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Taking a Deep Dive into the Healthcare Informatics 100—and the Health IT Market, Broadly

June 14, 2018
by Michelle Mattson-Hamilton and Ben Rooks, ST Advisors
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Two industry experts break down this year’s list and what’s happening in the market at this current moment

Editor's note: Rather than our typical review of mergers and acquisitions in the prior calendar year, this year, in an effort to capture and portray the breadth, acceleration, and impact of consolidation and M&A on the entire healthcare arena (e.g., payers, PBMs, providers, healthcare IT vendors, etc.), we’re going to look from Jan 2017 through year-to-date 2018 (i.e., May 2018).

For the last 18 months, bigger has (generally) been better, but in the mergers and acquisitions realm, the gambit has been run: from vertical integration to smaller strategic acquisitions (and it didn’t hurt that changes to tax policy, along with low interest rates, left a few extra coins in the couch cushions in Dec 2017). Let’s dissect some of this “deal mania” behavior from the last six quarters and consider the potential ramifications for healthcare technology vendors in 2018 and beyond.

Note: The 2018 Healthcare Informatics 100 list in full can be viewed here.

Payers Buy PBMs and Vice Versa! In our view, one of the most interesting, and potentially transformational, deals in healthcare this past year was CVS Health’s planned acquisition of leading health insurer, Aetna (which saw its attempt to acquire Humana thwarted by regulators). This will give CVS a host of assets to arrange in the healthcare sandbox including, a major PBM, a leading retail presence, nurse clinics, and now the full ability to underwrite risk and manage care. Meanwhile, Cigna announced its intentions to purchase Express Scripts for $68.4 billion in March ‘18.  (recall that Express Scripts had acquired eviCore in Dec 2017 for $3.6 billion.) Assuming these deals close successfully, the nation’s largest PBMs will all be aligned with the three largest payers, creating impressive, vertically-integrated healthcare entities. No doubt Amazon’s abandoned (for now) exploration of this space also got these companies’ attention!

Payers Buy Providers: Insurers continue to blur the line between payer and provider as they push further into the provision of patient care. In a move to expand the organization’s outpatient care services, in Dec 2017, United (Optum, #1) reached an agreement to acquire DaVita’s medical unit for $4.9 billion. Optum also acquired Surgical Care Affiliates in Jan 2017 and gained 210 ambulatory surgery centers performing ~1 million procedures annually and is now one of the largest owners of physician practices. Similarly, Humana made a big bet in home health when it spent $800 million on a 40 percent stake in Kindred at Home through a joint venture with TPG and Welsh, Carson, Anderson & Stowe in April 2018. Not to be outdone, Anthem secured HealthSun (Sept 2017), an integrated Medicare Advantage plan and healthcare delivery network in Florida, and Centene bought Community Medical Group, an at-risk primary care provider, in Mar 2018.

Payer Consolidation: No year would be complete without additional payer consolidation. In 2017, Centene’s acquired Fidelis Care (Sept 2017) and Anthem acquired America’s 1st Choice (Oct 2017).

Provider Mega-Mergers: In the face of continued vertical integration from payers, movement towards cheaper settings of care, and expanding financial pressures (e.g., high technology and staff expenses, reduced reimbursement, rising bad debt from increased consumer financial responsibility), providers have been seeking alternatives to remain competitive (and, in our view, materially increase their pricing power). This movement led to some massive provider deal announcements at the end of 2017, including:

  • December 5 - Illinois’ Advocate Health Care and Wisconsin’s Aurora Health Care (new system to be known as “Advocate Aurora Health Care” – catchy!). Serving 3 million patients annually, the combined entity would encompass 27 hospitals with annual revenues of ~$11 billion
  • December 7 - Catholic Health Initiatives and Dignity Health, where the combined organization would include 139 hospitals with operations in 28 states and combined revenue of $28.4 billion
  • December 10 - Merger of Ascension Health and Providence St. Joseph Health, where the resulting entity would have 191 hospitals in 27 states with annual revenue of $44.8 billion. (Although, reports indicate talks halted in March ‘18 due to the organization’s differing priorities.)

What about Healthcare IT Vendors?

