The Department of Homeland Security issued a proposed rule that would provide new factors for immigration officials to weigh when determining whether a noncitizen is a “public charge.” A public charge is someone deemed likely to be a long-term financial burden in the U.S. and therefore ineligible for a visa or permanent residency.

  • New factors for immigration officials to consider would include, among other things, whether the person receives or would receive certain government healthcare benefits, such as nonemergency Medicaid services.
  • Since the proposed rule was issued on Oct. 10, 2018, some case managers have reported noticing a trend of legal residents and refugees considering refusing healthcare services out of fear of being denied permanent residency or citizenship.

Case managers and other healthcare providers say they noticed a trend in fall 2018 when legal immigrant Medicaid patients became concerned about visiting doctors and hospitals and using their coverage to receive preventive care.

Legal residents, refugees, and other immigrants who received Medicaid or similar services began to say they were afraid of continuing to access services. Their expressed anxiety was attributed to a proposed rule issued by the Department of Homeland Security (DHS).

The proposed rule, published Oct. 10, 2018, in the Federal Register, would add more factors for immigration officials to consider when determining whether a noncitizen is a “public charge” — an individual likely to be a long-term financial burden in the United States and therefore ineligible for a visa or permanent residency.

The new factors would include, among other things, whether the person receives or would receive certain government healthcare benefits, such as nonemergency Medicaid services. (The proposed rule can be found at: http://bit.ly/2FqGM3R.)

“We are hearing stories of concerned individuals asking questions and not understanding whether or not they should or should not access healthcare services in California hospitals,” says Carmela Coyle, president and chief executive officer of the California Hospital Association in Sacramento.

Similar stories were coming out of other regions, as well.

“We have a large network of community-based organizations, and we sent out a survey in November. Almost half of them have told us they have clients who are nervous and are discussing disenrolling from Medicaid benefits and Medicare savings programs,” says Leslie Fried, JD, senior director at the Center for Benefits Access at the National Council on Aging in Arlington, VA.

This was occurring even though the rule is not finalized. The U.S. Citizenship and Immigration Services (USCIS) of DHS collected 216,102 comments from citizens and organizations, including many from case managers and other healthcare providers. An extensive look at the comments would suggest that most are opposed to the public rule change.

The proposed change would replace the May 26, 1999, regulation on public charge, published by the former Immigration and Naturalization Service. Mark Phillips, chief of the residence and naturalization division of USCIS, did not respond to an email request for comment. The request was sent during the government shutdown when some DHS offices were closed.

“DHS seeks to better ensure that aliens subject to the public charge inadmissibility ground are self-sufficient, i.e., do not depend on public resources to meet their needs but rather rely on their own capabilities, as well as the resources of family members, sponsors, and private organizations,” according to the proposed rule. (See chief changes in proposed rule in this issue.)

Among the more than 100 citizen comments supporting the proposed public charge rule are letters that express a desire to ensure immigrants do not receive government assistance. A few commenters wrote that they support “the public charge rule because new immigrants since our nation’s earliest days have been required to demonstrate they are self-sufficient.” (Comments about the proposed rule can be read at: http://bit.ly/2QQvDdG.)

Some healthcare organizations and case managers have expressed concern that the proposed rule goes too far — cutting off at-risk populations from the only health insurance they have, which could lead to these populations becoming sicker and overcrowding EDs.

“Our greatest concern is the impact on people,” Coyle says. “California is home to more than 10 million immigrants — we have more than any other state.”

What the rule does is supersize the barrier to allowing legal immigrants to stay in the United States, she adds.

“We’ve already begun to hear reports of that chilling effect, of individuals concerned about using their Medi-Cal [California’s Medicaid] for fear it will count against them on the big tote board of whether or not they can stay in the United States,” Coyle explains. “The case management concern is about how do you manage the case of any individual when that person is afraid to use healthcare services, and that’s what this proposed rule is doing.”

Based on the California Hospital Association’s recent analysis, 4.3 million Medi-Cal enrollees would forgo medical coverage if the proposed rule becomes a final rule, Coyle says.

“That’s a disaster,” she says. “One in three individuals in California is enrolled in Medi-Cal, so this is a very serious issue and, quite honestly, would create an enormous public health challenge.”

More children and elderly people would die from avoidable causes, and EDs and hospital beds would be filled with people whose acute and serious illnesses could have been prevented through primary care and case management services, she adds.

“I think about the important work that our case managers do, using a toolbox full of tools to help patients return to health,” Coyle says. “For immigrants, this proposed rule takes the toolbox, turns it upside-down, and empties it out.”

