This piece was co-authored by Haley Hamblin.

On October 4, 2019 President Trump issued a presidential proclamation that altered the definition of a “public charge” according to United States immigration policies.[1] The Department of Homeland Security (DHS) first announced the rule August 14, 2019, and intended for it to become effective October 15, 2019.[2] However, the rule was blocked by multiple federal judges and remains in litigation.[3] A person is considered a public charge if they are likely to become dependent on the government for subsistence.[4]Previously, when evaluating if a person is likely to become a public charge, factors such as age, health, financial status, and skills were taken into account as well as the use of cash assistance and government-funded long-term care.[5]The new rule now allows for consideration nearly all public benefits from federal, state, or local governments including Medicaid, Supplemental Nutrition Assistance Program (SNAP), Medicare Part D subsidies, and federal housing subsidies.[6] DHS has great discretion under this rule in determining if an immigrant will become a public charge. Such discretion could severely impede an immigrant’s ability to obtain a Green Card or enter the United States, as well as prevent non-immigrant temporary visa holders from extending their visas or changing their immigration status. This rule also could also have consequences for medical care access and the health of immigrants and their families.[7]

Impacts on Immigration

The new public charge primarily affects those applying for Green Cards and non-immigrant temporary visa holders, such as agricultural H-2A workers, high-skilled H-1B workers and students. According to 2017 immigration data, the Migration Policy Institute estimated the new “pubic charge” definition could affect up to 941,000 immigrants seeking Green Cards, 382,000 immigrants from within the U.S. and 559,000 from outside the U.S.[8] Additionally, the rule could affect up to 2.3 million non-immigrant temporary visa holders seeking to change their immigration status or extend their visa. Many of these individuals do not currently qualify for public benefit programs. However, this new rule allows DHS to deny immigrants they believe may make use of these benefits once they do qualify. The rule does not apply to asylum seekers, those with Green Cards who entered the country as refugees, children who qualify for “special immigrant juvenile status,” which is available to minors who were abused, neglected or abandoned by a parent. Those receiving CHIP and WIC benefits are also exempt from the “public charge” designation.[9]

Impacts on Healthcare

It is likely that many immigrants will become fearful of receiving public benefits, a concept known as the “chilling effect.”[10] Individuals will disenroll or not apply for benefits due to fear that there will be negative immigration consequences. Confusion and uncertainty about which public programs designate a “public charge” and which ones do not will likely lead to even larger effects as it extends beyond the targeted population of the rule. There could be negative effects on public health care systems due to the reduction of health coverage and increased use of emergency rooms by the uninsured.[11] Prior to the final rule, parents were disenrolling themselves and their children from Medicaid and CHIP despite being eligible because they feared being deemed a public charge once the rule took full effect.[12]These losses in coverage will decrease revenues for providers and increases the amount of uncompensated care that will spill over into the communities. Between 2.0 to 4.7 million people could disenroll because the rule causes disenrollment rates from 15 percent to 35 percent among Medicaid and CHIP enrollees who are non-citizens or live with a non-citizen.[13] According to a UCLA report, the rule could cause about 765,000 immigrants in California to disenroll from health care programs resulting in about 47 percent of job losses in health care.[14] It is estimated that 8.3 million children currently enrolled in Medicaid and CHIP are at risk of disenrollment.[15]

Further, the largest source of revenue for community health centers (CHC) is Medicaid. Since the public charge rule considers Medicaid use a factor, it is predicted that up to 2.6 million people would disenroll from the program, having negative effects on community health centers.[16] Research from the Milken Institute School of Public Health predicts that in one year community health centers could potentially lose between $346 million and $624 million in Medicaid revenue.

Outreach and education efforts could reduce the chilling effects from the new rule.[17] Removing any ambiguity about who will be affected by the rule will help address unnecessary disenrollment. Thus, providers should refer individuals to an immigration expert to consult on their care before taking any action to disenroll.[18] Community members should also be provided with accurate information about the rule through outreach toolkits and community flyers.[19] For example, Casa de Maryland, a nonprofit immigrant advocacy group, has printed brochures, conducted training for social service providers and set up websites explaining how the rule will work.[20]However, education efforts to clear up the confusion are complicated by uncertainty over the fate of the legal challenges, the Trump Administration’s many actions to limit legal and illegal immigration, and the consistently changing regulations.[21] Fear from the immigrant communities may prevent them from seeking assistance in the first place.

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[1] Presidential Proclamation on the Suspension of Entry of Immigrants Who Will Financially Burden the United States Healthcare System, https://www.federalregister.gov/documents/2019/10/09/2019-22225/suspension-of-entry-of-immigrants-who-will-financially-burden-the-united-states-healthcare-system-in, Federal Register, Published October 4, 2019.

[2] Inadmissibility on Public Charge Grounds, https://www.federalregister.gov/documents/2019/08/14/2019-17142/inadmissibility-on-public-charge-grounds, Federal Register, Published August 14, 2019.

[3] “Federal Judges In 3 States Block Trump’s ‘Public Charge’ Rule For Green Cards,” NPR, https://www.npr.org/2019/10/11/769376154/n-y-judge-blocks-trump-administrations-public-charge-rule, Published October 11, 2019.

