On Monday, after years of speculation, court injunctions, and false starts, the Trump administration will finally put into effect its so-called public charge rule. The new program, which was greenlit by the Supreme Court last month even as it remains tied up in litigation, generally expands the criteria for rejecting visa and green card applicants based on past, present, or expected use of certain government benefits such as Section 8 housing vouchers and Medicaid, among other socioeconomic factors. Like so many other policies to come out of this administration, it is a perfect marriage of antipathy toward the poor and malice toward immigrants.
And because of its unusually long public run-up, we have already been given a small taste of what to expect, which has illuminated both one of the policy’s primary dangers and a key obstacle to assessing its impact: Some people will stop using vital services; others will be deterred before even trying. Immigrant-heavy localities, even without the rule in effect, have already seen widespread disenrollments from a variety of benefits, including those—such as the Special Supplemental Nutrition Program for Women, Infants, and Children, or WIC—that won’t even be impacted by the rule.
To some extent, though, it’s irrelevant who and what kinds of benefits are or aren’t being directly targeted in the rule—that sense of ambiguity is precisely the point. Public charge determinations in the immigration context have existed for over a century and have long been understood to apply to those who were or could become primarily dependent on the government. The new definition is a 200-page blunt-force instrument intended to dissuade millions of people from using basic assistance and health insurance.
“You almost feel like you need a Ph.D. to understand what’s going in and what isn’t, and it’s better to just say, ‘Oh, don’t go there, don’t get a service because they’re going to track you down,’” said Dr. José Pagán, who serves as chairman of the board of New York City’s public Health and Hospitals Corporation in addition to chairing the Department of Public Health Policy and Management at NYU’s School of Global Public Health.
When it was rolled out, the justification from the administration mostly tacked toward preventing the “misuse” of federal funds and was first announced by the White House as “President Donald J. Trump is Ensuring Non-Citizens Do Not Abuse Our Nation’s Public Benefit.” (A racist fiction, but that’s come to be expected at this point.) But as a policy, it belongs less in its purported lane of fiscal responsibility and more in the company of policies like the travel ban: weapons aimed at large swaths of potential legal immigrants and visitors who have been categorically deemed undesirable, whether it’s due to their origin in “shithole countries” or their poverty. Accuracy here isn’t the goal—and indeed isn’t even possible. Travel ban restrictions have gravely impacted U.S. citizens and legal permanent residents across the country. The public charge rule will cast an even wider net. What the Trump administration has done, then, is introduced a potential public health crisis and called it a measure to protect public funds.
As its name suggests, the WIC program is meant to support the health of pregnant women, babies, and children under five years old. Participation in WIC will have no bearing on public charge determinations, but according to Dr. Susan Gross, a nutritionist and co-investigator at the Johns Hopkins WIC program, there’s far-reaching uncertainty: “We have people every week coming in and asking, ‘Does my participation here impact?’—and it’s often not their own naturalization, it’s usually a relative, so it’s like—‘Does this impact my aunt?’” (Naturalizations won’t be affected by public charge at all, only attempts at visas and residency.)
When reassurances aren’t enough to keep people participating, the repercussions can be serious and immediate. Dr. Gross pointed out a recent article in Maternal and Child Health Journal that found that, even controlling for mothers’ health and income level, among other factors, use of WIC led to lower rates of preterm birth, low birth weights, and perinatal death.
These aren’t issues that can just be easily resolved down the line. A lack of nutrition for mothers and babies will affect these infant patients for the rest of their lives, she said. “If you have impact during [fetal development], you see long-term consequences, just chronic illness and stunting of development or long-term consequences on something that’s developing and can’t be reversed,” according to Dr. Gross.
Such chronic conditions are already of special concern in the low-income immigrant population; the public charge rule will only exacerbate the problem. “In an immigrant population, asthma, epilepsy, cancer, disabilities, all of these issues are quite prominent and underaddressed even before this change,” Terry McGovern, chair of the Department of Population and Family Health and founder of the Program on Global Health Justice and Governance at Columbia University, told The New Republic. “This will obviously contribute to child deaths and poor outcomes throughout their lives.”
As the WIC program’s significance demonstrates, health isn’t just about health care. “Being able to have adequate housing impacts health. Food impacts health,” McGovern said. It also won’t just be children who are disproportionately affected but anyone with a chronic condition that requires consistent, routine care: “Immigrants with diabetes not being able to get Medicaid: That’s the difference between life and death there. I think without Medicaid, it’s just impossible to afford insulin.”
In recent years, some states and localities have tried to beef up their local health-delivery systems, partly in anticipation of a federal government increasingly hostile to immigrants in particular and public health services in general. In New York City, for example, the Health and Hospitals Corporation, or HHC, recently launched NYC Care, a program allowing uninsured New Yorkers in the Bronx, Staten Island, and Brooklyn to enroll in a free or low-cost managed-care system with primary and specialty care, similar to insurance. The program is slated to be available in the five boroughs by the end of this year.
The program targets the uninsurable, and nearly half of its eligible participants are undocumented, according to the city. By and large, the undocumented won’t be directly affected by public charge, as most cannot apply for immigration status anyway. In any case, participation in NYC Care, a municipal program, could not be taken into account for public charge purposes, but officials remain concerned that the impact will be the same: Immigrants with little free time on their hands and a deep-seated fear of the government will opt out.
“It’s very hard for somebody that came here just to work and certainly needs care, they don’t want to risk it, you know?” said Dr. Pagán, of NYU and the HHC board. “More than the actual impacts of the [public charge rule], it’s more like the people that you don’t see, that don’t show up, even if they qualify, due to misinformation. All the effort that we have done to make sure that people have primary care, that they have a doctor that they go to instead of going to the [emergency room], this idea of the public charge shatters all of that.”
Chris Keeley, an official with the HHC, said “the general public conversation around this has left the impression, probably intentionally from the perspective of those crafting the policy, that the impacts are much broader than they actually are,” and tied it directly to other tactics like the deployment of Border Patrol special forces in sanctuary cities.
The foremost priority of the HHC, with regards to the public charge rule, he said, was assuring vulnerable populations that the public hospital system and NYC Care remain open and available to them. “We can’t prove the negative of who is not coming in because of immigration fears,” said Keeley. “But what we can do is make every effort that we can to partner with and work with our individual hospitals, with our individual community clinics, with our community-based organizations all around the city, to do outreach.”
The flip side of the coin is that, if many people turn away from federally funded benefits and toward what alternatives exist, they risk overwhelming the capacity of local governments and nonprofits. Dr. Gross recalled that, when recent government shutdowns suddenly ballooned the numbers turning to emergency food pantries, some of these quickly started having trouble keeping up.
A crucial point in all of this is that health systems, especially in urban settings, are fully integrated, and what affects one population can affect the whole of the population. Much of the Trump administration’s bellicose immigration agenda revolves around the notion of hard, bright lines between the deserving and the undeserving: citizen and noncitizen, documented and undocumented, worthy refugee and lying opportunist. Even in the law, these differences are blurry at best. The basic realities of public health—how similar our needs are, how interconnected we are in daily life—defy these distinctions to the point of insignificance.
“If you’re trying to control flu, for example, if people are not getting the primary care that they need, you won’t have a good handle on it in a very dense environment,” said Dr. Pagán. He is especially worried about the effects on health infrastructure in smaller cities and towns, where systems may already be more fragile. “If you get services in the same community, and then these other folks living in town don’t go to the doctor, you may have less clinics in town, less providers, because there’s not enough demand for their services.”
The point was echoed by McGovern, whose department has been looking into the health impacts of the new Title X “gag rule,” which further limits federal funds to health care providers that offer abortion services or even provide referrals to abortion care. “With this public charge rule, I think in a number of states, we’re really going to see people not being able to get the care they need anywhere,” she said.
These threats to public health don’t necessarily evaporate in the event that another administration takes over next year and overturns the policy. “It takes time for myths or stories to dissipate. Even if you have a change in policy, that doesn’t mean that the change in policy is going to hit the communities that are scared about things,” said Dr. Pagán.
To a certain degree, there’s a level of trust that will never be recovered. When the Deferred Action for Childhood Arrivals program was introduced by President Obama in 2012, one of the foremost fears of potential applicants was that the data they provided would eventually be used to deport them. At the time, the federal government made assurances that this would not be the case, but the Trump administration hasn’t committed to honoring these assurances and has already indicated that it plans to deport any DACA recipients it can, in the event that the Supreme Court allows it to terminate the program. Ultimately, it doesn’t matter if a new administration reinstates the program or does anything else to assuage concerns about DACA or public charge or any other immigration-related policy: Some percentage of people will likely never take a chance again.
Even if there is a new administration that intends to address the damage done, it won’t necessarily have much data to go on, as there appears to be no plan in place to track the impact. That’s the other long-term consequence: all that we won’t know. “A lot of funding for this work used to come from the federal government, [National Institutes of Health], and other sources. So, I have a question about who’s going to pay for documenting the impacts of all of this,” said McGovern. “The harm done by all of this, I think we’ll probably never have an accurate picture. We’ll do the best we can.”