Immigrant Essential Workers Likely Avoided Medicaid And SNAP Because Of A Change To The Public Charge Rule

Abstract

During the COVID-19 pandemic in the US, essential workers have provided health care, food, and other necessities, often incurring considerable risk. At the pandemic’s start, the federal government was in the process of tightening the “public charge” rule by adding nutrition and health benefits to the cash benefits that, if drawn, could subject immigrants to sanctions (for example, green card denial). Census Bureau data indicate that immigrants accounted for 13.6 percent of the population but 17.8 percent of essential workers in 2019. About 20.0 million immigrants held essential jobs, and more than one-third of these immigrants resided in US states bordering Mexico. Nationwide, 12.3 million essential workers and 18.9 million of their household members were at risk because of the new sanctions. The rule change (which was subsequently revoked) likely caused 2.1 million essential workers and household members to forgo Medicaid and 1.3 million to forgo Supplemental Nutrition Assistance Program assistance on the eve of the pandemic, highlighting the potential of immigration policy changes to exacerbate health risks.

On October 10, 2018, the Department of Homeland Security announced a proposed change to the “public charge” rule that imposes sanctions (for example, denial of a green card, precluding the right to sponsor a family member for immigration, or even deportation) on noncitizens who use some types of public programs.¹ Implementation of the rule change was delayed until February 2020 and was reversed March 15, 2021.² However, during most of 2020 the rule was in effect (with brief interruptions resulting from dueling court rulings). Surveys indicate that by December 2019, just before the onset of the COVID-19 pandemic in the US, many immigrant families had already begun avoiding use of the benefits covered by the impending expansion of the rule (Medicaid and housing and food assistance), as well as some benefits that would not trigger sanctions. Immigrants’ tendency to avoid using benefits even before the rule’s actual implementation, as well as to forgo benefits not technically covered by the rule, has been termed a “chilling effect.”³

No previous studies have enumerated immigrants’ role in the essential workforce in the US or their use of public benefits. We hypothesized that many immigrants were employed in jobs that were deemed essential during the early months of the pandemic and that some of them were likely to have avoided enrollment in public programs because of the chilling effect of the public charge rule change. Hence, we sought to estimate the numbers of immigrant essential workers (and their household members), how many of them were using public benefits, and how many were likely to have forgone those benefits because of the rule change. Although our analysis used data from 2019, our findings provide rough estimates of employment figures and rule change–induced chilling effects at the outset of the COVID-19 pandemic.

Although the rule change was nullified by the incoming administration of President Joe Biden, some states are seeking to intervene to challenge the reversal,² and future administrations could reinstate similar changes. Moreover, even temporary enforcement of policies discouraging access to health and nutrition programs may have longer-term repercussions for social determinants of health.

Background

The term “public charge” first appeared in the 1882 Immigration Act, which denied entry to immigrants deemed “unable to take care of himself or herself and likely to become a public charge.”⁴ Nine years later Congress added a provision allowing the deportation of immigrants who became a public charge after their arrival.

The definition of public charge remained vague until a 1948 Board of Immigration Appeals ruling that allowed the deportation of immigrants who received public services if “the State or other governing agency imposed a charge for the services rendered to the [immigrant];…the authorities demanded payment of the charges; …and the [immigrant] failed to pay the charges.”⁴ However, although denial of entry was quite common, deportations remained rare.

Two laws passed in 1996 during Bill Clinton’s presidency raised concerns that public charge sanctions might increase. Among other provisions, the Illegal Immigration Reform and Immigrant Responsibility Act required some immigrants to provide an affidavit from a sponsor promising to maintain the immigrant at an income level of at least 125 percent of the federal poverty level. The Personal Responsibility and Work Opportunity Reconciliation Act barred recent immigrants from receiving most federal means-tested public benefits, such as welfare, nutrition assistance, or Medicaid. Although the law exempted some types of aid (for example, emergency medical care) and did not apply to immigrants legally present for five or more years, many immigrants worried that accepting any form of assistance could compromise their immigration status and began avoiding public benefits.

