UCLA CENTER FOR
HEALTH POLICY RESEARCH
e

iit

ISSN 2691-7475

One out of 4
(25%) low-income
immigrant adults
reported avoiding
public programs
out of fear that
participating
would negatively
impact immigration

—— The

California
Endowment

Support for this policy brief
was provided by a grant from
The California Endowment.

Health Policy Brief

 

March 2021

One in 4 Low-Income Immigrant Adults
in California Avoided Public Programs,
Likely Worsening Food Insecurity and
Access to Health Care

Susan H. Babey, Joelle Wolstein, Riti Shimkhada, and Ninez A. Ponce

 

SUMMARY: Recent changes to immigration
rules have expanded the number of public
programs considered when identifying
immigrants who are likely to become a “public
charge,” or dependent on the government as
their primary means of support. Policies and
systems that perpetuate fear and confusion
around immigration status contribute to the
avoidance of public programs, which has serious
implications for health and well-being. One
out of 4 (25%) low-income immigrant adults in
California reported avoiding public programs
such as Medicaid or nutrition assistance
programs out of fear that participating would
negatively impact their own immigration status
or that of a family member.

More than one-third (37%) of immigrants who
reported avoiding public programs in the past

year were uninsured, compared to less than
one-fifth of immigrants who did not avoid public
programs (16%). In addition, more than half of
those who avoided public programs in the past
year were food insecure (54%), compared to

just over one-third who had not avoided public
programs (36%). Even groups not subject to

the public charge rule reported avoiding public
programs: More than one-quarter (27%) of
lawful permanent residents reported avoiding
public programs, even though the public charge
rule does not apply to their applications for
citizenship.

These findings emphasize the adverse
consequences that exclusionary immigration
policies can have on health, and they highlight
the need for accurate information from resources
that people trust.

 

mmigration officials in the U.S. use the

term “public charge” to describe people
applying for lawful permanent residency
(also called a “green card”) who are deemed
likely to become primarily dependent on
the government as their main source of
support in the future. A proposal first made
in 2018 and finalized in 2020 expanded
the number of public programs considered
in determining who is likely to be deemed
a public charge. Additional programs

not previously considered include the
Supplemental Nutrition Assistance
Program (SNAP), formerly called food
stamps; federally funded Medicaid; and
several housing assistance programs.
Subsequent court challenges have kept

the new rule in the news.’ In February 2021,
the Biden administration began the process
of permanently reversing the changes by
calling for an immediate review of the
public charge rule.

 
2 UCLA CENTER FOR HEALTH POLICY RESEARCH

Hesttancy to
participate in
public programs
can negatively
impact health
and access to
health care.

Research suggests that even before the rule
was implemented, there was a chilling effect
in 2018 and 2019 among eligible immigrants
who qualified for public programs but avoided
participating in them out of concern it would
affect their own immigration status or that
of a family member.” * Chilling effects were
also observed among immigrants not subject
to the rule changes.’ Hesitancy to participate
in public programs like SNAP (or CalFresh
in California) and Medicaid (or Medi-Cal in
California) can negatively impact health and
access to health care. Decreased participation
in Medicaid leaves more individuals
uninsured, reducing their access to health
care services. Community health centers
reported decreased use of such health care
services as preventive care and prenatal care
among immigrant patients shortly after the
final rule was published in 2019.? Reduced
participation in nutrition programs such

as SNAP could contribute to worse health
outcomes, particularly for children, as well

as increased hardship if families experiencing
food insecurity forgo food assistance.®

This policy brief uses data from the 2019
California Health Interview Survey (CHIS)

to describe the characteristics of adults who
reported avoiding participation in public
programs due to concerns that it could
negatively impact their own immigration
status or that of a family member. The brief
also examines the association of avoiding
public programs with access to health care and
food insecurity. Measures are described in more
detail under “Data Source and Methods” at

the end of this policy brief. Please note that all
data presented in this brief were collected prior
to the COVID-19 pandemic.