Just as in other sectors of healthcare, in healthcare IT, tax policy and low interest rates enabling the current cycle of consolidation and vertical integration (and the need to “keep up with the Jones”). Healthcare IT vendors either keep up or get left behind, as competitors explore partnership, merger, and acquisition opportunities that enable significant leverage and economies of scale (among other advantages).

We’ve observed, for literally decades, that HCIT is harder than it looks, and in a dismal end to the HCIT career that came from its acquisitions of MedicalLogic, IDX Systems and API Healthcare, GE Healthcare (#16) divested its "value-based care" Division to Veritas Capital for $1 billion (20 percent less than it paid for IDX Systems alone in 2006!). Meanwhile, McKesson also left the pure IT world by divesting its connectivity (and some other) assets to Change Healthcare (#4) and its Enterprise Information Solutions business to Allscripts (#10), finally putting an end to its ill-advised HBOC debacle.  

Having freed itself of these properties, McKesson returned to its distribution roots acquiring both Francisco Partners-backed CoverMyMeds (electronic prior authorization vendor) in Jan 2017 (for the princely sum of $1.1 to 1.5 billion – there’s an earn-out) and RxCrossroads (specialty patient support services) from CVS in Nov 2017.

Looking at these counter-parties’ activities, Change Healthcare (#4) continued its core growth since the combination, expanding its credentialing capabilities by acquiring Docufill in Nov 2017, and National Decision Support Company, with its cloud-based imaging clinical decision support solutions, in Jan ‘18. In addition to its acquisition of McKesson’s fixer upper special, Allscripts (#10) continued to try to bulk up and join the two-horse Epic/Cerner race by buying Practice Fusion, a “free” ambulatory EMR, in Jan 2018. Its goal now is to move notoriously thrifty physician groups from a free to a paid solution. While on the subject of Allscripts, its partner/portfolio company Netsmart (#44) expanded further into homecare with its acquisition of DeVero, a home health EMR in July ‘17 and bought Change Healthcare's Home Care and Hospice Solutions in April ‘18

While we’re talking about connectivity vendors, Navicure and ZirMed combined to form Waystar, leaping to number 47 on this year’s list, and Availity (#49) brought in a significant capital infusion from active sector investor, Francisco Partners, so we’d expect to see it to deploy some of that capital and give us something to write about next year!

Meanwhile, many of our other Healthcare Informatics Top 100 vendors have also ridden this wave of consolidation and made big moves to vertically integrate, enter new markets, and / or increase scale over the last 18 months:

  • In addition to the aforementioned United and Optum (#1) acquisitions, Optum acquired The Advisory Board Company (Nov 2017) in an attempt to enhance its brand with ABCO’s provider credibility (and, of course, expand its advisory and technology capabilities). While threading the needle of vendor and oftentimes antagonistic payer has been something United has managed before, this iteration could prove more challenging.
     
  • Cognizant (#3) strengthened its revenue cycle position with the addition of Bolder Healthcare Solutions (Mar 2018) and its business process platforms for government and public healthcare programs with the acquisition of Medicare Advantage outsourcer, TMG Health (June 2017)
     
  • Royal Philips (#5) went on a bit of a shopping spree, acquiring TomTec Imaging Systems (July 2017), a provider of image analysis software for diagnostic ultrasound, Analytical Informatics (Nov 2017), a provider of vendor-agnostic workflow tools for the imaging department, VitalHealth (Dec 2017), a cloud-based population health solution, and Forcare (Dec 2017), an interoperability vendor
     
  • In what to us seemed a non-intuitive change in direction, Inovalon (#33) shelled out $1.2 billion for revenue cycle management consolidator ABILITY Network in Mar 2018. Supporting our “5 minute rule of M&A” (if a company makes an acquisition where price or valuation can’t be explained in five minutes of focused conversation with the CEO, Inovalon proceeded to miss its Q1 ‘18 numbers (1st quarter post ABILITY announcement) and the stock is now trading ~17 percent below the stock price on the date of the March transaction announcement (and 40 percent from its 52-week high).
     
