Non-citizen “documented” immigrants may soon have to decide whether accessing necessary healthcare is worth risking their path to citizenship.
On Monday, the Trump administration released its final version for “Inadmissibility on Public Charge Grounds.” The rule, scheduled to take effect in 60 days, makes obtaining permanent legal status harder for immigrants who receive public benefits including Medicaid, subsidized housing, and nutrition programs. Lawmakers and activists have denounced this latest attack on low-income immigrant communities of color. CT Attorney General William Tong has joined other states in taking legal action against the rule.
The new public charge rule accompanies a barrage of anti-immigration policies that establish documentation status as a social determinant of health. Squalid conditions in detention centers are morally reprehensible and detrimental to the health of new migrants. Doctors, medical students, and volunteer clinics have fought on the frontlines of this humanitarian crisis. Noncitizen immigrants already living in the U.S., regardless of legal status, are also discouraged from seeking healthcare: for fear of deportation, separation from family, or designation as a public charge. Green card applicants can be deemed likely to become a public charge if they have negative factors including a lack of private health insurance, medical conditions that require extensive treatment, or limited English proficiency.
A joint statement from National Hospital Associations urged the administration to withdraw the harmful rule, because it “could undermine access to care for legal immigrants by discouraging the use of critical public programs like Medicaid.” Over 13.5 million Medicaid and CHIP enrollees live in a household with at least one noncitizen; they may disenroll out of uncertainty or fear. At HAVEN Free Clinic, a Yale student-run primary care clinic serving uninsured patients in New Haven, eligible patients have mentioned not applying for Medicaid or nutrition assistance programs for fear of jeopardizing their family’s immigration status.
Government health programs are meant to help people receive lifesaving care and, more generally, to protect the overall health of the public. They are now being weaponized against low-income immigrants, a shortsighted move which can hurt vulnerable populations, widen health disparities, and harm public health for years to come. The vast majority of the healthcare community recognizes the dire need for evidence-based solutions to improve healthcare access for the undocumented and uninsured — not only as a moral imperative to protect the marginalized, but also a policy and economic priority for our nation’s well-being.
Barriers to accessing health insurance will increase uninsured rates and worsen health outcomes for the estimated 11 million undocumented immigrants and 22 million noncitizens residing in the United States. While the Affordable Care Act (ACA) expanded coverage to millions of Americans, it left intact the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PROWRA), which excluded undocumented immigrants from government-funded insurance including Medicaid, Medicare, and Children’s Health Insurance Program (CHIP)). The cost of uninsurance, in both economic and health terms, is immeasurable.
Without preventive primary care services, uninsured populations experience more avoidable health emergencies and expensive chronic illnesses. Medical debts are the leading cause of bankruptcies in the U.S., and low-income, uninsured patients are at the highest risk for catastrophic health expenditures. Under the Emergency Medical Treatment and Labor Act (EMTALA), hospitals receiving federal payments must treat all medical emergencies regardless of patients’ ability to pay. The cost of uncompensated care for uninsured populations in 2013 was estimated to be $84.9 billion.
Much of these costs, incurred when the uninsured are billed for medical services they cannot pay for, are already absorbed by the public system. The federal government helped offset about $32.8 billion through channels including Medicaid and Medicare; state, local governments and the private sector also shared the burden. Uncompensated care is mainly provided through a network of hospitals (60%), community health centers (26%), and office-based physicians (14%). However, as safety net hospitals that provide crucial healthcare for the underserved become strained, their closures can cause spillover pressure on nearby hospitals and state governments to cost-shift.
Medicaid expansion drastically lowered hospitals’ uncompensated cost burden. It also reduced emergency department visits by uninsured patients from 16% in 2006 to 8% in 2016. The public health benefits of expanding coverage are abundant, with improved healthcare access and health outcomes, mitigated infectious disease, enhanced economic productivity, and social inclusivity, among others. In the long run, public health insurance serves as an investment in children, their healthy development, and the financial stability of their families. Medicaid and CHIP expansions in the 1980s -1990s demonstrated that children with increased eligibility paid more taxes, collected less EITC, and had higher cumulative wages by age 28; the study also estimated decreases in mortality and increases in college attendance. In short, providing access to healthcare yields a positive return on taxpayer spending.
During his Monday announcement of the new public charge rule, acting director of Citizenship and Immigration Services Ken Cuccinelli was pressed on the Emily Lazarus poem inscribed on the Statue of Liberty: “Give me your tired, your poor, Your huddled masses yearning to breathe free.” Cuccinelli responded that he’s “certainly not prepared to take anything down off the Statue of Liberty.”
If we still dream to call the United States a land of immigrants, where all lives are created equal, we must protect not only those lives born within our borders, nor only those who are wealthy, healthy, and have self-sufficiency. Accessing healthcare should not be a roadblock to citizenship — it is a human right.
Grace Jin is a senior Global Affairs major and premedical student at Yale. Howard P. Forman MD, MBA is a Professor in the Practice of Management, Professor of Public Health (Health Policy) and a practicing physician at Yale.