[4] Public Charge Fact Sheet. USCIS. https://www.uscis.gov/news/fact-sheets/public-charge-fact-sheet. Published May 3, 2011. Accessed November 17, 2019.

[5] Parmet WE. The Trump Administration’s New Public Charge Rule: Implications For Health Care & Public Health. The Trump Administration’s New Public Charge Rule: Implications For Health Care & Public Health | Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20190813.84831/full/. Published August 13, 2019. Accessed November 17, 2019.

[6] Parmet WE. The Trump Administration’s New Public Charge Rule: Implications For Health Care & Public Health. The Trump Administration’s New Public Charge Rule: Implications For Health Care & Public Health | Health Affairs. https://www.healthaffairs.org/do/10.1377/hblog20190813.84831/full/. Published August 13, 2019. Accessed November 17, 2019.

[7] Read the Trump administration’s draft proposal penalizing immigrants who accept almost any public benefit. The Washington Post. http://apps.washingtonpost.com/g/documents/world/read-the-trump-administrations-draft-proposal-penalizing-immigrants-who-accept-almost-any-public-benefit/2841/. Accessed November 17, 2019.

[8] Migration Policy Institute, “Gauging the Impact of DHS’ Proposed Public-Charge Rule on U.S. Immigration,” https://www.migrationpolicy.org/research/impact-dhs-public-charge-rule-immigration, Published November 12, 2019, p. 4.

[9] “Trump to deny green cards to immigrants receiving public benefits,” https://www.politico.com/story/2019/08/12/trumop-immigration-public-benefits-1413690 POLITICO, Published August 12, 2019.

[10] Batalova J, Fix M, Greenberg M. Millions Will Feel Chilling Effects of U.S. Public-Charge Rule That Is Also Likely to Reshape Legal Immigration. migrationpolicy.org. https://www.migrationpolicy.org/news/chilling-effects-us-public-charge-rule-commentary. Published November 12, 2019. Accessed November 17, 2019.

[11] Batalova J, Fix M, Greenberg M. Millions Will Feel Chilling Effects of U.S. Public-Charge Rule That Is Also Likely to Reshape Legal Immigration. migrationpolicy.org. https://www.migrationpolicy.org/news/chilling-effects-us-public-charge-rule-commentary. Published November 12, 2019. Accessed November 17, 2019.

[12] Artiga S, Garfield R, Damico A. Estimated Impacts of Final Public Charge Inadmissibility Rule on Immigrants and Medicaid Coverage. The Henry J. Kaiser Family Foundation. https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-final-public-charge-inadmissibility-rule-on-immigrants-and-medicaid-coverage/. Published October 28, 2019. Accessed November 17, 2019.

[13] Artiga S, Garfield R, Damico A. Estimated Impacts of Final Public Charge Inadmissibility Rule on Immigrants and Medicaid Coverage. The Henry J. Kaiser Family Foundation. https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-final-public-charge-inadmissibility-rule-on-immigrants-and-medicaid-coverage/. Published October 28, 2019. Accessed November 17, 2019.

[14] Tefera D. UCLA report finds federal ‘public charge’ rule changes would hurt state economy. Daily Bruin. https://dailybruin.com/2019/01/07/ucla-report-finds-federal-public-charge-rule-changes-would-hurt-state-economy/. Accessed November 17, 2019.

[15] Zallman L. Implications of Changing Public Charge Immigration Rules for Children Who Need Medical Care. JAMA Pediatrics. https://jamanetwork.com/journals/jamapediatrics/article-abstract/2737098. Published September 2, 2019. Accessed November 17, 2019.

[16] Reichel C. The health effects of the ‘public charge’ immigration rule. Journalist’s Resource. https://journalistsresource.org/studies/government/immigration/public-charge-immigration-health-research/. Published September 9, 2019. Accessed November 17, 2019.

[17] Published: Aug 12 2019. Changes to “Public Charge” Inadmissibility Rule: Implications for Health and Health Coverage. The Henry J. Kaiser Family Foundation. https://www.kff.org/disparities-policy/fact-sheet/public-charge-policies-for-immigrants-implications-for-health-coverage/. Published August 13, 2019. Accessed November 17, 2019.

[18]Public Charge Rule Changes, Explained. Public Charge Rule Changes, Explained | Community Service Society of New York. https://www.cssny.org/pages/public-charge-immigration-explainer. Accessed November 17, 2019.

[19] Public Charge Outreach Toolkit. ILRC. https://www.ilrc.org/public-charge-outreach-toolkit. Published August 19, 2019. Accessed November 17, 2019.

[20] Public Charge Outreach Toolkit. ILRC. https://www.ilrc.org/public-charge-outreach-toolkit. Published August 19, 2019. Accessed November 17, 2019.

[21] Fessler P. Advocates Try To Help Migrants Navigate Trump’s Public Charge Rule. NPR. https://www.npr.org/2019/10/11/769109074/advocates-try-to-help-migrants-navigate-trumps-public-charge-rule. Published October 11, 2019. Accessed November 17, 2019.