Major policy changes have gone into effect that impact the health of some of the most vulnerable children in our nation, those of low-income immigrant families. This policy, better known as the public charge rule, is part of a compendium of highly controversial and litigated health-related federal immigration policies enacted by the Administration on the basis of financial criteria.1 

The public charge rule has been traditionally used to determine ineligibility for immigration or residency status on the basis of health, education, and financial factors under the Immigration Act of 1882 and Immigration and Nationality Act of 1996. Recent changes reflect a redefinition and expansion of the term “public charge” for those applying for permanent residency.1  Under this new rule, US residency applicants who use any number of public benefits, including Medicaid, government housing, and the Supplemental Nutrition Assistance Program, are now also deemed a public charge, meaning that they are likely to become dependent on the government for subsistence.1  This label, along with other factors, can be used negatively in determinations for permanent residency applications. By tying the use of vital public health programs to immigration and residency status, the Administration is forcing a choice between seeking critical services or securing status in the United Status.

Current antiimmigrant sentiment, rhetoric, and policy changes, such as the public charge rule, have resulted in a culture of fear, misinformation, distrust, and isolation, all of which have health implications for these communities.

Tragically, it is the children of low-income immigrant families, most of whom are US citizens, who are caught in the crossfire of this larger societal debate.2  Approximately 8.3 million children in families receiving public benefits, the majority of whom are legally eligible for Medicaid and/or the Children’s Health Insurance Program (CHIP), are at risk of being impacted by this rule change as immigrant parents resist interaction with government-based public safety net programs or health care systems for fear of how it may impact their immigration determinations.2  The majority of these children are US-born citizens and have a legal right to benefits such as Medicaid and CHIP. However, many of these children’s parents are impacted by the ruling and may not understand that the legal use of these benefits by their children will not affect their own immigration status determinations. If parents are scared to access health benefits for themselves, they are much less likely to access these benefits for their children.3  A 2019 study revealed that 1 in 5 adults in immigrant families with children reported that they or a family member avoided a public benefit (eg, the Supplemental Nutrition Assistance Program, Medicaid, or CHIP) for fear of risking green card eligibility; this number was even higher among adults in low-income immigrant families with children.4  Without routine care, children become increasingly susceptible to chronic conditions and communicable diseases.5 

Among those also caught in the web are the safety net clinics and hospitals that provide necessary support for child health. With an expected 538 000 fewer patients served annually, community health centers could experience a $346 to $624 million first-year revenue decline, impacting their financial viability.6 

Since the inception of the proposed rule on October 10, 2018, the public charge rule has been mired in controversy and legal battles. In October 2019, federal judges in New York, California, and Washington issued temporary injunctions against the public charge rule, claiming it discriminates against low-income minority immigrants.7  The US Department of Justice proceeded to appeal to the Supreme Court to rule on the New York judge’s injunction. On January 27, 2020, the Supreme Court of the United States ruled by a 5 to 4 vote to lift the preliminary injunction.7  After this ruling, the US Department of Homeland Security had the ability to implement the revised public charge rule. After implementation, on July 29, 2020, a New York federal judge temporarily blocked the Administration from enforcing the policy during the coronavirus disease 2019 pandemic, arguing that the rule makes it more difficult for immigrants to seek coronavirus disease 2019 testing and care.8  On August 5, 2020, a split ruling from the US Court of Appeals for the Fourth Circuit reversed another lower court injunction that blocked the public charge rule from taking effect, thus siding with the Administration.

