The voices of Urban Institute's researchers and staff
December 4, 2018

Proposed public charge rule could erode health insurance coverage gains among citizen children with noncitizen parents

A proposal from the Trump administration aims to remake immigration policy by expanding the definition of “public charge.” The proposed public charge rule could make it more difficult for applicants to secure lawful permanent residency (“green cards”) or temporary visas by negatively weighing recent or potential participation in safety net programs such as Medicaid during the immigration admissions process. Applicants whose benefit use exceeds a certain threshold or have other characteristics that officials would deem likely to lead to reliance on public assistance could be considered a potential “public charge” and denied permanent residency in or admission to the United States.

Immigration policy changes—such as the 1996 welfare reform law that tightened benefit eligibility rules for certain immigrants—can lead to “chilling effects” on program participation among groups beyond those for the whom the policy is intended. Although the proposed public charge rule wouldn’t penalize parents for their children’s benefit use, the rule is likely to discourage some immigrant families from seeking public health insurance coverage through Medicaid or the Children’s Health Insurance Program (CHIP) for their children, the majority of whom are US citizens.  

As we explore in our new brief, Medicaid/CHIP participation has increased significantly among citizen children living with one or more noncitizen parents. Between 2008 and 2016, Medicaid/CHIP participation rates rose and uninsurance rates declined more for citizen children with at least one noncitizen parent than for children living with only citizen parents. In 2016, citizen children with noncitizen parents accounted for one in five of all Medicaid/CHIP-enrolled children.  

From 2008 to 2016, policies such as the Affordable Care Act, Medicaid expansion, and CHIP reauthorization were put in place to increase health insurance coverage among the general population, which included targeted investments in outreach and enrollment for immigrant families. These investments were associated with narrowing gaps in Medicaid/CHIP participation and uninsurance between children with and without noncitizen parents. Evidence shows that public health insurance coverage improves access to preventive care, helps families gain financial stability, and leads to positive long-term educational, financial, and health outcomes for children.

Under the new public charge rule, however, parents’ concerns about immigration-related consequences may cause them to drop coverage for which they or their children remain eligible, eroding hard-won gains in Medicaid/CHIP participation and declines in uninsurance among immigrant families. In analyzing American Community Survey data from 2008 to 2016, we find the following:

The uninsurance rate for citizen children with noncitizen parents declined more than the uninsurance rate for citizen children with only US-citizen parents. The uninsurance rate fell 10 percentage points among citizen children with noncitizen parents and 3.5 percentage points among those with only citizen parents.

At the same time, the Medicaid/CHIP participation gap nearly closed between citizen children with noncitizen parents and citizen children with only citizen parents. Participation among children with noncitizen parents rose 15.5 percentage points to 93.3 percent and 10.5 percentage points to 94.0 percent for those with only citizen parents.

In 2016, 6.8 million citizen children with noncitizen parents were enrolled in Medicaid/CHIP. In nine states, citizen children with noncitizen parents covered by Medicaid/CHIP accounted for more than one in five Medicaid/CHIP-covered children: Arizona, California, Colorado, Illinois, Nevada, New Jersey, New York, Texas, and Washington.

In California, nearly 1.9 million citizen children with noncitizen parents were enrolled in Medicaid/CHIP, making up just over 40 percent of all Medicaid/CHIP-enrolled citizen children statewide. In Texas, 1.1 million citizen children with noncitizen parents were enrolled in Medicaid/CHIP, constituting nearly 32 percent of all Medicaid/CHIP-enrolled children statewide. And in New York, nearly 500,000 citizen children with noncitizen parents were enrolled in Medicaid/CHIP, making up about 24 percent of all Medicaid/CHIP-enrolled children statewide.

We anticipate that chilling effects created by fear and confusion over the proposed public charge rule could lead to declines in Medicaid/CHIP participation and higher uninsurance rates among children with noncitizen parents. And as we note in our brief, the effects of the expanded public charge rule will likely be felt beyond these families.

These outcomes would reverse progress in achieving long-standing Medicaid/CHIP policy goals and would likely reduce children’s access to health care, harming their long-term developmental, educational, and employment prospects and limiting their potential and ability to contribute to society later in life.

Photo by XiXinXing/Shutterstock.

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