How Changes to Public Charge Will Affect Medicaid

Who It Affects and How It Works

Immigrants can apply for a visa or a green card as long as they are not considered a public charge. What does that mean and how do recent changes to the public charge rule by the Trump administration affect someone's ability to come into the country?

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What Is Public Charge?

A public charge is an alien—an individual from another country—who receives certain government social welfare benefits when they migrate to the United States. Because these immigrants pose a financial burden on the country, the government reserves the right to deny their entry using the public charge rule.

The public charge rule has been in effect since 1882. Although there have been variations to the rule over time, the 1999 version is especially important to note since it remained in place through February 2020.

According to the 1999 public charge rule, people who required public funding for long-term care in a facility like a nursing home could be ineligible for entry or permanent legal residency. People who required direct monetary assistance from the government could also be considered a public charge. This included the use of programs like Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF) program, and General Assistance programs offered by states and local governments.

On the other hand, government programs that provided non-cash services did not count towards the public charge rule. These programs included, but were not limited to, the Children’s Health Insurance Program (CHIP), the Housing Choice Voucher Program (Section 8), Medicaid, Project-Based Section 8 Rental Assistance, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the Supplemental Nutrition Assistance Program (SNAP) (aka "food stamps").

While many people turn to Medicaid to afford placement in a nursing home (which would have made them a public charge), people who used Medicaid for other reasons were not considered a public charge.

Changes to Public Charge

The Trump administration proposed draft changes to the public charge rule in October 2018. The final rule was not posted until 2019. Although those changes were supposed to take effect in October 2019, legal challenges delayed implementation until they were addressed in the courts. In January 2020, the U.S. Supreme Court lifted the nationwide injunction in all states but Illinois. In February 2020, the injunction in Illinois was lifted as well.

Instead of limiting public charge decisions to the cash-related programs noted above—namely SSI, TANF, and General Assistance programs—the updated rule expands public charge to include other government programs as well. Specifically, the use of non-emergency Medicaid for non-pregnant adults over 21 years old, Section 8, and SNAP may now make someone ineligible for entry into the United States. CHIP and WIC are still not considered under the public charge rule.

Changes to the public charge rule did not take effect until February 24, 2020. To that end, the use of any government programs prior to that date will not be taken into consideration when determining whether or not someone is a public charge.

Who Is Affected by Public Charge

Not everyone will be affected by the public charge rule. While it applies to people seeking to immigrate to the United States and those applying for permanent legal residency with a green card, it does not apply to active duty service members, their spouses, or their children. It also does not apply to asylum seekers, refugees, survivors of domestic violence, Afghans and Iraqis with special immigrant visas, and other protected groups. The rule will not prevent current green card holders from applying to become U.S. citizens, either.

There is still confusion in many circles about who the public charge rule applies to. If someone is a U.S. citizen or current green card holder but lives in a household with family members who are not, they should access the programs that are necessary for their own safety and well-being without feeling they are putting their family member(s) at risk. The public charge rule will only apply to immigrants who directly apply for and receive those benefits.

How Public Charge Works

Use of these government programs weighs heavily when an immigration court determines if someone is a public charge. Someone may be deemed a public charge if they use any of these programs for 12 months within a 36-month period. The months do not have to be in consecutive order and calendar months may count more than once. For example, if two different programs are used in a given month, this will count as two months of services received. Three services in one month would count as three months, etc.

These programs are not the only thing taken into consideration when the government determines if someone is a public charge. Other factors include a person's age, health, employment status, financial assets, household income (greater than 250% of the federal poverty level is preferred), and their access to private health insurance that is not subsidized by Affordable Care Act tax credits.

Whenever possible someone should consider getting an immigration attorney to make sure they are presenting their best case for entry into the United States.

How Public Charge Affects Medicaid

The immigrant population has been adversely affected by these changes to the public charge rule. With a fear that they or a family member may not be eligible to stay in the country or get a green card in the future, some people are not accessing these safety net programs even when they are needed.

The Urban Institute surveyed nearly 2,000 adults in December 2018, after the first draft of the public charge rules were released. The survey participants were foreign-born or living with a foreign-born family member(s). As many as 13.7% of them did not apply or dropped out of non-cash public assistance programs like Medicaid, food stamps, and housing subsidies. That number increased to 20.7% if the household earned less than 200% of the federal poverty level (FPL). Especially concerning is the fact that current permanent residents and U.S. citizens to whom the public charge rule did not apply also deferred these services.

The Kaiser Family Foundation released results from the 2019 KFF/George Washington University Community Health Center Survey which collected data from 511 centers before the final draft of the public charge rule was released in August 2019. As many as 47% of the health centers reported that immigrants declined to enroll in Medicaid at all and 32% reported that they disenrolled or opted not to renew Medicaid. Even though the new public charge rule does not apply to Medicaid for pregnant women or children, the decrease in Medicare enrollment applied to these populations as well.

Misinformation and confusion are causing people to unnecessarily put their personal health and their family's health at risk. There needs to be better education about the public charge rule so that people can better protect themselves.

In light of the COVID-19 pandemic, the U.S. Citizenship and Immigration Services has emphasized that the use of emergency Medicaid services does not affect the public charge rule. Anyone who believes they may have been exposed to COVID-19 or who may be experiencing symptoms should seek care for their own health and to help stop the spread of infection.

A Word from Verywell

Being a public charge means that you could be denied entry to the United States for relying on certain government programs. Now that programs like Medicaid, SNAP, and Section 8 are taken into consideration, many immigrants are foregoing public assistance because they feel it will harm their chances of staying in the United States or otherwise get them deported. Unfortunately, the recent changes to the public charge rule have been confusing and many people are denying themselves the help they need. Know your rights. When in doubt, consider getting advice from an immigration lawyer.

7 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. U.S. Citizenship and Immigration Services. Public charge fact sheet.

  2. Fremstad S. The INS public charge guidance: What does it mean for immigrants who need public assistance?. Center on Budget and Policy Priorities

  3. Federal Register. Inadmissibility on public charge grounds.

  4. Supreme Court of the United States. Department of Homeland Security et. al. v. New York et. al. on Application for Stay.

  5. Bernstein H, Gonzalez D, Karpman M, Zuckerman S. With public charge rule looming, one in seven adults in immigrant families reported avoiding public benefit programs. Urban Institute.

  6. Tolbert J, Pham O, Artiga S. Impact of shifting immigration policy on Medicaid enrollment and utilization of care among health center patients. Henry J. Kaiser Family Foundation.

  7. U.S. Citizenship and Immigration Services. Public charge.

By Tanya Feke, MD
Tanya Feke, MD, is a board-certified family physician, patient advocate and best-selling author of "Medicare Essentials: A Physician Insider Explains the Fine Print."