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Original Investigation
July 1, 2019

Implications of Changing Public Charge Immigration Rules for Children Who Need Medical Care

Author Affiliations
  • 1Institute for Community Health, Malden, Massachusetts
  • 2Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
  • 3Harvard Medical School, Boston, Massachusetts
  • 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
  • 5City University of New York at Hunter College, New York
JAMA Pediatr. Published online July 1, 2019. doi:10.1001/jamapediatrics.2019.1744
Key Points

Question  How many children with medical needs are at risk of losing Medicaid and Children’s Health Insurance Program and Supplemental Nutrition Assistance Program because of the proposed public charge rule change?

Findings  This cross-sectional study found that 8.3 million children who are enrolled in Medicaid and Children’s Health Insurance Program or Supplemental Nutrition Assistance Program, of whom 5.5 million have specific medical need, are at risk of losing health and nutrition benefits. Between 0.8 and 1.9 million children with medical needs could be disenrolled from these benefits.

Meaning  The proposed public charge rule would likely cause millions of children to lose health and nutrition benefits, including many children with specific medical needs that, if left untreated, may contribute to child deaths and future disability.

Abstract

Importance  In October 2018, the Trump administration published a proposed rule change that would increase the chance of an immigrant being deemed a “public charge” and thereby denied legal permanent residency or entry to the United States. The proposed changes are expected to cause many immigrant parents to disenroll their families from safety-net programs, in large part because of fear and confusion about the rule, even among families to whom the rule does not technically apply.

Objective  To simulate the potential harms of the rule change by estimating the number, medical conditions, and care needs of children who are at risk of losing their current benefits, including Medicaid and Children’s Health Insurance Program (CHIP) and Supplemental Nutrition Assistance Program (SNAP).

Design, Setting, and Participants  A cross-sectional study used nationally representative data from 4007 children 17 years of age or younger who participated in the 2015 Medical Expenditure Panel Survey to assess their potential risk of losing benefits because they live with a noncitizen adult. Statistical analysis was conducted from January 3 to April 8, 2019.

Main Outcomes and Measures  The number of children at risk of losing benefits; the number of children with medical need, defined as having a potentially serious medical diagnosis; being disabled (or functionally limited); or having received any specific treatment in the past year. The numbers of children who would be disenrolled under likely disenrollment scenarios drawn from research on immigrants before and after the 1996 welfare reform were estimated.

Results  A total of 8.3 million children who are currently enrolled in Medicaid and CHIP or receiving SNAP benefits are potentially at risk of disenrollment, of whom 5.5 million have specific medical needs, including 615 842 children with asthma, 53 728 children with epilepsy, 3658 children with cancer, and 583 700 children with disabilities or functional limitations. Nonetheless, among the population potentially at risk of disenrollment, medical need was less common than among other children receiving Medicaid and CHIP or SNAP (64.5%; 95% CI, 61.5%-67.4%; vs 76.0%; 95% CI, 73.9%-78.4%; P < .001). The proposed rule is likely to cause parents to disenroll between 0.8 million and 1.9 million children with specific medical needs from health and nutrition benefits.

Conclusions and Relevance  The proposed public charge rule would likely cause millions of children to lose health and nutrition benefits, including many with specific medical needs that, if left untreated, may contribute to child deaths and future disability.

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