One in 4 Low-Income Immigrant Adults
Avoided Public Programs

In California in 2019, one-quarter (25%) of
immigrant adults with incomes below 200%
of the federal poverty level (FPL) reported
avoiding public programs out of fear it would
negatively impact immigration status, and
55% of those who avoided public programs
reported doing so in the past year. The
proportions who avoided public programs

 
UCLA CENTER FOR HEALTH POLICY RESEARCH 3

 

Percentage Who Ever Avoided Public Programs Out of Concern Over Negative Impacts on
Immigration Status, Adults Born Outside U.S., Ages 18 and Older, Income Below 200% FPL,

California, 2019

| Ever Avoided Public Programs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age

18-34 34% *
35-49 28% *
50-64 17%
65+ 17%
Race/Ethnicity

Latinx 30% *
Black 45% * t
Asian 14% *
White 6% +
Family Composition

No children 17%
Married with children 36% *
Single with children 32% *
English Proficiency

Speaks English only 6% +
Very well or well 25% *
Not well or at all 29% *
Citizenship Status

Naturalized citizen 16%
Noncitizen, Lawful Permanent Resident (LPR) 27% *
Noncitizen, not permanent resident 42% *
Overall 25%

 

Source: 2019 California Health Interview Survey

Note: There were no respondents of other races who reported
avoiding public programs.

were higher for adults younger than 50
compared to older adults, for Latinx and
Asians compared to whites, for families with
children compared to those without children,
and for those with limited English proficiency
compated to those who speak only English
(Exhibit 1). In addition, more than one-third
(34%) of noncitizens reported avoiding public
programs (data not shown). This percentage
was higher among noncitizens who are not

* Significantly different from those identifying as Ages 50-64,
White, No Children, Speaks English Only, Naturalized Citizen,
p<0.05.

+ Estimate is not statistically reliable.

permanent residents than among noncitizen
lawful permanent residents (LPR) (42% and
27%, respectively). It is worth noting that
more than one-quarter of LPR adults reported
avoiding public programs, suggesting a
chilling effect, since LPR immigrants applying
for citizenship are not subject to the public
charge rule (although it could affect family
members, depending on their immigration
status).

Exhibit 1

More than one-
quarter of LPR
adults reported
avoiding public
programs,
Suggesting a

chilling effect.

 
4 UCLA CENTER FOR HEALTH POLICY RESEARCH

 

Exhibit 2

Immigrants
who reported
avoiding public
programs in the
past year had
WOrSe ACCESS

to health care
and higher food

insecurity.

Health Care Access and Food Insecurity by Avoiding Public Programs in Past Year, Adults
Ages 18 and Older, Born Outside U.S., Income Below 200% FPL, California, 2019

| Avoided Public Programs in Past Year || Did Not Avoid

Currently uninsured

No usual source of care

Delayed prescription

Delayed needed medical care

Did not receive needed
mental health treatment

Food insecure

 

54%

 

Source: 2019 California Health Interview Survey

Food Insecurity and Uninsurance
Were High Among Those Who Avoided
Public Programs

Immigrants who reported avoiding public
programs in the past year had worse access

to health care than those who did not avoid
public programs (Exhibit 2). More than one-
third of immigrants who reported avoiding
public programs in the past year were
uninsured, compared to less than one-fifth

of those who did not avoid public programs
(37% vs. 16%). The percentage who reported

20% 30% 40% 50% 60%

** Significantly different from “Avoided Public Programs in Past
Year,” p<0.05, *p<.10

delays in needed medical care, delays in
getting prescription medication, and not
receiving needed mental health treatment was
twice as high among those who had avoided
public programs in the past year as among
those who had not. Immigrants who reported
avoiding public programs in the past year also
had higher food insecurity, with more than
half of those who avoided public programs

in the past year being food insecure (54%),
compared to just over one-third of those who
had not avoided public programs (36%).

 
UCLA CENTER FOR HEALTH POLICY RESEARCH 5

Conclusions and Recommendations

In 2019, 1 out of 4 low-income immigrant
adults in California reported having ever
avoided public programs like Medicaid or
SNAP out of fear it would disqualify them
for lawful permanent residency (a green card)
of citizenship, even before the public charge
rule went into effect. This avoidance of public
programs has important implications for
health and well-being. The percentages of
those having food insecurity, being uninsured,
and delaying needed medical care were all
higher among those who reported avoiding
public programs than among those who did
not avoid public programs.

In addition, the percentages who reported
avoiding public programs were higher among
certain population groups, including Latinx,
Asians, families with children, and those with
limited English proficiency. Even groups not
subject to the public charge rule reported
avoiding public programs: More than one-
quarter (27%) of LPR immigrants reported
avoiding public programs, even though

the public charge rule does not apply to
applications for citizenship.’

Other research provides evidence that the
announcement and subsequent release of

the new public charge rule led to a chilling
effect on enrollment in public programs like
Medicaid and SNAP.’ These studies show
that eligible immigrants began avoiding
public programs in 2018, well before the
rule went into effect, and that declines in
participation accelerated once the rule was
officially published for public comment. The
findings presented in this brief highlight the
potential negative consequences for health and
well-being of avoiding public programs like
SNAP and Medicaid.