By 1999 federal officials noted a “significant decline in the receipt of welfare, health, and nutrition benefits by immigrant families and their citizen children, even though many of these families (or individuals within these families) are eligible for such benefits.”⁵ They worried “that this lack of access to critical services may lead to negative health outcomes for immigrant families and children, as well as potentially undermining public health.”⁵ In response, the Clinton administration issued regulations clarifying that although receipt of cash benefits such as welfare or Supplemental Security Income (or residential care) might lead to immigrants being deemed “public charges,” receipt of health care or food assistance (or other noncash public benefits) would not.⁵

The Trump administration’s change to the public charge rule ended the exemption for health-related benefits and allowed immigration officials to impose sanctions on immigrants for receipt of Medicaid and low-income Medicare Part D assistance (which helps poor seniors afford medications), nutritional assistance under the Supplemental Nutrition Assistance Program (SNAP), and housing subsidies.

The Supreme Court rejected legal challenges to the rule change and allowed it to go into effect on February 24, 2020. However, in July 2020 a lower court enjoined enforcement because of the COVID-19 emergency, an injunction that a higher court lifted in September. The Biden administration stopped enforcement of the rule change in February 2021 and fully revoked it in March.

Although the Trump administration’s policy change was in effect for only a short period, it may have had a sustained impact on the behavior of immigrant families. Even before the change took effect, fear and confusion caused many immigrant families to avoid public benefits, including some (for example, Medicaid for minor children) that are technically exempt from the change. Avoidance of benefits likely persisted during periods when the rule change was enjoined and may linger after its revocation.

The repercussions from loss of health coverage and housing and nutrition assistance are particularly worrisome in the context of the COVID-19 pandemic, especially for essential workers, who were encouraged or even required⁶ to remain on the job. Such in-person work placed both essential workers and their families at risk for COVID-19 exposure and appears to have been partly responsible for the pandemic’s disproportionate toll on the Hispanic population.⁷

We applied survey-based estimates of the magnitude of the chilling effect to Census Bureau data on immigration status and employment in jobs subsequently deemed essential. Using these data, we estimated the number of essential workers and their household members who were likely avoiding enrollment in public nutrition and health benefit programs just before the onset of the pandemic both nationwide and in the four states bordering Mexico.

Study Data And Methods

DATA SOURCE

We analyzed data from the 2019 American Community Survey (ACS), a Census Bureau survey of a nationally representative sample of about 2.1 million households and 150,000 people living in group quarters. We identified essential workers on the basis of their reported occupation, which the ACS classifies using the Standard Occupational Classification system’s 867 codes. We designated occupations as “essential” according to a Department of Homeland Security list, which the Labor Market Information Institute and the Council for Community and Economic Research previously mapped to Standard Occupational Classification codes⁸ and which has been used in previous analyses of essential workers.⁹ Because that earlier mapping effort did not encompass some essential occupations, including several in health care (for example, radiologic technologists and technicians and personal care aides), Leah Zallman modified the classification scheme to include these occupations. (The online appendix provides details of the coding scheme.)¹⁰

CHARACTERISTICS OF WORKERS

Although the essential status of most workers in the ACS could be identified, about 1 percent were assigned codes indicative of broad occupation categories whose subcategories include both essential and nonessential workers. In these cases, where possible, we calculated the shares of workers in the broader category who were essential and who were immigrants (see the appendix for detail)¹⁰ and added these shares to our estimates of essential workers. We were unable to classify an additional 1 percent of workers as “essential” or “nonessential” and excluded them from all analyses.

For each individually identifiable essential worker (but not the 1 percent whose essential status was imputed), we determined their demographic characteristics, citizenship status, health insurance coverage (including public coverage through Medicaid, Medicare, or the Veterans Health Administration [VHA]), and receipt of two other types of public benefits: SNAP and cash welfare benefits (Temporary Assistance to Needy Families). We also assessed similar information about essential workers’ household members.

