If one of our patients withheld food or medication from her child, we would report her for child abuse. But come Oct. 15, when the Trump administration’s new public charge immigration rule goes into effect, we’ll have to rethink that strategy.
The public charge rule refers to a term used in immigration law to identify an individual who is primarily dependent on the government for support. The Trump administration has broadened the definition of what can be taken into account when denying green cards to include immigrants who use one or more of three government programs: Supplemental Nutrition Assistance Program (SNAP, also known as food stamps), some federal housing subsidizes, and adult Medicaid.
Although the new rule would, in theory, not penalize Medicaid enrollment by individuals who are pregnant, have given birth within the past 60 days, or are under age 22, fear and confusion are causing many immigrant families to disenroll from these governmental assistance programs.
Redefining the public charge rule aims to punish immigrant parents — including those who have entered the U.S. legally — by punishing their children, most of whom were born in the United States and so are U.S. citizens. For the first time, it takes prior use of health, nutrition, and housing benefits into consideration when determining if an immigrant can get a green card. It forces low-income families that are legally eligible for food stamps and Medicaid to decide whether or not to enroll in these vital benefit programs, knowing that if they do they risk being deported back to countries where violence or hunger await them.
The rule’s more than 200 pages of byzantine language are designed to create fear and confusion among immigrants, prompting parents to forgo benefits for their families. The public charge proposal “presents immigrant families with an impossible choice: keep yourself or your children healthy but risk being separated, or forgo vital services like preventive care and food assistance so your family can remain together in this country,” said Dr. Colleen Kraft, president of the American Academy of Pediatrics, in a statement.
Child abuse occurs when a child suffers serious harm due to the actions, or failure of action, of those entrusted with her or his care. The government is the ultimate caregiver, vested with the duty to ensure the safety of America’s children. So by that definition, under the public charge rule the Trump administration is abusing children. By forcing families to give up access to nutrition and health care, the government has rewritten its role from protector to perpetrator.
According to research that we published with several colleagues in JAMA Pediatrics, the Trump administration has chosen to jeopardize the health and well-being of children in immigrant families, most of whom are legal citizens of the United States. Even though the children of immigrants are, on average, slightly healthier than other children, two-thirds of the 8 million children in immigrant families have or will have medical needs for routine immunizations and require doctors’ visits for serious illnesses like asthma, diabetes, and epilepsy. The families of up to 2 million of these children are expected to pull out of these benefit programs and are thus likely to go without care and adequate food.
Let us be perfectly clear: Some of the children who will go without adequate food and medical care will suffer permanent injury and even die. A toddler without medications for asthma will find herself unable to breathe because her airways will close, denying her organs the oxygen they need to survive. A child with diabetes whose family cannot afford enough insulin will develop permanent kidney and nerve damage, and can slip into a coma and die. A teenager will go to school with hunger pains, unable to focus on his studies or change the trajectory of poor health and productivity that await him due to this lack of food.
This suffering is completely preventable with routine medical care available across the country and the food stamps that people are legally eligible to use.
Some of our patients have been asking if they should disenroll from Medicaid, SNAP, and housing assistance. When we ask how they will feed their children or get the care their families need without the benefits, they share that they aren’t sure. But, they say, returning their families to the violence and hunger that awaits them in the countries of their birth is worse, so for now they will forgo public assistance to steer clear from getting caught by the public charge rule.
Many of those who already have green cards aren’t sure that taking part in these program is worth the risk, even after we explain that the public charge rule does not apply to them. As mothers ourselves, and knowing the fierce drive to protect our children at all costs, we find ourselves at a loss of words.
If physicians like us can report parents who withhold food or medicine or housing from their children for committing child abuse, we should be able to charge the Trump administration with the same thing and use that leverage to overturn the new public charge rule.
Leah Zallman, M.D., is a primary care physician at Cambridge Health Alliance in Cambridge, Mass., the director of research at the Institute for Community Health in Malden, Mass., and an assistant professor of medicine at Harvard Medical School in Boston. Stephanie Woolhandler, M.D., is professor of health policy at Hunter College, City University of New York, in New York City and a lecturer in medicine at Cambridge Health Alliance and Harvard Medical School.