On October 10, the Trump administration published a proposed rule that significantly harms immigrant families, in part by dramatically reducing their access to health coverage and care. As our Center for Children & Families (CCF) colleague Kelly Whitener has documented on our sister blog (CCF’s Say Ahhh!), the so-called “Public Charge” rule would make it far more difficult to immigrate to the U.S. or to get a green card.

You can read more about the changes to federal immigration law here, and access a helpful slide deck about the relevant health care programs from the Robert Wood Johnson Foundation’s State Health & Value Strategies program here. As has been broadly reported, the Department of Homeland Security (DHS) is proposing to broaden the types of public benefits that would count against an immigrant’s application for admission to the U.S. or permanent residency to include such health programs as Medicaid, Medicare’s Low Income Subsidy, and, potentially, the Children’s Health Insurance Program (CHIP). However, although earlier drafts had suggested that receiving the Affordable Care Act (ACA’s) premium tax credits for private marketplace coverage might be included, the proposed rule would not consider that program to be counted as a “public charge.”

But we private insurance wonks are not applauding. The proposed rule could still have a significant dampening effect on marketplace enrollment, resulting in many legally present immigrants forced to choose between coverage for their families and putting their immigration status at risk. Three issues in particular stand out:

• In determining whether someone is a public charge, DHS is proposing to consider whether someone has applied for a public benefit, even if they never actually enroll. Currently, some state-based marketplaces, in an effort to streamline enrollment for consumers, automatically generate a Medicaid application when someone applies for marketplace coverage. Once the person is deemed ineligible for Medicaid, the marketplace then determines their eligibility for the ACA’s premium tax credits. Under the proposed rule, the marketplace’s submission of a Medicaid application, even if the applicant never enrolls, could put their green card application at risk.
• It is not uncommon for someone enrolled in a marketplace plan to have an income change during the year that makes them eligible for Medicaid. In some state-based marketplaces, when that occurs, the state may generate a Medicaid application for them automatically. While many states instituted these automatic processes in order to make it easier for consumers to maintain continuous coverage and streamline enrollment processes, this practice now could place some immigrant families at risk.
• Perhaps most significant is that many immigrant communities will be fearful of the potential consequences of enrolling in marketplace coverage, with or without financial help. This could dampen marketplace enrollment and leave people without access to critical primary and preventive care, as well as huge financial liability if they have an unexpected medical event or diagnosis.

Many legal immigrants work in industries that do not offer health benefits to their employees, such as retail, hospitality, and agriculture. It defies logic, reason, and basic human decency to think that denying these hard working families access to health coverage is good public policy. Even DHS itself admits that the proposed rule could increase poverty, and that immigrants who don’t enroll in benefits for which they’re eligible could experience a loss in productivity, adverse health effects, higher medical expenses, and reduced educational attainment. Comments on the rule are due December 10, 2018.