BENEFIT STATUS

We tabulated the number and share of essential workers (and their household members) receiving public benefits who were immigrants or noncitizen immigrants. Because eligibility for some public benefits (for example, food or housing assistance) that could trigger public charge immigration sanctions is determined at the household level, we defined immigrant essential workers (and their household members) as potentially at risk if the worker or any household member was a noncitizen. We refer to households shared by naturalized citizen immigrants and noncitizens as “mixed status” households.

Based on previous surveys by the Urban Institute that determined the proportion of immigrants who reported avoiding public benefits,^11,12 we estimated the number and share of essential workers and their household members likely forgoing such programs because of the public charge rule change. The surveys, which were completed shortly before the February 2020 implementation of the rule change, found that 15.6–31.5 percent of immigrant families were already avoiding public benefits because of the “chilling effects” and that lower-income families were more likely to be affected. Because both essential work and the use of public benefits were concentrated among lower-income immigrants, our baseline results assumed that the public charge rule change caused a 25 percent reduction in the use of benefits by immigrant essential workers at the onset of the COVID-19 pandemic. We also present a range of estimates based on the assumptions of 15 percent and 35 percent reductions of benefit use.

In addition to national estimates, we present estimates for the four states bordering Mexico: California, Arizona, New Mexico, and Texas. These border states continue to be major destinations for immigrants crossing the southern US border.

LIMITATIONS

This study had several limitations. Our figures combined Asians with Pacific Islanders because the number of Pacific Islander immigrant essential workers in the ACS was too small to analyze separately.We assumed that the chilling effect of the change in the public charge rule observed in the Urban Institute’s surveys (which surveyed English and Spanish speakers only) would apply to all immigrants employed in essential jobs.

The time course of the chilling effect is uncertain. Our analysis assumed that it did not depress enrollment in Medicaid and SNAP before the ACS’s 2019 data collection. If immigrants’ avoidance of public programs occurred earlier, our figures may understate the numbers affected specifically by the rule change and would be equivalent to a 20 percent rather than 25 percent chilling effect by early 2020.

The ACS does not collect information on housing assistance. That public benefit has particular public health salience in the context of the COVID-19 pandemic because housing assistance can help families avoid eviction and homelessness and can minimize residential crowding, all of which accelerate viral transmission.¹³ Housing crowding is particularly frequent among Hispanics, nearly half of whom live in homes too crowded to allow compliance with recommendations to isolate sick (or exposed) household members.¹⁴ Our estimates thus likely understated the number of people at risk for public charge–related health harms on the eve of the pandemic. In addition, the ACS does not delineate which of the Medicare enrollees we identified received (and might have forgone) Part D medication subsidies available to low-income enrollees. Finally, although we could determine Medicaid enrollment for each individual in our sample, the ACS assigns the same SNAP enrollment status to all individuals in a given household, which aligns closely but not perfectly with individuals’ eligibility for SNAP.

Study Results

We identified 1,088,622 essential workers in the 2019 ACS data (weighted N = 111,650,589, excluding 563,941 whose essential worker status was imputed). Essential workers accounted for 58.9 percent of all US workers and 44.0 percent of all US adults.

The essential workforce included 19,822,072 immigrants whose characteristics could be determined and an additional 66,706 whose essential status was imputed, for a total of nearly 20.0 million people. Immigrants’ share of essential workers was larger (17.8 percent) than their share of the US population (13.6 percent, or 44.8 million of the total of 328.2 million) and their share of all US adults (16.6 percent, or 42.2 million of the 255.3 million adults). Half of immigrant essential workers (50.3 percent) were naturalized US citizens.

Relative to US-born essential workers, immigrant essential workers were younger, more often male, and more likely to be Hispanic (48.1 percent versus 12.3 percent) or Asian/Pacific Islander (26.3 percent versus 1.8 percent) (exhibit 1). They also had lower incomes and were less likely to use welfare but were slightly more likely to live in a household receiving SNAP benefits. Among essential workers, immigrants were twice as likely to be uninsured (21.7 percent versus 10.2 percent). Although slightly more had Medicaid coverage, many fewer had public coverage through Medicare or the VHA, and, overall, fewer immigrants relied on public coverage (18.6 percent versus 20.5 percent).

