Marketplace Insurance: Public Charge Rule Change Impact

The Trump Administration's public charge rule change has raised concerns about its potential impact on immigrants' access to health insurance and their future immigration status. The rule expands the definition of a public charge to include certain health coverage programs like Medicaid, making it harder for immigrants to obtain permanent resident status or enter the US if they are deemed likely to rely significantly on government assistance. This has led to confusion and fear among immigrant families, with some avoiding public benefit programs despite their eligibility. However, it's important to note that marketplace insurance is not among the benefits that would negatively affect immigration applications under this policy.

The Trump Administration's proposal to change immigration rules

• Border Wall and Security: Trump proposed building a wall along the US-Mexico border to curb illegal immigration. He also deployed additional border patrol agents and implemented policies such as "zero tolerance" and "catch and release" to deter border crossings.
• Interior Enforcement: The administration increased immigration raids and deportations, targeting undocumented immigrants, including those with minor offenses or no criminal records.
• Visa and Asylum Restrictions: Trump imposed travel bans on citizens from several Muslim-majority countries and restricted the admission of refugees. He also sought to limit legal immigration by proposing changes to the H-1B visa program and green card issuance.
• Public Charge Rule: The administration introduced the "public charge" rule, which made it harder for immigrants to obtain permanent residency if they used public benefits like Medicaid or food stamps. This rule had a chilling effect on immigrant families, discouraging them from seeking necessary health and nutrition services.
• Family Separation: The administration implemented a "zero-tolerance" policy that separated migrant children from their parents at the border, causing widespread condemnation and sparking legal challenges.
• Sanctuary Cities: Trump targeted so-called "sanctuary cities," which limit cooperation with federal immigration enforcement, by threatening to withhold federal funding.
• Refugee Admissions: The administration drastically reduced the number of refugees admitted to the US, suspending resettlement from certain regions and imposing stricter security screenings.
• Temporary Protected Status: Trump sought to end Temporary Protected Status (TPS) for immigrants from certain countries, arguing that it was being abused and needed to be reformed.
• DACA: Trump attempted to end the Deferred Action for Childhood Arrivals (DACA) program, which protected undocumented immigrants brought to the US as children, but legal challenges kept the program in place.

The impact of the public-charge rule on immigrant families

The public charge rule has had a significant impact on immigrant families in the United States. The rule, proposed by the Trump administration in 2018 and finalised in 2019, expanded the definition of a "public charge" to include certain health coverage programs. This rule made it harder for immigrants to obtain permanent resident status (a green card) or enter the country if they were deemed likely to become dependent on government assistance. While the rule is no longer in effect as of March 2021, when the Biden administration returned to the previous policy, it had far-reaching consequences.

The rule created new barriers for immigrants seeking a green card or entry to the US, particularly those from low-income backgrounds. It led to decreased participation in health and nutrition programs such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP), as immigrant families avoided or withdrew from these programs due to fears about their immigration status. This, in turn, negatively impacted the health and financial stability of these families, especially those with US-born children.

The rule also disproportionately affected people with disabilities and older adults, as long-term institutional care covered by Medicaid was included in the public charge determination. Additionally, it had a chilling effect on immigrants who were exempt, with eligible legal immigrants avoiding enrollment or disenrolling from programs due to confusion and fear. This resulted in reduced access to healthcare and increased financial burdens for these families.

The Biden administration's reversal of the Trump-era rule in 2021 and the implementation of a new rule in December 2022 aimed to address these chilling effects and increase protections for immigrant families. The new rule clarified the categories of immigrants and benefits exempt from the public charge determination. However, the continued inclusion of long-term institutional care in the determination prevents a clear message that all Medicaid coverage is excluded.

Overall, the public charge rule had significant negative consequences for immigrant families, contributing to decreased access to essential services and increased financial instability. While the Biden administration has taken steps to mitigate these impacts, there are still concerns about the effects on immigrant families' well-being and their trust in accessing public benefits.

The effect of the rule on health coverage for citizen children

The Trump Administration's 2019 changes to the "public charge" rule have had a significant impact on citizen children, particularly those with noncitizen parents. The rule expanded the definition of a "public charge" to include certain health coverage programs, such as non-emergency Medicaid for non-pregnant adults, the Supplemental Nutrition Assistance Program (SNAP), and several housing programs. While citizen children's use of public benefits is not considered in their parents' public charge determinations, the rule has discouraged immigrant families from seeking public health insurance coverage for their citizen children.

The changes have led to decreased participation in Medicaid, the Children's Health Insurance Program (CHIP), and other programs among legal immigrant families, including their citizen children, even though they remain eligible. This is due to fears that their enrollment could negatively affect their or their family members' immigration status. As a result, there has been a rise in the number of uninsured citizen children, particularly those with noncitizen parents.

The impact of these changes is most prominent in states with large immigrant populations, such as California, Texas, and New York. In California, for example, research has shown that not only have foreign-born members of immigrant families disenrolled from public benefits, but so have U.S.-born children in those families. This has serious implications for health coverage, as immigrants in California are predominantly Latinx (50%) and Asian (34%), groups that already face health disparities.

