Pediatricians and public health officials are worried vaccination rates among children of immigrants will fall as new and stricter rules come into effect this autumn related to the public services available to people seeking to immigrate to the United States.

In fact, a number said they have seen a decline in immigrant families using preventive health care services for their children since the Trump administration published its proposed “public charge” update last fall — even when the children are U.S. citizens and are not subject to the rule.

Under the rule, noncitizens hoping to qualify for permanent residency —also known as a green card — can be denied if authorities deem them to be a drain on public coffers. The new rule defines a public charge as any noncitizen who receives benefits from public programs for more than 12 months over a three-year period. Use of two services in one month counts as two months towards the 12-month limit. (There’s a link to a fact sheet on the public charge rule at the end of this article.)

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The revised rule gained renewed attention when the final version was published on Aug. 14 in the Federal Register. Although it doesn’t list free vaccinations as a service that can be held against a green card applicant in a public charge analysis, there is such abundant confusion about it — and about what might put immigration status at risk — that families are forgoing services to which they are actually entitled, a number of experts told STAT.

Dr. Lanre Falusi, a Washington, D.C.-based pediatrician and a spokesperson for the American Academy of Pediatrics, said the rule as written does not stipulate that accessing free vaccines for a child would be a mark against an immigrant parent. But the rule is more than 100 pages long, and not easy to decipher.

A federal regulatory impact analysis estimated it would take between 16 to 20 hours to read the final rule “depending on an individual’s average reading speed and level of review.”

“I’ll tell you that people are not reading all of the details and are not picking up on all of the nuances,” Falusi said. “What communities, especially immigrant communities, are hearing is: Using these federal programs, using even state programs … could harm your application for a green card in the future. So that’s what they’re hearing. And the chilling effect is what I’m seeing.”

Dr. Jeffrey Duchin, chief of communicable diseases for the Seattle and King County Health Department, said Washington state has also observed an impact since the administration signaled its intent to update the rule.

“We’ve had incidents where mothers have refused infant child services, where children have been dis-enrolled from preventive health care benefits that they are eligible for,” Duchin said. “And we fear that this is not an isolated issue, that throughout the community there’s significant reluctance now and fear to access health care services that people need both to treat illness and to stay healthy.”

The revised rule, which goes into effect on Oct. 15, adds specific services that could have an immigrant declared a public charge, including non-emergency use of Medicaid for adults (not including pregnant women), the Supplemental Nutrition Assistance Program — known as SNAP, formerly called food stamps — and some housing support programs. Those services were previously exempt.

Several states and organizations have already filed lawsuits challenging the revised rule.

After the administration announced its intentions to make the public charge rule more restrictive last fall, a 60-day public comment period drew more than 266,000 submissions, many highly critical of the intended changes. But the final rule includes the broader list of services for which would-be immigrants can be penalized.

News of the new rule raced through immigrant communities. Dr. Sarah Polk, a Baltimore pediatrician whose practice is made up largely of Latino children from immigrant families, hasn’t yet seen a decline in vaccination rates, but has clearly seen a reduction in the number of eligible families signed up for SNAP.

“Simply the threat of a revised public charge sent fear throughout the immigrant community and had a chilling effect on health care utilization,” said Polk, an assistant professor of pediatrics at Johns Hopkins University. “Every time there are new pronouncements related to it by the administration, it’s a reminder to the immigrant community of their vulnerability.”

Paradoxically, many of the children in immigrant families in the United States are U.S. citizens and are not subject to the public charge rule. According to an analysis from the Henry J. Kaiser Family Foundation, about 10 million U.S. children — 13% of all children in the country — had a noncitizen parent in 2017. About a quarter of all children in the U.S. have a parent who is an immigrant.

Many immigrant parents fear that accessing public services for those children could endanger their own immigration status, even if their children are exempt from the public charge rule, Falusi and others said.

“While the proposal is particular to a subset of immigrants, it’s going to have a much more broad-ranging impact,” Polk said, noting that when parents tell her they don’t want to apply for benefits, she’s not comfortable urging them to reconsider.

“I don’t feel confident saying ‘You should go ahead. This is not targeting you. It will be fine,’” she said. “Even in applying, they have to provide a lot of personal information. Will that never be used to track them down and deport them? I can’t say that. So these are issues I don’t feel comfortable pushing on because what is the most important thing to the wellbeing of a child? It’s probably an intact family.”

Dr. Elizabeth Barnert, a pediatrician and assistant professor at UCLA’s David Geffen School of Medicine, pointed to a study published earlier this month by researchers at the University of California, San Diego.

The group, at the university’s U.S. Immigration Policy Center, conducted a survey involving 506 undocumented immigrants. Half were read a brief description of the previous public charge rule and were then asked how likely they were to apply for a range of services like food stamps, emergency health care, and free vaccinations for their children. The second half were read that description and the new definition of a public charge and then asked if they would be likely to apply for the services.

Nearly 82% of undocumented immigrants read the previous rule said they would vaccinate their children; only 69.3% read the other version said they would. The difference was statistically significant, and the authors noted that the effect is likely an underestimate, because the survey was conducted before the rule was finalized and respondents were told it was a proposal at that point.

Immigrant families are typically keen to vaccinate their children. “That’s the impossible choice that parents are faced with,” said Falusi. “Absolutely wanting to make sure that their kids stay healthy and not wanting to forgo any health care services but also being afraid that utilizing them could harm their chances of continuing with the legal immigration process that they may have already started.”

Barnert said the impact of the revised rule will likely be greater than the UCSD study suggests, given the current climate around immigration-related policies.

“Fear is infectious,” she said. “The real effect may well be worse, as things are broadcasting on television, as people are hearing from family members, as people are watching family members get denied, get deported.”

Amy Pisani, executive director of Vaccinate Your Family (formerly known as Every Child By Two), expressed dismay at the revised public charge rule and what she suspects will be its consequences. The organization, founded by former first lady Roslyn Carter and the late Betty Bumpers, was among those that objected to the proposed revision to the public charge rule.

“This country did an amazing job at eliminating disparities among races and socio-economic lines through the Vaccines for Children program,” Pisani said, referring to the program that provides free vaccinations for children either on Medicaid or who would qualify for Medicaid because of their household’s income status, even if their parents had not applied for the program.

If vaccination rates drop among the children of immigrant families, it won’t only affect those individuals, Pisani and others warned. Weakening so-called herd immunity affects everyone.

“We’re seeing outbreaks of vaccine-preventable diseases like measles happening now. And they’re primarily among people who have declined to vaccinate their children,” Pisani said. “The next step is going to be people who wanted to vaccinate their children, but either couldn’t access the services or feared retaliation if they did.”

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A fact sheet on the revised public charge rule, published by the Henry J. Kaiser Family Foundation, can be found here.

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