By Harris Meyer 

Hundreds of thousands of children and other members of low-income legal immigrant families could drop out of public programs providing healthcare, nutrition and housing assistance due to a controversial proposed Trump administration rule announced Saturday.

The 447-page proposed rule would allow immigration officials to consider legal immigrants’ use of public health insurance, nutrition and other programs as a strongly negative factor in their applications for legal permanent residency. 

The changes also would apply to citizens’ and legal residents’ requests to bring family members into the U.S., as well as to young people who have legal status under the Deferred Action for Childhood Arrivals program, known as Dreamers. They would not apply to people granted refugee status or political asylum.

The public benefits covered by the proposed rule—announced in an unusual Saturday night release by the Department of Homeland Security—include Medicaid, the Supplemental Nutrition Assistance Program and Section 8 housing vouchers. The agency is asking for public comment on whether the Children’s Health Insurance Program also should be included.

In an apparent retreat from a leaked draft of the proposal earlier this year, the DHS proposal would not consider Medicaid or other benefits received by U.S. citizen children as a negative factor in their families’ legal residency applications. Other changes from the leaked draft are that it would not consider Affordable Care Act premium subsidies, nutrition assistance under the Women, Infants, and Children program, use of earned-income tax credits, or participation in the Head Start educational program.

DHS Secretary Kirstjen Nielsen said the proposed “public charge” rule—which her agency said would be formally published “in the coming weeks”—is consistent with long-standing U.S. policy requiring immigrants to show they can support themselves financially.

“This proposed rule will implement a law passed by Congress intended to promote immigrant self-sufficiency and protect finite resources by ensuring that they are not likely to become burdens on American taxpayers,” Nielsen said in a written statement. Following publication, the public will have 60 days to comment.

But immigration officials currently are only allowed to consider families’ use of public cash benefits and Medicaid long-term-care benefits in evaluating applications for legal permanent residency and legal entry into the United States. A 1999 rule clarification said non-cash benefits like Medicaid cannot be considered. 

Healthcare leaders and advocacy groups say the proposed changes would have a massive impact on health-related services for low-income children and families. They say it could drive up uncompensated care costs, increase use of emergency departments, endanger maternal and infant health and heighten the risk of infectious disease epidemics. It also could shift major costs from the federal government to state and local governments.

“The public charge proposal presents immigrant families with an impossible choice: keep yourself or your children healthy but risk being separated, or forgo vital services like preventive care and food assistance so your family can remain together in this country,” said Dr. Colleen Kraft, president of the American Academy of Pediatrics. Her group is part of a broad coalition pressing the administration to drop the rule.

DHS estimated the proposed rule would affect about 382,000 people a year. But many experts said it would have a far broader impact.

Based on the earlier leaked draft, the Kaiser Family Foundation estimated that up to 2 million children who are U.S. citizens with immigrant parents could drop out of Medicaid and CHIP and most would become uninsured. That’s because the parents would worry that their children’s use of those programs could jeopardize their legal status. Those concerns likely would spill over to citizen children of undocumented immigrants, who are not covered by the proposed rule. 

In 2016, there were 10.4 million citizen children with at least one parent who isn’t a citizen, and 56% had Medicaid or CHIP coverage. An estimated 27 million immigrants and their children are part of families with at least one member receiving public benefits, according to the Migration Policy Institute.

Healthcare leaders say the coming of the public charge rule is widely known in the immigrant community and that many legal immigrant families already have withdrawn or declined to enroll in programs they or their children qualify for. These include Medicaid; CHIP; the Women, Infants and Children nutrition program; and free school lunches. Even families that already have permanent legal status and would not be subject to the proposed rule are leery about receiving public benefits, experts say.

America’s Essential Hospitals and other healthcare groups have been lobbying the administration for months to abandon or soften the public charge proposal. Advocates say their efforts seem to have had an effect in easing some provisions that were in the earlier leaked draft.

The proposed public charge rule is part of the administration’s broader campaign to limit both legal and illegal immigration, including bigger border barriers and stepped-up detention and deportation of undocumented residents. 

Critics pointed to the timing of the announcement six weeks before the hotly contested congressional and state elections, in which immigration is a major issue. They say the administration likely hopes the proposal will motivate anti-immigration Republicans to turn out to vote.

Groups opposed to the proposal signaled they will consider litigation to block the rule. 

Olivia Golden, executive director of the Center for Law and Social Policy, said there is no research support to justify the administration’s proposal, which she said would “leave the nation hungrier, sicker and poorer.”

That could form the basis for a legal challenge to the rule under the Administrative Procedure Act, which requires federal agencies to offer a reasonable explanation for changing long-standing policy.