Personal Responsibility and Work Opportunity Reconciliation Act of 1996 Proposed Changes Comments

August 13, 2025

The Honorable Robert F. Kennedy, Jr.

Secretary, U.S. Department of Health and Human Services

200 Independence Ave SW

Washington, DC 20201

Submitted via regulations.gov

Subject: Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA); Interpretation of “Federal Public Benefit” Comments

Comments:

Thank You for the opportunity to provide comments on the Department’s July 14, 2025, notice reinterpreting “Federal Public Benefit” under PRWORA (Personal Responsibility and Work Opportunity Act).

As background, HealthHIV is a national nonprofit organization that works with healthcare organizations, communities, and providers to advance effective HIV, viral hepatitis, and sexually transmitted infection (STI) care through education and training, technical assistance and capacity building, health services research and evaluation, communications, and advocacy.

The National Coalition for LGBTQ Health (“Coalition”), an initiative of HealthHIV, addresses public health issues affecting LGBTQ communities nationwide through research, education, and policy engagement.

Our response is grounded in decades of experience working with providers and community-based partners to deliver care and services to those hit hardest by communicable diseases and other public health challenges.

Summary

HealthHIV and the Coalition strongly oppose the Department’s reinterpretation of “Federal Public Benefit” under PRWORA. The notice would reach deep into the nation’s public health infrastructure—cutting people off from care, weakening disease surveillance, and disrupting the initiatives Congress put in place to protect community health. In short, it could undo years of work and make it harder to reach national health goals.

Key Areas of Concern

The points below outline our main concerns. They draw on national data and what providers are seeing in their day-to-day work. Unless otherwise noted, data come from the Kaiser Family Foundation and the 2024 State of Aging with HIV National Survey conducted by the National Coalition for LGBTQ Health (the State of Survey).

Crucially, millions of people will be more likely to avoid trusted safety-net settings—including primary care, integrated care clinics, and necessary supportive services—if they fear immigration verification. These are not incidental providers; they are the core of whole-person care models.

KFF data show that 27% of likely undocumented immigrants and 8% of lawfully present immigrants avoided applying for food, housing, or health care assistance in the past year because of immigration-related fears (KFF: July 2019 | Issue Brief Health Coverage and Care of Undocumented Immigrants). In the Coalition’s survey (n = 736), 92% said that changes to Medicare or Medicaid formularies would make it harder for patients to get the care they need. Respondents also reported that patients stockpile medications or seek unregulated sources when access is restricted—behaviors that increase safety risks and strain downstream services (State of Survey).

When people avoid care, safety-net systems fray or falter. We often miss early opportunities to detect and treat illnesses, and to keep people connected to services and treatment. Testing slows, treatment is delayed, and mental health or substance use needs go unmet. This means more late diagnoses, higher costs, and worse outbreaks. It also leaves gaps in public health data. When immigrants skip testing or treatment, they disappear from the record. This makes it harder to detect emerging problems and respond quickly to outbreaks like hepatitis or syphilis.

Nearly three-quarters of immigrant adults—and nine in ten likely undocumented immigrants—report uncertainty or mistaken beliefs about whether using non-cash benefits could harm their immigration status (KFF). These blind spots in the data are not just statistical problems. They slow response times and increase both transmission rates and long-term costs.

This notice would also shrink the pipeline of clinicians. Provider capacity is already fragile: 51% of respondents considered leaving their jobs in the last six months, and 63% cited the political environment as a top driver—conditions likely to intensify under the proposed reinterpretation (State of Survey).

Many immigrant providers enter the U.S. health workforce through federal workforce support efforts—the very pathways the reinterpretation now extends to. In many rural and underserved areas, especially in the South where the epidemic is concentrated, these providers may be the only ones offering HIV care that meets patients’ cultural and language needs.

Thirty-seven percent of respondents said the shortage of HIV-specialized providers was a significant barrier to care. Rural respondents were almost twice as likely to say this (State of Survey). Closing that door will make shortages worse and slow the delivery of care, leaving providers with fewer resources and fewer partners for years to come.

There’s also a real risk to the financial stability of services that keep people on life-saving medications and in consistent and routine care. When fewer patients come through the door or the payer mix shifts, safety-net hospitals and community clinics lose crucial revenue. That loss can jeopardize HIV services and disrupt care—pushing more people out of treatment and into preventable health crises, emergency visits, and costly hospital stays.

The explicitly undefined and expanded definition of “Federal Public Benefit” in the notice invites inconsistent state interpretations. Some states, acting out of caution or misunderstanding, could wrongly deny or disenroll people from public health coverage they are entitled to. Even a short break in HIV treatment can cause the virus to rebound and spread more easily—and it drives up costs for emergency rooms and public hospitals.

As of 2023, half of likely undocumented immigrant adults and 18% of lawfully present immigrant adults were uninsured—compared to just 8% of U.S.-born citizens (KFF). These ripple effects will not be limited to immigrants; mixed-status households will feel them immediately, as will U.S. citizens who are deterred—“chilled” in legal terms—from seeking care by the perception of new immigration checks.

Community-based reproductive health services and early childhood development services will be among the hardest hit. These services help families get prenatal care and disease testing, along with support for maternal health. State-level research indicates that extending Medicaid coverage to pregnant individuals, regardless of immigration status, results in increased access to prenatal care and improved pregnancy outcomes (KFF).  If parents stay away, preventable infections in newborns will rise and more mothers and babies will face serious health problems.

Community-based behavioral health and substance use services are also likely to see fewer people coming through the door. People who inject drugs, pregnant women with substance use disorders, and others already facing stigma and poverty will be pushed even further from the care that protects their health and their communities.

The Administration’s justification that immigrant participation “burdens” programs is contradicted by the data. On average, immigrants spend far less on health care each year than U.S.-born citizens—about two-thirds as much ($4,875 compared with $7,277). They also pay premiums and taxes that help cover the cost of care for U.S.-born citizens (KFF). Restricting access does not save resources—it destabilizes systems and shifts costs into emergency care and uncompensated care pools, driving up Medicaid and state indigent care spending, undercutting the Administration’s efforts to control federal and state health budgets.

This reinterpretation turns the law into a blunt instrument—disrupting outbreak control by deterring testing and treatment, reducing provider capacity in already underserved areas, and undermining the very foundational efforts that Congress and public health agencies have relied on to advance national health outcome goals. Furthermore, it ignores decades of bipartisan understanding that specific services—especially those focused on communicable disease prevention and treatment—must be open to all if they are to effectively protect the entire American public.

Conclusion

HealthHIV and the Coalition urge the Department of Health and Human Services (HHS) to withdraw the notice and keep the federal public benefit in place. We also urge HHS to work with immigrant-serving groups, local providers, and public health officials before making any changes, to understand how the policy would be implemented and enforced on the ground. That review should examine how changes could affect care, whether staffing levels could meet demand, and if public health data would still give an accurate picture of conditions in communities.

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