NWA Template Comments Addressing Public ChargeOctober 19, 2018 Comment Period Closes: December 10, 2018

Thank you for taking the time to submit a comment to the U.S. Department of Homeland Security (DHS) about public charge. This is an issue of importance for many WIC families. The National WIC Association (NWA) values your work on behalf of all participants. Remember: regulatory commenting is not lobbying. Lobbying restrictions are related to the legislative process – the public charge proposed rule is an administrative action being undertaken by the executive branch. The federal government is specifically asking the public for comment on this proposed rule, and your input is helpful to the Department’s decision-making.

Below are resources to assist you in forming your own comments in opposition to the public charge proposed rule. We encourage you to form a comment that reflects your own unique voice. Comments must be submitted here by December 10, 2018. The only identifying information that is required is a first and last name. For those individuals who may be concerned about divulging their identity, there is an option to have a third-party individual sponsor your comments. All comments must be in English or have an English translation available.

You may submit your comments in the text box at the above link, or you may choose to attach your comments in a Word document or PDF file (multiple attachments are accepted). There is an option to mail your comments to the Department of Homeland Security:

Samantha Deshommes, Chief, Regulatory Coordination Division, Office of Policy and Strategy, U.S. Citizenship and Immigration Services, Department of Homeland Security, 20 Massachusetts Avenue NW, Washington, DC 20529-2140. To ensure proper handling, please reference DHS Docket No. USCIS-2010-0012 in your correspondence. 

If you are having difficulty in forming or submitting your comment, please contact Brian Dittmeier for assistance at bdittmeier@nwica.org.

As you prepare your comments, please:

- Write comments in your own words. DHS must review every unique comment; therefore, it is helpful if you modify the template language to include your own perspective and thoughts. The template highlights in yellow particular opportunities to add your own thoughts. You are encouraged to modify the template language to reflect your own voice.

- WIC staff and direct service providers are encouraged to detail how WIC and the affected programs (Medicaid, CHIP, SNAP, and housing assistance) impact people’s lives. You may also wish to highlight specific experiences in your clinics. Please remember to safeguard the identity of concerned participants whose experiences you may wish to highlight.

- WIC participants and their families may wish to highlight their direct experience with WIC or one of the affected programs (Medicaid, CHIP, SNAP, and housing assistance). You may also wish to speak about the fear that you or your family member would feel about accessing one of these benefits if it is

considered a public charge, and what effect that would have on you and your family.

- Submit separate comments, rather than signing on to comments from someone else. The Department only considers unique comments and does not afford a comment greater weight if it has more signatories. Even if you are echoing similar themes, it is important to share your own distinct comment with the Department.

- Attach research, data, testimonials, or other supporting documents. The template comments below cite a number of academic studies and government reports. If you have research, data, or testimonials that are unique to your comment, you may wish to include these additional resources as an attachment to ensure that they are included in the Department’s record.

- If you have credibility in an issue area, say so. It is important to provide context as to why you are weighing in on the Department’s proposed rule. If you have specific expertise, please explain why you are uniquely qualified to offer your thoughts on this matter. As a WIC recipient or service provider, you have credibility to weigh in on this issue!

- If you have personal experience with any of the affected programs, say so. Personal experience with any of the affected programs can also lend greater credibility to your statements. If you have participated in WIC or any of the affected programs (Medicaid, CHIP, SNAP, or housing assistance), please highlight that and speak to how these programs have benefitted your life and your family.

- Provide translations of non-English comments. The Department will only consider comments that are in English or include an English translation. This restriction will likely diminish the comments from people most affected by the proposed rule. We recommend that non-English comments be submitted together with a translation, along with a statement from the translator that verifies the accuracy of the translation (e.g., “I, [Translator’s Name], hereby declare that I am fluent in [language] and English and that this translation is a true, accurate, and complete version of the original text to the best of my knowledge.”)

- When possible, avoid completely anonymous comments. The commenting website requires a comment to have a first and last name included. Address, phone number, and other contact information is not required. If an individual is still fearful of submitting a comment with just their name attached, it is possible for a third-party – any third-party – to sponsor that comment. WIC clinic staff, an attorney, or a neighbor could submit the comment on behalf of one individual – or multiple individuals. We recommend that the submission include an acknowledgment by the third-party of their relationship to the specific person whose comment they are sponsoring, in order to provide the comment with greater authenticity, context, and legitimacy.

Once again, thank you for taking some time to speak up on this important issue that will affect many WIC families. NWA is deeply disappointed that this proposed rule moved forward and we need as many voices as possible to stand up against this harmful policy change. NWA stands ready to assist if you have any difficulty with forming or submitting your comments!

Guidance for Participant Comments

October XX, 2018

Ms. Samantha Deshommes, ChiefRegulatory Coordination Division, Office of Policy and StrategyU.S. Citizenship and Immigration ServicesU.S. Department of Homeland Security20 Massachusetts Avenue NWWashington, DC 20529-2140

RE: DHS Docket No. USCIS-2010-0012;Proposed Rule on Inadmissibility on Public Charge Grounds

Dear Ms. Deshommes:

[Begin by providing some context to your life. Key details may include all or some of the following information: your family (including children and their ages), the name of the community where you live, your/your family member’s immigration status, where you/your family member lived before coming to the United States, your occupation and income, and whether you have accessed any of the following benefit programs: WIC, SNAP, Medicaid, CHIP, or housing assistance]

[Discuss how the benefit programs have improved your life. Highlight any medical assistance that you or your child received through Medicaid or CHIP, how SNAP helps you afford enough food to eat, how housing subsidies help you to afford a home, or how WIC has helped you to eat healthier or breastfeed your child.]

[Discuss how a change in immigration law – resulting in the classification of some programs as a public charge – would impact your ability to access these benefit programs. Would you continue to stay on the program, or would you try to disenroll? How would you obtain healthcare or healthy food for you and your children? What would change in your daily routines? Would significant events (e.g., an unexpected health issue) drastically change your family’s stability?]

[Finally, end with: The Department should withdraw the proposed rule. If the rule moves forward, WIC should be explicitly excluded from consideration in public charge review.]

Sincerely,[Include your name. Remember: you do not have to share address, phone number, or other identifying information!]

[Remember: the Department will only consider comments in English or with an English translation. If you cannot write in English, please work with someone in your community to have a third-party translate and submit your comment on your behalf. They may wish to include some language at the beginning of your comment to clarify who actually wrote the comment.]

Template Comments – please modify to reflect your own, unique perspective!

[agency letterhead]

October XX, 2018

Ms. Samantha Deshommes, ChiefRegulatory Coordination Division, Office of Policy and StrategyU.S. Citizenship and Immigration ServicesU.S. Department of Homeland Security20 Massachusetts Avenue NWWashington, DC 20529-2140

RE: DHS Docket No. USCIS-2010-0012;Proposed Rule on Inadmissibility on Public Charge Grounds

Dear Ms. Deshommes:

[Agency name] is a direct-service provider that administers the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in [your town and state]. We appreciate this opportunity to share our views on this potential policy change with the Department. We write to express our opposition to the U.S. Department of Homeland Security’s proposed rule on public charge determinations. While the proposed rule does not include WIC as written, it will have a direct impact on WIC’s ability to serve eligible participants and immediate health consequences for pregnant women, mothers, and young children. As a direct-service provider, we work with the families – including immigrant families – who will be impacted by the proposed rule.

[INSERT additional information on your agency, including caseload size, geographic scope, and services provided, especially if you have breastfeeding peer counselors. State data here.]

The proposed rule should be withdrawn. The Department’s proposals are a drastic change from current policy. Since 1999, the federal government has consistently maintained that programs like the Supplemental Nutrition Assistance Program (SNAP) and Medicaid could not be considered in public charge review, and that immigrants lawfully accessing these programs had nothing to fear.1 From our experience, even the hint of inclusion in public charge will deter immigrant families from seeking medical assistance or nutrition support.

[Discuss chilling effect if your agency saw decreased immigrant participation over the past year]

The Department’s choice to deter otherwise eligible individuals from accessing public assistance programs is unacceptable. The Department is clear about the likely consequences: “Worse health outcomes . . . especially for pregnant or breastfeeding women, infants, or children.”2 This is the

1 Dep’t of Justice, “Field Guidance on Deportability and Inadmissibility on Public Charge Grounds,” 64 Fed. Reg. 28,689 (May 26, 1999).2 Dep’t of Homeland Security, Proposed Rule: Inadmissibility on Public Charge Grounds, 83 Fed. Reg. 51,114, 51,277 (Oct. 10, 2018).

worst possible result in the provider community, as we strive every day to ensure healthy pregnancies, safe birth outcomes, and positive early child development.

