As physicians, we are taught that our duty is to do no harm. A proposed rule by the Department of Homeland Security may lead to harm by having the opposite of its intended effect.
The proposed “public charge” rule would make it harder for legal immigrants in this country to extend a visa or qualify for a green card if they have used public benefits. The rule could harm low-income workers by forcing them to choose between accessing vital work supports—basic health coverage, food and housing services that keep them healthy and able to work—and maintaining their immigration status. Their families could be affected, too.
The proposed rule broadens the factors the government considers when determining whether someone is considered a “public charge.” Immigration officials make an inference against extending visas or granting new ones when an individual is likely to be a “public charge.” The existing definition considers, for example, receiving cash assistance under Temporary Assistance for Needy Families or reliance on Medicaid-funded long-term institutional care when determining which immigrants may come and stay in our country. This makes sense and is good policy because of the financial burden placed on citizens and the fact that, for the most part, these activities involve immigrants not participating in the workforce.
However, in changing the definition, the proposed rule would dramatically expand the types of benefits considered to be a mark against granting or extending visas. They would now include health coverage under Medicaid, food assistance under the Supplemental Nutrition Assistance Program, and federally subsidized housing, all of which are vital to the health of those we are privileged to serve. Beyond benefits, the rule increases the odds that low-income individuals earning below 125% of the federal poverty level ($31,375 for a family of four) could be determined a public charge.
From a physician’s perspective, these changes throw the rule out of balance. They would discourage work and harm the health of individuals and communities. Immigrants are likely to drop or not apply for Medicaid coverage to avoid jeopardizing their immigration status. And given the rule’s incredible complexity, fear and confusion could further erode coverage, even among people receiving benefits not directly included in the rule.
The Department of Homeland Security itself acknowledges that the rule could hinder immigrants’ access to healthcare, especially for pregnant women, infants and children. For example, families could increasingly turn to the emergency department as a primary source of healthcare and may be forced to forgo necessary vaccinations, increasing the prevalence of communicable diseases across the country. This should be the end of the debate; a rule that has these consequences is simply unwise from a public health perspective. But in addition to these health concerns, declining use of Medicaid and other public benefits could hurt communities more broadly, increasing poverty, decreasing housing stability, eliminating jobs, and weakening our state and local economies.
I echo concerns jointly expressed by my fellow physicians that the proposed rule threatens the health of individuals and communities. While policymakers are not bound by the Hippocratic oath and its promise to abstain from harming patients, in this case, the federal government should consider the harm that this proposal will do and go back to the drawing board.