Policy in clinical practice: Impact of restoring the 1999 public charge rule on healthcare access for noncitizen immigrants

A 30-year-old woman with New York Heart Association Class III nonischemic cardiomyopathy is hospitalized for acute decompensated heart failure for the 2nd time this year. She did not see outpatient cardiology nor start home inotropes as previously recommended because she is uninsured and could not afford the out-of-pocket cost. Although she deferred medical care for as long as possible before her diagnosis due to concerns about immigration status, she recently received her green card and became a permanent resident of the United States. She asks about her options for health insurance to facilitate postdischarge heart failure care (Table 1). Nonmarketplace plan (private insurance) Since 1882, the federal government has used the concept of "public charge" to deny visas and/or green cards to applicants who might become dependent on federally funded benefits after being granted lawfully present immigrant status. 1999 federal guidance established that public charge should be determined based on past and not anticipated future use of federal benefits.1 Before 2019, visa and/or green card denials due to the public charge rule were uncommon since access to federal benefits is already restricted to permanent residents (i.e., those who already have a green card) and US citizens. In 2019, the Trump administration issued an executive order expanding public charge to consider whether a green card or visa applicant was anticipated to use any federal benefits.1 This expanded interpretation led noncitizen immigrants to delay seeking medical care due to concerns that accessing federal benefits would affect their own or family members' visa and/or immigration applications.2 In September 2022, the Biden administration reverted to the 1999 interpretation via executive order, with the intent of mitigating adverse health consequences for noncitizen immigrants.1 The expanded public charge interpretation magnified the tendency of noncitizen immigrants to already seek less healthcare than citizens.2 Despite the recent restoration to the 1999 public charge interpretation, there remains lingering fear and confusion that seeking federal benefits—including public health insurance such as Medicare or Medicaid—will adversely affect immigration status.1 Consequently, noncitizen immigrants are still more likely to remain uninsured and lack a regular source of care other than the emergency department (ED).3 Under the Emergency Medical Treatment and Active Labor Act of 1986, all people who present to an ED must receive stabilizing treatment for emergency conditions regardless of ability to pay. As such, hospitalists are likely to care for noncitizen immigrants hospitalized from the ED.4 To alleviate patient anxiety and optimize postdischarge care planning, hospitalists caring for noncitizen immigrant patients should reiterate that applying for Medicaid and/or receipt of "Emergency Medicaid" (pools of state money that cover emergency services and specific health conditions per individual states' discretion)5 will not affect visa and/or green card applications under current public charge interpretation. Furthermore, hospitalist physicians and all healthcare staff should be aware that they are not required to report immigration status—hospitals and healthcare settings are considered "sensitive locations" where immigration enforcement actions should only be taken in extreme circumstances. Immigration status is considered protected health information under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, and disclosure of a patient's immigration status to authorities without patient authorization would constitute a HIPAA violation.6 To be clear, other federal regulations continue to limit healthcare access for noncitizen immigrants. Major federally funded benefit programs, including Medicare and Medicaid (the latter is jointly supported by federal and state funds), have long excluded non-US citizens, particularly undocumented immigrants and deferred action for childhood arrival (DACA) recipients. Even lawfully present immigrants, including green card holders, are barred from receiving Medicare or Medicaid until after a 5-year waiting period. States have discretion to further restrict or expand Medicaid coverage for immigrants. Six states bar all noncitizen immigrants from accessing Medicaid entirely.7 Conversely, 35 states eliminated the 5-year waiting period for pregnant women and children. State Emergency Medicaid funds may cover emergency care for noncitizen immigrants but there is wide variation in what states consider "emergency care."5 Other states are using state funds without joint federal support to extend Medicaid eligibility to people who would otherwise be excluded. California is using this strategy to expand Medicaid eligibility to include all state residents irrespective of immigration status starting in 2024.8 Outside of public insurance, lawfully present immigrants without employer-sponsored insurance can purchase private insurance out-of-pocket, or via the federal Health Insurance Marketplace®. Federal tax subsidies to offset the cost of Marketplace® plans also exist, contingent on income eligibility. Without subsidies, Marketplace® plans may be