Targeted nutrition intervention and medical attention at the prenatal, perinatal, and postpartum periods is shown to have positive short- and long-term effects. WIC’s nutrition intervention and breastfeeding support has a strong record of reducing the instance of preterm birth,3 preventing infant mortality,4 and increasing breastfeeding rates.5 [Discuss specific efforts by your clinic or agency to improve health outcomes, including any work by a breastfeeding peer counselor to boost breastfeeding rates. If you have outcome data, include it here.] WIC’s targeted public health mission is a wise investment for our nation and communities, and the Department’s consideration of public assistance programs in immigration decisions has had a detrimental effect on our efforts to reach every eligible participant. For these reasons, if the rule moves forward, WIC should be explicitly excluded from public charge review.

WIC works together with other public assistance programs to alleviate poverty, ensure access to healthcare, and provide adequate nutrition for children. Indeed, Congress recognized the nexus between WIC and other public assistance programs when developing certification requirements. The Child Nutrition Act specifically authorizes WIC as adjunctively eligible to SNAP and Medicaid, thereby reducing initial certification requirements and paperwork.6 74.9% of WIC participants are adjunctively eligible, and WIC clinics rely on streamlined enrollment and certification procedures to reach this segment of the WIC-eligible community.7 Decreased participation in SNAP or Medicaid is likely to have a profound impact on WIC’s ability to serve all eligible participants by introducing new barriers to access.

Medicaid complements WIC’s effective and targeted provision of maternal and infant health services. Medicaid – which covers nearly half of all births in the United States8 – provides vital prenatal services for pregnant women, covers delivery costs to ensure safe birth outcomes, and offers postpartum support for breastfeeding mothers. Nearly all states have recognized

3 H. Hilary, et al., “Can targeted transfers improve birth outcomes? Evidence from the introduction of the WIC program,” 95 J. of Public Economics 813 (2011); Ralitza Gueorguieva, et al., “Length of prenatal participation in WIC and risk of delivering a small-for-gestational-age infant: Florida, 1996-2004,” 13 J. of Maternal Child Health 479 (2009); Marianne Bitler & Janet Currie, “Does WIC Work? The Effects of WIC on Pregnancy and Birth Outcomes,” 1 J. of Policy Analysis & Mgmt. 73 (2005)4 Kathryn Fingar, et al., “Reassessing the Association between WIC and Birth Outcomes Using a Fetuses-at-Risk Approach,” 21 J. Maternal and Child Health 825 (2017).5 U.S. Dep’t of Agriculture, “WIC Participant and Program Characteristics 2016,” https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2016.pdf (Apr. 20, 2018) (indicating that breastfeeding initiation rates in WIC increased from 42% in 1998 to 71% in 2016, reflecting the introduction of the breastfeeding peer counselor program in 2004); U.S. Dep’t of Agriculture, “WIC Infant and Toddler Feeding Practices Study – 2: Infant Year Report,” https://fns-prod.azureedge.net/sites/default/files/ops/WIC-ITFPS2-Infant.pdf (Jan. 2017) (indicating that WIC moms stick with breastfeeding longer – a key public health goal. Between 1998 and 2013, the WIC breastfeeding rate at one month postpartum rose by 85%, and the rate for 3-12 month-old babies more than doubled during the same period).6 42 U.S.C. § 1786(d)(2)(A)(ii), (iii).7 U.S. Dep’t of Agirculture, “WIC Participant and Program Characteristics 2016,” https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2016.pdf (Apr. 20, 2018).8 Kaiser Family Found., “Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017,” http://files.kff.org/attachment/Report-Implementing-Coverage-and-Payment-Initiatives (Oct. 2016).

Medicaid’s vital role as a provider of maternal and infant care, raising the income eligibility threshold for pregnant women and young children well above the limit for non-pregnant adults.9 Indeed, some states have income eligibility rates for pregnant women that are over twice as high as those for non-pregnant adults.10 [INSERT your state’s eligibility rates for pregnant women and young children, found here: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-eligibility-levels/index.html] As a result, 71% of WIC participants rely on Medicaid for health coverage.11

[Include this paragraph if your state provides increased access for immigrant mothers and children:] In the 2009 Children’s Health Insurance Program Reauthorization Act (CHIPRA), states were given the option to waive a five-year bar on health services for pregnant immigrant women and their children. [State name] has recognized the compelling public health interest in extending medical coverage to pregnant women and children [check with maps] regardless of immigration status. Families in our state are at greater risk of losing access to health services if the public charge rule is adopted as written.

Likewise, if the rule moves forward, the Children’s Health Insurance Program (CHIP) should be explicitly exempt from public charge review. Millions of children – and thousands of pregnant women – rely on CHIP for health coverage. Some states have opted to offer medical coverage for immigrant women who are pregnant and foreign-born young children through CHIP, waiving the five-year bar on medical coverage.12 CHIP has a significant impact on ensuring positive health outcomes and development for young children. CHIP’s public health goals closely align with WIC priorities, improving the healthcare access and medical attention for pregnant women and young children.

The proposed rule’s inclusion of Medicaid, SNAP, and housing assistance in public charge review is inconsistent with the core public health values of the WIC community and threatens to undermine WIC’s mission of ensuring healthy pregnancies, births, and child development. We therefore urge that the Department withdraw this proposed rule.

Sincerely,

NameTitleLocal Agency

9 See CMS, “Medicaid, CHIP, and BHP Eligibility Levels,” https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-eligibility-levels/index.html (accessed Oct. 1, 2018).10 See id.11 U.S. Dep’t of Agirculture, “WIC Participant and Program Characteristics 2016,” https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2016.pdf (Apr. 20, 2018).12 Nat’l Immigration Law Ctr., “Health Care Coverage Maps,” https://www.nilc.org/issues/health-care/healthcoveragemaps/ (last updated Aug. 13, 2018).

Template Comments (long) – please modify to reflect your own, unique perspective!

[agency letterhead]

October XX, 2018

Ms. Samantha Deshommes, ChiefRegulatory Coordination Division, Office of Policy and StrategyU.S. Citizenship and Immigration ServicesU.S. Department of Homeland Security20 Massachusetts Avenue NWWashington, DC 20529-2140

RE: DHS Docket No. USCIS-2010-0012;Proposed Rule on Inadmissibility on Public Charge Grounds

Dear Ms. Deshommes:

[Agency name] is a direct-service provider that administers the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in [your town and state]. We are writing to express our opposition to the U.S. Department of Homeland Security’s proposed rule on public charge determinations. As a direct-service provider, we work with families – including immigrant families – who may be impacted by the proposed rule.

[INSERT additional information on your agency, including caseload size, geographic scope, and services provided, especially if you have breastfeeding peer counselors] We appreciate this opportunity to share our views on this policy change with the Department.

We urge that the proposed rule be withdrawn. Public assistance programs like Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and housing assistance have not historically been considered in immigration determinations, including public charge review. This is for good reason: these programs ensure that families – including U.S. citizen children living with an immigrant parent – have access to medical care, adequate nutrition, and safe shelter. Seeking a basic standard of living for your children should not be a condition of remaining in the country.

This is particularly true of WIC access, which, while not explicitly included in public charge review, will be impacted by this rule’s effect on immigrant families. Since its establishment in the early 1970s, WIC has consistently supported healthy pregnancies, positive birth outcomes, and child development. WIC’s targeted nutrition intervention and breastfeeding support during the prenatal, perinatal, and postpartum periods have significant short- and long-term health gains for both the mother and child. As children born in the United States are automatically citizens,13 there is a strong government interest in protecting WIC participation by immigrant mothers.

13 U.S. Const. amend. XIV § 1.

WIC works in tandem with other programs – particularly Medicaid and SNAP – to ensure healthy babies and families. The proposed rule, as written, will undermine the health and economic security of WIC families. For this reason and those discussed below, we urge that the proposed rule be withdrawn.

I. Children – largely U.S. citizen children – will be harmed by an expansion of current public charge standards.

The Department asserts that “the proposed rule may decrease disposable income and increase the poverty of certain families and children, including U.S. citizen children.”14 We believe that such a policy result outweighs any purported benefit of the proposed rule, as millions of U.S. citizen children stand to lose access to medical care, a full meal, or a roof over their head. This result would be inconsistent with the core values of who we are as a country.

The public charge test, as articulated by the proposed rule, disincentivizes participation in any of the implicated programs – namely Medicaid, SNAP, and housing assistance programs. The mere application for any of the implicated programs is enough to be considered by an immigration official,15 whereas receipt of any of these benefits will be a “heavily weighted negative factor.”16 These provisions will result in non-citizens withdrawing from both listed and non-listed public assistance programs – both on behalf of themselves and on behalf of their dependent children – out of fear and caution that any interaction with the federal government could result in a negative consequence to their legal status. Children will bear a significant amount of the suffering that would result from families foregoing access to public assistance for which they are otherwise eligible.

