In Texas, where 5.6 million people live in mixed-status families with at least one non-U.S. citizen, the chilling effect from the proposed rule is likely to exacerbate alarming trends.

Last month, Elizabeth Hasse, an immigration attorney with the Tahirih Justice Center in Houston, spoke to a client about renewing her work permit. Hasse had helped the woman secure temporary status years before under a provision in the Violence Against Women Act protecting immigrant victims of domestic violence. Hasse asked her client to bring in her tax returns, paychecks, and proof that three of her four children, all U.S. citizens, were enrolled in the Supplemental Nutrition Assistance Program (SNAP) and Medicaid. But the client told Hasse she had decided not to renew their benefits this time.

“I was surprised because she’s a client who really needs those benefits and her children have consistently received them for many years,” Hasse said. “And out of fear, without even asking me about it, she just decided on her own that she was going to try to make it without.” The reason? The woman was afraid that receiving benefits like SNAP could be held against her in the future, possibly leading to the denial of a green card.

In the fall of 2018, the Trump administration proposed changes to a longstanding immigration policy known as the public charge rule, making it harder for low-income immigrants to become permanent residents or enter the country. Currently, immigrants applying for green cards and visas can be denied if immigration officers find them likely to receive more than half of their income from cash assistance programs or require long-term care. The new regulation would dramatically expand the criteria to decide if someone is a “public charge,” allowing immigration officials to consider the use of other public benefits like Medicaid, SNAP, and housing programs. Lacking English proficiency, having a medical condition, and being low-income could also hurt immigrants’ applications.

More than 13 million people nationwide are at risk of unenrolling from Medicaid and the Children’s Health Insurance Program as a result of the rule.

The rule was scheduled to take effect on October 15, but federal judges in New York, California, and Washington state temporarily blocked it on Friday. On Tuesday, judges in Maryland and Illinois joined in halting the policy. Judge George Daniels of the Southern District of New York found that the government failed to justify the need for a stricter definition of public charge and called the rule “repugnant to the American Dream.” Nine lawsuits have been filed so far challenging the rule, arguing that it will result in poorer health outcomes and increased food and housing insecurity for potentially millions of people.

“This rule is a deliberate attempt to exclude poor people from the citizenship pool,” said Cheasty Anderson, senior policy associate with the Texas Children’s Defense Fund. “They sanctimoniously call this merit-based immigration, but they’re imagining merit as only a dollar sign.”

The final rule, which the Department of Homeland Security estimates would directly impact around 382,000 people annually, would only apply to green card and visa applicants; it exempts asylum-seekers, refugees, and some victims of domestic violence and human trafficking (including Hasse’s client). But confusion around the rule has led many to unnecessarily refuse or unenroll from assistance programs that they or their children are eligible to receive. The government warned of this risk as early as 1999, when it issued a guidance acknowledging that similar confusion had stopped eligible immigrants from getting help, leading to “an adverse impact not just on the potential recipients, but on public health and the general welfare.”

Despite acknowledging potentially harmful public health consequences in the updated regulation, the Department of Homeland Security maintains that “self-sufficiency is the rule’s ultimate aim.” But experts and service providers say it’s part of the Trump administration’s broader efforts to crack down on legal immigration to the United States. Earlier this month, the government issued a proclamation blocking immigrants from entering the country without proof of health insurance.

The chilling effect extends far beyond immigrants subject to the rule. According to a Manatt Health analysis, more than 13 million people nationwide are at risk of unenrolling from Medicaid and the Children’s Health Insurance Program (CHIP) as a result of the rule, including 8.8 million U.S. citizens with noncitizen family members. More than one out of four children in Texas have a noncitizen parent, many of whom, advocates say, are now taking their children off of health care programs like Medicaid, wrongly assuming that if their family members receive public assistance it will impact their own ability to obtain a green card in the future. “Adoption of the rule will worsen Texas’ sky-high rate of uninsured, already the highest in the country, and immeasurably harm the health and well-being of Texas and Texans,” wrote Douglas Curran, former president of the Texas Medical Association, in a letter opposing the rule.

The Houston-based nonprofit Epiphany Community Health Outreach Services (ECHOS) reported a 60 percent decline in adult Medicaid and CHIP perinatal enrollment among their clients in the past two years. Executive director Cathy Moore says this decline has only accelerated since the public charge rule announcement. “We’ve been seeing less people coming into our building for help,” Moore said.

Kori Hattemer, director of financial programs with the Austin-based Foundation Communities, says many of the organization’s clients are also choosing to unenroll from health care programs. “I think a fraction of the people who are worried about this actually come in and talk to us,” Hattemer said. “And that’s our biggest worry: the people who don’t come in.”

As uninsured people forgo preventive care, they are more likely to show up to emergency rooms seeking treatment, even if they can’t afford to pay. The consequence is an increase in uncompensated care costs for hospitals and community-based clinics serving low-income populations.

In fact, the Manatt analysis estimates that, considering the role hospitals play in providing care to Medicaid and CHIP enrollees, hospitals could lose billions of dollars in reimbursement revenue. In Texas, an estimated 22 percent of Medicaid and CHIP payments to hospitals could be impacted by unenrollment because of the public charge rule. If hospitals and community health centers are deprived of this crucial source of funding, they might be forced to cut services. A George Washington University study estimates that 30,000 to 195,000 community health center patients in Texas, California, and New York could then lose access to care.

Although most immigrants aren’t eligible for SNAP, even if their U.S. citizen children are, the chilling effect is also overloading local food banks. Between 2017 and 2019, ECHOS reported a 47 percent decline in SNAP enrollment while also seeing a 460 percent increase in use of their food pantry. This increased reliance on emergency food relief will create an unmanageable demand at nonprofits, said Jamie Olson, policy analyst with Feeding Texas. “They will not be able to replace the vital assistance that SNAP and other health and housing programs provide for people,” Olson said.

The Trump administration may now appeal the judges’ rulings. No matter how the legal battle plays out, advocates say the damage has already been done. According to Andrea Guttin, director of the Houston Immigration Legal Services Collaborative, “It’s going to take a lot of work to roll back what the last two years have caused.”

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