Immigrant Health and Changes to the Public-Charge Rule: Family Physicians’ Response

There has been strong evidence showing that immigrants have lower healthcare coverage rates than individuals born in the United States [1]. Moreover, whether naturalized citizens or non-citizens, children of immigrants tend to have lower healthcare coverage rates [1]. As immigrants have less healthcare coverage, they tend to avoid utilizing primary care services (preventative, diagnostic, and therapeutic) and delay seeking care until their conditions become unbearable, resulting in seeking care in the emergency rooms. Their ability to get coverage and access to health care is affected by many factors, including socioeconomic status, employment status, English proficiency level, and immigration status.

To address the impact of immigrant status on health care access, we need to understand the concept of "public charge." A public charge was used to describe an individual who depended on the government for more than half of his/her income [2]. With the recent revision to the immigration law, the definition of the public charge was updated. It now identifies an individual who receives one or more public benefit(s) for more than 12 months in a 36-month period [2,3]. Under section 212(a)(4) of the Immigration and Nationality Act (INA), 8 U.S.C. 1182(a)(4), immigrants (aliens) who are seeking to adjust their immigrant status, to become lawful permanent residents or citizens, are inadmissible if they are a public charge or likely to become a public charge at the time of application for adjustment of status [3]. Furthermore, inadmissible aliens will not be granted adjustment of status [3]. Thus, many immigrants shy away from utilizing publicly-funded healthcare programs even if they qualify for them to avoid any consequences of becoming a public charge may have on adjusting their immigrant status.

In this article, a group of family physicians practicing in Southern California shared how immigrants and families whose income falls below the federal poverty level make the largest segment of the patient population they serve. Their practice offers many services designed to address the needs of these vulnerable populations. They utilize a sliding fee scale, employ social workers and case managers, and collaborate with various community programs to address their patients' needs. Furthermore, they encourage their patients to apply to all publicly-funded assistance programs for which they may be eligible. However, they found that many of the immigrants are reluctant to apply for these benefits.

This reluctance is the direct result of the new immigration reform. The new federal definition of the "public charge" has direct and indirect complications on legal immigrants' health. Many eligible immigrants are now discouraged from applying to publicly-funded health coverage due to the impact that receiving such benefit has on adjusting their status. This ultimately decreases the immigrants' overall ability to obtain coverage, and, subsequently, their ability to seek medical services. These eligible immigrants are also now discouraged from applying for food and housing benefits. Taking the social determinants of health into consideration, it becomes inevitable that not having secure food or housing further contributes to worse health outcomes. Since the months during which immigrants receive benefits will be counted against them, immigrants are discouraged from applying for healthcare coverage and other benefits such as food and housing assistance. This further exacerbates the health disparities that immigrants are already suffering from in the United States.

As a response to the updated public charge concept, the authors shared some approaches to address patients' concerns. A total of 11 approaches were proposed, and we think these approaches fell into four main categories: improvements in clinical practices, patient education, community outreach, and legislation. Improvements in clinical practices included creating a welcoming atmosphere for all patients regardless of immigrant status and offering payment plans based on their needs and abilities. Patient education included providing educational materials to patients and educating the medical staff about which publicly-funded services immigrants are excluded from counting towards the public charge. Regarding community outreach, the authors encouraged partnerships with local organizations, including legal and social entities that support immigrants. Concerning legislation, the authors encouraged healthcare providers to voice their concerns by joining forces with professional organizations that share similar values, contacting officials, and voting for health-promoting policies.

Overall, this article highlights how federal policies may negatively impact immigrants' health. Lawfully-present immigrants in the U.S. face financial hardships, which often qualify them for publicly-funded programs, including healthcare benefits. However, immigrants are now discouraged from seeking out these benefits as they anticipate the likely negative effects on their immigrant status.

As first-generation immigrants, United States citizens by naturalization, and a future physician and pharmacist, we believe that healthcare is a human right. It should be unaffected by immigration status. Moreover, immigrants should not be put in a position of having to avoid applying for publicly-funded healthcare coverage, for which they are eligible, because of the inevitable consequences this may have on adjusting their immigrant status. As future healthcare providers, we need to advocate for the immigrants in the United States to apply to health benefits that they qualify for without risking their immigrant status.

Ultimately, we encourage health professional students, like ourselves, to be involved and learn more about the policies that will frame our future practices and continue to shape the health of our patients. It is our responsibility to educate our patients about their health; it is equally our responsibility to listen and learn from their struggles as they navigate the healthcare system. Active efforts should be made to increase awareness among future health providers regarding the existing policies and legislation that may negatively impact the healthcare of millions of lawfully present immigrants in the United States. Raising awareness will serve as the first step for any meaningful change to eliminating health inequities among individuals in the United States.

References:
1. Derose KP, Escarce JJ, Lurie N. Immigrants and health care: sources of vulnerability. Health Aff (Millwood). 2007;26(5):1258-1268. doi:10.1377/hlthaff.26.5.1258
2. Haq C, Hostetter I, Zavala L, Mayorga J. Immigrant Health and Changes to the Public-Charge Rule: Family Physicians' Response. Ann Fam Med. 2020;18(5):458-460. doi:10.1370/afm.2572
3. Public Charge Fact Sheet. USCIS. https://www.uscis.gov/archive/public-charge-fact-sheet#:~:text=Definitio.... Accessed September 19, 2020.