The overwhelming majority of children living in the United States are American citizens, by virtue of the Fourteenth Amendment’s birthright citizenship clause. In 2016, 25.8% of all children living in the United States – nearly 18 million children – had at least one foreign-born parent; of those children, 88.2% were born in the United States and thus citizens.17 The proportion is even more commanding when limited to young children: of the 5.75 million children under age six living in the United States with at least one foreign-born parent, 93.5% were born in the United States and are thus citizens.18

A recent review of Census Bureau data indicates that 41.1 million noncitizens and their family members currently living in the United States – about 12.7% of the total population – could be discouraged from accessing benefit programs by the expansion of public charge review.19 Of that population, 10.7 million of the affected individuals are U.S. citizen children living in families 14 Dep’t of Homeland Security, Proposed Rule: Inadmissibility on Public Charge Grounds, 83 Fed. Reg. 51,114, 51,277 (Oct. 10, 2018) (“NPRM”).15 NPRM at 51,291 (to be codified in 8 C.F.R. § 212.22(b)(4)(i)(F)(i)).16 NPRM at 51,292 (to be codified in 8 C.F.R. § 212.22(c)(1)(ii), (iii)).17 Migration Policy Inst., “Children in U.S. Immigrant Families,” https://www.migrationpolicy.org/programs/data-hub/charts/children-immigrant-families (accessed Oct. 15, 2018) (based on 1990 Decennial Census and 2016 American Community Survey data).18 Id.19 Manatt, Phelps & Phillips, LLP, “Public Charge Proposed Rule: Potentially Chilled Population Data Dashboard” (Oct. 11, 2018), https://www.manatt.com/Insights/Articles/2018/Public-Charge-Rule-Potentially-Chilled-Population (review of American Community Survey data).

with one or more noncitizen member, which is approximately 15% of the total child population living in the United States.20

Children rely on programs that the Department would include within public charge review. Over eight million U.S. citizen children with an immigrant parent have Medicaid or CHIP coverage.21 Likewise, over 2.5 million U.S. citizen children with an immigrant parent rely on SNAP benefits to have full meals at home – approximately 8% of all SNAP participants.22 These children stand to lose their healthcare coverage or food benefits as a result of confusion or fear about the new immigration restrictions that this rule would engender.

Even if families continue to accept benefits on only their child’s behalf, the household will have reduced funds to cover medical expenses, food costs, and housing payments. A child does not pay for the doctor, groceries, or rent on their own. The child relies on their parent or guardian for support, and a reduction in the parent’s financial resources will have an impact on the child’s well-being. This is a result that the Department readily acknowledges, but it is one that we cannot accept. On behalf of the millions of children whose health, nutrition, and safety could be impacted by this rule, we urge the Department to withdraw this proposed rule.

II. WIC should be explicitly exempted from public charge review.

The Department requests comment on “whether an alien’s receipt of benefits other than those proposed to be included in this rule as public benefits should nonetheless be considered in the totality of the circumstances.”23 We strongly urge the Department against this approach, as review of additional benefits could implicate WIC in public charge determinations. Such a result is inconsistent with congressional intent and sound public health policy. We encourage the Department to explicitly exempt WIC from public charge review.

A. Congress never contemplated the inclusion of WIC within public charge review.

Congress never sought to inhibit WIC’s ability to serve immigrant populations, given the overriding public interest in promoting access to health services and nutrition assistance during pregnancy, infancy, and early childhood. Immigrant access to the program was not restricted in initial authorizing statutes; indeed, immigrant access to the program was not regulated until the 1996 reforms to federal programs.24 In the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), WIC and other child nutrition programs were explicitly exempted from the five-year bar and other restrictions to immigrant participation in federal programs.25

20 Id.21 Kaiser Family Found., “Nearly 20 Million Children Live in Immigrant Families that Could Be Affected by Evolving Immigration Policies” (Apr. 18, 2018), https://www.kff.org/disparities-policy/issue-brief/nearly-20-million-children-live-in-immigrant-families-that-could-be-affected-by-evolving-immigration-policies/. 22 Nat’l Ctr. for Children in Poverty, “SNAP Take-up Among Immigrant Families with Children,” 7 (Mar. 2011), http://www.nccp.org/publications/pdf/text_1002.pdf. 23 NPRM at 51,173.24 H.R. Rep. No. 104-725 (Conf. Rep.), at 379 (1996).25 Pub. L. No. 104-193 § 403(c)(2)(C), (D) (1996).

When the public charge test was developed in 1996, Congress likewise contemplated explicit exemptions for WIC and other child nutrition programs.26 The conference report made Congress’ intentions clear: “the managers believe that certain public health, nutrition, and in-kind community service programs should be exempted from the general prohibition on ineligible aliens accessing public benefits.”27 Congress’ view was echoed by the U.S. Department of Agriculture, which contributed to the U.S. Department of Justice’s formulation of the 1999 Field Guidance. Still effective today, the Field Guidance explicitly exempts WIC and other programs from public charge review.28 This view is consistent with Congress’ longstanding intentions.

B. There is strong evidence to support that WIC’s targeted nutrition intervention and breastfeeding support improves birth and health outcomes.

Congress has acted to create wide-ranging eligibility for WIC – including among immigrant mothers – because its targeted, time-limited assistance has an immeasurable impact on the development and health of both the child and mother. Congress specifically noted that “[t]he preventative aspects of the WIC program are among its strongest virtues.”29 Indeed, a wide body of research validates the role that WIC plays in ensuring healthy pregnancies and birth outcomes, ameliorating nutritional deficits in infants, and promoting positive health outcomes for young children.

WIC aims to reach eligible women as early as possible, in order to maximize the program’s impact on the pregnancy.30 Longer participation in WIC throughout the pregnancy is associated with lower risk of preterm birth and a greater chance of preventing low- or very low-birth-weight.31 These birth complications can result in long-term and serious health conditions, including: chronic conditions like diabetes, heart disease, and high blood pressure; neurological disorders like cerebral palsy; breathing problems like asthma, bronchopulmonary dysplasia (BDP), and respiratory distress syndrome (RDS); bleeding in the brain (intraventricular hemorrhage); intestinal problems, like necrotizing enterocolitis (NEC); vision problems, like retinopathy of prematurity (ROP); hearing loss; jaundice; and other conditions.32 [Discuss specific efforts by your clinic or agency to improve health outcomes, including any work by a breastfeeding peer counselor to boost breastfeeding rates. If you have outcome data, include it here.] Accordingly, WIC’s effective intervention has a key role to play in promoting healthier

26 H.R. Rep. No. 104-828 (Conf. Rep.), at 144 (1996).27 Id. at 238.28 Dep’t of Justice, Field Guidance on Deportability and Inadmissibility on Public Charge Grounds, 64 Fed. Reg. 28,689, 28,693 (May 26, 1999).29 124 Cong. Rec. S11467 (daily ed. July 21, 1978) (statement of Sen. McGovern). 30 See 7 C.F.R. § 246.7(e)(1)(v) (permitting temporary waiver of nutritional risk evaluation for pregnant women as a requirement of certification, to permit presumptive eligibility and immediate certification).31 Kathryn Fingar, et al., “Reassessing the Association between WIC and Birth Outcomes Using a Fetuses-at-Risk Approach,” 21 J. Maternal and Child Health 825 (2017); Ralitza Gueorguieva, et al., “Length of prenatal participation in WIC and risk of delivering a small-for-gestational-age infant: Florida, 1996-2004,” 13 J. of Maternal Child Health 479 (2009); Marianne Bitler & Janet Currie, “Does WIC Work? The Effects of WIC on Pregnancy and Birth Outcomes,” 1 J. of Policy Analysis & Mgmt. 73 (2005).32 See March of Dimes, “Long-term Health Effects of Premature Birth” (Oct. 2013), https://www.marchofdimes.org/complications/long-term-health-effects-of-premature-birth.aspx; March of Dimes, “Low Birthweight” (Mar. 2018), https://www.marchofdimes.org/complications/low-birthweight.aspx.

birth outcomes and preventing serious health conditions by supporting the healthy development of infants both in utero and after birth.

In addition to these health complications, low-birthweight babies are also more likely to die in the first year of life.33 Over 23,000 infants still die each year in the United States, an unconscionably high number for a nation with such abundant resources.34 WIC’s intervention plays a significant role in reducing perinatal and infant mortality by ensuring adequate nutrition and healthy development in pregnancy and the first few weeks of life.35 This intervention can reduce the likelihood of Sudden Infant Death Syndrome (SIDS) or other potentially fatal health complications throughout the infant period. Decreased immigrant participation in WIC will lead to more children – U.S. citizen children – being at risk of preventable poor birth outcomes that could result in infant death.

In addition to supporting healthy births, WIC takes active measures to promote and facilitate breastfeeding. Evidence has been building over the last several decades demonstrating the strong positive health impacts of breastfeeding for both mother and baby. Breastfeeding is associated with decreased risk of type-2 diabetes,36 lower rates of pediatric overweight or obesity,37 and reduced risk of other chronic diseases such as cardiovascular disease, hypertension, and some forms of cancer.38 Breastfeeding is also positively correlated with cognitive development.39

Unfortunately, breastfeeding rates are dramatically lower among certain racial and ethnic groups and among low-income mothers. African-American women experience the lowest breastfeeding rates in the United States.40 [INSERT any information you have about breastfeeding disparities in your state or community.] As WIC serves a diverse population of low-income women in the United States, we know that we have a role to play in improving breastfeeding rates in these high-risk groups.

