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A new report from the Urban Institute underscored the persistent effects of punitive immigration policies on the health and well-being of U.S. immigrants and their children. Their analysis found that 14% of adults in immigrant families, and nearly 25% of those in mixed status families avoided safety net programs because of green card concerns in 2023. These data demonstrate what is known as the “chilling effect,” or the avoidance of public benefits by immigrant families due to concerns about how use of these benefits might impact their legal status.  

More than three years have passed since the Biden administration rescinded a 2019 Trump-era ruling that broadened the definition of the “public charge” rule, an immigration policy that challenges the legal status of non-citizen immigrants in the U.S. As PolicyLab experts have previously discussed, the expanded public charge rule put in place by the Trump administration resulted in decreased enrollment in health, nutrition, and housing benefit programs, including programs excluded from the rule, such as Medicaid and the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

While the Biden administration’s revised public charge rule clarified that only the receipt of cash assistance programs and “long-term government assistance for institutionalization” would be considered in public charge determinations, these changes are insufficient in addressing lingering fear and widespread confusion among immigrant families. Many individuals without citizenship fear that receiving government benefits could jeopardize their chances of obtaining permanent resident status or expose undocumented family members to risk of deportation. This confusion may be exacerbated by the discourse around the 2024 presidential election amid calls for the restoration of Trump-era public charge regulations.

With this landscape as the backdrop, health systems must take action to reduce existing administrative burdens and language barriers that prevent immigrant families from accessing essential resources for their long-term well-being. Health systems can also help halt the spread of fear and misinformation with these efforts.

Lingering chilling effects of the public charge rule are driven by misinformation and fear

A 2023 national survey revealed that a significant portion of U.S. immigrants remain uncertain about the implications of the final public charge rule. In fact, 16% of immigrants incorrectly believe using public programs that assist with health care, housing, or food might reduce their chances of green card approval, while 58% report being unsure whether this is the case.

Confusion is likely even more pronounced among undocumented immigrants, who also avoid government programs at higher rates. Both misinformation and fear continue to deter eligible immigrant families from accessing essential resources, undermining the physical and mental well-being of an already marginalized population.

What prevents immigrant families from accessing resources?

In 2021, 50% of adults in immigrant families reported difficulties in enrolling in non-cash safety net programs, compared to 43.5% of non-immigrant families. The underutilization of many benefit programs is likely tied to both administrative burdens and stigma, which was explored in a recent PolicyLab article with a focus on health system-based strategies to promote WIC participation. The experience of stigma among those deemed “undeserving” of assistance may be intensified among immigrant individuals, who increasingly face racism and xenophobia amidst rising anti-immigrant sentiments domestically and internationally.

Program applications and recertifications often require significant time and effort to complete lengthy paperwork and fulfill stringent requirements, which can be overwhelming for families already struggling to understand their eligibility and the risks of participation. Additional stress and frustration can result from bureaucratic delays and requirements to travel to physical offices to remain compliant. In addition to learning, compliance, and psychological costs, immigrant families may face language barriers that hinder benefit enrollment and utilization.

How can health systems support immigrant families and increase public program participation?

Health systems can play a crucial role in supporting immigrant families and mitigating the chilling effects of the public charge rule. Strategies to support the language needs of immigrants include hiring multilingual staff and investing in professional interpretation and translation services to disseminate educational resources about the public charge rule and about eligibility and enrollment processes for different public benefit programs.

Critically, health systems can disseminate this information while building on community strengths by partnering with community-based organizations (CBOs) and community health workers (CHWs) to address how misinformation and insufficient outreach have damaged the trust immigrant families place in institutions. The essential role of CHWs in building trust through community outreach and education has demonstrated success in both alleviating the fears of immigrant families and overcoming administrative burdens to enrollment in safety-net programs.

A recent PolicyLab study examined the perspectives of Latine immigrant birthing people and asked them about approaches that could reduce chilling effects on prenatal health care utilization. Recommendations included training health care providers to initiate culturally competent conversations about immigrants’ rights to health care and providing educational materials to all patients. These efforts can be enhanced by expanding the services of medical-legal partnerships, such as Children’s Hospital of Philadelphia’s (CHOP) Family Justice Partnership, to help immigrant families understand their options and advocate for their rights. For instance, lawyers can help get families connected to essential benefit programs after a wrongful denial.

Finally, streamlining screening and enrollment processes can also help connect families to essential resources. Researchers from CHOP’s Possibilities Project and Clinical Futures successfully developed an EHR-embedded screener and resource navigation intervention to help food-insecure families enroll in WIC and the Supplemental Nutrition Assistance Program (SNAP). Expanding this innovation to other benefit programs and to resources specific to the needs of immigrant families is a promising direction.

Ultimately, eliminating the chilling effects of the public charge rule on benefit program enrollment will require health system-based interventions, partnerships with community-based organizations and upstream policy changes. Health care professionals can work with policymakers to advocate for public benefit modernization and continuous enrollment policies that can help increase enrollment and utilization while reducing gaps in enrollment due to ”churn.”

Additionally, providing sustainable funding for CHW programs could help ensure that these key members of the health care and public health workforce are able to provide families with the support they need. The Biden administration's increase in funding for Navigators to help eligible individuals enroll in Marketplace, Medicaid, and Children’s Health Insurance Program (CHIP) coverage is a positive step. However, broader investment in community-based outreach efforts will also be crucial to address the fear and distrust among immigrant communities and increase access to essential resources that support the health and well-being of immigrant children and families.