Trump Administration ‘Public Charge’ Rule Threatens Health Care for Immigrant Families, Including U.S. Citizen Children

Last week, the Washington Post published a leaked draft of a proposed regulation to drastically change requirements for certain immigrants to enter the United States and/or become permanent residents. The proposed regulation targets families who have immigrated lawfully, as well as their U.S. citizen relatives, by undermining their access to basic needs, including food, shelter, and health care. This would undercut years of hard work to build a better future for themselves, their communities, and our nation.

The proposal has several more steps to go before it is finalized, but it is important for the public to understand the harm it could cause to families and to the nation’s health care system now. There is still time for health advocates and the general public to raise their voices against this heartless, un-American proposal.

What the leaked draft proposes

Most immigrants who are either entering this country or applying for lawful permanent residency must show that they are not likely to become a “public charge” – that is, they will not be dependent on the U.S. government for their financial support.  For many years, the test for public charge has included a look at two types of benefits:

• whether applicants ever received cash assistance, such as Temporary Assistance for Needy Families (TANF) or Supplemental Security Income (SSI), and whether they are likely to need that cash assistance in the future; and
• whether applicants are likely to need long-term nursing home care paid for by the government.

Other health care benefits were off limits for this public charge determination.

The draft regulation proposes to change this rule. It expands the list of benefits that would be considered in a public charge determination to include (among others) whether the applicant or his/her dependents ever purchased health insurance through the marketplace with federal premium tax credits, or enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), and their likelihood of receiving these health care benefits in the future.

In recent days, another troubling issue has surfaced: Under current policy, public charge determinations generally affect the ability of families to improve their immigration status, but they generally cannot result in deportation.  Proposed regulations may change this longstanding rule, increasing the authority of federal immigration agencies to deport immigrants based on nothing more than their use of health care services or other assistance for which they fully qualify.

How will this proposal harm families’ health?

If adopted, this rule will force families to choose between staying together and getting the health care they need, even for the family members who are US citizens. It will discourage people from signing up for health insurance and, as a result, they will lose their access to care.

The proposed rule will have a huge impact on the health and well-being of children in particular. Medicaid and CHIP help millions of children get the regular care they need to develop into healthy adults. For example, CHIP and Medicaid cover oral health care so that toothaches won’t distract kids from school lessons, vision exams and glasses to help kids see the blackboard, vaccines and prompt care for the flu to keep children and their schoolmates healthy, and treatment for life-threatening conditions such as asthma. This proposal would force parents to make awful decisions. They could insure their children, who are legally entitled to health care benefits, but that could prevent the parent from becoming a lawful permanent resident. Which is better: to jeopardize the child’s health, or jeopardize the family living together?

The health insurance coverage of many working adults will also be in peril. Currently, legally present adults whose employers don’t offer affordable health insurance are able to get covered through the Health Insurance Marketplace and receive sliding scale financial assistance to help pay for the health plan they choose if they qualify. With health insurance, adults can keep themselves healthy and able to work and parent, keep contagious diseases from spreading to their coworkers and communities, and afford to get their illnesses treated before they worsen.

Currently, these health benefits are not included in public charge calculations for applicants seeking legal entry or lawful permanent residency. The leaked proposed rule would change that. If an immigrant, or even the immigrant’s citizen child, sought, applied for, or received health coverage through Medicaid, CHIP, or through the marketplace with premium tax credits, it could be held against them in public charge determinations.

Every form of health insurance involves some form of public subsidy in addition to whatever amount people pay for care themselves: employers get a tax deduction for covering their workers; people who buy their own health insurance similarly get tax deductions based on their incomes. There are subsidies for Medicare as well. It makes no sense to consider Medicaid, CHIP, and marketplace coverage in a public charge determination when the cost of health care is always shared broadly.

How will this proposal harm communities’ health?

The impact of this proposed rule extends well beyond the directly targeted individuals and families whose health will be at risk. A community’s overall health depends on the health of all of its members. The impact of this proposed rule will spill over to others in many ways. Without insurance, families may delay care or forego it altogether. This means there will be more children in school, and adults in the workplace, without needed preventive services and untreated illnesses. More people delaying care until the last possible moment will strain emergency resources. Hospitals’ and clinics’ uncompensated care burdens will increase.

The proposal will further undermine the individual health insurance market. Health insurance marketplaces must include enough people to attract insurers; they must include a mix of consumers, including many that are in good health, in order to offset the cost of care to those who are sicker. By forcing immigrants and temporary residents to choose between leaving their families uninsured or risking their residency status, the proposed rule will shrink marketplace enrollment.  Moreover, given that immigrants are, on average, much healthier than citizens, the pool will be sicker in addition to smaller. This is another potential blow to the stability of the marketplace.

The proposal will also hurt the health care workforce. About 17 percent of all health care workers and nearly one-fourth of health care support workers, such as nursing aides and home health aides, are immigrants. All too frequently, agencies that employ these health care workers do not provide them with insurance, and so these workers must rely on the marketplace or on Medicaid for their coverage. As baby boomers age and more and more people need health care services, including home care, discouraging these immigrants from coming to help, and making it harder for health care workers to get the coverage they need to stay healthy, are exactly the wrong things to do.

What immigrants would be affected?

Most commonly, the immigrant groups who are subject to public charge determinations are relatives coming to the US to reunite with family members who live here. This includes spouses, children, and parents of US citizens, and family members of lawful permanent residents (“green card” holders) who may have stayed behind in another country until one parent established a home and work in the United States. Sixteen million U.S. children have foreign-born parents. Each year, about 700,000 immigrants seek permanent residency in the U.S. to be united with family. People coming to the US for temporary work and their family members will also be affected, both when they initially apply to come to the United States and if they decide to seek permanent residency.

Some groups of immigrants – such as refugees, asylees, people fleeing domestic violence, and some other protected groups – are not subject to public charge determinations and would not be affected by this proposed rule.

What you can do

Making families choose between being together or being healthy is cruel, short-sighted, and bad for the whole country. It is also an affront to our core values as a nation. But we have a chance to take a stand.  We expect the proposed rule to be posted in the Federal Register for public comment very soon. As a member of the Protecting Immigrant Families campaign, Families USA has partnered with immigrant advocacy, anti-hunger, and anti-poverty, and other social justice organizations to present a united opposition to this dangerous proposal.

You can make a difference, and we need your help. Once the rule is posted, you can submit comments directly to the federal Department of Homeland Security. Meanwhile, express your concerns to elected officials, such as members of Congress, and to the media. Talk to health care providers and community organizations about the likely effects of this proposal in your community to get information to include in your comments, and get them to speak up too.  Immigrants have always been part of the lifeblood of our nation. We must stand together to protect them.