EXHIBIT 1.

Characteristics and service use of immigrant and US-born essential workers, 2019

	Immigrant		US born
	Weighted no.	Percent	Weighted no.	Percent
Nationwide total	19,822,072	100.0	91,828,517	100.0
Age, years
18–64	18,385,076	92.8	83,666,951	91.1
65+	1,436,996	7.2	8,161,566	8.9
Sex
Male	10,569,875	53.3	47,229,639	51.4
Female	9,252,197	46.7	44,598,878	48.6
Race/ethnicity
Asian/Pacific Islander	5,207,673	26.3	1,682,046	1.8
Black/African American	2,012,818	10.2	12,866,082	14.0
Hispanic	9,533,703	48.1	11,267,097	12.3
White	2,701,375	13.6	63171535	68.8
Other racea	366,503	1.8	2,841,757	3.1
Insurance
Medicaid	2,295,215	11.6	9,381,926	10.2
Medicare	1,363,478	6.9	9,068,032	9.9
Private	11,844,146	59.8	63,600,531	69.3
VHA (or other public)	18,506	0.1	367,078	0.4
Uninsuredb	4,300,727	21.7	9,410,950	10.2
SNAP recipient	2,223,140	11.2	9,555,010	10.4
Welfare recipientc	142,159	0.7	1,031,992	1.1
Primary language at home
English	2,924,001	14.8	82,421,616	89.8
Spanish	9,148,244	46.2	7,285,473	7.9
Other	7,749,827	39.1	2,121,428	2.3
Family income as percent of federal poverty level
<201%	5,656,029	28.7	20,042,723	22.3
201–400%	6,610,118	33.6	28,293,245	31.4
>400%	7,410,616	37.7	41,632,435	46.3
Citizenship status
Naturalized citizen	9,973,935	50.3	—d	—d
Noncitizen	9,848,137	49.7	—d	—d

SOURCE Authors’ analysis of data from the 2019 American Community Survey. NOTES Immigrant essential workers are noncitizens and naturalized US citizens ages 18 and older employed in essential jobs. Unweighted sample sizes: for immigrants, 160,740; for US born, 922,201. SNAP is Supplemental Nutrition Assistance Program. VHA is Veterans Health Administration.

^aIncludes Native American/Alaska Native, more than one race, and “other” identified races.

^bIncludes people covered only by the Indian Health Service.

^cAsked only for people ages 15 and older.

^dNot applicable.

Exhibit 2 displays the characteristics of immigrant essential workers and their household members who were at risk for immigration sanctions because of the public charge rule change. This group included the 9.8 million noncitizen essential workers as well as 2.4 million naturalized citizen essential workers living in mixed-status households (that is, households that included a noncitizen).

EXHIBIT 2.

Characteristics and service use of immigrant essential workers and their household members who were at risk for immigration sanctions because of the public charge rule change, 2019

