Legal immigrants will jeopardize their legal status in the U.S. if they use government benefits like Medicaid under a controversial rule finalized by the Trump administration Monday.
The so-called public charge rule, published in the Federal Register by the Department of Homeland Security, will allow federal immigration officials to consider legal immigrants' use of public health insurance, nutrition, housing and other programs as a strongly negative factor in their applications for permanent legal residency.
Other negative factors include having a medical condition that will interfere with being able to work or go to school; not having health insurance or being able to afford medical costs; and being younger than 18 or older than 61.
It takes effect on Oct. 15 and is not retroactive for participation in public benefit programs before the rule takes effect.
"The benefit to taxpayers is seeking to ensure that legal permanent residents can stand on their own two feet," said Ken Cuccinelli, acting director of the U.S. Citizenship and Immigration Services. "That self-sufficiency is a central part of the American value set."
But leaders of many healthcare organizations, including the American Hospital Association, America's Essential Hospitals, the American Academy of Family Physicians and the American Academy of Pediatrics, warn that the rule will hurt public health efforts and reduce their ability to serve millions of low-income children and families. They point to evidence that fear created by the proposal already has shrunk participation in health programs.
"This rule... creates barriers to appropriately caring for the sick and injured, and to keeping people healthy," said Rick Pollack, CEO of the American Hospital Association, in a statement. "Failure to provide such services also has public health implications that could have widespread impact."
Hundreds of thousands of children and other members of low-income legal immigrant families are likely to drop out of public programs providing healthcare, nutrition and housing assistance due to the 837-page rule, experts said.
The changes also would apply to citizens' and legal residents' requests to bring family members into the U.S., as well as to young people who have legal status under the Deferred Action for Childhood Arrivals program, known as Dreamers. They would not apply to people granted refugee status or political asylum.
The public benefits covered by the proposed rule include Medicaid, the Supplemental Nutrition Assistance Program and Section 8 housing vouchers. The agency did not include the Children's Health Insurance Program, after asking for public comment on that issue.
The final rule also excluded Medicaid received by pregnant women and those under age 21, as well as public benefits received by legal immigrant children of U.S. citizens.
Immigrants affected by the rule would have to use one of the designated public benefit programs for more than 12 months in total within any 36-month period.
The Trump administration pushed through the rule despite receiving more than 260,000 public comments last fall, with the overwhelming majority opposing the rule. Many commenters urged the administration to withdraw the entire rule.
Immigration officials currently are only allowed to consider families' use of public cash benefits and Medicaid long-term care benefits in evaluating applications for legal permanent residency and legal entry into the United States. A 1999 rule clarification said noncash benefits like Medicaid cannot be considered.
DHS has said the rule is consistent with long-standing U.S. policy requiring immigrants to show they can support themselves financially.
The agency said the rule will reduce federal and state spending on public benefit programs by $17.3 billion to $21 billion over 10 years. But it acknowledged that might negatively affect state and local economies, resulting in reduced revenues for healthcare providers, medical suppliers and other businesses.
In addition, DHS said the rule will impose "familiarization" costs on providers and other groups because it will take an estimated 16 to 20 hours per person to study the complex rule.
Healthcare leaders claim the rule would drive up uncompensated-care costs, increase use of emergency departments, endanger maternal and infant health and heighten the risk of infectious disease epidemics. It also could shift major costs from the federal government to state and local governments.
The American Hospital Association and other groups warned that legal immigrant families may forgo healthcare benefits and services out of fear of repercussions, such as deportation. That could drive up costs for all patients and payers.
DHS estimated the regulation will affect about 382,000 people a year. But many experts predicted it will have a far broader impact because families will worry that any member's use of a public benefit programs could jeopardize their legal status.
Those concerns likely will spill over to families and family members to whom the rule does not apply including citizen children of undocumented immigrants, those applying for political asylum and those who already have green card status or are naturalized citizens.
The chilling effect is even expected to reduce participation in programs not covered by the rule, such as CHIP; the Women, Infants and Children nutrition program; Head Start; and Affordable Care Act premium subsidies, experts said.
"Pediatricians across the country have witnessed the chilling effect, with immigrant families disenrolling or avoiding health services," said Dr. Julie Linton, chair of the American Academy of Pediatrics' Council on Immigrant Child and Family Health. "I'm unsure how to guide families when I know enrollment in key health programs could jeopardize their families' unity."
Cuccinelli sidestepped questions Monday about the chilling effect, saying that people can easily determine from his agency's website whether use of particular public benefit programs would adversely affect their legal permanent residency application.
In 2016, there were 10.4 million citizen children with at least one parent who isn't a citizen, and 56% had Medicaid or CHIP coverage. An estimated 27 million immigrants and their children are part of families with at least one member receiving public benefits, according to the Migration Policy Institute.
The Kaiser Family Foundation estimated last year that up to 2 million children who are U.S. citizens with immigrant parents could drop out of Medicaid and CHIP, and most would become uninsured.
A study published in May by the Urban Institute found that 13.7% of adults in immigrant families reported they did not participate in public benefit programs because they feared losing their legal status under the then-proposed rule. The percentage rose to 20.7% among adults in low-income immigrant families.
Of the families that reported not participating in a public benefit program due to concerns about the rule, 14.7% were in families where all the members who weren't citizens already had green cards, and 9.3% were in families where all members were naturalized citizens.
Adults in immigrant families with children were more than twice as likely to report chilling effects as adults in families without children—17.4% versus 8.9%.
SNAP, Medicaid and CHIP were the three most common programs that immigrants reported dropping out of or not signing up for.
The public charge rule is part of the administration's broader campaign to limit both legal and illegal immigration.
Marielena Hincapié, executive director of the National Immigration Law Center, said her organization and other groups will sue the agency to block the rule.
A group of 17 state attorneys general recently sent a letter to the Office of Management and Budget warning that DHS had failed to estimate the true costs of the public charge rule, including injury to states' economies.
House Democrats have filed a bill to block funding for the rule's implementation.