The Cruel Public Health Consequences of Anti-Immigrant Rhetoric

The United States has long used immigration policy to shape the demographic and economic future of the nation.¹ Federal policy balances several priorities, including economic stability, humanitarian goals, family (re)unification, and national security. Changes in immigration policy reflect shifts in the relative emphasis placed on each of these priorities. Since the 1980s, Americans’ increasingly polarized views on immigration have contributed to Congress’s failure to pass comprehensive immigration reform, frequent changes in aspects of immigration policy that can be regulated without Congress, and a system that is increasingly difficult for immigrants to navigate.¹

Two articles in this issue of AJPH address one federal immigration policy: the public charge rule. The public charge rule is designed to ensure that immigrants who enter the United States will be able to sustain themselves without relying on the government for financial support.² In 1999, the public charge rule stated that noncitizens may be denied a green card if they have received general cash assistance or long-term institutionalization funded by the US government or a state, regional, local, or tribal government.² Immigrants’ use of noncash benefits such as Medicaid and certain cash benefits such as childcare subsidies did not impact their green card eligibility.²

In 2017, the Trump administration leaked a draft of a new rule, stating that Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and housing, energy, and childcare assistance would now factor into public charge determinations. The final version of the rule was published in August 2019. The rule was challenged in court and was in effect off and on from October 2019 through March 2021.³ On September 9, 2022, the US Department of Homeland Security (DHS) released a new version of the public charge rule under which public charge determinations are again based on the guidelines used before 2019.²

The Migration Policy Institute estimates that, even under the broad 2019 rule, less than 1% of the 22.1 million noncitizens currently living in the United States could be denied a green card because of public benefits enrollment. Few noncitizens are both subject to the public charge rule and eligible for public benefits. Use of benefits by US citizen children or other household members does not count against a green card applicant in public charge determinations (http://bitly.ws/y35D).

Although very few immigrants are subject to the intended effects of this rule, there are widespread unintended effects (http://bitly.ws/y35D). As two articles in this issue of AJPH show, the 2019 public charge rule led many immigrants to avoid public benefits, even before the rule was implemented. Miller et al. (p. 1738) use the Survey of Income and Program Participation to show that mixed citizenship status households were less likely to use SNAP and school breakfast and lunch programs after the draft rule was leaked in January 2017. Using New York State Medicaid claims, Wang et al. (p. 1747) show that, compared with noncitizens who gave birth in 2014–2016, noncitizens who gave birth after January 2017 enrolled in Medicaid later in pregnancy; were more likely to have delayed, inadequate, or no prenatal care; and had smaller babies.

These findings contribute to growing evidence that after the 2019 rule was announced, enrollment in many means-tested benefits programs declined; immigrants avoided nongovernmental services, including those designed for survivors of domestic and sexual violence; and immigrants were afraid to access COVID-19 testing and vaccination.² Older adults, immigrants with disabilities, and US citizen children with immigrant parents were disproportionately impacted.² Through the 2022 rule, DHS attempts to limit chilling effects while adhering to the congressional mandate to identify immigrants who are likely to become a public charge.² However, experts expect some level of chilling effect to continue.³

CHANGING POLICIES CREATE CONFUSION AND MISTRUST

The public charge rule illustrates a broader issue: In the absence of congressional immigration reform, the executive branch is the primary driver of immigration policy. The federal immigration policy landscape changes drastically with each presidential administration. For example, President Obama used executive actions to establish the Deferred Action for Childhood Arrivals (DACA) program and to focus immigration enforcement primarily on immigrants who pose a threat to public safety and national security.^4,5 President Trump issued over 400 executive actions on immigration, including large cuts in refugee resettlement, an attempt to end DACA, and expanded immigration enforcement at the border and within the United States.^4,6 The Biden administration has used executive actions to undo some of President Trump’s policies, with varying success.^4,5

The legislative branch also has a key role in determining immigration policy, because many executive actions have been challenged in court. In 2020– 2021, court decisions repeatedly enjoined the 2019 public charge rule, then allowed it to go back into effect.² The same is true of other policies, including the termination of DACA and requirements that asylum seekers remain in Mexico while waiting for asylum hearings.^4,6

Frequent policy changes create confusion, misinformation, and mistrust among immigrants. It is difficult for immigrants and immigrant-serving providers to keep up with policy changes, and it is not always clear how policies will be implemented.³ Misinformation about the public charge rule includes the belief that noncitizen parents may be denied a green card or even deported if their citizen children enroll in Medicaid, as well as fears that if a green card holder accesses public benefits, they may be ineligible for naturalization.^2,3

Dramatic shifts in immigration policy also communicate to noncitizens that their presence in the United States is dependent on the whims of the current president. Immigrants act on the basis of not only current policy but also concerns that policies may become more punitive in the future.³ Even when immigrants know that they or their children are eligible for public benefits and can enroll without endangering their legal status, many decide that it is not worth the risk that these policies may change again soon.³

IMPLICATIONS FOR PUBLIC HEALTH RESEARCH

The articles published in this issue of AJPH advance our understanding of immigration policy in two key ways. Both Miller et al. and Wang et al. show that chilling effects on food assistance, Medicaid, and prenatal care emerged as soon as the 2019 public charge rule leaked—over two years before it went into effect. Past research has focused on the effects of policies that are passed and implemented⁷; these findings suggest that immigrant health is also harmed by policies that are proposed but fail to pass. Both studies also find that effects of the public charge rule varied on the basis of where immigrants lived. By examining how local context limits or amplifies the effects of federal policies, researchers may identify ways local communities can advance health equity for immigrants.

IMPLICATIONS FOR PUBLIC HEALTH PRACTICE

By deterring immigrants from seeking public benefits and health care, the 2019 public charge rule may have exacerbated the COVID-19 crisis.² The 2022 final rule is an important step toward addressing the public health consequences of the 2019 rule, but it must be accompanied by outreach so that immigrants feel safer accessing public benefits.³ DHS should disseminate information through community-based organizations that have already established trust in immigrant communities,⁸ and medical-legal partnerships could incorporate immigration lawyers who can provide up-to-date guidance on changing policies.³ However, until Congress passes comprehensive immigration reform, public health professionals will face an uphill battle against the misinformation, confusion, mistrust, and fear that currently constrain immigrants’ access to health care and public benefits.³

POST PUBLICATION UPDATE

February 15, 2023: When originally published, an online reference was omitted from the article text. The reference has been added as a hyperlink on pg. 1726 of the original article. An erratum has since been issued, and this PDF has been updated to include the change.