The Trump administration's "public charge" rule -- currently in effect after Supreme Court rulings in January and last week -- could have a "chilling effect" on immigrants considering signing up for Medicaid, analysts said.
"I think the chilling effect will be quite large and growing," said Allison Orris, counsel at professional services firm Manatt Health in Washington, D.C. "The fact that people in New York are apparently shying away from signing up for the Women, Infants, and Children (WIC) program is particularly noteworthy because WIC is not included in the rule. It underscores the idea that the impacts of this rule will be sweeping, whether because people stay away from benefits impacted under the rule or they stay away from other benefits ... It's understandable that people are both confused and fearful about the way the rules will be applied."
The , part of the Immigration and Nationality Act, was issued in October by the Department of Homeland Security. It states that immigrants who are applying for a permanent residency "green card" or for citizenship will be negatively affected on their applications if they have used public programs such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, or Temporary Assistance to Needy Families for more than 12 months in a 3-year period prior to applying.
Several states sued over the rule, claiming it was unfair, and two courts issued injunctions preventing its implementation while litigation continues. The Supreme Court to lift one of them -- a nationwide injunction that was issued by a federal district court in New York State. That left one other injunction, issued by a court in Illinois and affecting only that state. The high court lifted that one on Friday.
However, there are facets to the rule that many immigrants aren't aware of, according to Kelly Whitener, of Georgetown University's Center for Children and Families in Washington. For example, "for many immigrants, such as refugees and asylees, the public charge rule does not apply," she wrote in an email.
"And for those immigrant groups subject to the public charge rule, there are important exceptions to understand, including that children's use of Medicaid, CHIP [the Children's Health Insurance Program], or subsidized [Affordable Care Act] Marketplace coverage will not count in their own green card petitions or in the petitions of family members. Immigrant families in the U.S. should be armed with these facts so that they have every opportunity to make informed decisions rather than reacting based on misinformation and fear."
In addition, "people don't really know when the public charge applies -- it varies by immigration status and where you're applying from," Whitener said in a phone interview. The test is called a "totality of circumstances" test that is "meant to be prospective and consider all these different factors, and benefit use is one of many. Even if you are subject to the test, and even if you use the benefit and there isn't a special exception for you ... It may be that isn't the thing that holds you back from getting the green card or is even a main focus of the balance of the test. So that's a thing a lot of people don't understand either."
But the rule's exceptions come with a caution, according to Sara Rosenbaum, JD, professor of health law and policy at George Washington University in Washington. "The problem is not just who is not protected, it is the documented chilling effect on everyone because of fears that a child's use will in the end cost a parent a green card, especially if the child is using because she is sick," she said in an email. "This is evidence in and of itself of public charge. The disincentive is to use healthcare, not just health coverage. This point is too often missed. Health needs is a ground for denying green card status."
"What is most sobering is the court's apparent failure to consider the potential public health impact of allowing a rule with this type of powerful, documented impact on coverage and care to go into effect while the challenge makes its way through the judicial system," she added.
The White House, on the other hand, said it was "gratified" by the Supreme Court's decision. "This final rule will protect hardworking American taxpayers, safeguard welfare programs for truly needy Americans, reduce the federal deficit, and re-establish the fundamental legal principle that newcomers to our society should be financially self-reliant and not dependent on the largess[e] of United States taxpayers," White House Press Secretary Stephanie Grisham said in a .
Jerry Vitti, founder and CEO of Healthcare Financial, a Quincy, Massachusetts company that connects low-income, elderly, and disabled populations with public benefit programs, called the court decision "short-sighted." "It will result in contracted Medicaid enrollment, and those who no longer have health coverage will get sick -- plain and simple," he said in an email. "This in turn leads to bad news for the healthcare system as a whole. Those without coverage will drive up costs as hospitals experience more emergency room usage and more unpaid bills that will cripple their ability to serve the poor."
In addition, he pointed out, many of the people currently living in the U.S. with a legal visa but not a green card "are the people doing the hard work in our vibrant economy today, including in our healthcare system. They are the personal care attendants who help those with disabilities, the home health aides who care for seniors who cannot live alone, and the certified nursing assistants who groom, clothe, and feed those in America's nursing facilities. Imposing new barriers for immigrants to come here and begin the path to citizenship will severely limit our healthcare industry workforce."