	Immigrant essential workers at risk				Household members of essential workers at risk		Total at risk (workers + household members)
	Noncitizens	Citizens in mixed-status households	Total workers at risk
	Weighted no.	Weighted no.	Weighted no.	Percent	Weighted no.	Percent	Weighted no.
Nationwide total	9,848,137	2,411,052	12,259,189	100.0	18,923,868	100.0	31,183,057
Age, years
<18	—a	—a	—a	—a	9,154,015	48.4	9,154,015
18–64	9,520,184	2,239,242	11,759,426	95.9	8,705,703	46.0	20,465,129
65+	327,953	171,810	499,763	4.1	1,064,150	5.6	1,563,913
Sex
Male	5,609,095	1,290,516	6,899,611	56.3	9,115,333	48.2	16,014,944
Female	4,239,042	1,120,536	5,359,578	43.7	9,808,535	51.8	15,168,113
Race/ethnicity
Asian/Pacific Islander	2,055,757	686,651	2,742,408	22.4	3,180,089	16.8	5,922,497
Black/African American	737,228	350,773	1,088,001	8.9	1,464,444	7.7	2,552,445
Hispanic	5,911,823	1,141,337	7,053,160	57.5	11,630,574	61.5	18,683,734
White	991,102	192,084	1,183,186	9.7	2,196,394	11.6	3,379,580
Other raceb	152,227	40,207	192,434	1.6	452,367	2.4	644,801
Insurance
Medicaid	1,219,517	357,020	1,576,537	12.9	6,753,406	35.7	8,329,943
Medicare	290,574	165,021	455,595	3.7	1,099,429	5.8	1,555,024
Private	4,992,263	1,540,547	6,532,810	53.3	7,546,073	39.9	14,078,883
VHA (or other public)	4,430	3,277	7,707	0.1	14,232	0.1	21,939
Uninsuredc	3,341,353	345,187	3,686,540	30.1	3,510,728	18.6	7,197,268
SNAP recipient	1,253,255	316,563	1,569,818	12.8	3,533,571	18.7	5,103,389
Welfare recipientd	70,494	18,300	88,794	0.7	127,843	1.1	216,637
Primary language at home
English	1,006,122	254,981	1,261,103	10.3	3,116,888	19.1	4,377,991
Spanish	5,736,970	1,109,220	6,846,190	55.8	9,425,315	57.7	16,271,505
Other	3,105,045	1,046,851	4,151,896	33.9	3,802,336	23.3	7,954,232
Family income as percent of federal poverty level
<201%	3,659,852	603,305	4,263,157	35.1	8,294,095	43.9	12,557,252
201–400%	3,431,065	953,313	4,384,378	36.1	6,283,152	33.3	10,667,530
>400%	2,654,911	854,434	3,509,345	28.9	4,307,853	22.8	7,817,198
Citizenship status
US born	—a	—a	—a	—a	11,629,850	61.5	11,629,850
Naturalized citizen	—a	2,411,052	2,411,052	19.7	1,585,368	8.4	3,996,420
Noncitizen	9,848,137	—a	9,848,137	80.3	5,706,063	30.2	15,554,200

SOURCE Authors’ analysis of data from the 2019 American Community Survey. NOTES Household members of essential workers at risk include any person living in a household with a noncitizen essential worker or in a household with a naturalized citizen essential worker and at least one noncitizen. Column excludes these essential workers to avoid double counting. Immigrant essential workers are noncitizens and naturalized US citizens employed in essentialjobs. Mixed-status households are those with a naturalized citizen essential worker and at least one noncitizen. Unweighted sample sizes: Noncitizens, 71,483; citizens in mixed-status households, 19,492; total workers at risk, 90,975; household members, 137,686; and total at risk, 228,661. SNAP is Supplemental Nutrition Assistance Program. VHA is Veterans Health Administration.

^aNot applicable.

^bIncludes Native American/Alaska Native, more than one race, and “other” identified races.

^cIncludes people covered only by the Indian Health Service.

^dAsked only for people ages 15 and older.

As also shown in exhibit 2, an additional 18.9 million people lived in at-risk households, including 9.1 million children. Overall, of the 31.2 million essential workers and household members at risk, more than half were US citizens (including 11.6 million US-born household members). Although two in five families had incomes below 201 percent of poverty, few received cash welfare benefits. However, 5.1 million members of at-risk households used SNAP, 8.3 million had Medicaid coverage, and 1.6 million were covered by Medicare.

Immigrants played an especially large role in the essential workforce in the four US-Mexico border states, where they accounted for 28.6 percent of essential workers, including 35.6 percent of all essential workers in California, 23.0 percent in Texas, 17.8 percent in Arizona, and 12.8 percent in New Mexico (data not shown). As shown in exhibit 3 (and appendix exhibits A1-A4),¹⁰ the immigrant essential workers in these states were more likely to be Hispanic than those elsewhere in the US and were slightly poorer and less likely to be citizens.

