Bioethics Forum Essay

Immigrant Health and the Moral Scandal of the “Public Charge” Rule

A long-anticipated policy change proposed by the Trump administration that would count the use of many federally-subsidized programs against immigrants currently eligible to use them threatens public health and would undermine ethical practice in health professions and systems.

The policy would expand the definition of a public charge, someone likely to become dependent on government assistance. Noncitizens identified as likely public charges would become ineligible for lawful permanent resident (green card) status and for family reunification visas. As reported by NPR, Vox, and other news outlets based on the administration’s  public notice last spring and on analysis of leaked drafts of the Department of Homeland Security’s proposed public charge policy, this change would likely strip low-income households of access to a wide range of health-related benefits. While noncitizens who are legal residents in the U.S. would remain eligible for these benefits, enrolling in them could jeopardize their immigration status.

By portraying settled immigrants and prospective citizens as drains on American society, the proposed policy change is profoundly morally troubling. It raises at least four specific challenges to ethical practice in health professions and systems.

First, it will accelerate chilling effects on health care access and use of health-related services by immigrant households. The Migration Policy Institute’s analysis of the draft rule indicates that the expanded definition of public charge will likely include use of Medicaid apart from emergency benefits; publicly subsidized health insurance; the Children’s Health Insurance Program (CHIP); the Supplemental Nutrition Assistance Program (food stamps); the Special Supplemental Nutrition Program for Women, Infants, and Children; Section 8 housing vouchers and means-test home energy assistance programs; Temporary Assistance to Needy Families (TANF) and other state or local income maintenance programs; and tax credits. Legally present immigrants are currently eligible for these programs if they meet income and other criteria; undocumented (unauthorized) immigrants are ineligible for these programs. By making it risky for immigrants to apply for and use publicly funded benefits intended for low-income individuals and families, the public charge policy would especially disadvantage certain immigrant populations. According to MPI, “it would become more difficult for children, the elderly, persons with lower levels of education and/or limited English proficiency, and those with incomes under 250 percent of the federal poverty level to enter and remain in the United States.”

Impeding immigrants’ access to health-related benefits undermines population health. In a recent commentary in the New England Journal of Medicine, Krista Perreira, Hirokazu Yoshikawa, and Jonathan Oberlander–three eminent social science researchers who have studied the effects of public policy on low-income families, including immigrant households–concluded, “if this rule takes effect, it will most likely harm the health of millions of people and undo decades of work by providers nationwide to increase access to medical care for immigrants and their families.”

Second, this move undermines trust between immigrants and systems that aim to support health. While federal authorities responsible for immigration services have long had authority to limit noncitizens’ access to publicly funded programs, earlier restrictions excluded use of medical, nutrition, and similar programs being used to deny permanent residency or citizenship on public charge grounds. If a physician, nurse practitioner, medical social worker, or case manager cannot responsibly encourage an immigrant parent to enroll her U.S.-born child in health insurance or encourage this parent to use other subsidized programs for which she and her family are eligible, health and social systems will be blocked in normal efforts to strengthen public health and immigrant integration in the communities they serve.

Third, the proposed policy change feeds a resurgent untruth – the canard of immigrants as freeloading “enemies of the people,” as explored in James Morone’s classic 1997 essay on the morality of health policy – and obscures truth: immigrants are relatively low consumers of health care and other public resources. Recent quantitative studies by physician and health policy scholar Leah Kallman and colleagues have concluded that immigrants are a “low-risk pool” within the American health care system who “almost certainly paid more toward medical expenses than they withdrew,” and that unauthorized immigrants – who, as noted, are ineligible for federally-funded benefits – actually subsidize care for older adults insured by Medicare. These studies update 2013 research from the Cato Institute, which similarly found that low-income immigrants are relatively light users of publicly funded resources compared to low-income US-born citizens. There is no economic case for further restricting public benefits to immigrants or for the notion that doing so will result in benefits to citizens. Rather, discouraging immigration by a population that is largely in the workforce and “paying into the system” will undermine public systems citizens rely on.

Finally, the proposed wide expansion of what counts toward deeming a person who is a member of American society a “public charge” hardens perceptions of low-income minority immigrants as a caste without rights, protections, or prospects beyond low-status work. This is a hypocritical notion in an immigrant nation and is specifically bad for the prospects of a nation that relies on the immigrant workforce, as the U.S. and all aging societies do. A recent U.N. report on “care and older persons” reinforced that the care workforce in aging societies characteristically relies on two groups: immigrant women and family members, usually women.  Good care in aging societies therefore intersects with the status of immigrants and of women in those societies. Discouraging immigration and making life hard for immigrants and their children is self-defeating for an aging society.

Fortunately, there is some good news out of Colorado, which as of September 1 will cover standard outpatient dialysis for noncitizens with end-stage renal disease under the scope of its emergency Medicaid program. This policy change was informed by a series of qualitative studies led by Lilia Cervantes, a hospitalist at Denver Health and the University of Colorado, to study the health consequences of emergency-only dialysis requiring weekly hospitalization. Dr. Cervantes’s studies found that management of a chronic, life-threatening condition through emergency provisions led to higher mortality and longer hospitalizations, higher symptom burden and psychosocial distress, and greater professional burnout and moral distress. (Disclosure: I served as a co-author on Cervantes’s study of the experiences of patients and families.) In announcing this change, Colorado’s Medicaid program commended Dr. Cervantes for heightening awareness of problems and solutions.

Nancy Berlinger is a research scholar at The Hastings Center. She codirects The Hastings Center’s Undocumented Patients Project.

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