Millions of children stand to lose health and nutrition benefits if a proposed rule that influences immigrants' legal status in the U.S. is finalized by the Trump administration, according to researchers.
Leah Zallman, MD, MPH, director of research at the Institute for Community Health in Malden, Massachusetts, and colleagues noted that 1.3 million children with at least one potentially life-threatening condition, such as asthma or epilepsy, risk losing benefits if the "Public Charge" rule is enacted in its current form.
In addition, according to the analysis in JAMA Pediatrics, the proposed rule is "likely to cause parents to disenroll" from 0.8 million to 1.9 million children who have "specific medical needs" -- which includes everything from vaccinations to treatment for asthma, influenza, and epilepsy.
"These losses would likely contribute to child deaths and future disability," the team wrote.
Expanding 'Public Charge' Criteria
When immigrants apply for legal permanent residency (i.e., "green cards"), immigration officials weigh an individual's likelihood of becoming a "public charge" -- someone dependent on public benefits -- and consequently deny entry or re-entry to the U.S. for such individuals, the researchers explained.
Under a long-established policy, those receiving cash assistance or individuals who had been institutionalized in a government-funded facility were labeled public charges.
However, a rule proposed in October would direct immigration officials to expand the range of public benefits used to relegate an individual to "public charge" status, to include (non-emergency) Medicaid, Medicare Part D low income subsidies, and Supplemental Nutrition Assistance Program (SNAP), thus increasing the risk that an immigrant would be denied either entry to the U.S. or a green card, Zallman and co-authors noted.
They said they anticipate these proposed changes will sew "fear and confusion" among immigrant parents, who may disenroll their families from safety-net programs, even in cases where the rule doesn't apply. "Denial of green-card status for parents could lead to family separation or relocation of children (most of whom are U.S. citizens) to their parents' country of origin, where adequate medical care may not be available," the researchers stated.
They also stressed that disenrollment from SNAP or housing benefits would increase a child's risk of food insecurity, malnutrition, poverty, and homelessness.
Study Details
To examine the potential impact of the rule, the team used nationally representative data from 4,007 children under age 17 culled from the 2015 Medical Expenditure Panel Survey (MEPS).
MEPS is a household survey conducted by the Agency for Healthcare Research and Quality that includes data on healthcare needs, expenses, and medical conditions.
Using this and other data, the researchers conducted statistical analyses from January 3 to April 8, 2019. More specifically, the investigators cross-referenced MEPS data with information from the National Health Interview Survey to assess the citizenship of interview respondents and then tied the MEPS household interviews to MEPS data on medical illness.
The researchers found that a total of 8.3 million children currently receiving Medicaid and Children's Health Insurance Program (CHIP) or SNAP benefits "are potentially at risk of disenrollment" if the finalized rule closely matches the proposed one.
Any child who lives with a "non-citizen immigrant adult," is defined as "at-risk," because these adults "may face tough decisions about whether to disenroll their families from benefits or risk future immigration status changes," said Zallman, who is also affiliated with Harvard Medical School in Boston and the Cambridge Health Alliance.
Of the total 8.3 million immigrant children considered at-risk, 5.5 million have "specific medical needs," including the following, the researchers said:
- 615,842 children have asthma
- 53,728 children have epilepsy
- 3,658 children have cancer
- 583,700 children have disabilities or functional limitations
Using specific simulation techniques -- that assumed a 15%, 25%, or 35% disenrollment rate among these at-risk children -- the authors estimated that the proposed rule "is likely to cause parents to disenroll between 0.8 million and 1.9 million children with specific medical needs from health and nutrition benefits."
The investigators' simulations drew on research of immigrants before and after 1996 welfare reform policies (revisions to Medicaid eligibility standards that reflected individuals' immigration status) were enacted. The middle scenario, the authors' "principal estimate," assumed that 25% of at-risk individuals would disenroll from benefits, leaving approximately 1.4 million children without Medicaid, and CHIP or family benefits, they team noted.
Call to Action
Not all of the 0.8 million to 1.9 million children anticipated to lose benefits have a medical condition, Zallman told MedPage Today via email. Newborns needing vaccinations and developmental checks, for instance, were also included.
Nonetheless, the figures likely underestimate the rule's total impact, because Zallman and her colleagues did not include those who might lose housing benefits.
Zallman also highlighted recent research from the Urban Institute indicating that "even citizens are staying away from benefits out of fear." That research found that one in seven adults in immigrant families avoided public benefit programs in 2018, suggesting to Zallman and her colleagues that their estimate is "an undercount," she said.
"We couldn't estimate kids who might lose housing benefits, and we assumed that non-citizen adults may be 'chilled' (disenroll from benefits out of fear or confusion, even if the rule dose not technically apply to them)," Zallman said.
While she and her co-authors emphasized the damaging economic costs of such a rule that would result from increased school absenteeism and parents missing work if the rule were enacted, the team's core concerns were ethical, not economical, they said.
"We believe the denial of needed healthcare and nutrition to anyone, but particularly to children, violates human rights. We call on the medical community to speak out against this unjust and unethical proposal to change the public charge rule," the team wrote.
To curb further confusion, Zallman emphasized: "The rule is not finalized, is not in effect, and will not be retroactive, so there is no reason that immigrants should disenroll from benefits."