This legal uncertainty and mixed messaging has created great confusion and fear among immigrant communities.2  The health of low-income immigrant families (and specifically that of children) is projected to suffer because CHIP and Medicaid disenrollment is on the rise.5  By forgoing health benefits, fewer patients are expected to seek health services because of fear of connecting with the health system and therefore jeopardizing immigration determinations.5  There is often uncertainty about who the rule would apply to and whether it would apply to current green card holders and citizenship applicants, when it would be enforced, who would enforce the policy, and which public programs would be considered.5  In fact, the Urban Institute reports that nearly 4 in 5 adults do not understand that children’s Medicaid enrollment is not a factor in their parents’ public charge determination.4  In this growing climate of rapidly evolving policy changes, many immigrants, especially low-income families who are already vulnerable because of socioeconomic status and the uncertainty of navigating our immigration system, are turning away from our safety net and health care systems.

The American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American College of Physicians, and the American Psychiatric Association, which collectively represent 400 000 physicians, released a joint statement in opposition to the public charge regulation on the grounds that it imposes a barrier to care that threatens patients’ health.9  The president of the American Academy of Pediatrics reports that the rule forces immigrant families into an impossible choice: “keep yourself or your children healthy but risk being separated, or forgo vital services like preventive care and food assistance so your family can remain together in this country.”10 

Since implementation of the public charge rule, this statement has become increasingly important because it reflects the willingness of these esteemed organizations and thought leaders to advocate on behalf of their patients and communities. This united front of medical professionals operationalizes providers’ values as it relates to whole-patient care and exemplifies the concept of thinking beyond clinical walls.

The public charge rule poses a far-reaching threat to children of low-income immigrant families and has the potential to undo decades of work in increased insurance coverage and access to care. Despite the majority of these children being eligible for benefits and care, parents impacted by the public charge rule are fearful to use services even to care for their children. This is likely to impact child health outcomes. As laid out in Table 1, action is needed on multiple fronts to address this issue and support child health. Individual work and collaborative partnerships are both important moving forward to inform education, patient engagement, advocacy, and evidence generation. The latter will be powerful to inform practice and subsequent policy. Clinicians have a key role to play for a productive path forward.

TABLE 1

Recommendations to Foster an Actionable Path Forward

WhatWhoHow
Professional awareness Clinicians
Medical professional organizations 
Assessment of the literature, organizational reports, and regulatory action 
Dissemination through meetings, professional writing, practice or hospital communication channels, blogs, and education of students and trainees 
Patient engagement Clinicians Use of EHR data to identify at-risk patients 
Dissemination of standardized information and resources through the patient portal, mail, phone, clinic Web site, flyers in waiting room, and/or community organizations 
Advocacy Clinicians
Medical professional organizations
Policy makers
Community organizers 
Development of organizational policy 
Collaboration with community organizations 
Providing testimony on behalf of patients 
Use of social media (eg, Twitter) 
Evidence Clinicians
Medical professional organizations
Researchers 
Aggregation of data on practice-level metrics (eg, office visits, immunization schedules, routine laboratory work) 
Performance of qualitative research to uncover patient, family, and provider perceptions 
Performance of research to assess outcomes on child health 
Collaboration Clinicians
Medical professional organizations
Community organizers
Patients
Policy makers 
Initiation of a call to action 
Development of standardized materials for professional awareness, patient engagement, and advocacy 
Involvement in evidence generation to inform practice and policy 
 Development of policy 
WhatWhoHow
Professional awareness Clinicians
Medical professional organizations 
Assessment of the literature, organizational reports, and regulatory action 
Dissemination through meetings, professional writing, practice or hospital communication channels, blogs, and education of students and trainees 
Patient engagement Clinicians Use of EHR data to identify at-risk patients 
Dissemination of standardized information and resources through the patient portal, mail, phone, clinic Web site, flyers in waiting room, and/or community organizations 
Advocacy Clinicians
Medical professional organizations
Policy makers
Community organizers 
Development of organizational policy 
Collaboration with community organizations 
Providing testimony on behalf of patients 
Use of social media (eg, Twitter) 
Evidence Clinicians
Medical professional organizations
Researchers 
Aggregation of data on practice-level metrics (eg, office visits, immunization schedules, routine laboratory work) 
Performance of qualitative research to uncover patient, family, and provider perceptions 
Performance of research to assess outcomes on child health 
Collaboration Clinicians
Medical professional organizations
Community organizers
Patients
Policy makers 
Initiation of a call to action 
Development of standardized materials for professional awareness, patient engagement, and advocacy 
Involvement in evidence generation to inform practice and policy 
 Development of policy 

EHR, electronic health record.