WIC promotes and supports breastfeeding in a number of key ways, including providing educational materials, one-on-one consultations with peer and professional staff, group classes and support groups, and 24/7 hotlines for questions. [INSERT information on any noteworthy or unique breastfeeding activities at your agency.]

33 Lehman Black, et al., “Effects of birth weight and ethnicity on incidence of sudden infant death syndrome,” 108 J. of Pediatrics 209 (Feb. 1986).34 Kenneth Kochanek, et al., “Mortality in the United States, 2016,” CDC-National Center for Health Statistics Data Brief No. 293 6 (December 2017), https://www.cdc.gov/nchs/data/databriefs/db293.pdf. 35 Kathryn Fingar, et al., “Reassessing the Association between WIC and Birth Outcomes Using a Fetuses-at-Risk Approach,” 21 J. Maternal and Child Health 825 (2017).36 Bernardo Horta, et al., “Long-term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure, and type 2 diabetes: a systematic review and meta-analysis,” 104 Acta Paediatrica 30 (2015).37 Laurence Grummer-Strawn & Zuguo Mei, “Does Breastfeeding Protect Against Pediatric Overweight? Analysis of Longitudinal Data From the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System,” 113 Pediatrics 81 (2004).38 Colin Binns, et al., “The Long-Term Public Health Benefits of Breastfeeding,” 28 Asia Pacific J. of Public Health 7 (Jan. 2016).39 Id.40 Katherine Jones, et al., “Racial and Ethnic Disparities in Breastfeeding, 10 Breastfeeding Medicine 186 (2015).

WIC’s highly successful breastfeeding peer counselor program, along with these other initiatives, has helped improve the breastfeeding rates of WIC moms nationally from 42% in 1998 to 71% in 2016 and has contributed to a reduction in breastfeeding disparities.41 WIC moms have also been choosing to breastfeed for longer, with one-month postpartum rates having risen 85% between 1998 and 2013 and the rate for 3-12 month-old babies having doubled during the same time period.42

[INSERT statistics about breastfeeding outcomes among WIC moms in your state or community.] There are clear public health justifications for promoting breastfeeding, and WIC is one of the most effective tools that the federal government has to advance this priority.

WIC also has a profound effect on reducing the instance of iron-deficiency anemia and other malnourishment conditions that were more common in the 1970s.43 While malnourishment is not as prevalent as it was when WIC was established, there remains a critical need for WIC’s preventative nutrition assistance. There remain nearly 200,000 annual ambulatory care visits as a result of anemia, with most cases due to a nutritional deficiency; approximately 5,200 individuals died as a result of iron-deficiency anemia in 2015.44 WIC’s food package, which is associated with higher iron intake, is a critical supplement for those at risk of iron deficiency.45 [INSERT statistics about reduction in micronutrient deficiencies in your state or community as a result of WIC participation]

Finally, WIC’s overhaul of the food package in 2009 led to the introduction of healthier foods and greater access to whole-grain foods, fruits, and vegetables for WIC participants. In just a few years, the 2009 food package changes resulted in a marked increase in whole-grain and vegetable consumption among WIC participants, and a similarly significant reduction in whole milk consumption.46 It should be noted that the 2009 food package changes also resulted in a change in retail grocer practices, and healthier food options became available to all consumers as a result of this new policy.47 [INSERT any data you have about improvements in purchases and/or consumption of healthy foods in your state or community after the food package changes of 2009].

These food package changes likewise contributed to a modest decline in severe childhood obesity among young children of WIC families, highlighting how WIC’s health benefits continue

41 U.S. Dep’t of Agriculture, “WIC Participant and Program Characteristics 2016 Final Report,” 142 (Apr. 20, 2018), https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2016.pdf.42 U.S. Dep’t of Agriculture, “WIC Infant and Toddler Feeding Practices Study – 2: Infant Year Report,” https://fns-prod.azureedge.net/sites/default/files/ops/WIC-ITFPS2-Infant.pdf (Jan. 2017)43 Virginia Miller, et al., “Impact of the WIC Program on the Iron Status of Infants,” 75 Pediatrics 100 (Jan. 1985).44 Ctrs. for Disease Control and Prevention, “National Center for Health Statistics: Anemia or Iron Deficiency,” (Mar. 2017), https://www.cdc.gov/nchs/fastats/anemia.htm.45 See Steven Yen, “The effects of SNAP and WIC programs on nutrition intakes of children,” 35 Food Policy 576 (2010).46 Shannon Whaley, et al., “Revised WIC Food Package Improves Diets of WIC Families,” 44 J. of Nutrition Educ. and Behavior 204 (2012); June Tester, et al., “Revised WIC Food Package and Children’s Diet Quality,” 137 Pediatrics (May 2016).47 Amy Hillier, et al., “The Impact of WIC Food Package Changes on Access to Healthful Food in 2 Low-Income Urban Neighborhoods,” 44 J. of Nutrition Educ. & Behavior 210 (2012).

past the infancy period.48 Only 13.9% of children aged two to five are obese,49 and yet pediatric obesity is known to be a significant cause of adult obesity and can lead to serious chronic health conditions, including heart disease, some types of cancers, type-2 diabetes, and hypertension.50 WIC and its nutritious food package can play a role in promoting healthy behaviors from a young age and addressing pediatric obesity through preventative nutrition intervention.51

WIC’s public health success is one of the shining examples of government done right. WIC promotes healthy pregnancies and births by reducing preterm births, low birthweight, and other complications. WIC works to prevent infant mortality and ensure adequate nutrition in the critical first year through breastfeeding support and preventing iron deficiency. Likewise, WIC’s nutritious food package improves early childhood eating habits, providing access to healthy foods like whole grains and vegetables while also reducing the prevalence of pediatric obesity. Taken together, WIC’s targeted and time-limited intervention is a powerful investment in the future of each individual WIC child, regardless of the immigration status of their parents.

C. A decrease in WIC participation will have short- and long-term economic implications.

From its inception, WIC has been recognized by Congress as a “program that, in the long run, will save this country money by heading off disease and the handicapping of children in the early formative months and years in such a way as to avoid much more costly results to our society later on.”52 This perspective rings true today, and a decrease in WIC participation would lead to higher healthcare costs, decreased retail purchasing, and reduced economic productivity.

Foundational studies demonstrate that WIC leads to healthcare cost savings. For every dollar spent on WIC, there is an associated savings in Medicaid costs during the first 60 days after birth from $1.77 to $3.13 for newborns and mothers and from $2.84 to $3.90 for newborns only.53 The associations were found to be larger when costs from days 61 through one year were included.54 The investment in WIC not only leads to healthier children, but also saves the healthcare system significant costs by increasing the likelihood of a positive birth outcome, reducing hospitalizations, and managing or preventing long-term health conditions. [INSERT any cost-benefit data on WIC that you have for your state or community.]

48 Liping Pan, et al., “Trends in Severe Obesity Among Children Aged 2 to 4 Enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children From 2000 to 2014,” 172 Pediatrics 232 (2018).49 Craig Hales, et al., “Prevalence of Obesity Among Adults and Youth: United States, 2015-2016,” NCHS Data Brief No. 288 (Oct. 2017), https://www.cdc.gov/nchs/data/databriefs/db288.pdf. 50 Nat’l Institutes of Health, “Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,” NIH Pub. No. 98-4083, 100 (Sept. 1998), https://www.nhlbi.nih.gov/files/docs/guidelines/ob_gdlns.pdf. 51 Cynthia Ogden, et al., “Prevalence of Childhood and Adult Obesity in the United States, 2011-2012,” 311 J. of the Am. Med. Ass’n 806 (2014).52 124 Cong. Rec. S11466 (daily ed. July 21, 1978) (statement of Sen. McGovern).53 U.S. Dep’t of Agriculture, The Savings in Medicaid Costs for Newborns and their Mothers from Prenatal Participation in the WIC Program, xii (1990), https://fns-prod.azureedge.net/sites/default/files/SavVol1-Pt1.pdf. 54 U.S. Dep’t of Agriculture, “WIC-Medicaid II Feasibility Study,” 72 (Sept. 2018), https://fns-prod.azureedge.net/sites/default/files/SavVol1-Pt1.pdf.

WIC’s costs-savings are perhaps most clear in the program’s role in reducing preterm births and the incidence of low birthweight. The average preterm birth costs $49,033 in first-year medical expenses compared to a mere $4,551 for an uncomplicated birth.55 Meanwhile, an increase of just one pound at birth for a very low birth-weight baby can save approximately $28,000 in first-year medical costs.56 WIC’s prenatal intervention has reduced the incidence of low birthweight by approximately one-third and reducing preterm births by between 29% and 48%.57 By ensuring positive birth outcomes and healthy babies, WIC is reducing the first-year medical costs burden on both individual families and the broader healthcare system.