EXHIBIT 3.

Characteristics and service use of immigrant essential workers and their household members living in southern border states who were at risk for immigration sanctions because of the public charge rule change, 2019

	Weighted number
	Arizona		California		New Mexico		Texas
	Immigrant essential workers	At risk of sanctions	Immigrant essential workers	At risk of sanctions	Immigrant essential workers	At risk of sanctions	Immigrant essential workers	At risk of sanctions
Nationwide total	420,711	781,026	4,652,612	7,858,724	90,416	157,244	2,244,671	4,287,268
Age, years
<18	—a	244,090	—a	2,234,761	—a	48,702	—a	1,378,860
18–64	393,986	503,581	4,295,564	5,161,055	84,735	102,983	2,115,836	2,729,196
65+	26,725	33,355	357,048	462,908	5,681	5,559	128,835	179,212
Sex
Male	221,064	402,843	2,500,120	4,007,065	49,912	80,917	1,265,470	2,210,268
Female	199,647	378,183	2,152,492	3,851,659	40,504	76,327	979,201	2,077,000
Race/ethnicity
Asian/Pacific Islander	69,752	84,009	1,506,564	1,622,537	9,799	9,979	446,694	536,719
Black/African American	18,077	22,171	80,697	106,616	2,036	1,901	152,654	221,247
Hispanic	270,319	592,366	2,570,631	5,478,343	71,501	133,716	1,481,436	3,236,694
White	56,647	68,863	435,512	545,510	6,023	10,384	142,129	259,842
Other raceb	5,916	13,617	1,967	105,718	1,057	1,264	21,758	32,766
Insurance
Medicaid	58,801	230,772	846,199	2,791,042	16,935	59,369	77,481	841,648
Medicare	28,602	40,209	343,182	490,629	5,585	6,749	114,802	162,239
Private	221,837	299,239	2,675,672	3,283,352	37,267	43,280	1,215,019	1,675,247
VHA (or other public)	249	887	3,273	4,537	—a	—a	1,617	2,180
Uninsuredc	111,222	209,919	784,286	1,289,164	30,629	47,846	835,752	1,605,954
SNAP recipient	54,697	150,265	477,683	1,259,817	15,996	34,694	263,981	788,721
Welfare recipientd	3,120	5,461	39,858	68,027	1,207	1,185	7,385	14,746
Primary language at home
English	62,902	106,750	421,668	795,717	7,323	12,013	215,196	563,816
Spanish	252,896	506,761	2,473,755	4,761,705	67,834	98,343	1,430,782	2,755,319
Other	104,913	109,882	1,757,189	1,698,631	15,259	13,162	598,693	815,096
Family income as percent of federal poverty level
<201%	144,391	360,563	1,281,038	3,127,824	39,728	80,496	772,913	1,999,445
201–400%	157,136	287,664	1,509,977	2,705,406	29,202	54,406	779,144	1,448,955
>400%	115,782	128,311	1,838,981	2,001,355	19,896	20,703	674,220	819,367
Citizenship status
US born	—a	346,565	—a	3,201,630	—a	69,957	—a	1,760,375
Naturalized citizen	181,351	36,715	2,364,591	1,040,649	35,723	10,972	896,190	383,744
Noncitizen	239,360	366,744	2,288,111	3,616,056	54,693	76,315	1,348,481	2,142,250

SOURCE Authors’ analysis of data from the 2019 American Community Survey. NOTES “At risk of sanctions” includes noncitizen essential workers and their household members, and citizen immigrant essential workers living in mixed-status households and their household members. Immigrant essential workers are noncitizens and naturalized US citizens employed in essential jobs. Unweighted sample sizes: Arizona, 3,218 and 5,325; California, 42,036 and 63,760; New Mexico, 663 and 1,050; and Texas, 17,169 and 29,557. SNAP is Supplemental Nutrition Assistance Program.VHA is Veterans Health Administration.

