The health impact of Trump's new "public charge" rule

Driving the news: A homeland security proposal published this week lays out a new version of a "public charge" policy, which was expanded during Trump's first term and then rolled back during the Biden years.

• Critics say the latest effort, if finalized, could further discourage the use of health, nutrition and housing services after the GOP reconciliation package limited legal immigrants' access to health insurance.

State of play: The Department of Homeland Security on Monday said the policy could save nearly $90 billion over a decade as people unenroll from or skip out on public programs.

• The 140-page rule seeks to override previous policies that outlined which public benefits could disqualify immigrants from getting a green card, instead leaving decisions to the discretion of individual immigration officers on a case-by-case basis.
• Limiting criteria goes against congressional intent, DHS wrote. The change could mean that officers also consider use of services beyond Medicaid, like getting care at a community health center, when looking at green card applications, legal experts told Axios.
• The agency said it will issue policy and "interpretive tools" to aid officers' determinations, at an unspecified future date.

Between the lines: DHS acknowledged in the proposal that the policy could lead to worse health outcomes, like increased prevalence of obesity and communicable diseases.

• "[R]educed access to public benefit programs by eligible individuals, including aliens and U.S. citizens in mixed-status households, may lead to downstream effects on public health, community stability, and resilience," the proposal stated.

What they're saying: 40% of noncitizen adults in the U.S. report that immigration-related worries have negatively affected their health since January, a KFF/New York Times poll found this week.

• The new rule "just adds to the fear, it adds to the chaos," said Adriana Cadena, executive director of the Protecting Immigrant Families Coalition.
• "I have never seen a formal public policy from any administration that says we propose to be guided by absolutely no standards whatsoever," said Sara Rosenbaum, professor emerita of health law at George Washington University.

Between the lines: The proposal comes after the State Department reportedly concluded this month that it can deny visas to the U.S. based on an applicant's health conditions, including obesity and diabetes.

• The Department of Health and Human Services this year also prohibited community health centers from serving undocumented immigrants, though the move is being challenged in court.

The other side: DHS spokesperson Matthew Tragesser said in a statement to Axios that the proposed rule restores officers' broader discretion.

• It promotes self-reliance and the idea that "government benefits should not incentivize immigration," he said.

Context: The federal government has long weighed whether someone is likely to become overly reliant on public benefits when considering green card applications. Certain immigrant groups like refugees and asylum-seekers are exempt from the policy.

• The first Trump administration's change added most Medicaid services to public charge determinations. Fear and confusion led many immigrants and their U.S. citizen-family members to skip or drop out of health benefits for which they were eligible.
• The Biden administration reversed the change. But misconceptions about using health services lingered — about 25% of adults in families that include both citizens and immigrants avoided public benefits in 2022 because of green card concerns, per the Urban Institute.

Emergency room doctors are concerned that more people will skip primary and preventive care, leading them to get care only in ERs.

• "If finalized, this rule will deter people from seeking care early, worsen outbreaks of infectious disease, and further strain already overcrowded emergency departments — putting everyone at risk," L. Anthony Cirillo, president of the American College of Emergency Physicians, said in a statement.