unaffordable, with an average monthly premium of $1000 for the lowest-tier plans for a family of four.9 Undocumented immigrants and DACA recipients cannot purchase marketplace plans.3 For lawfully present immigrants in the 5-year waiting period, undocumented immigrants, and DACA recipients among other groups, a patchwork of resources addresses some gaps. Federally qualified health centers (FQHCs), community health centers, and migrant health centers provide care regardless of immigration status.10 Although they provide a breadth of services, access to subspecialists like cardiologists is limited.11 Additionally, these clinics are not always located in the areas of highest need.12 In some regions, state- and county-funded indigent health programs provide coverage to individuals regardless of immigration status.13 However, these are not uniformly available across the United States, and the breadth of available health services varies widely—ranging from charity care provided by contracted individual practices to hospital services only to comprehensive county-owned coordinated health care delivery systems.14 The geographic availability of accessible health services is a key determinant of access to longitudinal postdischarge outpatient care and can inform hospitalist discharge planning. Limited outpatient care access may prompt this patient's treatment team to deviate from strict evidence-based care. For example, the treating hospitalist might focus on selecting guideline-directed medical therapies (GDMT) available as low-cost prescriptions at some pharmacies ($4 formularies) and titrating them to optimal doses before discharge. In contrast, if close follow-up was accessible, optimization of GDMT to reduce readmission risk could be deferred to the outpatient setting. Additionally, if available, the patient could be referred for specialty cardiology care with consideration of advanced therapies including home inotropes, left ventricular assist device implantation and cardiac transplant—options that would be considered for insured patients. Restoring the 1999 interpretation of public charge is an important first step, but many barriers to accessing healthcare remain for both lawfully present and undocumented immigrants. Notably, changes to public charge interpretation were made via executive order, meaning they could be changed again by a new presidential administration in the absence of Congressional legislation. Inconsistent interpretation of the public charge rule has fed fears that using federal benefits could affect future immigration status regardless of current interpretation. Additionally, restoring the 1999 public charge interpretation does nothing to change the current limited and variable healthcare options outside of the hospital for uninsured noncitizen immigrants across the nation. Without robust postdischarge transitions to outpatient care, hospitalization becomes a stopgap rather than a meaningful opportunity to change illness trajectory for patients. Hospitalists and health systems can now take several steps to improve healthcare access for their noncitizen immigrant patients. From a clinical perspective, hospitalists should be aware of posthospitalization care options in their region and tailor discharge planning accordingly. From a policy perspective, hospitalists could consider supporting advocacy efforts to expand county and state-funded patient assistance programs, and to address federal policy to improve healthcare access for immigrants. This could include advocating for: (1) lawfully present immigrants to receive federal benefits without a waiting period; (2) county and state programs to enable healthcare access irrespective of immigration status; and (3) federal legislation to codify the public charge interpretation into law, thereby making it less vulnerable to future changes via executive order. In this clinical scenario, the patient resides in a state with a 5-year waiting period for "qualified immigrant" status but fortuitously is in a county with a comprehensive county-owned coordinated health delivery system that provides care to indigent county residents irrespective of immigration status. She could apply for a Marketplace® plan and may be eligible for federal subsidies to defray the cost; if that is cost-prohibitive, she should apply for the county indigent health program to obtain access to needed healthcare services. However, individual recommendations must be tailored to the regional policy environment. In some states, applying for Medicaid or a Marketplace insurance plan might be feasible; in others, the only option might be to seek care at local free clinics or FQHCs with the understanding that outpatient specialty care might be inaccessible. Restoring the 1999 interpretation of public charge is an important first step to improving healthcare access for noncitizen immigrants, but many barriers remain in the current policy landscape. Some counties and states have developed innovative solutions around these barriers, which could serve as models for broader action. In the meantime, robust evidence-based hospital care, discharge planning and transitions to outpatient care remain constrained by federal policy and regional variation in available healthcare services for noncitizen immigrants. The authors declare no conflict of interest.