“On November 2, a federal judge in Illinois vacated the public charge rule nationwide, claiming it violated administrative law (Cook County et al v Wolf et al*). On November 4, the 7th Circuit Court of Appeals placed a stay on this lower court ruling, allowing US Citizenship and Immigration Services to continue implementing the rule. It is likely that a final decision on the legality of this rule will ultimately be made by the US Supreme Court. *Cook County et al. v Wolf et al., No. 20-3150 (7th Cir. 2020) for the November 4, 2020 decision from the Seventh Circuit Court of Appeals; Cook County et al. v Wolf et al., No. 19 C 6334 (N.D. III. 2020) for the November 2, 2020 decision from the U.S. District Court for the Northern District of Illinois”

Ms Patel conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Reddy and Wilson reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

     
  • CHIP

    Children’s Health Insurance Program

1
US Citizenship and Immigration Services, Department of Homeland Security
.
Inadmissibility on public charge grounds
.
2019
. Available at: https://www.federalregister.gov/documents/2019/08/14/2019-17142/inadmissibility-on-public-charge-grounds. Accessed April 19, 2020
2
Artiga
S
,
Damico
A
.
Nearly 20 million children live in immigrant families that could be affected by evolving immigration policies
.
2018
. Available at: https://www.kff.org/disparities-policy/issue-brief/nearly-20-million-children-live-in-immigrant-families-that-could-be-affected-by-evolving-immigration-policies/. Accessed July 30, 2020
3
Ibarra
AB
.
Fearing deportation, parents worry about undocumented kids in Medicaid program
.
2017
. Available at: https://khn.org/news/fearing-deportation-parents-worry-about-undocumented-kids-in-medicaid-program/. Accessed July 17, 2020
4.
Haley
JM
,
Kenney
GM
,
Bernstein
H
,
Gonzalez
D
. One in five adults in immigrant families with children Reported chilling effects on public benefit receipt in 2019.
2020
. Available at: https://www.urban.org/research/publication/one-five-adults-immigrant-families-children-reported-chilling-effects-public-benefit-receipt-2019. Accessed July 28, 2020
5.
Bernstein
H
,
McTarnaghan
S
,
Gonzales
D
.
Safety net access in the context of the public charge rule.
2019
. Available at: https://www.urban.org/sites/default/files/publication/100754/safety_net_access_in_the_context_of_the_public_charge_rule_2.pdf. Accessed April 19, 2020
6
Rosenbaum
S
.
The new “public charge” rule affecting immigrants has major implications for Medicaid and entire communities
.
2019
. Available at: https://www.commonwealthfund.org/blog/2019/new-public-charge-rule-affecting-immigrants-has-major-implications-medicaid-and-entire. Accessed April 23, 2020
7.
US Department of Homeland Security v New York, 589 US 1 (2020)
8.
New York v US Department of Homeland Security, 19 Civ 7777 (SDNY 2020)
9
American Academy of Family Physicians
.
Joint statement of America’s frontline physicians opposing public charge proposal
. Available at: https://www.aafp.org/dam/AAFP/documents/advocacy/prevention/equality/ST-GroupSix-Public%20Charge-092218.pdf. Accessed April 22, 2020
10
Miller
D
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AAP, members speak out against ‘public charge’ proposal
.
2018
. Available at: https://www.aappublications.org/news/2018/10/16/washington101618. Accessed April 23, 2020

Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: Dr. Wilson-purchased stock options from Vitreos Health; partial funding for the BUILD Initiative from Johnson and Johnson and Medtronic. The other authors have no financial disclosures.