Expert Commentary

The potential health effects of the ‘public charge’ immigration rule

This research roundup looks at the potential health care-related effects of the new "public charge" rule due to go into effect Oct. 15.

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On Aug. 14, the U.S. Department of Homeland Security issued a rule to restrict immigrants’ ability to obtain legal permanent residency, based on whether they have received government benefits. The rule is due to go into effect Oct. 15.

The rule considers immigrants who receive benefits such as the Supplemental Nutrition Assistance Program (SNAP) and Medicaid likely to become “public charges.” (Also known as food stamps, SNAP is a program that offers low-income adults a form of debit payment to purchase groceries at authorized retailers.) Per a definition from the U.S. Citizenship and Immigration Services, the term “public charges” refers to individuals who are “likely to become primarily dependent on the government for subsistence, as demonstrated by either the receipt of public cash assistance for income maintenance, or institutionalization for long-term care at government expense.” These individuals would be denied green cards, which provide a legal means for immigrants to remain in the country permanently.

This new rule is an expansion of a policy that has existed since 1882. Currently, immigrants can be considered public charges if they are in long-term institutional care or if they rely on Supplementary Security Income, which supports people who are disabled, blind, or aged.

“The public charge rule is affecting people who have been admitted legally to the U.S., but they have not yet become citizens,” says health policy researcher Leighton Ku, a professor and director of the Center for Health Policy Research at George Washington University. “The public charge rule is basically saying that people who are participating in Medicaid, SNAP or public housing may find that they cannot become lawful permanent residents — that is, they can’t get a green card.”

This roundup of research looks at the public charge rule from a variety of angles. First, we summarize research that examines the economic mobility of immigrants as well as their health care expenditures compared with the rest of the U.S. population. Overall, the research finds that immigrants account for a disproportionately smaller share of health care expenditures than the U.S.-born population.

Next, we summarize research predicting health care-related effects of the new rule — repercussions that might affect both immigrants and U.S.-born individuals who seek medical care at community health centers, children with special medical needs born to immigrant parents and people who rely on home health care provided disproportionately by immigrants.

Ku says that some of the research is preliminary, because of the recency of the rule. It’s worth noting that some of the work has not yet been published in peer-reviewed journals. “If you have a cutting edge issue, you don’t want to wait for six months to a year to two years for something to get out,” Ku explains. Two pieces of scholarship included in this roundup — a working paper and an academic policy brief — haven’t been peer reviewed. (To learn more about the differences between peer-reviewed research, working papers and white papers, consult our tip sheet).

As journalists work to communicate the potential impacts of the public charge rule, Leah Zallman, who is director of research at the Institute for Community Health, a primary care physician at Cambridge Health Alliance and an assistant professor of medicine at Harvard Medical School, offers the following advice:

“I think the biggest thing that journalists can do is be really clear and concise about who the rule applies to and who it does not,” she says. “This does not apply to people who have their green card. It does not apply to citizens. And even among the people for whom it does [apply], there are a lot of exclusions.”

For example, she notes, the rule does not count Medicaid received by pregnant women or individuals under age 21 as a benefit that would render these groups ineligible for permanent residency.

Zallman adds that it is also important to clarify misperceptions about which benefits are included in the new public charge rule.

The Department of Homeland Security lists the following as benefits that would render recipients ineligible for permanent residency under the new public charge rule:

  • Any federal, state, local, or tribal cash assistance for income maintenance
  • Supplemental Security Income (SSI)
  • Temporary Assistance for Needy Families (TANF)
  • Federal, state or local cash benefit programs for income maintenance (often called “General Assistance” in the state context, but which may exist under other names)
  • Supplemental Nutrition Assistance Program (SNAP, or formerly called “Food Stamps”)
  • Section 8 Housing Assistance under the Housing Choice Voucher Program
  • Section 8 Project-Based Rental Assistance (including Moderate Rehabilitation)
  • Public Housing under section 9 the Housing Act of 1937, 42 U.S.C. 1437 et seq.
  • Federally funded Medicaid (with certain exclusions)

She also suggests journalists stress that the rule hasn’t yet gone into effect and that it might be delayed due to ongoing litigation. Additionally, the rule stipulates that benefits that individuals have received in the past will not be held against them – only when the public charge rule goes into effect does receipt of benefits become a potential issue.