WIC’s role in reducing the prevalence of childhood obesity also has a significant effect on healthcare expenditures. The Medicaid costs of a child being treated for obesity are estimated at $6,730 annually, while the average healthcare costs for children covered by Medicaid is $2,446.58 As WIC works to provide nutritious foods and educate families on healthy eating habits, WIC’s preventative role in reducing childhood obesity leads to additional healthcare costs savings.

In addition, WIC leads to increased expenditures in retail grocery stores. In the 2016 fiscal year, $3.95 billion was spent on the redemption of WIC foods at over 45,000 unique vendor sites.59 [INSERT statistics on how many WIC dollars are spent in WIC-authorized retailers in your state or community]

Indeed, research indicates that the vast majority of WIC participants purchase their supplemental WIC foods at the same store where they do most of their other food shopping.60 WIC shoppers have demonstrated influence on the business practices of retail grocery stores: changes to the WIC food package in 2009 – including the addition of a cash-value voucher (CVV) for fruits and vegetables – caused retail grocers to stock more healthful foods, which benefited all shoppers.61 Decreases in WIC participation are therefore likely to have a profound impact on the economic output of retail grocery stores, as well as the availability of healthy foods to all consumers.

Finally, WIC’s positive health outcomes are also associated with a long-term increase in economic productivity. Early brain development – which is linked to the attainment of adult economic productivity – is deeply impacted by access to adequate nutrition and healthcare in the

55 Institute of Medicine, Preterm Birth: Causes, Consequences, and Prevention (2006).56 March of Dimes, “The Cost of Prematurity and Complicated Deliveries to U.S. Employers” (2008).57 Kathryn Fingar, et al., “Reassessing the Association between WIC and Birth Outcomes Using a Fetuses-at-Risk Approach,” 21 J. Maternal and Child Health 825 (2017).58 59 U.S. Dep’t of Agriculture, “WIC Program: Food Cost,” https://fns-prod.azureedge.net/sites/default/files/pd/24wicfood$.pdf (data as of Oct. 5, 2018); U.S. Dep’t of Agriculture, “Where Do WIC Participants Redeem Their Food Benefits? An Analysis of WIC Food Dollar Redemption Patterns by Store Type” (Apr. 2016), https://www.ers.usda.gov/webdocs/publications/44073/57246_eib152.pdf?v=0.60 U.S. Dep’t of Agriculture, “Where Do WIC Participants Redeem Their Food Benefits? An Analysis of WIC Food Dollar Redemption Patterns by Store Type” (Apr. 2016), https://www.ers.usda.gov/webdocs/publications/44073/57246_eib152.pdf?v=0. 61 Tatiana Andreyeva, et al., “Positive Influence of the Revised Special Supplemental Nutrition Program for Women, Infants, and Children Food Packages on Access to Healthy Foods,” 112 J. of the Amer. Academy of Nutrition & Dietetics 850 (June 2012); June Tester, et al., “Healthy food availability and participation in WIC in food stores around lower- and higher-income elementary schools,” 14 Public Health Nutr. 960 (Sept. 2015).

prenatal and early childhood periods.62 Prenatal and early childhood access to nutrition support and health services ensure that children grow up to be healthier and achieve more in school.63 These children are more likely to be active participants in the workforce and become self-sufficient in adulthood.64 Indeed, WIC’s role in reducing childhood obesity can help address the significant costs – estimated at $4.3 billion annually – associated with obesity-related absenteeism in the workplace.65 This fundamental dynamic underlies the wisdom of investing in WIC and other supports for pregnant women and new children – it is all about our future.

Indeed, it should be noted that school meals programs – the chronological predecessor and demographic successor to WIC – were adopted after the Second World War as a means of ensuring that there is a healthy population from which to muster an army. In passing the National School Lunch Act, Congress specifically noted that funding school meals programs was “a measure of national security.”66 Even recently, the United States military struggles with the prevalence of overweight and obesity among recruits for the armed services.67 The compelling public interest to ensure adequate health and nutrition remains as salient today.

WIC’s targeted, time-limited assistance plays a vital role in ensuring positive pregnancy and birth outcomes, leading to better long-term health for the mother and child. These health results are correlated with healthcare savings and increased economic output, illustrating that WIC is a wise investment. Congress recognized the benefits of extending WIC eligibility to pregnant women and took specific steps in 1996 to safeguard participation by immigrant mothers. The Department should follow in Congress’ steps and guarantee through an explicit exemption that WIC participation will not be considered in any public charge or any immigration determination.

III. The inclusion of Medicaid and SNAP in public charge review would negatively impact WIC’s ability to provide services to eligible families.

WIC works in tandem with Medicaid and SNAP to advance its public health mission. Congress recognized the beneficial relationship between programs, as WIC’s targeted intervention for pregnant women, new moms, and young children complements the broader purpose of Medicaid to provide health coverage and SNAP to ensure adequate nutrition for low-income families. As a

62 Institute of Medicine, From Neurons to Neighborhoods: The Science of Early Childhood Development (2000) (“[V]irtually every aspect of early human development, from the brain’s evolving circuitry to the child’s capacity for empathy, is affected by the environments and experiences that are encountered in a cumulative fashion, beginning in the prenatal period and extending throughout the early childhood years.”).63 Hilary Hoynes, et al., “Long-Run Impacts of Childhood Access to the Safety Net,” 106 Amer. Economic Review 903 (Apr. 2016); Stavros Petrou, “Economic consequences of preterm birth and low birthweight,” 110 BJOG: an Int’l J. of Obstetrics and Gynaecology 17 (Apr. 2003) (noting that babies with low birthweight are 50% more likely to be in special education programs).64 See Hilary Hoynes, et al., “Long-Run Impacts of Childhood Access to the Safety Net,” 106 Amer. Economic Review 903 (Apr. 2016) (finding increased economic outcomes for women who were raised on nutrition assistance programs, including increases in educational attainment, earnings, income, and decreases in welfare participation).65 John Cawley, John Rizzo & Kara Haas, “Occupation-specific Absenteeism Costs Associated with Obesity and Morbid Obesity,” 49 J. of Occupational and Environmental Med. 1317; see also Donna Gates, et al., “Obesity and Presenteeism: The Impact of Body Mass Index on Workplace Productivity,” 50 J. of Occupational and Environmental Med. 39 (2008).66 Pub. L. No. 79-396 § 2 (1946).67 Aleda Hruby, et al., “Trends in overweight and obesity in soldiers entering the US Army, 1989-2012,” 23 Obesity 662 (2015).

result, Congress enacted provisions that reduce administrative barriers and promote cross-participation between WIC and other programs. Medicaid and SNAP’s inclusion in public charge review will therefore have a detrimental impact on both WIC program administration and participation.

A. Medicaid and SNAP’s inclusion in public charge review would increase the paperwork burden on WIC certifications.

WIC’s targeted nutrition and public health intervention necessitates appropriate program integrity efforts to ensure that services are delivered to those in need. WIC routinely certifies participants to ensure continuing eligibility, and certification periods last, at most, for one year.68 With few exceptions, a participant must be physically present in the WIC clinic each time that participant is certified – including infants and young children.69 Therefore, it has been a long-standing program priority to promote efficiency by streamlining the certification process, which reduces barriers to WIC participation and maximizes clinic time for WIC’s public health services.

In the Child Nutrition and WIC Reauthorization Act of 1989, Congress recognized this priority and implemented WIC’s adjunctive eligibility provisions.70 Adjunctive eligibility permits individuals to be automatically income-eligible for WIC if they or certain family members participate in Medicaid, SNAP, TANF, or other benefit programs at the discretion of the state, thus reducing one of the most burdensome elements of the WIC certification process. In 2016, 74.9% of WIC participants reported receiving at least one of the adjunctively-eligible programs, and it is possible that even more WIC participants are adjunctively eligible through family members.71

Decreased participation in Medicaid or SNAP among WIC families would have a significant impact on WIC’s certification process. Income certification through adjunctive eligibility takes less time than an income screening involving pay stubs or other financial documents.72 The additional time spent on income certification in clinics will increase administrative costs. One state estimated that income screening involving pay stubs or financial documents costs $12.50 per participant, whereas the administrative costs for an income screening with adjunctive eligibility is only $3.75 per participant.73 The additional $8.75 per participant cost – if applied to the whole program – could add significant new pressures on WIC’s budget. [INSERT information about the importance of adjunctive eligibility in your state or community and how devastating it would be (in terms of impacts on participants and administrative costs) if many WIC participants were prevented from using adjunctive eligibility to enroll in WIC.]

