On September 21, 2018, the Secretary of Homeland Security signed a proposed rule that would allow immigration officials to refuse admission and deny visa extensions to immigrants who use public benefits, such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, and federally-funded housing assistance programs. The Department of Homeland Security (DHS)’s rule seeks to prevent immigrants from becoming “public charges” dependent on these benefits, with the stated purpose of ensuring self-sufficiency. The proposed rule would have a troubling impact on the health of many people living in the US, citizens and noncitizens alike.
In the U.S., noncitizens (which include both documented and undocumented immigrants) are significantly less likely than citizens to have health insurance. In 2016, 17% of documented and 39% of undocumented immigrants residing in the U.S. were uninsured, while only 9% of citizens were uninsured, among the nonelderly population. The public charge rule would only further dis-incentivize documented immigrants’ enrollment in Medicaid, as well as other federally-funded programs that contribute to improved health outcomes. The rule, for example, would likely affect lawfully present immigrants and mixed-status families (those in which some members are documented and some are not), and may discourage immigrants from accessing health services for their U.S.-born children. Physicians have already observed that individuals excluded from the rule’s scope, “including refugees and asylum seekers, are afraid to apply for benefits, worried that their legal status will be threatened next”.
The public charge rule’s potential “chilling effect” is not a new phenomenon in this context. Concerns about exposure to immigration law enforcement authorities already deters many immigrants from accessing needed health care services. For example, in Baltimore, a pregnant immigrant woman diagnosed with syphilis left a health clinic after seeing an armed security guard at the door because she feared deportation. According to the Migration Policy Institute, even though the public charge rule has not yet been adopted or implemented, “there is some evidence to suggest this chilling effect is already taking place, as service providers report some immigrant clients dropping out and others failing to access benefits for which they are eligible”. Once in effect, the rule would likely discourage many more.
The proposed rule, moreover, could also adversely affect the health of U.S. citizens. The public charge rule would does not extend to Medicaid Emergency services, meaning that an immigrant’s use of such services could not serve a criteria for determining green card and visa eligibility. However, when patients with treatable conditions avoid seeking care and turn to health systems only for emergency services, costs increase because hospitalizations tend to be more costly than outpatient primary care. A National Academy of Medicine study found that high rates of un-insurance can destabilize local health care systems, affecting the quality and timeliness of care for insured people, as well as uninsured people. Additionally, decreased enrollment in health insurance threatens the general population’s health, putting the public at a heightened risk of contracting preventable diseases.
The proposed public charge rule not only deters immigrants from utilizing Medicaid and other social services, it fosters additional distrust in the health system and health providers among these communities. Moreover, it puts immigrant families in the impossible position of having to decide between accessing essential social services and risking the possibility of deportation.