^aNot applicable.

^bIncludes Native American/Alaska Native, more than one race, and “other” identified races.

^cIncludes people covered only by the Indian Health Service.

^dAsked only for people ages 15 and older.

Use of Medicaid by immigrant essential workers varied considerably by state. For instance, 0.8 million of the 4.7 million immigrant essential workers in California (about one in six) were covered by Medicaid, whereas only 77,000 of the 2.2 million (one in thirty) immigrant essential workers in Texas had Medicaid coverage (exhibit 3).

Exhibit 4 shows the number of essential workers and their household members nationwide and in the four border states who were likely forgoing Medicaid and SNAP just before the pandemic because of the chilling effect of the public charge rule. If, as surveys suggest, 25 percent of all at-risk immigrant essential workers and their household members chose to forgo participation in these programs, 1.3 million (range: 0.8–1.8 million) went without SNAP and 2.1 million (range: 1.2–2.9 million) were forgoing Medicaid coverage nationally. In addition, as many as 389,000 may have avoided Medicare Part D low-income subsidies (data not shown). In California alone, 0.7 million are likely to have forgone Medicaid, and 0.3 million probably avoided the SNAP program.

EXHIBIT 4.

Immigrant essential workers and their household members likely forgoing Medicaid and nutrition assistance because of the public charge rule change, by geographical area, 2019

	Likely to forgo Medicaid				Likely to forgo SNAP
	Immigrant essential workers		Household members		Immigrant essential workers		Household members
Geographical area	Estimate	Range	Estimate	Range	Estimate	Range	Estimate	Range
Arizona	11,003	6,602–15,404	46,690	28,014–65,366	10,744	6,446–15,041	26,823	16,094–37,552
California	160,728	96,437–225,019	537,033	322,220–751,846	90,015	54,009–126,020	224,940	134,964–314,916
New Mexico	2,892	1,735–4,048	11,951	7,170–16,731	3,038	1,823–4,253	5,636	3,381–7,890
Texas	14,618	8,771 −20,465	195,794	117,477–274,112	52,541	31,525–73,557	144,639	86,784–202,495
United States	394,134	236,481–551,788	1,688,352	1,013,011–2,363,692	392,455	235,473–549,436	883,393	530,036–1,236,750

SOURCE Authors’ analysis of data from the American Community Survey, 2019. NOTES Immigrant essential workers are noncitizens and naturalized US citizens employed in essentialjobs. Household members of immigrant essential workers are people other than immigrant essential workers residing in households with an immigrant essential worker. Immigrant essential workers and their household members were defined as at risk from the public charge rule change if any household member was a noncitizen. Estimates are based on the assumption that the rule change would result in 25 percent (range: 15–35 percent) of at-risk people forgoing public benefits. SNAP is Supplemental Nutrition Assistance Program.

Discussion

The COVID-19 pandemic has highlighted both the importance of immigrant workers in the US workforce and their economic and health vulnerabilities. Immediately before the pandemic’s onset in the US in January 2020, immigrants accounted for nearly one in five essential workers nationally, although they make up only 13.6 percent of the US population. Immigrants played an even larger role in states along the US-Mexico border, where they accounted for more than one-quarter of essential workers. We estimate that 2.1 million immigrant essential workers and their household members avoided enrolling in Medicaid and that 1.3 million went without SNAP benefits because they feared sanctions as severe as deportation under the public charge rule as changed by the Trump administration.