  • TPG-backed Mediware (#53) acquired Kinnser in May ‘17 expanding into home health and hospice software. To complement the RCM capabilities acquired with Kinnser, Mediware also acquired MEDTranDirect, an RCM solution and an approved Medicare network service vendor, in Jan 2018
     
  • Continuing its move towards population health begun with its 2016 acquisition of Essette, HMS Holdings acquired PE-backed patient engagement vendor, Eliza Corporation for $170 million
     
  • A few other smaller, but interesting, deals: Battery Ventures-backed WebPT (#97) acquired adjacent companies, BMS and Strive Labs to expand its physical therapy market dominance, and Medecision (#90) tucked-in Axispoint’s care management products (HCIT Jeopardy players might recall that Axispoint was divested from McKesson a few years ago, and old timers would remember them from HBOC/HPR)

While not part of our Healthcare Informatics 100 list, Roche’s Feb 2018 acquisition of the remaining 87.4 percent equity stake in Flatiron Health deserves a brief mention before we sign-off – primarily because of the eye popping $1.9 billion price tag! Oncology therapeutics contribute ~60% of Roche’s total revenue, and the U.S. patents of the company’s key drugs, Rituxan, Herceptin, and Avastin, are set to expire in 2018, 2019 and 2020 respectively. The company is likely looking to expedite new drug development and approval through real-world evidence and analytics; enter Flatiron. While Roche obviously felt that was worth paying up for, we wonder why they felt it had to own the asset and how they justified it to its board. As ever in cases like this, recall our oft stated view that "immateriality means never having to say you’re sorry!"

What are the Implications for Healthcare IT Vendors?

At the end of the day, healthcare IT vendors will struggle as total market size (number of customers) declines, the buying power of remaining customers significantly increases, and, in some cases, new or stronger competitors emerge as a result of industry M&A. Many vendors are responding through strategically-focused inorganic growth; this will leave small (or under-funded) vendors, especially those with limited differentiation, at a disadvantage. As competition heats, all companies will need to hone their product, craft and message, but it will be especially important for companies of limited scale to ensure differentiation and to be extremely focused in target market and go to market approach.

With those extra coins from tax reform continuing to burn a hole in the pockets of healthcare companies (and mountains of dry powder available from private equity firms and their portfolio companies) the remainder of 2018 should continue to be a rollercoaster of M&A fun. Stay tuned!

ST Advisors is a strategic and financial advisory firm focused in healthcare IT and healthcare services that serves both companies and their investors (as well as, occasionally, plans and providers).  Of the companies mentioned above, ST Advisors has provided advisory services in the past three years to Medecision and TPG Capital.


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Should Physicians and HIT Leaders Worry about the Implications of the Walgreens/Microsoft Deal?

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As architect Daniel Burnham once said, “Make no little plans”; the leaders of the Walgreens/Microsoft alliance, like so many others, certainly are thinking big these days
architect Daniel Burnham

Nearly every day, it seems, new business combinations are announced that are threatening to alter the landscape of U.S. healthcare forever. CVS’s acquisition of Aetna, completed last November; the announcement a year ago now that the executives of Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. were launching a broad (if not well defined) initiative to improve consumer satisfaction and reduce costs for their employees; Cigna’s acquisition just last month of pharmacy benefit management (PBM) company Express Scripts; and Amazon’s acquisition last summer of online pharmacy company PillPack.

Every one of those business deals represents a disruptive move in U.S. healthcare, with unalike “species” of organizations combining with one another. And now, the retail drugstore giant  Walgreens Boots Alliance Inc. and Microsoft Corp. are coming together in yet another disruptive venture. As Managing Editor Rajiv Leventhal wrote in an article on Tuesday, the corporations “are joining forces on a major seven-year healthcare partnership that will aim to ‘deliver innovative platforms that enable next-generation health networks, integrated digital-physical experiences and care management solutions.’” As he wrote, “The companies announced today that they will combine the power of Microsoft Azure, Microsoft’s cloud and AI (artificial intelligence) platform, healthcare investments, and new retail solutions with WBA’s customer reach, volume of locations, and outpatient healthcare services to accomplish their goals: to make healthcare delivery more personal, affordable and accessible.”

