Immigrant-Inclusive Policies Promote Child and Family Health

In this issue of AJPH, findings by Miller et al. (p. 1738) suggest that anti-immigrant rhetoric and proposed changes to public charge during the early years of the Trump administration significantly reduced federal nutrition assistance program participation among mixed-status immigrant households. Mixed-status households in states with the most, compared with the least, generous eligibility provisions for noncitizens had greater declines in Supplemental Nutrition Assistance Program (SNAP) participation, and those in moderately generous states saw declines across SNAP and school meals programs. Public charge is a determination made when some potentially eligible noncitizens seek legal permanent residency. Trump-era changes to public charge included an expansion of assistance programs considered indicative of whether the applicant is deemed likely to be dependent on long-term government assistance in the future (i.e., a “public charge”). Prior to final rule issuance in August 2019, the proposed rule and several leaked drafts, as well as speculation about the scope, time frame, and contents of the rule change, perpetuated fear in immigrant communities. Miller et al.’s results indicating significant participation reductions in SNAP, the National School Lunch Program (NSLP), and the School Breakfast Program (SBP) are concerning, given robust evidence demonstrating these programs’ health and educational benefits. These findings suggest potentially harmful long-term consequences of anti-immigrant rhetoric and regulatory changes, underscoring the urgent necessity of implementing policy solutions that promote equitable assistance program access without fear.

HEALTH EFFECTS OF REDUCED BENEFIT PARTICIPATION

Decades of research show that SNAP participation is associated with health benefits across the life span, including positive birth outcomes, healthy cognitive development among children, and good overall health status and reduced acute health care use and spending for children and adults, in addition to reducing food insecurity.^1–3 Beneficial health impacts of SNAP participation in childhood persist into adulthood.² School meal programs are associated with positive health and education outcomes among children. NSLP is linked to reduced rates of poor health and obesity among school-age children and improved attendance, behavior, and academic achievement.⁴ SBP is associated with improved nutrient intake, better student mental health, and positive education outcomes.⁵ Given these public health considerations, paired with the fact that more than one-fourth of children in the United States have at least one immigrant parent, maintaining consistent access to federal nutrition assistance programs is essential for promoting optimal population health.

Although Miller et al. did not find changes in food security, other research demonstrates increased rates of food insecurity among families with immigrant mothers following the 2016 election.⁶ Both the final expanded rule, which took effect in fall 2019, and the COVID-19 pandemic occurred after the study period presented in Miller et al.’s article⁷; still, following these events, chilling effects in federal assistance program participation persist. Given rising economic hardships resulting from the COVID-19 pandemic, Miller et al.’s findings become only more relevant for ensuring that families with noncitizens continue to be able to afford basic needs. Lessons from the pandemic response may further illuminate necessary action. Noncitizen and mixed-status families have faced an increased risk of COVID-19–related poor health outcomes and economic hardships during the pandemic compared with US-born households while being less likely to benefit from COVID-19–related protections and relief policies.^8,9

SYSTEMIC, POLICY CHANGES NEEDED

The Biden administration has taken steps to reverse harmful changes to the public charge rule and has finalized a rule returning the public charge definition to the 1999 precedent, which narrowly focused on specific cash benefits and public long-term institutionalization and excluded other housing, food, and health care programs (Miller et al.). This effort was undertaken by the administration to stem well-documented chilling effects in health and assistance programs among immigrants and their families. Reversal is an important step toward alleviating chilling effects, but issuance of the new public charge regulation alone is unlikely to ameliorate harms inflicted upon immigrant communities across decades of US policy.

Miller et al. rightfully emphasize effects on public assistance participation among noncitizens following exclusionary policymaking efforts in the late 1990s and the ways state-level responses interacted with federal level changes in families’ lives. In addition to existing public assistance program eligibility restrictions and changes to public charge, increasing efforts across the nation to criminalize immigrant communities, separate families, and marginalize immigrants through xenophobic rhetoric have resulted in significant harm that is not easily undone.¹¹ Responding to the public health issue of xenophobia and anti-immigrant policymaking will require a robust response across all levels of government and society.¹¹

Policy and programmatic solutions responsive to the needs and requests of immigrants themselves are important for advancing equity and immigrant inclusion. In addition to comprehensive immigration reform that creates a path to citizenship, eliminates family separation, and lifts pandemic-era border restrictions on asylum seekers, federal legislation that simplifies eligibility, is inclusive, and eliminates barriers to assistance programs is paramount. The complex patchwork of eligibility rules across public assistance programs creates significant confusion—not just for immigrant families in need of support but also for public assistance workers, service organizations, and legal professionals, not to mention the general public. Removing all immigration-related rules from eligibility determinations would provide the most seamless and health-promoting access to the essential support provided by SNAP, school meals, and other public assistance programs. Experience gained during the pandemic shows implementation of universal school and child care meals nationwide would mean that all children, regardless of immigration status, have access to healthy meals without unnecessary and costly administrative burden. For SNAP, important progress toward more inclusive policy would include lifting the five-year bar that prevents otherwise eligible, lawfully present noncitizens who have resided in the United States for less than five years from accessing SNAP and other health-promoting federal programs. These changes are critically important investments in the current and future health of children in the United States.

Congress and the current administration have several imminent opportunities for enacting transformative policy improvements. These include current efforts to develop a national strategy to end hunger by 2030 as part of the White House Conference on Hunger, Nutrition, and Health; ongoing Child Nutrition Act reauthorization deliberations; and the forthcoming farm bill debate. Intentionally focusing on addressing the marginalization of immigrant families, including specific attention to both mixed-status and noncitizen families, in federal policy discussions is critical to reverse harms documented by Miller et al. and many others. In addition to federal policy change, investment in and support for community-based groups with a track record of responding to the needs of noncitizen and mixed-status families is important for further bolstering immigrant health and the health of the more than one fourth of children in the United States with immigrant parents. Miller et al. hypothesize that these community groups may have been key in promoting food security among mixed-status families despite declines in federal assistance program participation.

Finally, although these changes and investments are important, an adequate response to generations that have experienced historical bias and trauma requires further action. Rebuilding trust in public institutions and reversing adverse outcomes will require sincere engagement with trusted immigrant-led community groups and elevation of a diversity of immigrant voices in decision-making. Following the leadership of immigrants is essential not only for establishing trust but also for ultimately ensuring that equitable policies are enacted, evaluated, and continuously improved. Only then can we achieve truly equitable child and family health for all families in the United States.