Ethical debate, controversy, protests, and lawsuits all have resulted from the U.S. Department of Homeland Security’s recently announced “public charge” rule.1,2 According to the rule, using public benefits, including Medicaid, may affect individuals’ ability to enter the United States or adjust to legal permanent resident status.

The rule “creates barriers to appropriately caring for the sick and injured and to keeping people healthy,” said Rick Pollack, president and CEO of the American Hospital Association (AHA), in a public statement.3 “Failure to provide such services also has public health implications that could have widespread impact.”

Multiple lawsuits have been filed to prevent the rule from taking effect.4 According to a brief filed by the AHA and other hospital groups, “Although the Public Charge Rule will have the greatest impact on immigrant communities, the hospitals that serve them will also be affected. Coverage losses will lead to sicker immigrant populations and increased emergency room visits, forcing hospitals to provide more uncompensated care and divert resources from expanding access to healthcare and other community services.”5

Ken Cuccinelli, acting director of U.S. Citizenship and Immigration Services (USCIS), said in a statement: “Self-reliance, industriousness, and perseverance laid the foundation of our nation and have defined generations of hardworking immigrants seeking opportunity in the United States ever since. Through the enforcement of the public charge inadmissibility law, we will promote these long-standing ideals and immigrant success.”6

Hospitals routinely screen patients for Medicaid eligibility. “The public charge rule limiting the ability of legal residents to obtain citizenship if they use social support services, including Medicaid, likely will cause some legal residents to avoid applying for Medicaid,” says Joyeeta G. Dastidar, MD, an associate clinical ethicist at NewYork-Presbyterian Hospital and an assistant professor of medicine at Columbia University Vagelos College of Physicians and Surgeons.

This could increase the number of uninsured or underinsured patients, says Dastidar, “thereby shifting the costs of healthcare coverage from the government to the patient and/or healthcare system.”

A USCIS spokesperson declined to comment on this specific concern due to pending litigation. According to the final rule, “DHS appreciates concerns expressed about increasing healthcare costs, worse health outcomes, increased use of emergency rooms, and the economic health of hospitals.”

The rule further details that “DHS has made a number of changes in the final rule itself. DHS has excluded the Medicare Part D LIS, receipt of public benefits by children eligible for acquisition of citizenship, and Medicaid receipt by aliens under the age of 18 from the definition of public benefit in the public charge determination. In addition, DHS is not including CHIP in the public benefit definition. DHS also adopted a simplified, uniform duration standard for public charge determinations for assessing the use of public benefits.”

Another potential consequence is that the length of stay and overall costs of hospitalization would increase in the population, according to Dastidar. “If these predictions are borne out as a consequence of the public charge rule, it seems unethical,” she says. “It penalizes poorer residents for needing government assistance.”


  1. U.S. Citizenship and Immigration Services. 8 CFR Parts 103, 212, 213, 214, 245 and 248 [CIS No. 2637–19; DHS Docket No. USCIS–2010–0012] RIN 1615–AA22. Inadmissibility on Public Charge Grounds. Federal Register. Available at:
  2. Kaiser Family Foundation. Changes to “public charge” rule: Implications for health and health coverage, Aug. 12, 2019. Available at:
  3. American Hospital Association. Statement on public charge rule, Aug. 12, 2019. Available at:
  4. Hajela D. Lawsuits around U.S. seek to block Trump’s public charge rule. PBS NewsHour, Oct. 8, 2019. Available at:
  5. City and County of San Francisco and County of Santa Clara v. U.S. Citizenship and Immigration Services. Available at:
  6. U.S. Citizenship and Immigration Services. USCIS announces final rule enforcing long-standing public charge inadmissibility law, Aug, 12, 2019. Available at: