[Editor’s Note: On September 22, 2018, the Department of Homeland Security posted a draft regulation that would change the public charge test. The posted draft is different from “leaked” versions analyzed here in several key respects, and the conclusions of this blog post should not be used in reference to the September 22 posting. The posted draft has not been published in the Federal Register, and therefore it is not an official notice of proposed rule-making. We will write about the posted draft as soon as possible.]

Amid the general anti-immigration landscape, one of the more troubling potential policy changes is a change in the definition of public charge. The proposed policy change has not been formally announced, but two versions of the draft regulation have been leaked to the press. Though there are some differences in the two versions, the general direction is clear – the Administration would like to decrease the number of immigrants gaining green cards, especially immigrants using family-based petitions, and believe that creating a strong disincentive to use public benefits will do the trick.

Regular readers of SayAhhh! already know that we’ve reached historic coverage levels for children, thanks to Medicaid, CHIP and the ACA, with 95% of children covered in 2016. Coverage levels for parents and other adults are not as high; about 12% of adults were uninsured in 2016. But even with the success we’ve seen for kids’ coverage generally, disparities persist. For example, 8% of citizen children with a noncitizen parent are uninsured, compared to 5% for children overall. These families are sometimes referred to as “mixed status” families because some family members – the children in this case – are citizens, while others – like one or both parents – are not. In fact, the vast majority of the remaining uninsured (including children and adults) are citizens and this potential change would likely lead to even more uninsured citizen children.

The potential public charge change has two prongs – first, to expand the list of benefits that immigration officials consider when deciding whether a person is likely to become a public charge and second, to include in that consideration benefits used by family members, including citizen children. This policy change would leave noncitizen parents of 10.4 million US citizen children with an awful choice – enroll your citizen children in public benefits to which they are legally entitled and risk your ability to stay in the US long term, or decline benefits that your children need to grow and thrive in order to preserve your chances of staying together as a family. This puts 10.4 million citizen children in mixed status families between a rock and a hard place, and it could have damaging effects well beyond this group and impact the nearly 20 million citizen children with an immigrant parent through what is known as the chilling effect.

Though it’s impossible to know how families would manage this terrible dilemma, the researchers at the Kaiser Family Foundation released an important new brief outlining a range of possibilities. The brief, Potential Effects of Public Charge Changes on Health Coverage for Citizen Children, describes the impact the proposed change would have on citizen children’s health coverage including changes to the number of children covered by Medicaid/CHIP and changes to the number of uninsured children.

As of 2016, 5.8 million citizen children with a noncitizen parent were enrolled in Medicaid/CHIP (see appendix table 2 for state-by-state numbers) and 790,000 (8%) were uninsured. The report assumes that some of these citizen children would disenroll from Medicaid and CHIP even though they remain eligible because of fears about how using such benefits would impact their parents’ immigration status. To estimate the magnitude of this effect, the authors turn to disenrollment rates following welfare reform in the 1990s and set a range around that midpoint, resulting in three scenarios.

The results are startling. The Kaiser analysis finds that between 657,000 to 1.5 million citizen children could become uninsured if the guidance is implemented. The range is as follows:

• Assuming a 15% disenrollment rate, 875,000 citizen children would lose Medicaid/CHIP and 657,000 would become uninsured.
• Assuming a 25% disenrollment rate, 1.5 million citizen children would lose Medicaid/CHIP and 1.1 million would become uninsured.
• Assuming a 35% disenrollment rate, 2 million citizen children would lose Medicaid/CHIP and 1.5 million would become uninsured.

This would take the uninsured rate among citizen children with a noncitizen parent from 8% to as high as 22%, with a subsequent increase in the uninsured rate for all children from 5% to as high as 7%.

The analysis suggests that implementing the public charge guidance will have the practical effect of turning the clock back five years on all the progress that has been made covering kids to 2013, just before the ACA was implemented. The cynic in me wonders if this might be another goal of the Administration – having failed to repeal the ACA and cap Medicaid, they are finding other ways to cutback on health coverage.  

Even though these numbers are staggering, the authors caution that they may have underestimated the impact for three main reasons. First, the disenrollment rates could be much higher. The rates cited come from research done following changes to eligibility for cash assistance in the 1990s, but unlike the proposed public charge changes, the eligibility changes at that time did not affect immigration status. Second, more children losing Medicaid/CHIP could become uninsured. Research suggests that about 25% of children enrolled in Medicaid/CHIP may have other coverage options, but without regard to affordability. Third, the authors do not include an estimate for coverage losses resulting from decreased participation in the Marketplace, even though receipt of premium tax credits to purchase such coverage would also be included in the public charge determination under the leaked draft.

There are always confounding factors making it hard to determine with certainty the cause of coverage changes. But even though the policy has not yet been implemented and may never be, its effects along with other anti-immigrant policy changes are rippling through immigrant communities now. A climate of fear and intimidation of immigrant families has clearly taken hold as a result of actions by the Trump Administration. And we know the general direction this is going – more and more children in immigrant communities will be losing coverage, widening the divide between children in working families and children of color and children in more affluent and more white communities.