Abstract: The "Inadmissibility on Public Charge Grounds" rule will jeopardize the ability of immigrants to enter the U.S. or become permanent residents based on their eligibility for federal health care programs.

On August 12, the Department of Homeland Security (DHS) released its final “Public Charge” policy, which governs legal immigrant’s ability to obtain permanent resident (LPR) status, a/k/a a “green card” or a pathway to citizenship. According to DHS, a “public charge” is an individual who is likely to lean on the government for financial assistance in the future. Under this new rule, “public charge” status is determined by considering an individual’s age, health, disability status, family status, financial status, education, and skill level, together with their assets and resources. This can be expanded to include having a medical condition that may interfere with work or school, not having enough money in one’s savings account to cover possible future medical costs related to the condition, having a low credit score, lacking a college degree, lacking “sufficient” English language skills, and having a sponsor who has been determined unlikely to provide future financial support. Nearly all noncitizens (94%), have at least one characteristic that could weigh negatively in determining public charge status, steering this nation toward a very exclusive immigration policy (Artiga, Garfield, & Damico, 2018). If a legal immigrant is determined a “public charge”, a change of status to “insured, tax paying, citizen” is not granted.

From an occupational therapy perspective, our clients and communities are invaluable. It was therefore troubling when DHS admitted that the new rule could affect “aliens” with disabilities more harshly. They noted however, the final rule was not put in place to discriminate against disabled “aliens”, but was intended to better ensure that those who become legal citizens are self-sufficient. In their defense, DHS provided case histories from 1911, detailing how disability has always been a consideration when making immigration decisions. DHS used century old examples, in an attempt to illustrate how disabled “aliens” could not be “self-sufficient.” With this final public charge rule, we as a nation are essentially saying “if you are poor, elderly, have a disability or a health issue, have a large family, you didn’t attend college or you don't have the skill set we deem most valuable, you are not welcome.”

Policies that restrict benefits for immigrants affect not only the individual and his or her family, but our communities at large. Clinics, hospitals, and local public health agencies will be negatively affected. The chilling effect causes decreased participation in Medicaid, due to fear of being labeled a “public charge”, and will increase the uninsured rate, reducing access to care and contributing to worse health outcomes. Coverage losses result in lost revenue for clinics, hospitals, and public health agencies. Larger number of uninsured individuals means increasing uncompensated care for providers and spilling over effects within communities. Immigrant parents may fear allowing their U.S. born children to receive occupational therapy services in school under Medicaid, for misguided fear it may affect their own immigrant status The ramifications of the final rule affect occupational therapists in more ways than one: less clients, less jobs, less pay, less therapy.

“Give me your tired and your poor who can stand on their own two feet and who will not become a public charge,” stated the acting director of U.S. Citizenship and Immigration Services on NPR’s Morning Edition August 13th, 2019. The real version of the poem, engraved on the Statue of Liberty since 1903, boldy states “Give me your tired, your poor, your huddled masses yearning to breathe free, the wretched refuse of your teeming shore. Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!”

If the original poem rings true for you, you are concerned for your clients and community, or if you or a loved one will be negatively affected by this ruling, there are a few things you can do.

1. Educate yourself and others on the finalized ruling and its implications. There are numerous resources to help weed through the legal jargon, including Facebook groups such as Moms Rising's immigration team, who have created a social media tool kit.
2. Assure immigrant parents that their born in the U.S, citizen children can get occupational therapy services in school under Medicaid that it is not supposed to penalize them.
3. Each situation is different. Urge your “alien” neighbors to consult with an immigration attorney before making any decisions about applying for or disenrolling from any benefits programs.
4. Talk to your clients/co-workers. Explain why this is so important to healthcare and the implications that it will have on individuals with disabilities
5. Support advocates’ efforts to fight the new rule in the courts.
6. Contact and urge your elected officials to halt implementation of the new public charge rule, and advocate for an appeal.

TRUMP'S PUBLIC CHARGE PROPOSAL IS HURTING IMMIGRANT FAMILIES

The Trump Administration’s New Public Charge Rule: Implications For Health Care & Public Health

Changes to “Public Charge” Inadmissibility Rule: Implications for Health and Health Coverage

Safety Net Access in the Context of the Public Charge Rule