The Affordable Care Act helped spread the benefits of case management and promoted preventive care and population health efforts. This measure could undermine those benefits for a significant number of people, one self-identified case manager wrote in a comment to immigration services in opposition to the proposed public charge changes.

“We cannot afford to go backward and make our population sick again. It just costs too much,” wrote Debra Spence, a case manager for 18 years. She did not offer her professional affiliation.

The change will directly affect case management, making care transitions challenging, Coyle says.

“It’s the case manager’s job to make sure someone accesses hospital services and has a clear pathway back into the community,” Coyle explains. “But if you have a patient who is fearful of accessing that care, it creates an enormous wall between the case manager and the individual they are trying to serve.”

Another potential effect would be infectious disease outbreaks among immigrant children who were not immunized out of fear of the public charge changes — or as a result of the changes, if the rule is finalized as proposed, she says. (See suggestions for how case managers can educate affected patients in this issue.)

The Children’s Health Insurance Program (CHIP) makes preventive healthcare, including vaccines, affordable for low-income families, including immigrants. DHS is considering including CHIP in the list of benefits that would trigger a public charge finding because “the total federal expenditure for the program remains significant, and because it does provide for basic living needs (i.e., medical care), similar to Medicaid,” the proposed rule states.1

One case manager wrote to DHS that if CHIP is included on the public charge list, it could prevent parents from vaccinating their children, forcing them to choose between their healthcare and green cards. This already is being felt, wrote Lily Sonis, LCSW, MPH, medical case manager, immigrant and refugee health program at Boston Medical Center.

“An immigrant mother I worked with was too afraid to sign her child up for CHIP because she was worried about how it might affect the child’s ability to apply for permanent residency,” Sonis writes. “The child needed vaccines to enter school, and the family had to pay out of pocket for the child’s preventive care, which posed a significant burden to the family.”

Sonis also notes that the proposed rule has a negative effect on refugees who would not be affected by the rule change.

“These populations are still often afraid to access services for which they are eligible,” Sonis wrote. “One of our patients, who is seeking asylum on political grounds after being tortured and experiencing sexual violence, called me after the public charge proposed changes were announced to express her fear and confusion. She was worried that she might be deported if she continues to receive health coverage through emergency Medicaid.”

Emergency Medicaid is not on the public charge list, but this refugee patient could not be convinced that it was safe to continue her necessary medical and mental healthcare, she added.

Immigrant and refugee patients already are avoiding healthcare appointments and are not asking for help — a trend that could grow if the proposed rule becomes a final rule.

“Patients avoiding asking for help is antithetical to the foundation of my profession and will have disastrous consequences for our patients’ health,” Sonis wrote.

A care manager at a federally qualified health center in East Harlem, NY, submitted a comment about how the proposed rule would lead to severe health consequences for immigrant women and children, and is already having a deleterious impact.

“Recently, I sat with a pregnant woman in my office. She explained that she has difficulty putting food on the table for her and her two kids,” wrote care manager Belkyss Arias. “I urged her to enroll in SNAP [Supplemental Nutrition Assistance Program] services given her eligibility, but she refused. She feared that her immigration status would be threatened,” Arias continued.

“I pleaded with her to enroll, explaining that this was not the case, but she refused. I worry about the health of her two children without food and the health of her future child if she is not able to nourish herself throughout this pregnancy.”

The proposal could lead to an increase in morbidity and mortality during delivery, longer NICU stays for infants, and an increase in preventable birth defects, Arias predicted.

Low-income immigrant families particularly would be harmed by the proposed changes, according to Richard E. Besser, MD, president and chief executive officer of the Robert Wood Johnson Foundation in Princeton, NJ.

“Children become a negative factor because they tend to be eligible for public benefits,” Besser wrote in a comment to DHS.

An estimated 42% of noncitizens entering the U.S. without permanent residency status have characteristics that would be deemed “heavily weighted negative factors” and could trigger DHS to consider them public charges, Besser said.2

Besser’s letter refers to a 2018 Kaiser Family Foundation study that also found that 94% of noncitizens who entered the U.S. without legal permanent resident status have “at least one characteristic that DHS could potentially weigh negatively in a public charge determination.”2

According to Besser, “The proposed standard would reach all aspects of daily life, implicating millions of immigrants and their families — either directly or as a result of the rule’s chilling effect — potentially leading to a wholesale withdrawal from public programs.”


  1. Department of Homeland Security: Inadmissibility on Public Charge Grounds. Fed Reg. 83(196):51114-51296.
  2. Artiga S, Garfield R, Damico A. Estimated impacts of the proposed public charge rule on immigrants and Medicaid. Kaiser Family Foundation, Oct. 11, 2018. Available at: http://bit.ly/2M80txT.