The Biden Administration reversed the Trump-era public charge rule changes in 2021, but the effects on immigrant families' participation in public programs are likely to persist. Outreach and education efforts are necessary to alleviate fears and confusion, rebuild trust, and encourage eligible individuals to enroll in programs such as Medicaid and CHIP.

The history of the public charge concept

The concept of the "public charge" has been part of immigration law in the US since at least 1882, when the Immigration Act of 1882 was passed. This was the first federal immigration law, and it included a provision to exclude immigrants deemed "unable to take care of himself or herself without becoming a public charge". However, the public charge concept has deeper roots in American history, dating back to the colonial era.

The Colonial Era to the Late 1800s:

During the colonial era, various measures were implemented to protect against the entry of "undesirables". This included mandatory reporting of ship passengers, immigrant screening, and exclusion upon arrival of designated "undesirables". For example, a law enacted in colonial Massachusetts in 1700 kept out the infirm who had no security against becoming public charges. Similar laws were enacted in other colonies and states, such as New York, Delaware, and Georgia. These laws often targeted specific groups, such as felons, slaves, and free Black individuals, reflecting the racial and social biases of the time.

The Immigration Act of 1882:

The Immigration Act of 1882 was the first federal law to include a public charge provision. This Act excluded immigrants who were deemed "unable to take care of himself or herself without becoming a public charge". The Act did not define what constituted a public charge, leaving it to the discretion of immigration officials. This law reflected the public sentiment of the time, which was increasingly negative towards immigrants from Southern and Eastern Europe and Asia.

The 20th Century:

Over time, the public charge provision was modified and expanded upon. The Immigration Act of 1891 continued the exclusion of immigrants likely to become public charges and added additional criteria, such as the exclusion of convicts, the insane, and those with contagious diseases. The Immigration Act of 1903 allowed for the deportation of immigrants who became public charges within their first two years in the country. The Immigration Act of 1917 extended the time limit for deportation to five years.

In 1952, the Immigration and Nationality Act was enacted, which provided for both the exclusion and deportation of public charges. This Act defined a public charge as "any alien likely at any time to become a public charge". Immigrants who became public charges within five years of entry were subject to deportation unless they could prove that the causes of their reliance on public assistance arose after their entry into the US.

The 1996 Welfare Reform and Recent Changes:

In 1996, the Personal Responsibility and Work Opportunity Reconciliation Act overhauled the welfare system and restricted immigrant access to public benefits. This Act also raised the standards for sponsors of immigrants, requiring them to demonstrate greater financial capacity. In the same year, the Illegal Immigration Reform and Immigrant Responsibility Act strengthened the public charge doctrine by increasing the qualifications and obligations of immigrant sponsors.

In 1999, the Department of Justice issued Field Guidance on public charge determinations, defining a public charge as "an alien who has become or is likely to become primarily dependent on the federal government for subsistence". This guidance clarified that non-cash benefits, such as Medicaid, would not be considered in public charge determinations.

In 2019, the Trump administration broadened the scope of programs considered in public charge determinations and redefined a public charge as an "alien who receives one or more public benefits for more than 12 months in the aggregate within any 36-month period". This change led to increased fears and confusion among immigrant families, causing many to forgo or disenroll from eligible programs.

In 2021, the Biden administration proposed a new public charge rule that mirrored the 1999 Field Guidance, defining a public charge as someone "primarily dependent on the government for subsistence". This rule took effect in December 2022.

The impact of the rule on individuals with no coverage

The Public Charge Rule, which was changed in 2019 and then again in 2022, has had a significant impact on individuals with no insurance coverage. The rule allows federal officials to deny entry to the US or lawful permanent resident (LPR) status (a "green card") to those deemed likely to become a "public charge", or primarily dependent on the government for subsistence.

The 2019 rule change, implemented by the Trump Administration, broadened the definition of a public charge and the scope of programs that the federal government would consider in public charge determinations. This included previously excluded health, nutrition, and housing programs, such as non-emergency Medicaid for non-pregnant adults, the Supplemental Nutrition Assistance Program (SNAP), and several housing programs. The rule also established an income standard of 125% of the federal poverty level (FPL), with family incomes below this threshold considered a negative factor in public charge determinations.

The 2019 rule change had a chilling effect on immigrant families, leading to decreased participation in Medicaid and other programs. Many individuals chose to forgo enrollment or disenroll themselves and their children from these programs due to fear and confusion about the rule's implications for their immigration status. This resulted in an increase in the number of uninsured individuals, negatively impacting their access to care and contributing to worse health outcomes.

The Biden Administration's 2022 rule change reversed the 2019 policy, returning to the previous definition of a public charge and the programs considered in public charge determinations. The 2022 rule aims to address the chilling effects of the 2019 rule and encourage participation in public programs by clarifying that only cash assistance programs and long-term institutionalization at government expense will be considered in public charge determinations.

While the 2022 rule change is intended to reduce fears and increase enrollment in public programs, it may take sustained community-level efforts to rebuild trust among immigrant families. Even with outreach and education initiatives, some families may remain fearful and confused about the policy, particularly with the continued inclusion of long-term institutional care covered by Medicaid in public charge determinations.

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