Trump "public charge" rule resets health test for green cards

The Trump administration formally laid the groundwork Monday to weigh immigrants' use of programs like Medicaid and CHIP in determining whether they should get permanent residency.

Why it matters: The policy shift could discourage immigrant families from seeking health coverage if it could put their legal status at risk, public health groups warn.

• That could increase emergency room use, raise the cost of uncompensated care and widen health disparities, according to health policy experts.

Driving the news: The Department of Homeland Security published a new version of a "public charge" policy, which was expanded during President Trump's first term and then rolled back during the Biden years.

• It overrides previous policies that limited which public benefits could disqualify immigrants from getting a green card, instead leaving decisions to the discretion of immigration officers on a case-by-case basis.
• It also clarifies that a person's receipt of means-tested public benefits like Medicaid, CHIP and SNAP can be used to determine whether green card applicants would likely rely on government support.
• The new policy "restores broader discretion for DHS officers to evaluate all pertinent facts and aligns with long-standing policy that aliens in the United States should be self-reliant and government benefits should not incentivize immigration," the rule states.

Between the lines: Public health and immigrant aid groups say the change could have a chilling effect.

• A KFF-New York Times survey found 11% of immigrant adults said they stopped participating in public benefit programs last year due to immigration-related concerns, including about 4 in 10 (42%) who were likely undocumented and about 1 in 6 (17%) parents.

What they're saying: "This rule will exacerbate the pervasive fear and uncertainty among immigrant families," Andrew Racine, president of the American Academy of Pediatrics, said in a statement.

• He said the change could "lead to children — including those who are U.S. citizens — not receiving vital health services and supports they need and are eligible for."
• DHS estimated that more than $13 billion could be saved annually through the total reduction in transfer payments from federal and state governments.
• It acknowledged the rule might result in reduced revenues for hospitals and other health providers participating in Medicaid, as well as for companies that make drugs or medical supplies.

Context: The federal government has long had policies for permanent residency to determine whether a person is likely to become overly reliant on public benefits. Certain immigrant groups like refugees and asylum-seekers are exempt.

• The first Trump administration added most Medicaid services to public charge determinations. The Biden administration reversed the change, largely limiting determinations to cash welfare benefits.
• But misconceptions about using health services lingered. About 25% of adults in families with both undocumented and legally present members avoided public benefits in 2022 because of green card concerns, per the Urban Institute.

What's ahead: The new policy will apply to applications for green cards made on or after Sept. 18.