The Economic Mobility of Immigrants: Public Charge Rules Could Foreclose Future Opportunities
Ku, Leighton; Pillai, Drishti. Center for Health Policy Research at George Washington University’s Milken Institute School of Public Health working paper, November 2018.

This paper challenges an assumption underlying the new public charge rule. “At its heart, the policy is based on the belief that the United States should screen out and exclude low-income immigrants, especially those who use public benefits, because they may remain poor in the future and fail to contribute to the nation’s economy,” the authors write.

To test this assumption, the authors analyze data from the 2016 American Community Survey (ACS), a large, nationally representative survey conducted by the Census Bureau. They model how immigrants’ income changes over time as compared with non-immigrants. They find that while immigrants start out with lower incomes than U.S.-born individuals of the same age, they eventually catch up. “With time and experience, immigrants’ job skills, language proficiency and social capital accumulate and the gap between the U.S born and immigrants gradually converges, on average within about twenty years,” the authors write.

Further, when comparing immigrants and non-immigrants with less than a high school education, immigrants — who start off with relatively lower incomes — are able to close the income gap faster than their peers with more education. These less educated immigrants are able to close the gap separating them from similarly situated U.S. citizens within six or seven years, on average. “The economic mobility of less educated (and low income) immigrants is especially strong,” the authors write.

“Policies that make it harder for recent low-income immigrants to remain in the U.S. ignore the upward progress that immigrants have as they assimilate into the mainstream, which has been part of the immigrant experience for generations,” they conclude.

Medical Expenditures on and by Immigrant Populations in the United States: A Systematic Review
Flavin, Lila; Zallman, Leah; McCormick, Danny; Boyd, J. Wesley. International Journal of Health Services, August 2018.

This review looks at the state of the research on health care expenditures of U.S. immigrants and U.S.-born individuals. “A common misperception among U.S. policymakers and the general public is that immigrants use more health care assets than those born in the United States, thereby draining our country’s medical resources,” the authors write. This paper addresses that misperception through a systematic review of the literature. After evaluating the relevancy of 188 papers related to the topic, the researchers ultimately decided to summarize 16 studies published between 2000 and 2017.

Key findings:

  • Immigrants’ overall health care expenditures were between one-half to two-thirds that of U.S.-born individuals.
  • Per capita public health care expenditures (e.g., Medicaid and Medicare) were lower for immigrants than for U.S.-born citizens.
  • Further, immigrants, including those without documentation, contributed $14 billion more to Medicare’s Trust Fund than they withdrew.
  • In 2003, immigrants who had lived in the U.S. for less than 10 years had annual health care expenditures of $1,380, on average. U.S.-born individuals had expenditures of $3,156.
  • Immigrants account for a disproportionately small percentage of health care expenditures relative to the U.S.-born population. While they account for 12% of the population, they account for 8.6% of total U.S. health care expenditures, per an analysis of data collected between 1999 and 2006. Undocumented immigrants account for 5% of the population and 1.4% of total medical expenditures, according to analysis of data from 2000 to 2009.
  • The majority of emergency Medicaid users were immigrants without documentation. Their expenditures accounted for less than 1% of Medicaid’s total budget.
  • “While annual U.S. medical spending in 2016 was a staggering $3.3 trillion, immigrants accounted for less than 10% of the overall spending — and recent immigrants were responsible for only 1% of total spending,” the authors conclude. “Given these figures, it is unlikely that restrictions on immigration into the United States would result in a meaningful decrease in health care spending.” Further, the study authors add that restricting immigration would “financially destabilize” aspects of the health care economy, such as Medicare, to which immigrants contribute more than they withdraw.
  • “Latino immigrants were 20% less likely to have health insurance than their non-Latino white U.S.-born counterparts,” the authors write. “Even when immigrants were insured, they had lower health care expenditures.” They suggest that immigrants “may constitute a low-risk pool that subsidizes the insurance market for U.S.-born individuals.”

How Could the Public Charge Proposed Rule Affect Community Health Centers?
Ku, Leighton; et al. Geiger Gibson / RCHN Community Health Foundation Research Collaborative Policy Issue Brief, November 2018.

This study comes from scholars at the Milken Institute School of Public Health at the George Washington University who have received support from the RCHN Community Health Foundation, a non-profit devoted to supporting community health centers through investment, outreach, education and research.

