Animated hands connecting teeth of gears against blue background

Public Charge has been on the minds of immigrants and those working with the immigrant community for many years. Determining whether someone will be a “public charge,” or dependent on government help through reliance on public benefits, has always been a part of the immigration process in the United States. A public charge determination could cause an individual’s application for a visa, permanent residence, or admission to the U.S. to be denied.

In 2018, the Trump Administration proposed a rule that was later finalized which broadened
the programs that the federal government could consider in making a public charge determination to include previously excluded health, nutrition, and housing programs. Later, the Biden Administration reversed and tried to codify into law the pre-Trump era policy that governed public charge. 
However, in the time leading up to and following the rollout of the Trump Administration public charge policy, a particularly negative and lasting “chilling effect” continues to be felt widely in health care and other places where people seek help. These offices saw dramatic declines in their enrollment numbers for Medicaid, CHIP, SNAP and other
financial assistance programs as immigrant families avoided applying and one in five adults in immigrant families with children reported that they were avoiding public benefits for fear that they would jeopardize eligibility for a future green card.

Navigators and those conducting outreach and enrollment activities including Community
Health Workers become trusted messengers in their community
, often guiding overwhelmed and fearful clients to health coverage, access to care, and other benefits such as food and housing. Understanding the facts around public charge instead of rhetoric and media headlines is a critical responsibility to serve as a trusted messenger. 

A Case Example

While working in a South Texas health center in 2016, we noticed a trend in our immigrant patients refusing to apply for insurance via Medicaid and Children’s Health Insurance Programs (CHIP). We worked with these consumers to apply for other safety-net health care services and discovered that their immigration attorneys were advising them to not apply for and disenroll from any public benefits program. Notably, many of the attorneys representing the consumers we were seeing were erring on the side of caution, fearing that their or their family’s use of Medicaid or SNAP may negatively impact their applications for visas or permanent residency. The problem with this protectionist approach was people were not getting enrolled in life-saving benefits. 

We quickly took action to guide our patients on the eligibility requirements for health and food programs, informing them that the public charge determination would not look at their family’s use of Medicaid or SNAP, and even went so far as to call the immigration attorneys of several particularly concerned patients to correct their understanding of the policy. It wasn’t until a 2020 report by the Children’s Defense Fund of Texas was published that we realized our approach was unique and successful in keeping our community members enrolled in programs.

What We Did and Why it Worked

An important part of our approach to combating the chilling effect was using easy-to-read, client-oriented materials from Protecting Immigrant Families. At the time, there weren’t any materials specifically tailored toward educating immigration attorneys, so we printed copies of their “Does Public Charge Apply to Me?” flyer and provided it to clients to take to their lawyers. However, with the publication of the 2020 CDFTX report, partners at PIF were inspired to develop the “Herlinda Letter” for use in outreach to immigration attorneys. The letter can be customized and used to educate attorneys on the facts of public benefits use and any potential impacts on public charge determinations. 

the Herlinda letter

The steps we took in the health center ultimately resulted in no significant decline in Medicaid/CHIP enrollments among our clients between 2016 and 2019. This serves as an example of the impact that enrollment assisters can make when they learn the facts and set out to educate their community. In preparation for a potential “chilling effect”, organizations may take these same steps to protect their communities.

  1. Train and identify your agency’s Public Charge point person. Having a single person or small department within your organization where clients can be referred for additional information and guidance will be important to ensure that clients receive factual information. These subject experts should research Public Charge and any policy concerns specific to their state using reliable sources, such as the National Immigration Law Center and Protecting Immigrant Families. With the information gathered from these sources, your point person should be able to speak confidently with concerned clients about their health care or food benefits while also knowing when to refer a client for additional legal assistance.
  2. Develop an internal referral process. If a client speaks with any of your staff and expresses concern about your services impacting their immigration status, staff should be able to quickly refer the client to your Public Charge point person. This referral process may be as easy as scheduling a phone call between the concerned client and your point person or may require a brief in-person meeting to discuss concerns.
  3. Build awareness among your staff. Not all staff will have the time to learn in-depth about Public Charge, however regularly discussing the topic of Public Charge and the referral process to your in-house experts will allow all staff to be able to support your clients.
  4. Display materials throughout your center. Providing information sheets in your clients’ preferred languages may invite them to ask questions and potentially apply for benefits they may have previously avoided. The Protecting Immigrant Families (PIF) Public Charge Community Resource page provides several client-facing materials that are easy to understand and available in multiple languages.
  5. Educate clients and their attorneys about their rights to benefits. Attorneys don’t always get it right when it comes to health care and food benefits programs and may advise clients to refrain from enrolling or even to disenroll their household from benefits like Medicaid and SNAP. It’s important for enrollment staff to see themselves as experts in benefits enrollment and to feel confident in educating clients and their attorneys on their rights to access benefits. While reaching out to speak directly with every client’s attorney to correct their misunderstanding of the Public Charge policy is not realistic, providing a personalized copy of PIF’s “Herlinda Letter” for the client to share with their attorney is an equally powerful alternative. This tool provides clear information about which programs are not considered in a public charge determination and educates the attorney while encouraging the client to apply for benefits.
  6. Leave the door open to apply. Regardless of the information you share with clients, they may not be ready to apply for health and food programs. Reassure clients that they are welcome to discuss with their attorneys and families before applying.

    With noncitizens significantly more likely to be uninsured than citizens and over half of Asian health center respondents reporting that they lack enough information about recent immigration policy changes, the need for continued outreach and education is apparent. Even with the new Public Charge rule in effect, sustained efforts to build back trust and address the fears in the immigrant community will be needed. Health coverage enrollment navigators and assisters will play an important part in this outreach and education and with several new resources and workflows, they can find success in helping immigrant families access health care.

    Connect with Us

    Interested in working with us on Outreach and Enrollment strategy? Contact Heather Bates at heather@transformhc.com to discuss a partnership with Transform Health.