A CHANGE OF COURSE BY THE NEW ADMINISTRATION

The rule change occasioned many months of legal wrangling involving federal courts in various jurisdictions. Although still in force, it remained under appeal at the time of President Biden’s inauguration. On February 2, 2021, President Biden ordered a broad review of immigration policy and regulations, including the public charge rule.¹⁵ Shortly thereafter, the Supreme Court agreed to hear an appeal to overturn a lower court ruling that would have blocked the change. But before the Court heard the case, the Department of Homeland Security announced, on March 9, its conclusion that it is “neither in the public interest nor an efficient use of limited government resources” for the Department of Justice to continue defending the rule.¹⁶ Hence, the Supreme Court case was abandoned. The Department of Homeland Security formally revoked the rule change March 15, 2021, and reverted to the 1999 version of the rule.²

However, the rule change had remained in effect for much of the COVID-19 pandemic’s first year, and even before its implementation (and the pandemic), the announcement of the impending change likely led many rightful beneficiaries to forfeit participation in health, nutrition, and housing programs. Although the revocation of the rule change ended the imminent threat of immigration sanctions, some immigrants may perceive that using public benefits could put them at risk for sanctions if the rule change is reinstated by a future administration.

IMMIGRANTS’ ROLE AS ESSENTIAL WORKERS

A previous study that enumerated the characteristics of essential workers and their household members emphasized their vulnerabilities to COVID-19—for example, the large numbers who were elderly, uninsured, or low income.⁹ However, no previous analysis has addressed immigrants’ role in the essential workforce or the likely effects of the public charge rule change in that group.

The COVID-19 pandemic has underscored the importance of immigrants’ contributions as workers. Nearly one-quarter of long-term care workers¹⁷ and more than half of farm laborers are immigrants,¹⁸ with unauthorized immigrants accounting for 24 percent of all agricultural workers.¹⁹

Immigrants play an especially large role in California, where they account for more than one-quarter of the population and three-quarters of workers in the state’s large agricultural sector.²⁰ That state’s relatively liberal policy stance toward immigrants, including a 2015 law enabling Medicaid coverage of undocumented children, is reflected in the somewhat larger share of immigrant essential workers who receive Medicaid. In contrast, Texas, whose 5 million immigrants represent one-sixth of the population,²¹ covers only 3.5 percent of its immigrant essential workers under Medicaid–one-fifth the rate in California (calculated from exhibit 3).

HEALTH CONSEQUENCES OF FORGOING PUBLIC BENEFITS

The pandemic has revealed immigrants’ health vulnerabilities. Although immigrants as a group are believed to be healthier, on average, than the US-born population, many immigrant communities have recorded high COVID-19 case and death rates, driven in part by risks associated with essential work (for example, in the meatpacking and nursing home industries), as well as residential crowding.²²

Forgoing public benefits may well compound the health harms of essential work and inadequate housing. Although the ACS does not include data on housing assistance, it is likely that the public charge rule change caused some immigrant families to forfeit such benefits. Some who remained uninsured because they eschewed Medicaid enrollment may have avoided consultations for mild COVID-19 symptoms, thwarting efforts to identify cases and stop the virus’s spread.²³ Others may have skipped routine care, exacerbating chronic conditions such as diabetes that increase COVID-19 risks. Before the onset of the pandemic, lack of health insurance was associated with substantial increases in mortality.²⁴

Forgoing SNAP benefits could have broad consequences. SNAP reduces hunger and food insecurity, lifts millions of low-income US residents out of poverty,²⁵ lowers health expenditures, and ameliorates the harmful effects of food insecurity on health.²⁶ For adults, receipt of SNAP benefits is associated with fewer illnesses, physician visits, and work absences and less psychological distress. For older adults, SNAP appears to improve the ability to live independently and comply with medication regimens and appears to reduce the need for medical care and hospitalization. For children, SNAP improves overall health and appears to lower the later-life incidence of obesity, diabetes, and heart disease and to increase educational attainment. Studies in the 1960s and 1970s linked SNAP receipt during pregnancy to decreased rates of low birthweight.²⁶

Conclusion

Immigrants play important roles in food production and distribution, medical care, and other essential services in the US. Their contributions have been especially vital and have become more visible during the COVID-19 pandemic; they account for a large share of the workforce that has been urged or mandated to remain on the job. The Trump administration’s change to the public charge rule likely caused many essential workers and their household members to forgo enrollment in public programs, undermining their access to health care and nutrition assistance. Our findings illustrate how seemingly non-health-related policies, such as immigration rules, can affect health.