“Public Charge and Private Dilemmas”: The Cost of Health Care for Immigrant Families

In 2019, the Trump administration enacted sweeping changes to the public charge regulations in order to make it harder for a low-income applicant to get their green card. Families, terrified of being deported and having their family torn apart by Trump’s “arcane” public charge rule, left social programs—like SNAP and Medicaid—in droves.

Nutrition coordinator Nagelli Rodriguez provides tips at the San Antonio Food Bank (SAFB) reception area, in San Antonio, Texas, on Oct. 31, 2011. (U.S. Department of Agriculture / Flickr)

In July of 2019, Maria Hernandez was on the phone with Cheasty Anderson of the Children’s Defense Fund of Texas (CDF-TX). Hernandez typed a few numbers into a spreadsheet, and hit enter on a calculation.

“Oh, wow,” she murmured. “Can that be right?”

“What does it say?” asked Anderson. Hernandez checked the numbers and tried the calculation again. Same answer.

“Eighty percent,” Hernandez said.

“Did you say eighty?” asked Anderson. “Like eight-zero?”

“Yeah, eighty. That is … quite a bit worse than I had expected,” Hernandez said.

Hernandez is the founder and executive director of an organization in Austin, Texas, called VELA, which provides assistance, support and training to families who have children with disabilities. These children rely on programs like Medicaid and SSI for the therapies that help them communicate, learn and sometimes even walk or swallow.

VELA’s job, in part, is to help them enroll in SSI, Medicaid, SNAP, WIC—any program for which parents or their children are eligible that would help the family care and provide for that child. They work with around 1,000 families a year, 85 percent of which are mixed immigration status families.

In 2017, VELA staff began noticing a change that went hand-in-hand with an uptick in conversations and questions about an immigration rule called the public charge (more on that below).

The number Hernandez had calculated on the phone was the “year-over-year” change in families enrolled in SNAP—that is to say, 80 percent fewer VELA families were enrolled in SNAP in the summer of 2019 than had been in the summer of 2018.

This story, a tale of hundreds of families in one community, en masse, abandoning a support upon which they had relied, is the story that launched a research project on the “chilling effect” in Texas. After that phone call, Anderson wanted to learn more. She began calling around to other service sector organizations she knew, and asking what they were seeing.

After months of research, the report CDF-TX published, called “Public Charge and Private Dilemmas: Key Challenges and Best Practices for Fighting the Chilling Effect in Texas,” revealed that VELA was not alone. Interviews with three dozen organizations around Texas—from health clinics to food pantries to insurance providers to job training programs—revealed why this dramatic withdrawal from public benefit programs was happening, and to whom.

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All across the state, organizations that work primarily with low-income, mixed-status immigrant families were experiencing similar problems. Families who had formerly been willing to enroll their eligible children in important anti-poverty programs like Medicaid, CHIP and SNAP were suddenly reluctant to do so.

Over a two year period, Texas enrollment numbers for Children’s Medicaid and CHIP dropped by around 7 percent—that’s 237,000 children who had formerly had health insurance and were now uninsured.

SNAP enrollment dropped even more drastically, by 13.5 percent.

WIC, a program that supports pregnant women and infant children, saw a drop of almost 19 percent.

Outreach specialist Seth Villalobos (left) with Olivia Hernandez and Cesar Trevino on Oct. 31, 2011, in the San Antonio Food Bank (SAFB) Outreach Office. (U.S. Department of Agriculture / Flickr)

These numbers were alarming, but the state-wide averages obscured the truly shocking numbers within immigrant communities. Drops of 80 percent, like VELA reported, were echoed by other organizations serving these families. In Houston, one  organization reported a 31 percent decline in Children’s Medicaid enrollments among their low-income immigrant clients. It was clear that the decline in enrollment was predominantly in mixed status families. But why was this the case?

The Trump Administration’s Harmful, “Arcane” Public Charge Rule

The Trump administration has always been unabashed in its virulently anti-immigrant stance. Rhetoric and policy combined in various ways from early in 2017 to frighten and police immigrants. But regarding public benefit use, there was one big change that mattered: an arcane immigration rule called the public charge.

The Trump administration enacted sweeping changes to the public charge regulations in order to make it harder for a low-income applicant to get their green card. If that applicant was eligible for, and then used, public benefit programs like Medicaid, SNAP, cash assistance or housing subsidies, it would negatively impact their application.

The rule is complicated, dense and hard to understand. Making it even worse, there was a lot of misinformation circulating that caused families to worry that, for example, a parent’s application would be harmed if their citizen child was enrolled in Medicaid.

This was not true, but the damage was done: Families, terrified of being deported and having their family torn apart, left these programs in droves.

As a result, Texas, and most states, have a big problem on their hands. Huge numbers of newly uninsured children are concentrated in low-income immigrant communities, and even among those still enrolled, we are seeing startling declines in basic preventive care like vaccinations. One health plan in Houston reported a 40 percent drop in routine vaccinations among their insured members, a worrying statistic in light of the current COVID epidemic and the vaccine we hope for in the spring. In addition to these health-related concerns, the staggering drop in SNAP has created an immigrant community that is facing a food crisis, with malnutrition rates on the rise. This is untenable and inhumane.

Without a dedicated response to address this crisis and to build a robust community outreach and enrollment effort, negative outcomes are inevitable. Widespread reduction in benefits enrollment has direct impacts on public health outcomes, educational attainment, and the economy. Action is needed now to rebuild trust between public programs and the communities they are supposed to serve.

Undoing the Harm

Fortunately, there are clear steps that can be taken  at the local, state, and federal level. First and foremost, the incoming Biden administration must prioritize a reversal of  numerous damaging policies enacted by the Trump administration. If possible, it must be encoded in law, rather than in administrative code, which could be changed easily by another administration.

At the state and local level, there are also things that can be done reach out and educate families who are, reasonably, frightened for their own safety.

The report outlines these steps in greater depth, but in summary: Community-facing organizations can invest in frequent, repeated education for their staff and their communities on what policies exist, what they mean, and what is safe. These organizations can make good use of community education resources available in many languages from the Protecting Immigrant Families campaign.

In addition, advocacy organizations should check in with their state agencies to make sure that personal data collection efforts are in line with federal guidance, and that reassuring language on privacy protections is stated clearly in all applications.

But the fight does not end there. We have the opportunity with this change of administration to undo much of the damage the Trump administration did to children’s access to health care and nutrition in this country, but whether we undo some of it or all of it has entirely to do with how hard we fight to pass meaningful reform, and how effective we are at buttressing state and local efforts to engage immigrant communities who have good reason not to trust.

We must work fast, and we must work hard. American children, the children of immigrants and their families, are counting on us.

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Dr. Cheasty Anderson is the Director of Immigration Policy and Advocacy at the Children’s Defense Fund-Texas. Her work focuses on the intersection of children’s issues and immigration, including family separation, immigrant detention, and the challenges faced by mixed-status families living in the United States.