Lourdes Juarez has lived in North Carolina since 2000, working part-time to help children with disabilities improve their motor skills. Originally from Mexico, she is now a lawful permanent resident of the United States with plans to apply for citizenship.
After bouts of pancreatic and liver cancer left her struggling with medical debt, she learned that she qualified for Medicaid, the government health program for low-income people. But she had a nagging concern that accepting government benefits would affect her chances of gaining citizenship. She had heard rumors to that effect among her friends and in the news.
Juarez’s fear reflects the growing sense among immigrants that they should avoid public programs, which also include food stamps and certain housing programs, in case they count against their ability to stay in the country permanently. In December, Juarez called the Charlotte Center for Legal Advocacy, which reassured her that her citizenship would not be affected if she enrolled in Medicaid. Only then did Jaurez relax and sign up. “I’m now more at ease, but there are other people who are confused and need true information,” she told me through an interpreter.
In October, Donald Trump’s administration released a proposed rule that, if finalized, would affect a part of immigration policy known as “public charge.” From the founding of the country, several American states expelled immigrants deemed too poor or otherwise “undesirable.” The U.S. government formally codified the practice in the form of the Immigration Act of 1882. The term public charge has, in past decades, been applied loosely, as Public Radio International has reported. In 1911, for example, a 15-year-old Italian immigrant was turned back at Ellis Island because his genitals were too small. “Persons so affected are liable, owing to inability to satisfactorily perform sexual congress, to become addicted to unnatural practices,” a public-health officer wrote at the time.
More recently, the provision has applied to foreigners who hope to immigrate and noncitizens already in the United States who are likely to need long-term institutional care or government cash assistance. The government might consider those factors when it comes time to decide who should be allowed to obtain visas or green cards. With the Trump administration’s new proposed rule, though, the U.S. government would broaden the definition of a public charge, examining whether immigrants have used public-health programs such as food stamps or Medicaid during their time in the United States. Immigration officials could then look less favorably on legal immigrants who used those benefits when they seek to obtain green cards or extend their immigration status.
Though the number of immigrants whom the new public-charge determination would apply to is much smaller, the consulting firm Manatt estimates that as many as 41.1 million noncitizens and their families, or 12.7 percent of the U.S. population, could be deterred from using public benefits because of a chilling effect resulting from the proposed change.
The proposal is just one in a slew of policies backing up the president’s assertion that America is “full” and should admit fewer immigrants. This month, the Trump administration announced that it wants to close a loophole and evict undocumented immigrants from public housing.
In addition to the proposed public-charge rule change, in January 2018, the State Department gave embassies and consulates wider leeway to consider the likelihood that a visa applicant would become a public charge when determining whom to let in to the country. Consular officers are now allowed to take into account the past or current use of government programs by a visa applicant’s family when deciding whether to grant an applicant entry. Subsequently, State Department data revealed that visa denials on public-charge grounds rose threefold from 2017 to 2018.
“What the State Department data show is that anyone sponsoring an immigrant is having a tougher time already,” says Stuart Anderson, a former Immigration and Naturalization Service official under George W. Bush who is now the executive director of the National Foundation for American Policy, an organization that analyzed the visa data.
Immigrants became nervous about using public benefits almost immediately after Trump’s election, perhaps due to the president’s inflammatory rhetoric about foreigners. But emerging data from around the country suggest that these and other recent proposals have heightened this fear. Though some of the rules haven’t been implemented yet, the mere discussion of these changes has been enough to scare many immigrant families away from health services for which they or their children are legally eligible. “They’re hearing all about all sorts of changes,” says Sonya Schwartz, a senior policy attorney from the National Immigration Law Center. “It all fits together like, I have to keep a low profile. My life is very risky.”
Social-services providers, doctors, and attorneys describe immigrant communities that are rife with misinformation and fear. Their immigrant patients and clients steer clear of even those government programs that won’t count against them, in some cases hurting their health as a result.
“I don’t think I’m exaggerating by saying this affects nearly every single immigrant family that I see,” says Lanre Falusi, a pediatrician at Children’s National Health System in Washington, D.C. “I’ll see a mom with a newborn, and sometimes … the mom is having trouble affording formula. I talk about programs that they might be eligible for. More and more, I’m having new parents decline, saying, ‘I’m not gonna sign up.’”
According to the National Immigration Law Center, which summarized the impacts of the public-charge proposal in a recent fact sheet, health-care providers and insurers in some states have noticed sizable decreases in enrollment in food stamps and Medicaid. After a decade of increases, participation in the food-stamp program among immigrants fell by eight percentage points from 2017 to the first half of 2018, even though the employment rates among this group remained the same. Politico cited the National WIC Association, the advocacy arm of the government program that provides food to low-income children and mothers, in saying that “nearly two-thirds of WIC providers, from 18 different states, reported they have noticed a difference in immigrant WIC access in the wake of the news about potential changes in the public-charge rules.”