As Leventhal noted in his report, “While innovation in healthcare has occurred in pockets, officials of the two companies believe that ‘there is both a need and an opportunity to fully integrate the system, ultimately making healthcare more convenient to people through data-driven insights.’” Further, he noted, “As part of the strategic partnership, the companies have committed to a multiyear research and development (R&D) investment to build healthcare solutions, improve health outcomes and lower the cost of care. This investment will include funding, subject-matter experts, technology and tools, officials noted in the announcement. The companies will also explore the potential to establish joint innovation centers in key markets. Additionally, this year, WBA will pilot up to 12 store-in-store ‘digital health corners” aimed at the merchandising and sale of select healthcare-related hardware and devices.

“This gap creates an opportunity for the pharmacist to help monitor the patients’ health and prompt the patient to receive preventative care in the retail clinic or through a virtual care visit. Using an enterprise health cloud, like Azure, you create a more connected ecosystem so that we can share that data with the patient’s additional providers, track outcomes, and intervene earlier when an issue arises,” Microsoft CEO Satya Nadella said in a statement Tuesday.

And, Leventhal wrote, “Notably, the companies will also work on building an ecosystem of participating organizations to better connect consumers, providers—including Walgreens and Boots pharmacists—so that major healthcare delivery network participation will provide the opportunity for people to seamlessly engage in WBA healthcare solutions and acute care providers all within a single platform.”

Speaking to the difference between retail pharmacies and traditional care providers, Forrester analyst Arielle Trzcinski said in a statement emailed to the press that “[R]etail pharmacies offer an opportunity to engage with the patient much more frequently than at an office visit, giving an example of how chronic care patients see their pharmacist frequently, while some figures indicate that the average diabetic patient sees his or her provider once every six months.”

The implications of all of this are, of course, huge. For one thing, if one were to ask the average patient/healthcare consumer with whom they interacted more, doubtless, the vast majority would cite their retail pharmacists, rather than their primary care physicians. What’s more, what happens if Walgreens is able to follow through, as CVS also intends to do, in creating minute clinics in retail pharmacy locations? The impact could be revolutionary.

Indeed, it’s no secret that many patients are dissatisfied with the cumbersome, challenging processes around accessing primary and specialty care in the U.S. healthcare system. Simply accessing a timely appointment often proves to be a major hassle; and encounters around needed follow-ups and around questions to doctors and nurses often turn out to be such a hassle that many patients simply give up, with the result of medication non-compliance and other issues.

So what will happen if Walgreens, like CVS, manages to achieve success with one or more elements of this initiative? Those could include enhanced continuum of care for patients, especially those with chronic diseases; improved communication among all care delivery stakeholders; and enhanced patient/consumer satisfaction.

A few stakeholder groups should be paying particular attention here, including practicing physicians and healthcare IT leaders. For practicing physicians, could anyone deny that this business initiative, along with the others mentioned above, should be disconcerting at the very least? Already, patients needing relatively immediate medical attention, are turning en masse to urgent care centers, as both health systems and health insurers are working to cut down on the volume of emergency department visits, which are tremendously expensive, and which burden the healthcare delivery system in ways that are not sustainable. But now, with both Walgreens/Microsoft and CVS/Aetna, is anyone denying that the era of pretty-close-to-immediate medical attention is on the horizon?

The reality is that, while most patients like their primary care physicians and are satisfied with their care overall, strong majorities, in polls, continue to complain about poor service, bad communication, and delays accessing care and accessing follow-up support. What happens when most decent-sized Walgreens and CVS drugstores are staffed up with PCPs or advanced practice nurses, to handle the colds, coughs, flus, strep throats, and minor skin and digestive issues that could easily be handled by such service offerings?

One of the core policy issues here is that the U.S. healthcare payment system remains largely predicated on primary care physicians physically touching patients in order to get paid. Yes, telehealth services are expanding daily; but in most situations, patients still need to go through the awkward, inconvenient, sometimes even-arduous process of scheduling an appointment, using some form of transportation to get to that appointment, and waiting in a crowded physician office, in order to access primary care.  But in 2019, when GrubHub can deliver one’s banh mi Vietnamese sandwich to one’s home, and Amazon is sending everything from books to clothing to furniture to God-knows what, directly to people’s doors, how much longer will healthcare consumers continue to be patient with the glacial pace of care delivery change in U.S. healthcare?

