Public Charge Rule

A line of people gathered around a U.S. immigration office in San Francisco. The “public charge” rule would deny green cards to migrants who use Medicaid, food stamps, housing vouchers or other forms of public assistance.

The mother broke into gasping sobs. “He has a form of muscular dystrophy,” she said, sniffling. “And he’s been without his medication for five months already.”

Her 6-year-old son looked plaintively up at her as I handed over the tissue box. The mother had escaped a desperate situation in Honduras and hadn’t had time to collect her sick child’s medical records. The boy was obviously weak, and I knew that if he missed out on a few more months of medication, physical therapy and other treatments, he might lose the ability to walk.

I explained that I would refer her child to the necessary specialists to get him back on track.

The mother brightened, and shared that after getting her son’s care situated she hoped to apply for citizenship.

However, a recent move by the Trump administration threatens the dreams of this mother and could impact millions of immigrant children and families — the “public charge” final rule.

The new rule, issued just last week, would affect immigrants, including those who have legally immigrated, who rely on resources such as the Supplemental Nutrition Assistance Program, Medicaid and affordable housing assistance.

The rule expands the test used to determine if someone can become a permanent U.S. resident or obtain a visa, and will now consider use of these programs. Under this new rule, families will undoubtedly avoid or disenroll from these programs out of fear that they will not be able to remain together in this country.

Children with complicated conditions like my patient with muscular dystrophy need a high level of medical care. This boy would need regular follow-up not only with me, his general pediatrician, but also with a neurologist, a physical therapist and possibly other specialists in order to move independently and grow and develop on track. What’s more is that this child endured the trauma of fleeing with his mother from danger in his home country, and as a pediatrician I know this can have serious consequences for his health.

We know that this exposure to serious stress — what we call toxic stress — can permanently change the architecture of the developing brain. A child affected by toxic stress is at increased risk of mental health problems, substance use, chronic diseases in adulthood and involvement with the criminal justice system.

Add that to childhood diseases like muscular dystrophy, or more common ailments such as asthma and obesity, and lack of services is truly a recipe for multiple negative outcomes.

Access to health care coverage, nutrition and housing assistance can ensure children have the resources they need to combat toxic stress, and help parents be the best caregivers they can be. If parents “choose” to forgo these services in order to enhance their chances of gaining citizenship, then we all lose.

In truth, I don’t remember my patient’s immigration status or whether he would be impacted by the public charge rule — and that’s exactly the point. The confusion and threats this looming regulation has posed to the health of patients like the one I write about here have already led to a chilling effect.

Families, left to face an impossible choice — to risk their child’s health and development, or to risk their family’s chance of staying in a safe place — opt out of services they are eligible for out of fear. Nearly 1 million children have disenrolled from Medicaid and the Children’s Health Insurance Program, and the public charge proposal is considered to be one of the likely factors. But our future depends on our ability to help children grow into healthy and resilient adults; it’s best for all our health, and it’s the right thing to do.

The American Academy of Pediatrics is unequivocal: The public charge rule is “a threat to the health of immigrant children and families.” I am urging federal leaders to reverse this rule. As long as other countries are ravaged by violence and poverty, families will seek safer places to live. We must pass policies that support the health and well-being of immigrants, not those that do the opposite.

That day in clinic, I welcomed my patient’s mother. “I am so happy that you two made it,” I told her. “I can’t imagine what you went through, but we are glad that you’re here.”

Irène Mathieu is a general pediatrician and writer in Charlottesville. Contact her at ipmath@gmail.com.

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