Despite the Biden administration’s recent amendments to the criteria of what constitutes a “public charge,” non-citizens of the United States still cannot receive Medicaid-funded long-term care without jeopardizing their path to citizenship.
The concept of a “public charge” dates back to the 1800s and was used to deny entry into the United States to people who were unable to care for themselves. In the late 1990s, a “public charge” was formally defined as someone “primarily dependent on the government for subsistence,” as demonstrated by either (a) using public cash assistance for income maintenance or (b) institutionalization for long-term care at government expense. Under the Trump administration, new regulations were introduced that included public benefits like Medicaid, SNAP and several housing programs in public charge considerations.
Public charges are either denied entry into the United States or, if already in the country, become ineligible for a green card — thereby eliminating citizenship prospects.
In December 2022, the Department of Homeland Security officially reversed many of the Trump administration’s additions to public charge criteria — effectively reverting back to the definition established in the 1990s. This was important as research has shown that the public charge criteria can have negative effects on the health and well-being of immigrants resulting in significant societal costs.
However, one long-standing criterion remains: non-citizens who receive long-term care paid for by the government — including nursing home care — will continue to be viewed as public charges.
The precedent for this is, of course, that admitting individuals into the United States who exclusively rely on the government for financial support is not a sustainable immigration strategy and is not likely to contribute to the economic infrastructure of our society. However, the chilling effect that these policies have on people who are so frail and/or seriously ill, such that they require round-the-clock care and must choose between their health and their immigration status, is equally problematic.
Fearful of the potential impact on their prospects of permanent residency, immigrants may forego much-needed long-term care. The inclusion of long-term institutionalization within the public charge construct merely shifts the responsibility of older non-citizens’ care to their immigrant families — a troubling trend that disproportionately affects women and racial/ethnic minorities who perform the majority of caregiving and potentially compromises the safety and well-being of people who develop serious illness. Policies such as this continue to put more burden on family caregivers and do not provide reforms such as respite and paid family leave to support immigrant caregivers.
It also creates a backlog in many hospitals that have no suitable long-term care placement options for immigrants. Reports of immigrants “living” on hospital units because a suitable skilled nursing placement is unavailable are not uncommon and shift resources away from patients who need them.
Homeland Security Secretary Alejandro N. Mayorkas said the changes to public charge criteria “ensure fair and humane treatment of legal immigrants and their U.S. citizen family members. Consistent with America’s bedrock values, we will not penalize individuals for choosing to access the health benefits and other supplemental government services available to them.”
However, continuing to penalize seriously ill, elderly and disabled immigrants for using Medicaid-funded long-term care does not necessarily equate to fair and humane treatment and may have more deleterious impacts on society than forcing people to choose between health and lawful permanent resident status.
The Biden administration’s revisions to the public charge rule were sorely needed but did not go far enough. Amidst a rapidly growing aging population, we need to ensure America can meet people where they are — even if it is in long-term care facilities — without threatening their path to citizenship.
Moroni Fernandez Cajavilca, MS, BSN, RN is a Ph.D. student at NYU Rory Meyers College of Nursing. His research, affiliated with the Hartford Institute for Geriatric Nursing, focuses on older adults and minority health.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.