Meanwhile, healthcare IT leaders will inevitably find themselves somewhat behind a proverbial eight-ball on all this, caught between the intensifying demands on the part of practicing physicians, especially primary care physicians, for full clinical IT support for their practices, and constant business changes, including merger-and-acquisition activity in their own organizations that is continuously scrambling their long-term planning.

So we’re seeing both business and technology changing, and changing quickly, with numerous examples already of industry-disruptive business combinations, and technology advancing to the point where previously unimagined breakthroughs are now imaginable. For example, Walgreens and Microsoft noted that, “Through this agreement, Microsoft becomes WBA’s strategic cloud provider, and WBA plans to migrate the majority of the company’s IT infrastructure onto Microsoft Azure,” as corporate officials put it. And “Microsoft also plans to roll out Microsoft 365 to more than 380,000 Walgreens employees and stores globally.” And, to make things just that more intriguing, the announcement quoted Stefano Pessina, executive vice chairman and CEO of the Walgreens corporation, as stating that “WBA will work with Microsoft to harness the information that exists between payors and healthcare providers to leverage, in the interest of patients and with their consent, our extraordinary network of accessible and convenient locations to deliver new innovations, greater value and better health outcomes in health care systems across the world.”

As renowned Chicago architect Daniel Burnham so famously said, “Make no little plans; they have no magic to stir men's blood and probably themselves will not be realized.” There’s no question that the senior leaders of all of these business alliances, combinations, and initiatives are going to be “no little plans.” It would behoove clinicians, clinician leaders, healthcare IT leaders, and all c-suite leaders in provider organizations to think Burnham-sized thoughts; these businesspeople from outside traditional healthcare delivery are certainly doing so.

 

 

 

 

 

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Blue Cross NC, Five Health Systems Announce Major Shift to Value-Based Care

January 16, 2019
by Heather Landi, Associate Editor
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The insurer aims to have half of its 3.89M customers covered by VBC contracts by next year; all customers in VBC arrangements in five years
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Blue Cross and Blue Shield of North Carolina (Blue Cross NC), one of the state’s largest insurers, and five of the state’s major health systems in North Carolina have announced a new value-based care program that encompasses hundreds of thousands of healthcare customers throughout the state.

The five health systems—Cone Health, Duke University Health System, UNC Health Care, Wake Forest Baptist Health and WakeMed Health & Hospitals—and their accountable care organizations (ACOs) have committed to participating in Blue Premier, a new value-based model of care in which Blue Cross NC and the health systems will be jointly responsible for better health outcomes, exceptional patient experience and lower costs, according to a Blue Cross NC press release.

“With agreements from five of the state’s major health systems and their ACOs, Blue Premier is one of the most rapid and comprehensive shifts to value-based payments in the nation,” Blue Cross NC officials stated. Patrick Conway, M.D., serves as president and CEO of the Durham-based health insurer and previously served as the Chief Medical Officer, Deputy Administrator, and Director of the Center for Medicare and Medicaid Innovation (CMMI), a division of the Centers for Medicare and Medicaid Services (CMS).

Within five years, Blue Cross NC has committed to having all 3.89 million customers covered under Blue Premier’s value-based care contracts. By early 2020, fifty percent or more of all Blue Cross NC members will have a provider who is jointly responsible for the quality and total cost of their care, the health insurer stated.

“As a practicing physician, I have experienced first-hand the challenges plaguing our health care system,” Conway said in a statement. “Historically, our health care system pays for services that may or may not improve a patient’s health, and our customers simply cannot afford this approach. Moving forward, insurers, doctors and hospitals must work together, and hold each other accountable for improving care and reducing costs. We applaud the leadership and commitment of these five leaders in health care to help transform health care delivery in North Carolina.”

During the HLTH Conference, held at the Aria Resort in Las Vegas last May, Conway discussed the payer-provided landscape in North Carolina and alluded to opportunities accelerate the move to value-based care and payment models, according to reporting from Editor-in-Chief Mark Hagland. “We’re looking at a new model, where patient care organizations can partner more fully with Blue Cross North Carolina,” Conway said, per Hagland’s report. And Conway continued, “We’re saying, you can take this alternative pathway with us. And we’ll jointly be accountable for the total quality and cost of care. And we want you to go into two-sided risk. And we’re wondering, should we turn off all prior authorization? And documentation other than for risk coding and STARS measures, we won’t worry about how you document. And for people in the audience, those kinds of partnerships are very exciting, because you’ve now got a provider and payer that are no longer locked into rigid rules, but where you can innovate on quality and customer experience.”

