The public charge rule is basically discrimination against children

The public charge rule is basically discrimination against children
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Last week, the U.S. Department of Homeland Security (DHS) released long-awaited proposed rule changes that could block lawful permanent residence in the U.S. for immigrants who either use key safety net programs like Medicaid or are believed to be likely to use such benefits in the future by virtue of having a potentially disabling medical condition or being poor.

While perhaps not obvious at first, these proposed changes — which will be open to a 60-day public comment period once published in the Federal Register — to what is known as the “public charge” rule paint a picture of how the current administration prioritizes child health and well-being. 

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For the last century, the public charge rule, which exists to reduce risk to our welfare system by preventing immigrants from entering or remaining in the country if they were almost entirely dependent upon cash assistance or long-term institutionalized care, has been narrowly defined.

Now, however, the administration has proposed allowing immigration officials to factor in not only children’s enrollment, but future likelihood of enrollment in a much broader array of public assistance that was previously explicitly left out of the public charge assessment. This would include many of our nation's most important programs that support the health and well-being of children, such as Medicaid, food assistance through the Supplemental Nutrition Assistance Program (SNAP), Social Security and Section 8 housing vouchers.  

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What’s more, the changes would mean the government could now penalize non-citizen, legal immigrant parents — and by default their U.S.-citizen children — for “a lack of sufficient funds for self-support,” or put another way, simply for being poor. 

This proposal is not unexpected, as there have been rumors and leaked drafts. For the past year and a half, pediatricians have struggled when counseling immigrant families. Should physicians push the under-insured immigrant teen with a facial malformation to apply for Medicaid?

It might compromise her planned green card application, but without it her surgery will be unaffordable. What should physicians tell the parent of an immigrant child with Down syndrome? This child needs comprehensive and sub-specialized medical care to reach her full potential. But will seeking Medicaid prevent her from remaining in the U.S. with the rest of her family? 

If the proposed regulations are adopted by DHS, health-care providers will know what to tell these families: that the government requires them to choose between ensuring that children have access to public health insurance and their future immigration status.

Most tragically, providers will have to tell them that even if they find other forms of health insurance, their children may be forced to leave the U.S. due to their disability or perceived disability.

That’s because DHS’ proposal penalizes immigrant children with disabilities in two ways. First, it would encourage health- and disability-based discrimination by instructing immigration officials to negatively weigh "any medical condition that is likely to require extensive medical treatment or institutionalization, or that will to interfere with the alien’s ability to care for him- or herself, to attend school, or to work."

Second, the proposal discounts future advancements in medical science and social norms by allowing immigration officials to make present-day judgements about children's future capabilities. For example, when my parents were young, Type 1 diabetes was a disabling condition. Now, adults and children with this disease lead full, productive, independent lives.  

Finally, I am most worried that this potential for discrimination could severely impact immigrant children with mental illness. Conditions such as major depression, bipolar disorder, generalized anxiety disorder and post-traumatic stress disorder are all responsive to treatment.

And, as the public stories of several professional athletes, acclaimed authors and physicians have recently illustrated, mental illness is not a barrier to achievement. Unfortunately, however, the stigma surrounding mental illness still remains, creating barriers to seeking treatment. Immigration-based discrimination would then just add one more factor preventing children from obtaining the physical and mental health care they need. 

Decades of pediatric research has shown us that children have an incredible capacity for healing and resilience. And my own personal experience working with medically complex immigrant children has taught me that they should never be underestimated. The government should prioritize children’s health, not stand in the way of any child, particularly those with greater-than-typical needs, receiving the care they need to grow into healthy, productive adults.  

Katherine Yun, MD is a faculty member at PolicyLab and a pediatrician in the Division of General Pediatrics and the Refugee Health Program at Children’s Hospital of Philadelphia.