Defunct Public Charge Rule Still Impacts Immigrant Health Choices

Immigrant families who are in the process of getting their green cards or temporary visas continue to avoid using government-funded programs including public payer coverage due to the 2019 public charge rule, Urban Institute researchers found.

The 2019 public charge rule’s expansions—which are now no longer in effect—allowed the government to deny visas and green cards on the basis of whether an immigrant used public programs. The rule was a point of much debate, traveling up the legal system to the Supreme Court which ultimately affirmed the government’s authority to establish such boundaries.

The Department of Homeland Security stopped applying the expanded 2019 public charge rule in March 2021. Nevertheless, the rule has had repercussions for immigrants' healthcare as, one year after the rule went into effect, the nation was swept up in a global pandemic.

“Reluctance to use public benefits among families with children could have both short- and long-term consequences, because food insecurity, financial hardships, and problems accessing needed health care can affect children’s health and well-being both immediately and as they grow,” the researchers explained. 

“And given the greater financial risks and needs for assistance for noncitizens during the pandemic, program avoidance may also be particularly harmful.”

The Urban Institute researchers leveraged the organization’s Well-Being and Basic Needs Survey (WBNS) which is an online, national survey of immigrant families.

The survey results showed that one-fifth of immigrant adults with children and a little over a quarter of low-income immigrant families with children had avoided leveraging public benefits in 2020. These public benefits could have helped address social determinants of health needs.

Of the public benefits that immigrants avoided—which could include food aid and housing assistance—the second most common benefit that immigrant adults with children reported avoiding were public payer programs: Medicaid and Children’s Health Insurance Program (CHIP). The most common benefit that this population avoided was food aid.

Over six percent of immigrant adults with children avoided public payer benefits. As a result, nearly 30 percent of adults said that a family member had foregone care due to affordability or that they were struggling to pay medical bills and a little more than 30 percent had an uninsured family member.

For many, their decisions to forego care did not appear to be for lack of need. Over four in ten adults in immigrant families with children reported that a household member had a chronic disease or disability.

Immigrants with children were more likely to forego public benefits, compared to individual immigrants without children.

Adults in families with nonpermanent residents were most likely to have had a family member forego using government benefits, followed by adults in families with green card holders.

Specifically, among those who reported that someone in the family did not receive medical care because of cost barriers or that they struggled to pay medical bills, 39.2 percent were nonpermanent residents, 31.9 percent were green card holders, and 22.2 percent were naturalized citizens.

Additionally, in that same population, 55.2 percent of the nonpermanent residents were uninsured, compared to 29.1 percent of the green card holders and 19.4 percent of naturalized citizens.

The researchers stressed that targeted outreach will be crucial in boosting immigrant families' use of public benefits, now that the public charge expansions have been eliminated. Additionally, they looked favorably on the American Rescue Plan’s ability to diminish the 2019 public charge rule’s repercussions.

Apart from diminishing the immediate impacts of the rule, the researchers gave recommendations for correcting the long-term implications, specifically broadening immigrants' access to safety net programs. 

Previous studies have indicated that a failure to reinforce immigrants' access to public payer programs due to the public charge rule expansions may result in poor health outcomes and increased uninsurance among immigrant children.

“Though a small number of states and localities have helped support immigrants ineligible for federal relief, such as through cash assistance programs, expansion of state tax credits, and expansions of eligibility for health care benefits, federal legislation to change immigrant eligibility rules more broadly would be necessary to expand benefit eligibility to more immigrants nationwide,” the researchers explained. 

“Federal proposals to improve the functioning of the immigration system and provide a path to citizenship for many undocumented immigrants could also expand access to benefits, though such proposals face legislative hurdles.”