In mid-August, the Trump administration extended its xenophobic and racist immigration agenda to the health care sector when the Department of Homeland Security (DHS) finalized its expanded “public charge” rule. The policy, which is scheduled to go into effect on October 15, 2019, would intentionally heighten the barriers immigrants already face to legal immigration and residency in the United States, either through the regulation itself or a de-facto chilling effect.
Among its many harms, the public charge rule would also threaten immigrants’ overall health and sexual and reproductive health by effectively denying them access to health insurance through Medicaid. If implemented, this policy would damage the health, financial security and well-being of immigrants and their families.
“Public Charge” Then and Now
This regulation broadens an existing policy and makes it more difficult for immigrants with low or moderate incomes to enter the country or stay as permanent residents. The previous public charge rule was problematic itself: An individual could be considered a “public charge” (and thus ineligible for entry or permanent legal residency) if they were currently or expected to be reliant on governmental cash assistance or publicly funded long-term institutional care.
The updated rule expands the list of relevant public benefits to include Medicaid, nutrition assistance and housing assistance. It also evaluates individuals’ likelihood of becoming a public charge based on their age, health, family status, financial status, education, English proficiency and skills, thus perpetuating existing social and economic inequities.
Devastating to Immigrants’ Health Coverage and Care
The rule would be devastating for immigrants and their families who rely on Medicaid. According to one estimate, there are 22.7 million people in the United States—including 10.3 million noncitizens—whose benefits fall under the purview of the rule or who have a family member who is subject to it. Most of those people are Medicaid enrollees, and millions of them may drop that coverage or not apply for coverage at all for fear of it endangering their chances to stay in the country. Medicaid is an essential source of coverage today, including for women of reproductive age: As of 2017, 29% of low-income women aged 15–44 who were not citizens were insured through the program.
By effectively denying many immigrants an affordable source of health insurance, the updated public charge rule will deepen already sizable inequities for immigrants, particularly around sexual and reproductive health. Medicaid is the central U.S. program for ensuring that people with low incomes have coverage and access to reproductive health services. Yet, many lawfully present immigrants are ineligible for Medicaid during their first five years of legal residency, while undocumented immigrants are largely barred from public coverage. As a result, 32% of million noncitizen immigrant women of reproductive age were uninsured in 2017, compared to 9% percent of U.S.-born women.
Immigrant women also face gaps in use of sexual and reproductive health services. Only half of immigrant women at risk of unintended pregnancy have received contraceptive care in the previous year, compared to two-thirds of U.S.-born women. Evidence also suggests that immigrant women are less likely to receive other preventive services, such as Pap tests and hepatitis B vaccinations. Immigrant women, particularly those who are uninsured and noncitizens, are also significantly less likely to obtain mammograms.
Counterproductive and Cruel
By undermining immigrants’ ability to obtain affordable health insurance, the public charge rule contradicts Medicaid’s central objective to provide coverage of and access to needed health care services. For many, Medicaid is the only insurance option available: Just 30% of U.S. workers with incomes below the federal poverty level are even offered employer-sponsored insurance, and many of them cannot afford the premiums. This problem is heighted for immigrants because they are more likely to have low incomes and to work in industries that seldom offer health coverage.
The impact of this rule would also run contrary to the Trump administration’s own stated goal of ensuring that immigrants to the United States are “self-sufficient.” The rule would deny people affordable health coverage that has demonstrated long-term health and financial benefits. New Medicaid enrollees report improvements to their overall health status, reduced credit card and medical debt, less difficulty paying bills and more money left over to spend on other necessities.
More so, denying coverage for family planning care specifically would interfere with people’s ability to complete their education, get and keep a job, and take care of themselves and their families. Rather than ensure access to affordable health care or promote “self-sufficiency,” this policy only furthers the administration’s attacks on immigrants’ rights and Medicaid enrollees’ ability to get the care they need.
The precise impact of the updated public charge rule is unknown, but a chilling effect is certain to extend its reach. This could manifest by people being confused about specifics of the rule or being overly cautious in using public programs. Since the draft version of the rule was proposed in fall 2018, some people have dropped out of Medicaid and other impacted programs due to fear and confusion. Anxieties over the rule are compounded by reports that the Department of Justice is currently drafting its own version of the public charge rule that would impact deportation decisions.
Meanwhile, in September, Sen. Hirono introduced a bill that would effectively block the rule by prohibiting federal funds and resources from implementing it. This is a companion to a House bill introduced in June.
All of this could be impacted by ongoing litigation challenging the DHS rule, with at least eight lawsuits having been brought by states, counties and advocacy groups across the country.