Blog: The Trump Administration's Final Public Charge Rule as a Public Health Threat

By Sara RosenbaumAlthough immigrants tend to be found in larger numbers across the U.S., in reality, they have become essential contributors to American communities from coast to coast. Today, immigrants are present in all communities – urban and rural, large and small. Their health thus becomes an essential aspect of the overall health and well-being of countless localities. To the extent that a national policy implicates immigrant health, it threatens the broader public health. Communicable disease risks increase, as does the stability risks faced by critical community services on which an entire region may depend. Thus, in measuring the effects of a national immigration policy such as the recently-issued public charge rule, it is essential to consider its broader consequences for public health as part of any rational agency impact estimate. Policies ostensibly aimed at promoting a deeper goal of self-sufficiency may have serious and unintended consequences if, in a blind quest to exclude those who use public services, they are designed so clumsily that they threaten obvious consequences for entire communities. Much research has catalogued the likely effects of the Trump administration’s public charge rule for immigrants and their family members. The results of this research are apparent throughout the vast number of comments in opposition to the rule and summarized by the administration in its Preamble.However, these implications resonate beyond these families. For example, if families with immigrants avoid participation in Medicaid, SNAP or public housing because of fears inspired by the rule, their medical and nutritional needs will not disappear. Instead, families may turn to community-based public and nonprofit community resources such as safety net hospitals, community health centers, food banks and pantries, shelters and public health agencies. Their increased reliance on services often designed to fill in the gaps in public programs will threaten the stability of these programs as the level of reliance grows. The problem does not end with the rule’s designated “public benefit” programs – Medicaid, SNAP and certain forms of public housing assistance. First, even ostensibly exempt services (e.g., Medicaid for children) are not safe; indeed, the administration explicitly states (Preamble p. 41380) that “the fact that an alien received public benefits as a child is a relevant consideration when determining that the alien will receive public benefits in the future”. But it’s worse than the public benefit policy alone – as punitive and confusing as it is – would suggest. Nowhere in this 200-plus page rule does the Administration make clear that community-wide benefits such as health centers, hospitals, social services, shelters, or food banks will not be considered evidence of a lack of self-sufficiency, the rule’s underlying, stated goal. Yet, without such clarification, it remains unclear what the impact of using other public services made available community-wide basis will be. (As the Preamble’s reference to children’s use of Medicaid underscores, even ostensibly safe services in fact may not be safe). As the rule stands, it may push immigrants and families with immigrants to cease using public health services altogether. How big an impact might this rule have on overall population health? Quite large, as it turns out. According to our analysis of the 2012-2017 American Community Survey, about 50 million Americans live in counties where more than one-quarter of the population is foreign-born, including about 16.5 million immigrants and 32.6 million people born in the United States. Roughly half of the nation's population lives in counties where more than 10 percent of residents are immigrants – the tipping point for measuring community-wide safety levels for vaccine-preventable illnesses, according to the CDC. When 10 percent of the population is deterred from using public health services, the avoidance factor becomes large enough to begin to sway broader public health outcomes. And anecdotal evidence from the nation’s safety net health care providers suggests that immigrant patients indeed are beginning to disappear – not just from Medicaid, but from sources of health care themselves. These early-warning public health threat signs are hard to miss. They are like flashing red lights – telling us that the consequences of the public charge rule will be far broader than immigrants and their families and likely will wash over the broader communities in which they live. As a matter of basic common sense, the public health threat posed by a rule designed to drive immigrants away from public programs would have been a front-and-center consideration, but it is nowhere in the final rule.