Federally-funded community health centers are legally required to serve all community residents, regardless of insurance status. Reimbursements from Medicaid — a health insurance program for people who don’t have sufficient income or resources to otherwise attain health insurance — are the single largest source of revenue for these centers. Accordingly, as Medicaid enrollment rises, community health centers are likely to see increased Medicaid revenue. Recent policy reforms provide evidence to this effect: Community health centers in states that did not expand Medicaid eligibility following policy changes that took effect in 2014 tend to be smaller and serve fewer patients than those in expansion states.

Because the new “public charge” rule would consider Medicaid enrollment a factor in denying green card applicants permanent residency, the authors of this study predict that many people – including U.S. citizens — will disenroll from the program. The authors go on to estimate potential effects on community health centers.

The researchers estimate that about 5.3% of the 13.3 million Medicaid beneficiaries who received care at community health centers in 2017 — that’s 709,000 individuals — were immigrants who entered the country legally but were not yet citizens. The researchers suggest that members of this group might disenroll from Medicaid due to the public charge rule. They add that citizen family members and family members who entered the country legally but are not yet citizens might also disenroll, bringing the estimate of people who might disenroll up to 2.6 million people.

The researchers estimate community health centers could lose between $346 million and $624 million in Medicaid revenue in a year as a result of the new “public charge” rule.

They indicate that if half of the immigrants who entered the country legally and used community health centers in 2017 disenrolled from Medicaid, community health centers would lose $346 million in a year. The centers, however, will continue to serve all, and so the researchers expect demand to stay the same while reimbursement revenue decreases (self-pay for services received at community health centers depends on income). In turn, health centers might reduce staff and hours, scale back services or close entirely. The researchers estimate that 295,000 fewer patients will receive care in a year due to potential cutbacks related to decreased revenue.

Higher estimates, which take family members into account, predict a $624 million yearly revenue loss as well as reductions in patient capacity. Centers would be able to provide care to over half a million fewer patients over one year. These estimates affect the entire community, regardless of immigration status. “Health centers care for everyone in the community without regard to citizenship status or other personal characteristics not related to health care need,” the authors write. “Because the communities in which health centers operate also tend to have sizable immigrant populations, policies that either directly or indirectly implicate their Medicaid enrollment are likely to produce significant spillover effects.”

Trends in Food Insecurity and SNAP Participation Among Immigrant Families of U.S.-Born Young Children
Bovell-Ammon, Allison; et al. Children, 2019.

This research finds that despite their eligibility, many immigrant parents whose children are U.S. citizens do not participate in the federal Supplemental Nutrition Assistance Program (SNAP), commonly known as food stamps. The study involved 37,570 caregivers of young children who were interviewed in emergency rooms and primary care clinics in cities across the U.S. to determine their food security status and participation in SNAP. Of the caregivers in the sample, 21.4% were immigrants.

The findings indicate a sharp decline in participation among immigrant families in the first six months of 2018. Lead researcher Allison Bovell-Ammon spoke with Journalist’s Resource in November 2018, after she presented her findings at the American Public Health Association’s annual meeting. She said her findings document a “chilling effect” in immigrant communities in which fear prevents immigrants from accessing social programs despite their continuing eligibility. This matches anecdotal reports from frontline providers, she added.

Bovell-Ammon’s research finds that among foreign-born mothers in the study who had been in the United States for less than five years, SNAP participation stood at 43% in 2017. It then dropped to 34.8% in the first half of 2018. For families in the study that had been in the U.S. for more than five years, SNAP participation grew to 44.7% in 2017 and then dropped to 42.7% in 2018. Throughout the period studied, SNAP participation was higher among families with U.S.-born mothers than with immigrant mothers.

Meanwhile, food insecurity rates grew among all groups from 2007 to 2018.

“Food insecurity is associated with poor health outcomes from the prenatal period all the way through old age,” Bovell-Ammon told Journalist’s Resource. “SNAP is effective at reducing food insecurity, which improves health,” she added.

Forgoing Food Assistance out of Fear: Simulating the Child Poverty Impact of Making SNAP a Legal Liability for Immigrants
Laird, Jennifer; Santelli, Isaac; Waldfogel, Jane; Wimer, Christopher. Socius, 2019.

