Public Charge & Health Care in California

August 14, 2019

Finalized Federal Rule Could Increase the Number of Uninsured in California

On August 12, 2019, the U.S. Department of Homeland Security (USDHS) released the final rule on “public charge.” The new rule adds to the factors and conditions the federal government will consider when deciding whether to grant permanent residency status (green cards), or entry into the U.S., for immigrant applicants. The attached ITUP Fact Sheet provides additional background on the final rule.

The final rule is scheduled to take effect October 15, but lawsuits challenging the rule have already been filed in federal court.

Prior to this rule change, only two public benefits, cash assistance and long-term institutional care, were factors in the federal “public charge” determination. The final rule adds certain housing and nutrition assistance programs, and federally funded, non-emergency Medicaid (Medi-Cal in California) as factors in a federal public charge determination.

Most undocumented immigrants are ineligible for federally funded Medicaid services; except for emergency Medicaid and pregnancy-related services, which are exempt from a public charge determination. Therefore, the inclusion of non-emergency Medicaid in public charge assessments should not have a significant impact on immigrants seeking to legalize their status.

However, the complexity of the rule, combined with the current negative climate surrounding immigrants and immigration, will likely have a chilling effect on immigrant access to health care and coverage.

USDHS directly acknowledges the chilling effect in the final rule, by estimating $2.5 billion in annual public savings, because some eligible immigrants will choose to disenroll or forgo enrollment in public programs.

Because some immigrants may be deterred from enrolling in coverage, the final rule could increase the number of uninsured Californians[1] and frustrate California’s efforts to build toward universal health care coverage in the state.

Fear and confusion could keep some California immigrants from enrolling in and staying on state-funded Medi-Cal or accessing federally supported Medi-Cal for emergency and pregnancy-related services, even though under the new rule those programs are not factors in public charge.

California extended eligibility for comprehensive Medi-Cal using state funds to undocumented children in 2016 and young adults ages 19-25 in the 2019-20 state budget. (For more information on these and other health care programs serving California immigrants, read the ITUP fact sheet, Health Care Programs for California Immigrants.)

Notably, release of the proposed public charge rule in 2018 did have a chilling effect in California. For example, some L.A. County immigrants, including some undocumented children, dropped Medi-Cal coverage, despite being legally eligible to enroll, and canceled medical appointments, fearing immigration consequences if they accessed any government health care program.[2]

Under the final rule, immigration officials will consider in a public charge determination any medical condition, including a disability, that affects an immigrant’s ability to attend school or work, or otherwise care for themselves. The final rule also adds an evaluation of an immigrant’s financial status and requires officials to evaluate the potential costs of treatment for the medical condition and whether an applicant has the resources to cover the anticipated future medical needs, including whether they have health insurance coverage.

The release of the final rule comes against the backdrop of increased federal immigration enforcement activities, including the continuing detention of thousands of migrants, including many children, in border facilities, and large-scale enforcement raids by Immigration and Customs Enforcement growing increasingly more common. In addition, the federal administration is reportedly preparing yet another proposed rule on public charge that will impact new lawfully residing immigrants.

Mitigating the anticipated chilling effect from the final rule and the continuing negative climate surrounding immigration will be important to protect the coverage gains California has made. This will require robust outreach, education, and enrollment assistance, resources to help immigrants get accurate information about their right to services and legal assistance to ensure those rights are adequately protected.


For resources to help immigrants understand and secure their rights, visit the California Department of Social Services website.

[1] Ninez A. Ponce, Laurel Lucia and Tia Shimada, Proposed Changes to Immigration Rules Could Cost California Jobs, Harm Public Health, UCLA Center for Health Policy Research, December 2018.

[2] Leslie Berestein Rojas, Thousands of LA Immigrant Families Are No Longer Enrolled in Public Benefits. A Pending Trump Rule Could Be Why, LAist, August 2, 2019.