Medical students give a check-up to a Jamaican migrant worker on a H2A visa at a Connecticut apple orchard and farm.
Photo: Getty

Last weekend, the Trump administration finally released the text of a proposed rule that would make it harder for immigrants to gain legal status if they use most public benefits, including Medicaid and food stamps. The policy, spearheaded by Stephen Miller and known as the “public charge” rule, has already been widely denounced by advocates for immigrants and the poor; one letter opposing the rule was signed by more than 1,100 organizations across the country. It is a vicious and evil policy, and one that will quite literally affect America’s health.

The rule would add new barriers for people seeking permanent resident status, also known as a green card, by adding new categories of benefits that could lead the government to determine an immigrant is a “public charge.” Using the term “public charge” as a legal category dates back to 1882, but the concept of restricting poor people from immigrating is much older than that. The term also provides a tidy historical parallel with the Trump administration’s Medicaid work requirements, with their roots in England’s 17th century poor laws, which excluded the “able bodied” who supposedly chose not to work from receiving aid. (Britain, my country of birth, also restricts immigration on the basis of income.) And just as Medicaid work requirements will do little to improve work while drastically affecting health outcomes, restricting legal immigration for those who have used programs like Medicaid and food stamps will undoubtedly make both immigrants and natural-born Americans sicker.

Shawn Fremstad, a senior fellow at the Center for American Progress, highlighted on Twitter over the weekend just some of the potential negative impacts the Department of Homeland Security itself acknowledges in its proposal. These are numerous, running the gamut from implications for state and local economies and reduced revenue for grocery stores that accept food stamps. Among the potential health-related harms the rule explicitly outlines:

  • Worse health outcomes, including increased prevalence of obesity and malnutrition, especially for pregnant or breastfeeding women, infants, or children, and reduced prescription adherence;
  • Increased use of emergency rooms and emergent care as a method of primary health care due to delayed treatment;
  • Increased prevalence of communicable diseases, including among members of the U.S. citizen population who are not vaccinated;
  • Increases in uncompensated care in which a treatment or service is not paid for by an insurer or patient.

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The rule is narrower than some previous leaked versions had been: It doesn’t penalize people for purchasing health insurance on the exchanges created by the Affordable Care Act, for example, which had previously been floated as a possible restriction, though it would penalize you for not having health insurance coverage if you have a health condition. Immigrants can apply for benefits that cover only their children who are U.S. citizen without affecting their green card applications, but cannot get the same benefits—such as food stamps—to cover themselves. Hope you like strained peas.

Advocates are working overtime to inform people about the details of the proposal, though we won’t know exactly what the rule entails until it’s finalized. Cheryl Fish-Parcham, the private insurance program director at Families USA, told Splinter: “It’s really important that [immigrants] know that this has not gone into effect yet,” adding, “It is not scheduled to be retroactive,” meaning that immigrants won’t be penalized for benefits they’ve used in the past. The rule is “likely to be confusing,” she said, and “immigrants should consult an attorney or public benefits officials.” Immigration attorneys are already too expensive for many poor people to afford, though a number of organizations hold immigration clinics, and organizations like the National Immigration Law Center are also monitoring the situation. Still, it seems inevitable that some immigrants will drop out of programs they’re still entitled to; Politico reported this has already happened with the WIC program, which isn’t even included in the final rule.

Overall, Fish-Parcham said the rule will “make it very hard for immigrants to get the proper healthcare they need to keep themselves and their families healthy.” There are many ways this could endanger all kids, no matter their immigration status, such as through communicable disease; Fish-Parcham mentioned strep throat as an example of an illness that, if it goes untreated because the child doesn’t have insurance, will be more likely to be passed on to other kids. Your MAGA hat-wearing neighbor might love this rule in the abstract, but it’ll mean his unfortunate kids are more likely to get sick, too.

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This demonstrates a fundamental principle of public health. One person lacking access to healthcare is bad in itself, but it also endangers the rest of the population by encouraging the spread of disease. If an immigrant can’t afford health insurance and can’t access Medicaid without jeopardizing their immigration plans, maybe they won’t get their flu treated. Kelly Whitener, an associate professor at Georgetown University’s Center for Children and Families, told Kaiser Health News that immigrant families who are worried about the rule’s impact on their legal status could be too scared to use services like free vaccines for children, even though those aren’t penalized under the rule. Higher rates of unvaccinated children are a significant public health risk; vaccines rely on “herd immunity” to be effective.

While it’s vile to assess the impact of policies like this based only on their cost, it’s worth noting how many of the harms that DHS listed carry their own associated costs. Reduced prescription adherence (patients not taking prescribed drugs), for example, costs money; a study published this year in the British Medical Journal found that “non-adherence places a significant cost burden on healthcare systems.” Using the emergency room costs more than seeing primary care doctors, and is more prevalent among low-income people, but emergency rooms also simply cannot provide the full range of effective preventive care that primary care can. We know this. A 12-year-old could understand this. Stephen Miller either does not or, more likely, doesn’t care.

The potential negative effects of this rule on immigrant families’ health go beyond those explicitly related to our healthcare system. Limiting the availability of food stamps will impact nutrition, which Fish-Parcham said “makes a tremendous difference” to overall health. Limiting housing subsidies will make people less healthy; the Pew Charitable Trusts said in 2016 that research “has consistently demonstrated a well-established link between housing and health,” and that being able to afford housing “enables people to pay for other basic needs,” including medical care.

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Fish-Parcham made the stakes even more clear: “If people are poorly housed in homes that are laden with lead paint, or that are cold, or that are overcrowded, or are homeless totally, that certainly impacts their health.” This is the situation the rule would put poor immigrants in: Do you want a house, or do you want to stay in this country?

Navigating changing immigration rules is hard enough for anyone—take it from me—but it’ll be even more difficult for poor immigrants, who will be harder for advocates to reach with information about what they can and can’t access once the final rule is approved. As we’ve seen in Arkansas, where many Medicaid recipients were reportedly not aware of the new work requirements on the books before they were kicked off their healthcare—as thousands of low-income residents have been already—getting solid information to the poor is tricky. Low-income residents tend to change addresses more often, making it harder to reach them via snail mail; they’re less likely to have home internet or smartphones. Word of mouth may be the only way they hear about the rules, but that can mean spreading misinformation, only adding to the atmosphere of confusion and fear.

Going through the legal process of immigrating to the United States is already incredibly difficult, a process made even worse the less money and privilege you have. It’s not just the endless forms and expensive lawyers; it’s the constant, crushing fear that you might lose your status here, either because you got one of the myriad little rules wrong or because the government fucked up. This rule will heighten that terror for people who already live in uncertainty, for the sin of using government programs that millions of native-born Americans rely on. No one born here gets kicked out of the country because they applied for Medicaid. In a just world, we’d be able to vastly expand our welfare state, not restrict it. A person’s immigration status wouldn’t provide a basis for them to be turned away from receiving benefits, no would it come back to haunt them as they apply for permanent residency.

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But that is not Stephen Miller and Donald Trump’s vision for America. Their new rule exists to make immigrants afraid, plain and simple. It exists to enhance the climate of fear that’s been so carefully honed by the Trump administration: a fear of ICE knocking on your door, fear of applying for benefits you need to feed and house your children, fear of speaking out on social media, fear of driving to work or even the hospital, or taking your kids to school, or being anywhere without your papers. It does nothing to encourage immigrants to come here “the right way,” that great right-wing lie. It only makes the process harder for everyone, in a way that just so happens to disproportionately affect poor, Hispanic immigrants. It’s cruel, it’s stupid, and it’s pure Stephen Miller.