Public Charge Announcement May Have Impacted Childhood Insurance

The public charge rule, which allows for citizenship denial to certain groups of immigrants who use US safety-net programs, may have led to thousands of children being uninsured when the coronavirus pandemic struck the nation, a study published in Health Affairs noted.

“As announced, the rule penalized legal immigrants seeking permanent residence for the use of safety-net programs such as Medicaid and SNAP. Because the rule excluded multiple categories of noncitizens, it applied to only a small proportion of the total,” the researchers stated. “Nevertheless, we observed statistically significant declines in Medicaid and WIC enrollment.”

The public charge rule has been in place since the 1880s.

However, in 2018 the Trump Administration—with the backing of the Supreme Court—expanded the definition of a “public charge” to include immigrants who rely on Medicaid or Supplemental Nutrition Assistance Program (SNAP). The rule has yet to go into effect because a federal court ordered the Administration to delay implementation due to the pandemic.

The move made some experts concerned that immigrants would forego getting public insurance for fear of throwing away their chances at citizenship. Experts also feared that program directors may fail to share program information with eligible individuals based on a misunderstanding of the rule.

Previous research showed that noncitizen, legal immigrants are already more likely to be uninsured.

To clarify the impact of the Trump Administration’s 2018 public charge rule announcement, the Health Affairs study referred to county-level public program enrollment data for Medicaid, SNAP, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). The study covered enrollment from January 2015 to June 2019.

Since not all states offer program-specific public health coverage data, the study only analyzed five states that contained the highest amounts of children enrolled in the relevant programs. Altogether, these states contribute 10 percent of the SNAP-enrolled population, 15 percent of WIC child population, and 30 percent of Medicaid-covered children.

The study’s results identified a 2.33 percentage-point drop in children’s Medicaid enrollment between 2016 and 2019. SNAP enrollment in Texas dropped 3.62 percentage points and WIC enrollment in California and Washington fell over 1.6 percentage points.

Researchers found that a one percentage-point increase in a county’s noncitizen population, corresponded with a 0.1 percentage-point decrease in child Medicaid enrollment. County-by-county, this decline was larger for counties with more noncitizen residents.

As a result, nearly 79,000 children lost Medicaid insurance in the five states that this study observed. When scaled up to a nationwide level, the researchers found that this would mean that 260,000 children dropped out of Medicaid between 2017 and 2019.

In the SNAP program in Texas, the public charge rule announcement in 2018 accompanied a drop in child enrollment overall of around 0.32 percent.

As in Medicaid, the effect was particularly pronounced in counties with more noncitizens. One percentage point higher county noncitizen population size attended a 0.08 percentage point decline in that county’s child SNAP enrollment.

“Although the confidence interval crosses zero, the estimated effect implies that the decline in child SNAP enrollment after the public charge rule announcement for a county in the seventy-fifth percentile of noncitizen share was 0.83 percentage points larger than for a county in the twenty-fifth noncitizen percentile,” the researchers stated.

Expanded nationwide, this would mean that 149,000 children lost SNAP enrollment after the public charge announcement.

In California and Washington, when the Administration announced the public charge rule, every one percentage point higher noncitizen population size accompanied a 0.06 percentage point drop in child WIC enrollment.

Applied nationally, 21,000 children may have lost WIC enrollment. When placed in the context of percentage of enrollment share, this is triple the impact on Medicaid.

“Unsurprisingly, we found a smaller impact since we calculated anticipatory effects alone, while those analyses estimated the impact of the rule’s adoption,” the researches stated.

The study underscored the impact of misinformation or lack of information about the public charge rule.

Some of the largest declines in enrollment occurred in the public program that was exempt from the public charge rule. Although the rule has various exemptions, people will react based on their own perceptions of what the rule means, in this case leading to potentially unnecessary loss of coverage.

The study also highlighted the importance of healthcare coverage early on in life.

“Because the benefits in early childhood are more difficult to reproduce later in childhood, proposed legislation or regulatory changes affecting young children must be held to a higher standard than policies that do not affect this group,” the study argued. “Given this large impact and the limited autonomy during childhood, stronger defaults should be put in place to reduce the likelihood of policy changes that could cause harm to young children.”

Finally, COVID-19 has produced a situation in which healthcare coverage is more needed and more at risk than ever. The study ended with a call for greater clarity on this rule’s exemptions.

Importantly, the drop in public healthcare coverage between 2016 and 2019 did attend a strengthening economy. This may have influenced whether Americans found public coverage necessary, the researchers acknowledged.

The researchers also noted that the study results may not be entirely representative of the public charge rule’s effect on enrollment because other policies were also put into practice that made public health insurance more expensive for immigrants.

However, the researchers investigated the effects of the other policies as well and were confident that their research provided a reliable foretaste of the public charge rule’s impact when it goes into effect. Other experts have already voiced concerns about the drop in Medicaid and CHIP enrollment.