68 7 C.F.R. § 246.7(g)(1).69 Id. § 246.7(o).70 Pub. L. No. 101-147 § 123 (Nov. 10, 1989) (codified in 42 U.S.C. § 1786(d)(2)(A)(ii), (iii)).71 U.S. Dep’t of Agriculture, “WIC Participant and Program Characteristics 2016 Final Report,” 31-32 (Apr. 20, 2018), https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2016.pdf. 72 See Nat’l WIC Ass’n, “WIC State Directors Value Medicaid Adjunctive Eligibility” (2015), https://s3.amazonaws.com/aws.upl/nwica.org/medicaid-ae-study.pdf. 73 Id.

Any additional administrative cost comes out of WIC’s “Nutrition Services & Administrative” (NSA) grant, which funds not only administrative costs, but also WIC’s wide-ranging public health and education efforts.74 About one-third of the total NSA grant – approximately 9.5% of total WIC funding – is used for program administration costs, as WIC seeks to promote efficiency and maximize available funding for nutrition education, breastfeeding support, or other client services.75 Increased income screening in the clinics takes away from both clinic time with participants and funding for WIC’s nutrition education classes, breastfeeding support, and public health screenings and referrals for immunizations, tobacco cessation, postpartum depression, opioids, and more.

WIC agencies will also likely have to hire additional staff to conduct longer certification appointments.76 This would diminish the capacity of WIC agencies and clinics to attract specialized staff with expertise in nutrition education and breastfeeding support, such as Registered Dietitians (RDs) or International Board Certified Lactation Consultants (IBCLCs).

A more burdensome screening process will inevitably lead to new barriers for WIC participants. Fewer than half of the geographic states accept income certification documents electronically,77 and applicants must produce all necessary income-related documents at the certification appointment. As the certification process generally requires physical presence in the clinic, a lengthier, more time-consuming process coupled with an applicant’s failure to produce all necessary documentation at an initial appointment will prevent access to WIC’s services at that clinic visit, likely deterring further participation in the program.

Furthermore, the inclusion of Medicaid and SNAP in public charge review will undermine state efforts to streamline enrollment processes between different public assistance programs. Certain states have explored universal online applications that permit an individual to apply for or pre-screen eligibility for multiple public assistance programs at one time.78 The proposed rule would permit immigration officials to review an individual’s attempt to simply apply for Medicaid or SNAP benefits.79 This provision will discourage states from continuing with efforts to develop innovative enrollment processes, and likewise discourage individuals from using uniform or joint applications or pre-screening tools where an implicated program is listed. [INSERT information about any efforts in your state to integrate online applications for multiple public assistance programs.]

WIC complements the work of Medicaid and SNAP to ensure healthy families with adequate access to nutritious foods. Congress has recognized that connection by authorizing adjunctive eligibility, which has helped to reduce paperwork burdens on both clinics and participants, freeing up WIC funding to be used for nutrition education and breastfeeding support. The 74 42 U.S.C. § 1786(b)(4).75 U.S. Dep’t of Agriculture, “WIC Nutrition Services and Administration Cost Study” (Nov. 2017), https://fns-prod.azureedge.net/sites/default/files/ops/WICNSACostStudy.pdf. 76 See Nat’l WIC Ass’n, “WIC State Directors Value Medicaid Adjunctive Eligibility” (2015), https://s3.amazonaws.com/aws.upl/nwica.org/medicaid-ae-study.pdf.77 Ctr. for Budget and Policy Priorities, “Modernizing and Streamlining WIC Eligibility Determination and Enrollment Processes,” 29-31 (Jan. 6, 2017), https://www.cbpp.org/sites/default/files/atoms/files/1-6-17fa.pdf. 78 Ctr. for Budget and Policy Priorities, “Modernizing and Streamlining WIC Eligibility Determination and Enrollment Processes,” 18 (Jan. 6, 2017), https://www.cbpp.org/sites/default/files/atoms/files/1-6-17fa.pdf.79 NPRM at 51,291 (to be codified in 8 C.F.R. § 212.22(b)(4)(i)(F)(i)).

inclusion of Medicaid or SNAP in public charge review would undercut WIC’s efforts to improve efficiency, streamline certification processes, and focus WIC services on its core public health mission.

B. A chilling effect on some public assistance programs will impact others.

The proposed rule notes that an expansion of the current public charge standard would result in “[d]isenrollment or foregoing enrollment in public benefits programs by aliens otherwise eligible for these programs.”80 This is likely an understatement: the proposed rule has created and will continue to foster a chilling effect on participation in all public assistance programs, both by an immigrant parent and by U.S. citizen children of an immigrant parent. Notably, this chilling effect will stifle participation even in programs that are not specifically named in the proposed regulations, including WIC.

The 1996 reforms – which combined changes in program eligibility with discussion about public charge – provide insights into the widespread magnitude of a chilling effect. After Congress eliminated immigrant eligibility for SNAP and limited eligibility for Medicaid,81 both participants and providers were uncertain about new program standards. Participant fear and misunderstanding about program requirements led to an increased chilling effect, even by immigrant parents and U.S. citizen children who remained eligible for certain programs without any consequences to a family member’s immigration status.82

Indeed, 1990s-era data demonstrates that participation in Medicaid, SNAP, and TANF declined more steeply among non-citizen households than citizen households after the passage of the 1996 reforms.83 The decline was also substantial for refugees, who had been granted explicit exemptions in PRWORA. Of note, low-income84 families with U.S. citizen children saw the most significant decline compared to noncitizen families, with participation falling to about half the level of noncitizen families.85 Studies estimated that nearly 25,000 U.S. citizen children in Los Angeles County alone lost access to public assistance programs as a result of the chilling effect.86 Today, these are the WIC families that are most in need of consistent and fair application of immigration law.

Since January 2017, WIC clinics have reported increased concern from immigrant participants, many of whom have withdrawn from the program, withdrawn their children from the program,

80 NPRM at 51,270.81 PRWORA’s arduous restrictions on immigrant access were later eased – especially on behalf of pregnant women and children – in the 2002 farm bill, Pub. L. No. 107-171 § 4401 (2002), and the 2009 CHIP reauthorization, Pub. L. No. 111-3 § 214 (2009).82 Chitose Soto, “‘Mixed-Status Families’ in the Age of Welfare Reform, 26 Japanese J. of Amer. Studies, 145, 158 (2015).83 Michael Fix & Jeffrey Passel, “Trends in Noncitizens’ and Citizens’ Use of Public Benefits Following Welfare Reform 1994-97” (Mar. 1, 1999), http://webarchive.urban.org/publications/408086.html. 84 These studies defined low-income as households with income below 200% of the Federal Poverty Line, which exceeds the income limits for WIC, SNAP, and most other public assistance programs.85 Id.; see also Wendy Zimmerman & Michael Fix, “Declining Immigrant Applications for Medi-Cal and Welfare Benefits in Los Angeles County” (Jul. 1, 1998), http://webarchive.urban.org/publications/407536.html. 86 Zimmerman & Fix.

and sought to return food instruments or breast pumps.87 [INSERT information about the impacts of the leaked public charge rule on your agency – participants dropping out, trying to return benefits, etc.]

One particular concern is that immigration attorneys have given overly cautious advice, encouraging participants to disenroll from all public assistance programs to enhance their petitions for legal status.88 This confusion – bound to continue under a public charge regulation that does not outright bar participation, but simply disincentivizes or deters participation – will lead eligible WIC participants, including U.S. citizen children, to refuse access to WIC services out of fear of immigration consequences for themselves or family members.

Additionally, participants who disenroll out of fear may choose to return to WIC services at a later date once their immigration case is more certain. The process of reenrolling past participants, known as churning, is associated with higher administrative costs and increased clinic time spent on paperwork and the certification process.89 These administrative costs, while significant, likely pale in comparison to the costs associated with the lost opportunity at connecting those participants to WIC’s preventative health services.

Even though WIC is not explicitly mentioned in the rule, the proposed rule will heap additional costs on WIC agencies while also deterring participation by immigrants and their families. The inclusion of Medicaid and SNAP in public charge review specifically affects WIC’s longstanding efforts to streamline the certification process through adjunctive eligibility and redirect WIC resources to its public health services, rather than administrative costs. Given WIC’s interconnected relationship with Medicaid and SNAP, the proposed rule, as drafted, would have a profound impact on WIC’s ability to reach participants, retain them within the program, and fulfill its core public health mission.

IV. The inclusion of Medicaid/CHIP, SNAP, and housing assistance in public charge review would harm the health and economic security of WIC families.

The proposed rule’s ill effects would fall mostly on the shoulders of WIC families, as the federal government explicitly discourages them from accessing other crucial programs and supports. WIC does not provide services in a bubble – clinic staff are acutely aware of the financial pressures on participant families as they welcome a new child. It is precisely for this reason that WIC actively works to cross-refer participants to programs in which they are also eligible, particularly programs that further address a participant’s health or nutrition needs. Medicaid, SNAP, and housing assistance programs all play a vital and interconnected role in improving the health and economic security of WIC families. The inclusion of these programs in public charge review would undermine decades of the federal government’s work to address poverty and build a clearer path to the middle class for millions of families.