“When the office reaches out to [immigrants] to inform them that proposed changes to the public charge policy have not taken effect, they respond that it is too risky and their attorneys are advising them against receiving benefits,” said Kurt Larrick, the assistant director of the Arlington County Department of Human Services in Virginia, via email. About 200 families stopped receiving WIC benefits in the county from 2017 to 2018.
WIC is not included in the public-charge proposal, but advocates told me that this drop is an indication that immigrant families are afraid to use any benefits at all, out of an overabundance of caution. Rodrigo Aguirre, a case manager with Catholic Charities, has seen the same effect with free and reduced-price school lunches, which are similarly not part of the current proposal.
Many immigrants live in mixed-status families, and some reportedly avoid enrolling even authorized family members in programs, fearing that doing so might alert authorities to the presence of an unauthorized parent or spouse. “We have seen clients afraid to have their U.S.-citizen children continue to receive Medicaid, even though for most people that should be fine,” says Laurie Ball Cooper, the legal director of Ayuda, an immigrant-aid organization in the Washington, D.C., area.
When the Kaiser Family Foundation conducted a focus group with 20 immigrant families in 2018, it found that though some of the families were struggling to afford food, they felt signing up for nutrition programs might put them or their family members at risk of deportation. What’s more, a 2019 poll by the Kaiser Family Foundation and the California Health Care Foundation found that 40 percent of uninsured Californians said they are “worried that if they signed up for health insurance, they would draw attention to their own or a family member’s immigration status.”
Advocates told me that word of these changes spread through word of mouth or through scraps of information on Spanish- or English-language news. Because the immigration rules are so complex, the message tends to get distilled down. “If you’re an immigrant and you’re using federal programs, you’re at risk,” says Falusi, the pediatrician, summarizing the sentiment among her patients. Even for those who likely wouldn’t be affected, she says, “it’s difficult for them to rest assured, given that what we know now might change on a whim.”
Occasionally, the game of telephone yields wild theories about immigrant children being forced to serve in the military or being made to pay back their food-stamp benefits later.
Doctors and immigrant-aid attorneys told me they are conflicted about how to counsel immigrant families about using government programs. They emphasize that the rule has only been proposed. Technically, nothing has changed yet. But many nevertheless feel uneasy assuring immigrants that they won’t be affected. Sometimes, advocates said, it comes down to the individual family’s tolerance for risk.
Lisa David, the CEO of Public Health Solutions, the largest WIC provider in New York State, says she sees spikes in the number of people leaving the WIC program any time there’s news about a Trump-administration crackdown on immigrants. “We’ve had families walk in and say, ‘I don’t want these checks anymore; please take me out of your database,’” she says. “I can’t actually tell them ‘Don’t worry about it,’ because I can’t say that truthfully.”
The Trump administration, for its part, has denied that the public-charge change is meant to frighten immigrants into not using benefits. An official from the Department of Homeland Security told Politico that the agency is trying to “better align U.S. immigration policy with federal law.” In an email, a State Department official told me that “public charge determinations are based on a consular officer’s assessment of the totality of the applicant’s circumstances … age; health; family status; assets, resources and financial status; education and skills; and an affidavit of support from a sponsor if one is required by law.” The White House did not return a request for comment.
Robert Rector, a senior research fellow at the conservative Heritage Foundation, argues that the public-charge rule is valuable because it keeps out low-skill immigrants, who, he says, are likely to take in more government services than they pay for. But, he adds, “the proper way to implement this rule in the future would be to place it on people before they come into the country rather than after. Trying to apply it to people after they come into the country isn’t going to save very much money.”
Regardless of whether the goal of these measures is to get legal immigrants to stop using government benefits, that appears to be happening. Many are looking to less-tracked means of getting help. Schwartz, from the National Immigration Law Center, says some food banks are seeing an increase in demand. However, many immigrant families work and therefore don’t have time to wait in line at soup kitchens and food pantries.
With this proposal, many immigrants feel they must choose between protecting their chances of staying in the United States and protecting their health. Some, advocates say, are choosing America. The families that are declining to participate in WIC are turning to less-healthy food options, David says, such as starches and fast food that will fill up a hungry child on just a few dollars.
Beyond the nutritional deficits, Falusi says she sees families that are ground down by stress, and kids who report vague symptoms of stomachaches and headaches. She and others paint a picture of an immigrant community that has added hunger to an already long list of worries.
“One time a family came in, and the kid was unmotivated. He had his head down the entire time,” Aguirre, of Catholic Charities, says. “The mom said, ‘We don’t have food stamps … so they didn’t have breakfast today.’”
Ena Alvarado contributed reporting.