress, and the Courts, represents a set of government actions that will make the country, especially its children, less healthy, less fed, less educated, and less economically strong. Children and families in communities across the country, regardless of immigration status, will suffer from these restrictions. The solution is to increase funding for these programs, not restrict eligibility.https://childrenshealthwatch.org/wp-content/uploads/welfare_reform_child_health_7_02.pdf Head Start, Federally Qualified Health Centers, and the other programs included in this notice are public health benefits that support entire communities and therefore should not be considered public benefits that exclusively impact individuals. We strongly urge HHS to withdraw this notice and not proceed with any further guidance, regulations, or other harmful changes in interpreting PRWORA.