87 Helena Bottemiller Evich, “Immigrants, fearing Trump crackdown, drop out of nutrition programs,” Politico (Sept. 3, 2018), https://www.politico.com/story/2018/09/03/immigrants-nutrition-food-trump-crackdown-806292. 88 Id.89 See U.S. Dep’t of Agriculture, “Understanding the Rates, Causes, and Costs of Churning in the Supplemental Nutrition Assistance Program (SNAP),” xii (Nov. 2014), https://fns-prod.azureedge.net/sites/default/files/ops/SNAPChurning.pdf (estimating an $80 per participant cost associated with churning in SNAP).

A. WIC participants rely on access to Medicaid and/or CHIP for healthcare coverage, including coverage of delivery costs.

Pregnancy and childbirth incur significant medical costs, and WIC families overwhelmingly rely on Medicaid to provide coverage for these expenses. Medicaid covers nearly half of all births in the United States,90 but a higher proportion of WIC participants – 71% - turn to Medicaid to cover healthcare costs.91 [INSERT statistics on how many WIC participants in your state are also enrolled in Medicaid] Medicaid’s tailored assistance to pregnant women – including immigrant women – complements WIC’s efforts to ensure positive birth outcomes and healthy children, and participation in both Medicaid and WIC is shown to lead to greater healthcare access for children and stronger links between families and the healthcare system.92 Given Medicaid’s outsized role in supporting the health needs of WIC families, we strongly urge that the Department withdraw its proposed inclusion of Medicaid within public charge determinations.

The majority of WIC families would likely lack access to any health insurance option without Medicaid coverage,93 which would leave families with particularly expensive balances for maternity care and delivery costs.94 The average cost per maternity stay for an uncomplicated birth ranges from $1,189 to $11,986, with a median cost of $4,215.95 Complicated births, of course, can be significantly more expensive – even as much as ten times that of an uncomplicated birth.96 These costs would have to be assumed by the mother if there is no insurance, diminishing the financial resources that can support a new life at its most vulnerable time. Medicaid protects new parents against this significant financial liability, limiting families’ exposure to catastrophic healthcare costs, reducing out-of-pocket expenditures, and ensuring that new mothers have the economic security to focus on the needs of their newborns.97

In addition, Medicaid provides a range of other prenatal and postpartum services. Most states cover access to prenatal vitamins, ultrasounds, amniocentesis, chorionic villus sampling (CVS) tests, genetic counseling, breast pumps, and postpartum home visiting.98 This coverage plays a

90 Kaiser Family Found., “Implementing Coverage and Payment Initiatives: Results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017” (Oct. 2016), http://files.kff.org/attachment/Report-Implementing-Coverage-and-Payment-Initiatives.91 U.S. Dep’t of Agriculture, “WIC Participant and Program Characteristics 2016 Final Report,” 31-32 (Apr. 20, 2018), https://fns-prod.azureedge.net/sites/default/files/ops/WICPC2016.pdf.92 Paul Buescher, et al., “Child Participation in WIC: Medicaid Cost and Use of Health Care Services,” 93 Am. J. Public Health 145 (Jan. 2003).93 Benjamin Sommers, “From Medicaid to Uninsured: Drop-Out among Children in Public Insurance Programs,” 40 Health Servs. Res. 59 (Feb. 2005).94 Xiao Xu, et al., “Wide Variation Found in Hospital Facility Costs For Maternity Stays Involving Low-Risk Childbirth,” 34 Health Affairs 1212 (2015).95 Id.96 See Institute of Medicine, Preterm Birth: Causes, Consequences, and Prevention (2006).97 Kaiser Family Found., “Health Care Spending Among Low-Income Households with and without Medicaid” (Feb. 2016), https://www.kff.org/medicaid/issue-brief/health-care-spending-among-low-income-households-with-and-without-medicaid/; Katherine Baicker, et al., “The Oregon Experiment – Effects of Medicaid on Clinical Outcomes,” 368 N. Engl. J. Med. 1713 (May 2013).98 Kaiser Family Found., “Medicaid Coverage of Pregnancy and Perinatal Benefits: Results from a State Survey” (Apr. 2017), https://www.kff.org/womens-health-policy/report/medicaid-coverage-of-pregnancy-and-perinatal-benefits-results-from-a-state-survey/.

critical role in guiding a safe pregnancy, identifying preventable risks, and promoting healthy practices like breastfeeding. Without Medicaid coverage, these services would be out of reach for many WIC families, resulting in poorer pregnancy and birth outcomes.

The security of Medicaid coverage permits millions of American families to use their limited financial resources to meet other basic needs. Families will often prioritize health spending at the expense of other basic needs, including food and housing.99 Medicaid coverage permits families to access vital healthcare services – especially during the prenatal and perinatal periods – without having to forego other key household expenditures.100 Given the high costs associated with pregnancy and childbirth – especially if there are complications – it is likely that Medicaid coverage makes all the difference between economic security and financial ruin.101

For these reasons, both the federal government and states have actively supported Medicaid access for pregnant women and young children – including immigrants. Medicaid permits states the option to set income eligibility thresholds for pregnant women and young children that are higher than non-pregnant adults. Nearly every state has exercised this option, with several states adopting income limits over two times higher than the highest limit allowed for non-pregnant adults.102 [INSERT your state’s eligibility rates for pregnant women and young children, found here: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-eligibility-levels/index.html] Increased Medicaid access serves the urgent public health goal of providing access to preventative health services and access to maternity and delivery care to ensure positive birth outcomes and healthy children.

For over twenty years, most legal immigrants were subject to the five-year bar on accessing Medicaid coverage under the 1996 reforms.103 This position was reversed in the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), which permitted states to extend medical coverage to children and pregnant women who are lawfully present and would otherwise be eligible for Medicaid or CHIP.104 Since the option became available in 2009, thirty-three states have elected to exercise this option with respect to immigrant women who are pregnant.105

It should be noted that the Department explicitly requested comment on whether CHIP should be included in public charge review. In addition to millions of children, CHIP serves about 370,000 pregnant women each year.106 Some states that have exercised the CHIPRA option to serve immigrant women who are pregnant have organized those medical services under CHIP.

99 Id.100 Luojia Hu, et al., “The Effect of the Patient Protection and Affordable Care Act Medicaid Expansions on Financial Wellbeing,” NBER Working Paper No. 22170 (Apr. 2016).101 Michel Boudreaux, Ezra Golberstein & Donna McAlpine, “The long-term impacts of Medicaid exposure in early childhood: Evidence from the program’s origin,” 45 J. of Health Econs. 161 (Jan. 2016) (noting an 11% reduction in the instance of medical debt in low-income families relative to moderate-income families after the adoption of Medicaid).102 See Ctrs, for Medicare & Medicaid Servs., “Medicaid, CHIP, and BHP Eligibility Levels,” (Apr. 2018), https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-eligibility-levels/index.html.103 See 8 U.S.C. § 1613.104 Pub. L. No. 111-3 § 214 (2009).105 Nat’l Immigration Law Ctr., “Health Care Coverage Maps,” https://www.nilc.org/issues/health-care/healthcoveragemaps/ (last updated Aug. 13, 2018).

[INSERT here if your state exercised this option; reference maps here] It is our view that the inclusion of CHIP in public charge review would exacerbate the negative public health effects of the proposed rule and lead to significant administrative burden; we urge that, like WIC, CHIP should be explicitly exempted from public charge determinations.

The higher income thresholds for Medicaid and CHIPRA’s state option represents a clear intent by Congress to ensure that immigrant women who are pregnant have access to the medical services that they need to ensure a healthy pregnancy and positive birth outcomes. The reasons are obvious: preventative health treatment in the prenatal, perinatal, and postpartum periods leads to positive health outcomes throughout life – a strategic investment in both the health and the future of the child.107 The Department should recognize the compelling public health interest in preserving Medicaid access for eligible immigrants and exclude Medicaid from public charge review.

B. WIC participants rely on SNAP to ensure a full basket of foods to support the nutrition needs of the whole family.

WIC is a supplemental program aimed at providing targeted foods that address the nutrition needs of expectant mothers and young children. WIC cannot effectively supplement the diets of pregnant women if the family cannot afford a full grocery basket of food in the first place. SNAP’s benefit provides families with the much-needed resources to purchase food, alleviating financial stressors on the family and ensuring that children do not go hungry. [INSERT any statistics you have about the importance of SNAP in your community or state to WIC families] As many WIC families also rely on SNAP to afford groceries, we urge that the Department withdraw its proposed inclusion of SNAP within public charge review.

