August 3, 2018

A new ‘Perspective’ article, published Aug. 1 in The New England Journal of Medicine, describes changes to U.S. immigration policy that are having an impact upon the country’s health policy. Specifically, a rule currently being formulated about people who are considered potential “public charges” could have major life and health consequences for millions of immigrant families.

Dr. Krista Perreira

Dr. Krista Perreira

Krista M. Perreira, PhD, professor of social medicine in the University of North Carolina at Chapel Hill School of Medicine and adjunct professor of health behavior, maternal and child health, and health policy and management at the UNC Gillings School of Global Public Health, is lead author of the article.

A “public charge” is a person considered to be primarily dependent upon the government for more than half of his or her personal income. In determining which immigrants may fall into this category, the government considers age, health, financial status, education and skills.

Those so labeled can be denied legal entry into the U.S., prevented from changing their status from a work or student visa to legal permanent residency, and in rare cases, in which someone becomes so labeled within the first five years after being admitted to the country, can be arrested and deported.

The Department of Homeland Security is proposing to expand the definition of a public charge to include any immigrant who “uses or receives one or more public benefits.” These include nonemergency Medicaid, the Children’s Health Insurance Program (CHIP), subsidized health insurance through the marketplaces created by the Affordable Care Act (ACA), the Supplemental Nutrition Assistance Program (SNAP), the Women, Infants and Children (WIC) program, the Earned Income Tax Credit, housing assistance, and the Low-Income Home Energy Assistance Program, among others.

“Notably, unauthorized immigrants are not the primary target of the draft rule,” Perreira and colleagues write, “since they are already ineligible for most federally funded public assistance. Instead, lawfully present immigrants would bear the brunt, as well as persons living in ‘mixed-status’ families (those in which some members are citizens and others are not) and persons living abroad who wish to immigrate to the United States.”

In determining whether someone is a public charge, the government would have power to assess the use of public benefits by family members who actually were born in the U.S. This includes more than 10 million children who are citizens but have at least one noncitizen parent.

“The new policies would have a chilling effect on lawfully present immigrants’ use of public programs,” the authors write.

More than one million people likely could disenroll from Medicaid, publicly subsidized health insurance coverage and SNAP benefits, and fear will cause underutilization of health care, including prenatal and postnatal care. Losing access to food and medical care will plunge millions more adults and children in the U.S. into poverty.

“If this rule takes effect, it will most likely harm the health of millions of people and undo decades of work by providers nationwide to increase access to medical care for immigrants and their families,” the authors say.

Co-authors of the article include Jonathan Oberlander, PhD, professor of health policy and management at the Gillings School and professor and chair of social medicine in the UNC School of Medicine, and Hirokazu Yoshikawa, PhD, Courtney Sale Ross Professor of Globalization and Education in New York University’s Steinhardt School of Culture, Education and Human Development.


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