This study estimates the effects of the public charge proposal on SNAP enrollment. The authors look at data came from the 2017 Current Population Survey, conducted by the Census Bureau and the Bureau of Labor Statistics. They estimate the effects on children if between 2% and 35% of adult noncitizens seeking green cards cancel their SNAP benefits for the entire household.

At the lower end of the range, the authors estimate that about 300,00 people will disenroll in SNAP in response to changes to the public charge rule. Over one-third of this group consists of U.S. citizen children, the authors specify. At the high end of the range, they estimate that up to 7.9 million people — including almost 2 million children, most of whom are U.S. citizens — will lose access to SNAP.

“The typical SNAP household with noncitizens would have to increase their income by more than 10 percent to make up for their lost SNAP benefit,” the authors calculate. If this is not possible, the authors predict an increase in the country’s child poverty rate.

Implications of Changing Public Charge Immigration Rules for Children Who Need Medical Care
Zallman, Leah; et al. JAMA Pediatrics, July 2019.

This study estimates how many children might lose benefits through programs such as Medicaid and the Children’s Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program due to changes to the public charge rule. The authors looked at nationally representative survey data on 4,007 children under age 18. Included were children who were insured by Medicaid and CHIP or resided in a household where at least one household member reported receiving SNAP. Kids who lived with at least one non-citizen adult were considered by the researchers to be at risk of losing benefits. The researchers made their estimates by drawing on a similar, past scenario: In 1996, the federal government made changes to Medicaid eligibility requirements; subsequently, immigrant parents – and their children — dropped out of the program.

The researchers estimate that 8.3 million children currently enrolled in Medicaid and CHIP or receiving SNAP benefits are at risk of disenrollment. About 5.5 million of these kids have specific medical needs, which the authors define as a medical diagnosis or disability or need for a specific treatment.

Zallman and her colleagues emphasize that because the public charge rule does not apply to individuals under age 21, children will be needlessly deprived of health care because of fear and confusion.

The authors add that their analysis might underestimate the number of children at risk of losing benefits. “Because of widespread fear and confusion, some immigrant families in which all members are citizens might also disenroll from benefits,” they write. “Similarly, our estimates of the number who may disenroll are based on scenarios from welfare reform that denied federal benefits to some immigrants but did not impose specific sanctions; because the proposed public charge rule explicitly threatens families’ immigration status, disenrollment rates might be higher than we estimate.”

Care for America’s Elderly and Disabled People Relies on Immigrant Labor
Zallman, Leah; et al. Health Affairs, June 2019.

This study analyzes nationally representative survey data collected on 180,084 adults in 2017 to understand the composition of the “direct care” workforce. The data came from the 2018 Current Population Survey, conducted by the Census Bureau and the Bureau of Labor Statistics. The researchers define direct care occupations as those in the personal and home care field, including home health aides and nursing and psychiatric aides. For the purposes of their analysis, respondents who were born outside the U.S. were considered immigrants. The survey did not collect information about documentation status, so the researchers used a method that has been applied previously to this dataset in labor economics and health care research to estimate proportions of unauthorized immigrants.

Key findings:

  • In 2017, 27.5% of direct care workers were immigrants.
  • Immigrants with legal, noncitizen status accounted for 9% of direct care workers. Naturalized citizens made up 13.9% and unauthorized immigrants totaled 4.3% of direct care workers. For reference, the paper cites the following statistics: immigrants with legal noncitizen status comprise 5.2% of the U.S. population, naturalized citizens make up 6.8% and unauthorized immigrants account for 3.6%.
  • Immigrant health care workers were more likely than U.S.-born workers to be employed by home health agencies (13.1% vs. 7.9%) and in settings such as private households and residential facilities that do not have nursing services.
  • The authors write that these findings emphasize immigrants’ disproportionate role in providing health care support for people in the U.S. “In light of current shortages, high turnover rates, low retention rates, growing demand for direct care workers, and immigrants’ already disproportionate role in filling such jobs, policies that curtail immigration are likely to compromise the availability of care,” the authors write. “Moreover, the anti-immigrant rhetoric and policies that restrict immigration threaten the health and well-being of immigrants who are entrusted with the care of the nation’s elderly and disabled people.”

Looking for more research? We’ve written about a study that finds enrollment in the Supplemental Nutrition Assistance Program (SNAP) and the Affordable Care Act declined among Hispanic citizens of the United States after a new immigration enforcement program took effect.

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