SNAP has a demonstrated track-record of reducing the number of households facing both poverty and food insecurity. This is particularly true of households with children, with conservative estimates attributing a reduction in childhood food insecurity of at least 8.1% to SNAP.108 Other studies assert that a mere six months of participation in SNAP reduces the likelihood of food insecurity by one-third compared to similarly situated households.109 In addition, SNAP’s support has long-lasting effects, increasing the likelihood of continuing food security in later years.110 Meanwhile, when SNAP benefits are added to household income, the program reduces the depth of child poverty by an average of 15.5%.111 SNAP is a vital lifeline

106 March of Dimes, “CHIP Coverage for Pregnant Women,” https://www.marchofdimes.org/materials/chip-coverage-for-pregnant-women-may-2014.pdf (accessed Oct. 1, 2018).107 See Michel Boudreaux, et al., “The long-term impacts of Medicaid exposure in early childhood: Evidence from the program’s origin,” 45 J. of Health Economics 161 (2016); Georgetown Univ. Health Policy Inst., “Medicaid Provides Needed Access to Care for Children and Families,” https://ccf.georgetown.edu/wp-content/uploads/2017/03/Medicaid-provides-needed-access-to-care.pdf (Mar. 29, 2017).108 Brent Kreider, et al., “Identifying the effects of SNAP (Food Stamps) on child health outcomes when participation is endogenous and misreported,” 107 J. of the Am. Statistical Ass’n 958 (2012).109 James Mabli & Julie Worthington, “Supplemental Nutrition Assistance Program participation and child food security,” 133 Pediatrics 1 (2014).110 Tracy Vericker & Gregory Mills, “Childhood Food Insecurity: The Mitigating Role of SNAP,” Urban Institute (2012).

that not only helps families afford groceries, but creates an opportunity for families to climb out of poverty and become self-sufficient.

SNAP also leads to healthier children by reducing malnutrition and other stressors. Children in food-insecure households have fewer hospitalizations than comparable children that do not have access to SNAP.112 Likewise, when a child loses access to SNAP benefits, that child is more likely to be at risk of developmental delays and in poorer health overall.113 SNAP provides a family with much-needed resources, helping to eliminate the choice between whether to pay for groceries or for other basic needs, like medical care or housing. Too often, when a family loses access to SNAP, the choice is to forego food.114

This is particularly true of immigrant or mixed-status families that participate in SNAP. When a child of an immigrant mother is participating in SNAP, that child is more likely to be in good or excellent health.115 Furthermore, the child’s participation in SNAP contributes to the child’s overall financial security, and the family is less likely to have to make tough choices between paying for food for the child or paying for the child’s medical expenses.116

Of course, many immigrants are prohibited from accessing SNAP until they meet certain conditions; those restrictions, however, neither bar immigrants completely from participation nor affect the eligibility of U.S. citizen children. Indeed, the onerous restrictions initially placed on immigrant participation in SNAP during the 1996 reforms were reversed at the next available opportunity – the 2002 farm bill.117 Congress’ reversal illuminates the sound public policy of ensuring that every family living in the United States has access to the resources necessary to feed their children.

SNAP is a crucial support for families dealing with food insecurity, and the primary nutrition program that partners with WIC to ensure adequate nutrition among pregnant women and young children. SNAP’s inclusion in public charge review will obstruct WIC’s public health and nutrition mission, especially by discouraging participation by otherwise eligible U.S. citizen children. For these reasons, we urge the Department to exclude SNAP from public charge review.

C. WIC participants rely on housing assistance programs to obtain adequate shelter for the whole family.

Although WIC’s primary mission is to ensure that pregnant women and children have access to nutritious foods, we also understand that a family’s surroundings can have a significant impact 111 U.S. Dep’t of Agriculture, “Alleviating poverty in the United States: The critical role of SNAP benefits,” 132 (2012).112 John T. Cook, et al., “Child food insecurity increases risks posed by household food insecurity to young children’s health,” 136 J. of Nutrition 1073 (2006).113 Stephanie Ettinger de Cuba, et al., “Punishing Hard Work: The Unintended Consequences of Cutting SNAP Benefits,” Children’s HealthWatch (2013).114 Id.115 Stephanie Ettinger de Cuba, et al., “The SNAP Vaccine: Boosting Children’s Health,” Children’s HealthWatch (2012).116 Id.117 Pub. L. No. 107-171 § 4401 (2002).

on the child’s development. Housing subsidies – including Section 8 Housing Assistance and Project-Based Rental Assistance – assist families with obtaining affordable and stable housing, which in turn leads to positive child development. [INSERT any statistics you have about the importance of housing subsidies for WIC families in your state or community] We therefore urge the Department to withdraw its consideration of housing assistance programs within public charge review.

The environment in which pregnant women live and children are raised have a profound effect on that child’s development. Children understand when they are living in an unstable or unsafe location, and children internalize the instability associated with a shifting environment or relocated living quarters. The stress of uncertain living scenarios can lead the child to experience mental health problems, developmental delays, and depression.118 Housing subsidies can provide the stability that a family may otherwise be lacking: reducing both the likelihood of mental health problems, but also instances of malnourishment, iron deficiency, and underdevelopment.119

As with other public assistance programs, housing subsidies provide much-needed economic security that removes stressors on a family’s finances. Housing subsidies work in tandem with other critical public assistance programs to ensure that families can attain a stable existence.120 Families with access to both housing subsidies and other assistance programs – like SNAP and WIC – were 72% more likely to have stable housing.121

Public assistance programs work collectively to address the basic needs of families across the country, including immigrant families and mixed-status families with U.S. citizen children. The inclusion of Medicaid, SNAP, or housing subsidy programs within public charge review will devastate the economic security of many families, forcing them to make difficult choices about whether to pay for healthcare, food, or a roof over their heads. These are not the choices that we should have to make in the United States. For these reasons, we call on the Department to withdraw the proposed rule.

118 Bonnie Zima, Kenneth Wells & Howard Freeman, “Emotional and Behavioral Problems and Severe Academic Delays Among Sheltered Homeless Children in Los Angeles County,” 84 Am. J. of Public Health 260 (1994); Lisa Goodman, Leonard Saxe & Mary Harvey, “Homelessness as Psychological Trauma,” 46 Am. Psychologist 1219 (1991); Yvonne Rafferty & Marybeth Shinn, “The Impact of Homelessness on Children,” 46 Am. Psychologist 1170 (1991); Ellen Bassuk & Lynn Rosenberg, “Psychosocial Characteristics of Homeless Children and Children with Homes,” 85 Pediatrics 257 (1990); David Wood, et al., “Health of Homeless Children and Housed, Poor Children,” 86 Pediatrics 858 (1990).119 Deborah Frank, et al., “Heat or Eat: The Low Income Home Energy Assistance Program and Nutritional and Health Risks Among Children Less Than 3 Years of Age,” 118 Pediatrics 1293 (2006); Alan Meyers, et al., “Subsidized Housing and Children’s Nutritional Status: Data from a Multisite Surveillance Study,” 159 Archives of Pediatrics and Adolescent Medicine 551 (2005); Alan Meyers, et al., “Public Housing Subsidies May Improve Poor Children’s Nutrition,” 83 Am. J. of Public Health 115 (1993).120 Barbara Lipman, “Something’s Gotta Give: Working Families and the Cost of Housing,” Ctr. for Housing Policy (2005); U.S. Dep’t of Housing and Urban Dev., “Impacts of Welfare Reform on Recipients of Housing Assistance: Evidence from Indiana and Delaware” (2003); Helen Levy & Thomas DeLeire, “What Do People Buy When They Don’t Buy Health Insurance and What Does That Say About Why They Are Uninsured?,” NBER Working Paper No. 9826 (2003).121 Megan Sandel, et al., “Co-enrollment for child health: how receipt and loss of food and housing subsidies relate to housing security and statutes for streamlined, multi-subsidy application,” 5 J. of Applied Research on Children 2 (2014).

V. Conclusion

WIC serves all eligible individuals because the health of a newborn baby knows no border. The proposed rule puts forth daunting disincentives that will leave millions – including many U.S. citizen children – without access to benefit programs that address their basic needs. Other programs, like WIC, may not be explicitly included in the proposed rule, but the overriding fear within immigrant communities will functionally nullify the distinction. For that reason, we urge the Department to explicitly exclude programs like WIC and CHIP from public charge review.

That exemption alone is not sufficient. The implicated programs – including Medicaid, SNAP, and housing subsidies – provide vital assistance to families. These programs help families with the costs of delivering a baby in a hospital, purchasing a full basket of food at the grocery store, and putting a roof over their child’s head. Time and time again, these programs are demonstrated to work – not only reducing the financial stressors on low-income families, but improving the health, nutrition, and economic security of families with young children. For these reasons, we cannot support this potential change and strongly urge the Department to withdraw the proposed rule.

We thank the Department for this opportunity to comment. If you have any questions, please do not hesitate to contact [Agency contact] at [contact information].

Sincerely,

NameTitleAgency