Community clinics squeezed by immigration checks

• Health centers aren't sure how to carry out seemingly contradictory directives, and worry that an incorrect move could result in being kicked out of multiple federal programs. And that could be crippling amid already ominous health workforce challenges and looming Medicaid cuts from Republicans' tax-and-spending law.

There's "a high level of confusion," said Louise McCarthy, CEO of the Community Clinic Association of Los Angeles County.

• "We don't want to break any rules. We don't want to jeopardize our funding. We want to make sure that we can speak to our patients. ... But what can we tell them?"

Friction point: Community health centers serve more than 32 million people annually. But leaders told Axios they don't track patients' immigration status, let alone ask for proof of citizenship before providing care.

• Nothing in last week's notice changes the underlying requirement in federal law that health centers must serve any resident in their designated service area, said Sara Rosenbaum, a professor emeritus of health law and policy at George Washington University.
• Health centers also are nonprofits, which technically are exempt from the citizenship verification requirement under the 1996 welfare reform law that last week's notice reinterprets.

Zoom out: Until Health Secretary Robert F. Kennedy Jr. issued the notice, the clinics weren't considered federal public benefits. That meant even undocumented immigrants could access their services.

• Health and Human Services said changing its interpretation of the law to include health centers as public benefits will make sure that federal resources are "no longer used to incentivize illegal immigration," per a news release.

HHS hasn't yet issued further guidance to address the apparent contradiction. It could fall to the Health Resources and Services Administration, which runs point on the health center program, to work out conflicts down the road.

• Meanwhile, the National Association of Community Health Centers held a call on the policy change earlier this week that attracted 3,000 health center and state primary care association professionals, the organization told Axios.
• The notice went into effect immediately, but health centers need more information before they change their practices, "if for no other reason than you cannot discern what is intended by the currently available language," said Emily Cook, a partner at law firm McDermott Will & Emery.
• Health center leaders say that for now they're searching for and relying on legal guidance, putting strapped clinic staff on the spot.

Threat level: The consequences for defying the new policy aren't yet clear. But losing federal grants and the other benefits that come with federal health center status — including discounted drugs and malpractice insurance — could be a death knell for health centers.

• "The grant is one piece, but if you lose that and everything else — I mean, you're not keeping your doors open," said McCarthy, of the Community Clinic Association of Los Angeles County.

Between the lines: The policy will likely have a chilling effect on immigrants' use of health center services, even for those with the required documentation.

• That would create a cascade of public health effects, said Megan Prior, a D.C.-area pediatrician who used to work at a community health center.
• People who stop coming in for preventive care are likelier to wind up in the emergency room, adding costs to the health care system.
• The health centers also are frequently on the front lines of outbreaks like COVID-19 and avian flu, meaning the more people that bypass them, the higher the risk of community spread, Prior said.

What to watch: The notice will be challenged in court.

• Head Start state associations, also impacted by the policy change, on Tuesday amended their ongoing lawsuit against the Trump administration to ask the judge to halt the most recent policy change, too.