White House’s Latest Public Charge Proposal Would Further Intimidate Lawfully Residing Immigrants from Accessing Health Care
The Trump administration’s proposed rule would grant enormous discretion to immigration officers while targeting noncitizen’s lawful use of health programs.
Authors: Elizabeth Dervan and Alice Lam
Editors: Patti Boozang and Amanda Eisenberg
tl;dr
The Trump administration on Nov. 17 unveiled a proposed rule on “public charge,” reviving a flashpoint from the administration’s first term targeting immigrants and their lawful use of health care and other programs.
Under federal immigration law, immigrants applying for a visa or to become lawful permanent residents (LPRs), or green card holders, must be evaluated by the Department of Homeland Security (DHS) for whether they are likely to become a “public charge” (i.e., reliant on the government). The Biden administration established important guardrails for these determinations by codifying longstanding protections through regulations.
The Trump administration’s new proposed rule would repeal the Biden-era rules and direct immigration officers to use their wide-ranging discretion to consider any factor they deem relevant — including a person’s lawful use of public benefits, such as Medicaid, the Children’s Health Insurance Program (CHIP), the Supplemental Nutrition Assistance Program (SNAP), housing assistance, and state or local health, nutrition, and housing programs.
If finalized, the rule would have major implications for who can enter and reside in the U.S., penalize immigrants for receiving the health care, nutrition, housing, and other services for which they qualify through federal, state, or local programs, and, more broadly, discourage immigrants and their citizen family members from seeking medical care. The consequences could be severe and far-reaching for immigrant communities, health care systems, and states as people forgo medical care and other critical services — leading to worse health, more uncompensated care, and greater poverty.
The 80 Million Impact
Background on Public Charge
Under the Immigration and Nationality Act (INA), immigration officers at DHS must determine whether someone is likely to become a “public charge” when they apply for a green card or a visa to enter the U.S. For years, immigration officers were limited in how they conducted these determinations and could only consider certain factors — including a person’s use of cash assistance or long-term institutional care paid for by the government.
During President Trump’s first term, for the first time, public charge determinations were expanded to explicitly include a person’s use of, or application for, Medicaid, SNAP, housing assistance, and other benefits (among other changes). The Biden administration later re-established the prior protections and guardrails, ensuring that a person’s lawful use of Medicaid or CHIP would not hinder their ability to enter or remain in the country.
The Trump Administration’s New Proposal
The Trump’s administration’s new proposed rule would repeal the Biden-era guardrails and give immigration officers far-reaching discretion to consider any factor they deem relevant in a public charge determination — including an individual’s lawful use, or application for, any means-tested public benefit. This could include Medicaid, CHIP, SNAP, housing assistance, as well as state or local programs.
Immigration officers would be expected to continue considering a person’s overall circumstances, including specific factors from the INA. However, officers would no longer be required to give a detailed explanation when denying a person’s visa or green card application on this basis — making appealing denials even harder going forward.
In a notable move, DHS is declining to spell out their new requirements using regulations and indicated it would instead put forward policy tools to guide immigration officers’ decisions (and did not indicate these tools would be subject to public notice and comment). DHS also announced its intent to use data on immigrants and federal benefits to inform these tools, saying little else about how the data would be used. Notably, DHS has come under a spotlight for using health care data to target immigrants in unprecedented ways this year.
The public comment period for the proposed rule is under an expedited 30-day timeline. The comment period closes Dec. 19.
Impacts for Immigrants, Families, and Communities
These changes to public charge would directly penalize immigrants for using the health care, nutrition, housing and other services for which they qualify, creating higher barriers for lower-income immigrants to enter and remain in the U.S. These changes would reshape who is able to immigrate successfully to the U.S. and, eventually, become a U.S. citizen. Broad officer discretion means public charge determinations would also become more variable, with little transparency and accountability for final decision-making.
Changes to public charge would also have far-reaching impacts beyond those applying for a visa or green card. As was extensively documented during the first Trump administration, opening up public charge could lead millions of people — including immigrants not subject to public charge and their citizen family members, including children — to avoid seeking health care and other needed services for which they qualify out of fear or confusion over how those services could impact their status. These “chilling effects” would no doubt be worse in the wake of the Trump administration’s aggressive targeting of immigrants to date. A Kaiser Family Foundation (KFF)/New York Times survey recently found that four in 10 (41%) immigrants say they personally worry they or a family member could be detailed or deported — far higher than the 26% who said so in 2023.
KFF also estimated that the chilling effects from the public charge proposed rule could lead 1.3-4 million Medicaid and CHIP enrollees in a household with at least one noncitizen to disenroll from those programs, including nearly 600,000 to 1.8 million citizen children. Uninsured immigrants and family members could also avoid enrolling in coverage. KFF estimated between 200,000 to over 500,000 uninsured individuals in a household with at least one noncitizen could forgo enrollment in Medicaid despite being eligible, including roughly 50,000 to 150,000 citizen children.
Going without coverage and care would mean worse health for families and communities across the country, all on top of increased poverty, malnutrition, and housing instability. Ripple effects from the proposed rule are already being felt: Providers in New York City and San Diego told The 80 Million that they’re already seeing patients delay care and limit interactions with community resources altogether.
Health, social services, and immigration advocates are mobilizing in response. The Protecting Immigrant Families Coalition has developed a range of resources to support public comments and crucial messaging to immigrant communities.
Impacts on Health Care Systems and State and Local Governments
Health care providers and state and local governments would also feel the effects. Delayed medical care, increased use of emergency rooms, poor nutrition, housing instability, and deteriorated public health are likely to drive up health care costs, while rising uninsurance can lead to more uncompensated care. Safety net providers — including hospitals and community health centers — would likely feel the effects most acutely, while state and local governments would absorb the costs of worse health and greater poverty.
The Bottom Line
The administration’s public charge proposal is the latest in a series of actions designed to discourage and block lawfully present people from accessing needed health coverage and care. Widespread chilling effects will no doubt be more profound in the wake of the administration’s broader immigration agenda and other cuts to health care for noncitizens, including H.R.1’s forthcoming rollback of Medicaid and CHIP eligibility for many lawfully residing immigrants.
The comment deadline for the public charge proposed rule is fast-approaching — comments must be submitted by Dec. 19.