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.

This post was orig­i­nal­ly pub­lished in The Hast­ings Center’s Bioethics Forum.  Please click here to access the orig­i­nal post online.

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