According to the insurer, Blue Premier ties payments to doctors and hospitals over time to the value of services that improve patient health. This means that total payments to the health systems under Blue Premier will be based on the health systems’ ability to manage the total cost of care and their overall performance, measured by industry quality standards. Through a “shared risk” financial model, the health systems will share in cost savings if they meet industry-standard goals to improve the health of patients – and share in the losses if they fall short. “The unprecedented commitment from these five large health systems makes Blue Premier one of the most advanced and comprehensive value-based care programs in North Carolina and the nation,” Blue Cross NC officials stated.

“This unprecedented step by Blue Cross NC and many of the state’s leading health care organizations will make a big difference in advancing high-quality, innovative care in North Carolina,” Mark McClellan, M.D., Ph.D., director of the Duke-Margolis Center for Health Policy said in a statement in the press release. “At Duke-Margolis, we remain committed to supporting state government and private-sector initiatives to reform payment and improve care – providing needed examples for the nation.” 

In a statement, Donald Gintzig, president and CEO, WakeMed Health & Hospitals, said, “This collaboration represents an important step forward in our efforts to provide patients in our area and across the state with high quality, coordinated services for the best value. Our health systems are bringing together valuable resources in a more integrated way that will ultimately lead to better health and more affordable health care.”

The news of the value-based care collaboration comes a month after the health insurer announced a partnership with Aledade, a Bethesda, Md.-based company focused on physician-led ACO development, to launch a value-based care initiative to support primary care physicians across the state. Through the initiative, the two companies will support physician-led ACOs tailored specifically for primary care physicians and the communities they serve. Through these ACO arrangements, Blue Cross NC will collaborate with Aledade to provide physicians with technology and data analytics tools to better manage patient care and costs. After joining these ACOs, practices gain a more comprehensive view of their patients’ total cost of care, gaps in quality of care, and experiences throughout the entire health care system, the companies said.

 

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Kaiser Health News Report: Clinics Treating Immigrants Find Themselves in Limbo Around Notification

January 15, 2019
by Mark Hagland, Editor-in-Chief
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The clinicians and leaders of U.S. patient care organizations continue to find themselves in a policy limbo around the information they share with federal and state authorities around their care for undocumented immigrants

The clinicians and leaders of U.S. patient care organizations continue to find themselves in a kind of policy limbo around the data and information they share with federal and state authorities around their medical care for undocumented immigrants, a new report in Kaiser Health News finds.

As Ana B. Ibarra wrote in a new report in Tuesday’s Kaiser Health News, “While the Trump administration decides whether to adopt a controversial policy that could jeopardize the legal status of immigrants who use public programs such as Medicaid, doctors and clinics are torn between informing patients about the potential risks and unnecessarily scaring them into dropping their coverage or avoiding care.” In her story, Ibarra quoted Tara McCollum Plese, chief external affairs officer at the Arizona Alliance for Community Health Centers, which represents 176 clinics, as saying, “We are walking a fine line. Until there is confirmation this indeed is going to be the policy, we don’t want to add to the angst and the concern.” However, if immigrants do come to a clinic wondering whether using Medicaid can affect their legal status, trained staff members will answer their questions, Plese told Ibarra.

Patient care organization leaders are working to figure out how to handle the situation, with some providers deciding to prepare their patients for the potential enactment of the proposal. At Asian Health Services, a clinic group that serves Alameda County, Calif., staff members pass out fact sheets about the proposed changes, provide updates via their patient newsletter and host workshops where patients can speak to legal experts in several Asian languages. “We can’t just sit back and watch,” CEO Sherry Hirota told Ibarra. “We allocate resources to this because that’s part of our job as a community health center — to be there not only when they’re covered, but to be there always,” even when that coverage is in jeopardy, she said.

The proposed “public charge” rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants’ use of an expanded list of public benefit programs including Medicaid, CalFresh and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people. Currently, people are considered public charges if they rely on cash assistance (Temporary Assistance for Needy Families or Supplemental Security Income) or need federal help paying for long-term care.

 

 

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