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Figure.  Perceptions of and Outcomes Associated With the Public Charge Rule Among Low-Income Adults in Texas
Perceptions of and Outcomes Associated With the Public Charge Rule Among Low-Income Adults in Texas

Data are from a telephone survey of 400 low-income Texans, who were all US citizens aged 19 to 64 years, with family incomes below 138% of the federal poverty level, conducted in November and December 2019. SNAP indicates Supplemental Nutritional Assistance Program.

aThis question was asked only of those who reported having heard about the public charge rule.

bThis question was asked only of those who reported knowing someone avoiding program participation or obtaining medical care.

Table.  Factors Associated With Awareness of the Public Charge Rule and Program Participation and Receipt of Medical Carea
Factors Associated With Awareness of the Public Charge Rule and Program Participation and Receipt of Medical Carea
1.
Ku  L. New evidence demonstrations that the public charge rule will harm immigrant families and others. October 9, 2019. Accessed February 2020. https://www.healthaffairs.org/do/10.1377/hblog20191008.70483/full/
2.
Sommers  BD, Blendon  RJ, Orav  EJ, Epstein  AM.  Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance.   JAMA Intern Med. 2016;176(10):1501-1509. doi:10.1001/jamainternmed.2016.4419PubMedGoogle ScholarCrossref
3.
Davern  M.  Nonresponse rates are a problematic indicator of nonresponse bias in survey research.   Health Serv Res. 2013;48(3):905-912. doi:10.1111/1475-6773.12070PubMedGoogle ScholarCrossref
4.
Solis  D, Manuel  O. Trump’s new public charge rule may have already scared thousands of Texas families off public health insurance. Published January 28, 2020. Accessed February 2020. https://www.dallasnews.com/news/immigration/2020/01/28/trumps-new-public-charge-rule-may-have-already-scared-thousands-of-texas-families-off-public-health-insurance/
5.
Bernstein  H, Gonzalez  D, Karpman  M, Zuckerman  S. One in seven adults in immigrant families reported avoiding public benefit programs in 2018. Published May 22, 2019. Accessed April 2020. https://www.urban.org/research/publication/one-seven-adults-immigrant-families-reported-avoiding-public-benefit-programs-2018
6.
Skopec  L, Musco  T, Sommers  BD.  A potential new data source for assessing the impacts of health reform: Evaluating the Gallup-Healthways Well-Being Index.   Healthc (Amst). 2014;2(2):113-120. doi:10.1016/j.hjdsi.2014.03.001PubMedGoogle ScholarCrossref
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    Research Letter
    Health Policy
    July 15, 2020

    Assessment of Perceptions of the Public Charge Rule Among Low-Income Adults in Texas

    Author Affiliations
    • 1Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
    • 2Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
    • 3Columbia University School of Social Work, New York, New York
    JAMA Netw Open. 2020;3(7):e2010391. doi:10.1001/jamanetworkopen.2020.10391
    Introduction

    In January 2020, the US Supreme Court allowed the Trump administration to implement a new rule regarding the definition of public charge. The rule establishes participation in public programs (Medicaid, the Supplemental Nutritional Assistance Program [SNAP], and subsidized housing), health status, and income as criteria in determining whether legal immigrants are able to gain permanent residency (green cards). Critics contend that this creates a chilling effect that dissuades individuals from participating in programs or obtaining medical care, even among people outside the policy’s intended scope (such as citizens with immigrant relatives).1 We surveyed low-income adults in Texas, a state with a large immigrant population, to examine perceptions of the public charge rule and its association with program participation and receipt of medical care.

    Methods

    We conducted a random-digit dialing telephone survey in November and December 2019 among US citizens aged 19 to 64 years in Texas with family incomes below 138% of the federal poverty level. Our sample was limited to citizens for 2 reasons: this was part of a larger longitudinal study of health insurance focused on citizens using a validated method,2 and noncitizens may be reluctant to participate in this type of assessment, which could generate nonresponse bias not easily addressed through reweighting. The survey was available in English and Spanish and was administered on cellular and landline telephones. As an anonymous survey, the study was deemed exempt by the Harvard T.H. Chan School of Public Health’s institutional review board. Participants provided oral informed consent.