In addition, previous research demonstrates
widespread confusion and misunderstanding
about which programs are included under the
new tule and who will be subject to the rule.
For example, according to research by the
Urban Institute, only 23% of California adults
in immigrant families knew that the public
charge rule does not apply to applications for
citizenship.’ The finding presented in this
brief that 27% of LPRs reported avoiding
public programs may have resulted from
confusion around the public charge rule.

Our findings, along with previous research,
provide evidence of disenrollment from or
avoidance of public programs. In addition,
our findings indicate that avoiding public
programs is associated with adverse health
outcomes. Taken together, these findings
suggest the need for strategies to provide
accurate information about immigration
rules, as well as the need to consider the
public health consequences of rules impacting
participation in public programs. The
following strategies may help protect the
health of Californians, particularly during a
pandemic:

© Provide accurate, reliable information to
overcome misinformation and confusion.
The documented confusion about the
public charge immigration rule, along
with evidence presented here of avoidance
of public programs by those not affected
by the public charge rule, highlights the
need for accurate information from sources
that people trust. More than one-quarter
of LPRs in California reported avoiding
public programs, even though citizenship
applications are not subject to the public

charge rule. According to a survey conducted

by the Urban Institute, some of the most

 

These findings
suggest the need
to consider the
public health
consequences of
rules impacting
participation
in public

programs.
6 UCLA CENTER FOR HEALTH POLICY RESEARCH

trusted sources of information on public
charge were community legal organizations
and state and local agencies.® Investments

Inclusive policies
that provide
access to public
programs could
help combat the
chilling effects of
the public charge
rule.

in information campaigns led by these
types of organizations can provide a path for
communicating accurate information about
public programs and their relationship to
immigration. In addition, the finding that
avoidance of public programs was higher
among nonnative English speakers suggests
that this information needs to be provided
in-language.

e Avoid and reverse policies that negatively
impact participation in public programs.
Several studies have documented
disenrollment or avoidance of public
programs associated with changes to the
public charge rule. Inclusive policies that
provide access to public programs could
help combat the chilling effect of the rule.
This brief provides evidence that avoidance
of public programs such as Medicaid and
SNAP was linked to several adverse health
outcomes, including high levels of food
insecurity and lack of health insurance.

In addition, previous research suggests

that disenrollment from public programs
would disproportionately impact California
children.? Our findings provide further
evidence that avoidance of public programs
was higher among families with children.

It is difficult to build trust in immigration
policies, and policies like the current
public charge rule cause families to fear
participating in public programs that
provide health care, nutrition, and housing
support. These public programs serve as a
crucial safety net for California families.
To protect public health, exclusionary
policies that lead to disenrollment from
public programs benefiting health should
be avoided.

Data Source and Methods

This policy brief presents data from the 2019
California Health Interview Survey (CHIS), which
collected data from 22,160 adults. Interviews were
conducted in English, Spanish, Chinese (Mandarin
and Cantonese), Vietnamese, Korean, and Tagalog.
CHIS has a complex survey design that requires
analysts to use survey weights to provide accurate
variance estimates and statistical testing. All analyses
presented in this policy brief incorporate these survey
weights.

Beginning in 2019, adults born outside the U.S.

or its territories were asked, “Was there ever a time
when you decided not to apply for one or more
noncash government benefits, such as Medi-Cal,
food stamps, or housing subsidies, because you wete
wottied it would disqualify you or a family member
from obtaining a green card or becoming a U.S.
citizen?” Those surveyed were also asked whether
this had happened in the past 12 months. Analyses
presented in this brief are limited to adult California
immigrants with household incomes below 200%
FPL (n=1,394), because those with higher incomes
are much less likely to be eligible for public programs
such as CalFresh and Medi-Cal.

Author Information

Susan H. Babey, PhD, Joelle Wolstein, MPP, PhD,
and Riti Shimkhada, MPP, PhD, are research
scientists at the UCLA Center for Health Policy
Research. Ninez A. Ponce, MPP, PhD, is a professor
at the UCLA Fielding School of Public Health and
director of the UCLA Center for Health Policy
Research.

Funder Information
Support for this policy brief was provided by a grant
from The California Endowment.

