Pediatricians speak out: A ‘public charge rule’ is dangerous for children

Every child has a right to housing, food and medicine. As physicians and humanists, we affirm this fundamental principle. By targeting our nation’s residents who access publicly funded programs to provide for these basic needs, the Department of Homeland Security’s final rule on public charge — set to take effect this October — is a direct threat to the health of our most vulnerable neighbors. 

As pediatricians practicing in New York City’s diverse Washington Heights neighborhood, we condemn this rule and applaud the efforts of states throughout the nation that have filed lawsuits to block the rule.

The term “public charge” historically has been used to classify individuals who are likely to require government assistance due to disability or lack of economic resources. Since 1882, the government has denied visas and lawful residence status to immigrants who have used certain public resources. 

The recent changes will worsen this effect: by broadening the term “public charge,” immigrant families can now be denied pathways to legal status simply for use of subsidized health benefits, public housing and food assistance.  

Targeting of families that utilize community assistance carries devastating consequences. When the new public charge rule was first proposed last October, we immediately saw significant dis-enrollment from vital food access programs including the Special Supplemental Nutrition Program for Women Infants and Children (WIC) and the Supplemental Nutrition Assistance Program (SNAP). 

Although the new rule did not target WIC enrollment, we saw that the protections put in place for children were ineffective in the face of fear and confusion over how the public charge rule was applied. 

Even though the new public charge definition does not include Medicaid use by those under the age of 21, we expect to see a drop in pediatric health-care enrollment. Fear plays a significant role in this setting; in 2018, one in seven immigrant adults reported that they or a family member did not participate in benefit programs to which they were entitled, for fear of jeopardizing their ability to secure legal permanent residence status.

It is reasonable to expect that such fear will have a similar effect in the realm of pediatric health care. Parents of children who are worried that enrollment in Medicaid will have an effect on their family’s immigration status may be less likely to enroll their children in Medicaid, even if they are eligible for this service. 

In light of the recent changes to public charge, we anticipate dis-enrollment from the Children’s Health Insurance Program (CHIP) and Medicaid, undoing the substantial advances made in the past ten years in providing health insurance to children.

For example, the number of uninsured children in the US has been cut in half since 2008, largely due to broader availability of publicly funded insurance through Medicaid and CHIP. A recent study estimates that due to the new public charge rule up to 1.9 million children will be dis-enrolled from health insurance, increasing the number of uninsured children from 3.9 million in 2018 to nearly 6 million children. Many of these children have serious medical conditions such as asthma, seizures, cancer and disabilities necessitating ongoing and frequent care. 

Besides rolling back the progress we have made in providing coverage for children in the United States, the health consequences of depriving these children of vital services will be dire. For example, a premature infant needs specialized high calorie nutrition in order to gain weight and achieve optimal brain development.

Without access to adequate nutrition, parents will be forced to ration their baby’s formula, leading to the adverse outcomes we see as physicians — among them poor growth, seizures and cognitive deficits. Certain medications, such as insulin and some antibiotics, require refrigeration, which becomes impossible without stable housing. The monumental progress we’ve made in the treatment of childhood cancers will not matter if children cannot access regular chemotherapy because of lapses in insurance. 

As pediatricians, we know that health in childhood is essential for success in adulthood. Rather than promoting self-sufficiency, as proponents of the new rule assert, this rule will ad yet another stumbling block to the lives of vulnerable children. As physicians, and as human beings, we have a collective moral responsibility to ensure the needs of our communities are met. It is in this light that we strongly oppose any policy — including the final rule on public charge — that will cause direct harm to the children for whom we care. 

Avital Fischer, M.D., Sumeet Banker, M.D., M.P.H., and Claire Abraham, M.D.are pediatricians at Columbia University Medical Center and Morgan Stanley Children’s Hospital of New York-Presbyterian. The views expressed here are entirely their own and do not necessarily reflect those of their affiliated institutions.