    We used demographic weighting to reduce potential nonresponse bias.3 The survey assessed demographic characteristics, awareness of the public charge rule, and whether respondents had friends or family who had stopped participating or avoided public programs because they were “worried it would disqualify them from obtaining a green card or becoming a US citizen,” or who had avoided visiting a physician or a hospital “because they did not want to be asked about their immigration status.”

    We calculated descriptive proportions and conducted logistic regression analysis for selected outcomes. Statistical significance for the logistic regression model was based on 2-tailed P value of .05. Data analysis was performed using Stata statistical software version 14.0 (StataCorp). Analyses were performed from January to February 2020.

    Results

    The survey was completed by 400 adults (mean [SD] age, 38.6 [13.7] years), with a response rate of 7%, using the American Association for Public Opinion Research’s RR3 definition. The sampling frame corresponded to 3.9 million low-income citizens in Texas. The sample was 192 Latino respondents, (40.3%), 125 white respondents (35.5%), and 54 black respondents (17.5%); 213 female respondents (56.8%); and 84 rural respondents (13.6%) (Table); total unweighted numbers of respondents and weighted percentages are shown.

    The survey found that 58.9% of respondents had heard of the public charge rule (Figure), mostly from news sources (50.2%) or social media (28.7%); only 0.8% had primarily heard from a physician’s office or hospital. Of those familiar with the rule, 45.2% were very concerned or somewhat concerned about its potential impact on their friends or families.

    The survey also found that 11.6% of respondents (corresponding to over 400 000 low-income citizens statewide) reported knowing friends or family who had avoided participating in Medicaid, SNAP, or public housing, or had not visited a physician or hospital because of immigration-related concerns in the past year. Eight percent had avoided medical care, with smaller numbers avoiding Medicaid (2.9%), SNAP (3.5%), and public housing (2.4%). For all but SNAP participation, the majority said these changes were a serious problem.

    Predicted probabilities for the awareness of the rule were lower among young adults aged 19 to 30 years (41.1% [95% CI, 29.9% to 52.3%] vs 76.9% [95% CI, 68.2% to 85.7%] among respondents aged 46 to 64 years; P < .001), rural residents (45.4% [95% CI, 31.3% to 59.5%] vs 61.3% [95% CI, 54.6% to 68.0%] among urban residents, P = .05), and people with chronic conditions (54.0% [95% CI, 45.9% to 62.2%] vs 68.0% [95% CI, 58.0% to 78.0%] among people with no conditions; P = .05) (Table). Avoidance of public programs was more commonly reported among Latino respondents (10.1% [95% CI, 4.6% to 15.5%] vs 0.8% [95% CI, −0.1 % to 1.7%] among white respondents; P < .001), black respondents (9.8% [95% CI, 0.7% to 19.0%] vs 0.8% [95% CI, −0.1 % to 1.7%] among white respondents; P = .001), and urban populations (6.6% [95% CI, 3.6% to 9.5%] vs 1.3% [95% CI, −0.8% to 3.4%] among rural residents; P = .04). There were no factors significantly associated with avoiding needed medical care.

    Discussion

    In this timely survey, 11.6%, or nearly 1 in 8, low-income Texans had friends or family who avoided public programs or medical care in the past year because of immigration-related concerns. This represents a substantial population-level impact of nearly half a million people in Texas. This is consistent with reported reductions in Texas’s Medicaid enrollment linked to immigration concerns4 and national estimates that millions of legal immigrants may forego health insurance because of the public charge rule.1,5 These results are even more concerning in the context of the current coronavirus disease 2019 pandemic.