 
UCLA CENTER FOR HEALTH POLICY RESEARCH 7

Acknowledgments

The authors would like to thank the centet’s
Communications Department for assistance with
production and dissemination, Julian Aviles for
statistical support, and Andrew Juhnke and Parneet
Ghuman for CHIS data access support. The authors
are grateful to the following reviewers for their
thoughtful and thorough reviews: Laurel Lucia,
MPP, director of the Health Care Program at the
UC Berkeley Labor Center; Tia Shimada, MPH,
director of programs, and Betzabel Estudillo, MSW,
senior advocate, Nourish California; and Steven

P. Wallace, PhD, associate director of the UCLA
Center for Health Policy Research and a professor in
the Department of Community Health Sciences at
the UCLA Fielding School of Public Health.

Suggested Citation

Babey SH, Wolstein J, Shimkhada R, Ponce N.
2021. One in 4 Low-Income Immigrant Adults in
California Avoided Public Programs, Likely Worsening
Food Insecurity and Access to Health Care. Los Angeles,
Calif.: UCLA Center for Health Policy Research.

Endnotes

1

btitps://www.ilrc. org/sites/default/files/vesources/2020.01.08_
public_charge_timeline.paf

Bernstein H, Gonzalez D, Karpman M, Zuckerman

S. 2020. Amid Confusion Over the Public Charge Rule,
Immigrant Families Continued Avoiding Public Benefits in
2019. Washington, D.C.: Urban Institute.

Capps R, Fix M, Batalova J. Anticipated “Chilling Effects”
of the Public-Charge Rule Are Real: Census Data Reflect

Steep Decline in Benefits Use by Immigrant Families, 2020.
Washington, D.C.: Migration Policy Institute. bttps://
www.migrationpolicy.org/news!anticipated-chilling-effects-
public-charge-rule-are-real

Bernstein H, Karpman M, Gonzalez D, Zuckerman S.
2021. Immigrant Families Continued Avoiding the Safety Net
During the COVID-19 Crisis. Washington, D.C.: Urban
Institute.

Tolbere J, Artiga S, Pham O. 2019. Impact of Shifting
Immigration Policy on Medicaid Enrollment and Utilization
of Care Among Health Center Patients. San Francisco, Calif.:
Kaiser Family Foundation.

Changes to “Public Charge” Inadmissibility Rule: Implications

Jor Health and Health Coverage. 2019. San Francisco, Calif.:

Kaiser Family Foundation. brtps://www.kff. org/racial-
equity-and-health-policyl fact-sheet|public-charge-policies-for-
immigrants-implications-for-health-coveragel

The public charge rule applies to applications for lawful
permanent residence (green cards), as well as to new
applications for temporary visas or extensions or changes
to existing visas. It does not apply to applications to
become naturalized citizens.

Bernstein H, Gonzalez D, McTarnaghan S, Karpman
M, Zuckerman S. 2020. One in Six Adults in California
Immigrant Families Reported Avoiding Public Benefits in
2019. Washington, D.C.: Urban Institute.

Ponce NA, Lucia L, Shimada T. 2018. Proposed Changes
to Immigration Rules Could Cost California Jobs, Harm
Public Health. Los Angeles, Calif.: UCLA Center for
Health Policy Research, UC Berkeley Labor Center, and
California Food Policy Advocates.

 

california
| health

interview

survey

The California Health
Interview Survey covers a
wide array of health-related
topics, including health
insurance coverage, health
status and behaviors, and
access to health care. It

is based on interviews
conducted continuously
throughout the year with
respondents from more
than 20,000 California
households. CHIS is a
collaboration of the UCLA
Center for Health Policy
Research, the California
Department of Public
Health, the California
Department of Health Care
Services, and the Public
Health Institute. For funders
and other information on
CHIS, visit chis.ucla.edu.
UCLA CENTER FOR HEALTH POLICY RESEARCH

 

10960 Wilshire Blvd., Suite 1550
Los Angeles, California 90024

UCLA CENTER FOR °
HEALTH POLICY RESEARCH «>

The UCLA Center
for Health Policy Research
is part of the
UCLA Fielding School of Public Health.

UCLA
FIELDING

SCHOOL OF
PUBLIC HEALTH

 

The analyses, interpretations, conclusions,
and views expressed in this policy brief are
those of the authors and do not necessarily

represent the UCLA Center for Health Policy
Research, the Regents of the University
of California, or collaborating
organizations or funders.

PB2021-2
Copyright © 2021 by the Regents of the
University of California. All Rights Reserved.

Editor-in-Chief: Ninez A. Ponce, PhD

 

Phone: 310-794-0909
Fax: 310-794-2686
Email: chpr@ucla.edu
healthpolicy.ucla.edu

 

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