    Study limitations include the low response rate, similar to other telephone polls.6 Reluctance to answer immigration-related questions—potentially associated with rising anti-immigrant sentiment nationwide—likely led us to underestimate the policy’s impact. Our sample came from a single state, although one with a sizeable immigrant population. Finally, the sample was limited to citizens asked about the experiences of friends and families; again, this likely led us to underestimate the changes associated with this policy in immigrant communities.

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    Article Information

    Accepted for Publication: May 3, 2020.

    Published: July 15, 2020. doi:10.1001/jamanetworkopen.2020.10391

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Sommers BD et al. JAMA Network Open.

    Corresponding Author: Benjamin D. Sommers, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Rm 406, Boston, MA 02115 (bsommers@hsph.harvard.edu).

    Author Contributions: Dr Sommers had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Sommers, Blendon, Epstein.

    Acquisition, analysis, or interpretation of data: Sommers, Allen, Bhanja, Orav, Epstein.

    Drafting of the manuscript: Sommers, Bhanja.

    Critical revision of the manuscript for important intellectual content: Sommers, Allen, Blendon, Orav, Epstein.

    Statistical analysis: Sommers, Bhanja, Orav.

    Obtained funding: Sommers, Blendon.

    Administrative, technical, or material support: Allen, Blendon.

    Supervision: Sommers, Blendon.

    Conflict of Interest Disclosures: Dr Sommers reported receiving grants from the Commonwealth Fund, the REACH Healthcare Foundation, and Baylor Scott & White; personal fees and nonfinancial support from AcademyHealth, University of Chicago, Northwestern Medical Center, University of Rochester, and Washington University; personal fees from American Economic Journal, Massachusetts Medical Society, and Urban Institute; and nonfinancial support from University of Cincinnati, outside the submitted work. Dr Epstein reported receiving grants from the Commonwealth Fund and the National Institutes of Health. No other disclosures were reported.

    Funding/Support: Support for this study was provided by the Robert Wood Johnson Foundation’s Policies for Action program.

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The views expressed here do not necessarily reflect the views of the Robert Wood Johnson Foundation.

    References
    1.
    Ku  L. New evidence demonstrations that the public charge rule will harm immigrant families and others. October 9, 2019. Accessed February 2020. https://www.healthaffairs.org/do/10.1377/hblog20191008.70483/full/
    2.
    Sommers  BD, Blendon  RJ, Orav  EJ, Epstein  AM.  Changes in utilization and health among low-income adults after Medicaid expansion or expanded private insurance.   JAMA Intern Med. 2016;176(10):1501-1509. doi:10.1001/jamainternmed.2016.4419PubMedGoogle ScholarCrossref
    3.
    Davern  M.  Nonresponse rates are a problematic indicator of nonresponse bias in survey research.   Health Serv Res. 2013;48(3):905-912. doi:10.1111/1475-6773.12070PubMedGoogle ScholarCrossref
    4.
    Solis  D, Manuel  O. Trump’s new public charge rule may have already scared thousands of Texas families off public health insurance. Published January 28, 2020. Accessed February 2020. https://www.dallasnews.com/news/immigration/2020/01/28/trumps-new-public-charge-rule-may-have-already-scared-thousands-of-texas-families-off-public-health-insurance/
    5.
    Bernstein  H, Gonzalez  D, Karpman  M, Zuckerman  S. One in seven adults in immigrant families reported avoiding public benefit programs in 2018. Published May 22, 2019. Accessed April 2020. https://www.urban.org/research/publication/one-seven-adults-immigrant-families-reported-avoiding-public-benefit-programs-2018
    6.
    Skopec  L, Musco  T, Sommers  BD.  A potential new data source for assessing the impacts of health reform: Evaluating the Gallup-Healthways Well-Being Index.   Healthc (Amst). 2014;2(2):113-120. doi:10.1016/j.hjdsi.2014.03.001PubMedGoogle ScholarCrossref
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