Written by: Cameron Goff & Tom Fadial
The term ‘public charge’ is used by the US government to describe someone who is likely to depend on government benefits. When considering green card applications, immigration officials consider whether an applicant could be classified as a ‘public charge,’ which can prevent them from attaining their green card.
While many factors are considered in making a ‘public charge’ decision, the most relevant for healthcare professionals is the use of Medicaid. As Medicaid use is a factor, many green-card seekers may be dissuaded from seeking medical care for themselves or their children. There are many exceptions, however, of which patients should be aware and with which healthcare providers should familiarize themselves:
- Use of Medicaid for emergency services, children under 21 years, pregnant women, and new mothers (60 days postpartum) are not considered in public charge decisions.
- The public charge rule does not apply to asylum seekers or refugees.
- Use of CHIP, WIC, food banks, and school lunch programs are not considered in public charge decisions.
How can healthcare providers help patients using this knowledge? In the following anecdote, Dr. Tom Fadial, an emergency medicine physician in Houston, details how physician knowledge of the Public Charge Rule can help a patient access the healthcare they need:
The following anecdote does not represent a real patient encounter or real individuals. It is a fictional representation of real concerns that patients and physicians face with respect to the new Public Charge Rule changes.
A young mother, Elena, brings her seven-month old daughter to the emergency center at Franklin D. Roosevelt Hospital in Houston, Texas. She is distraught. Siomara is her first child, and she has had a fever for the past three days. Elena left El Salvador three months ago seeking safety and a better life in the United States for her new family. In addition to losing the comforts and familiarity of home, she lost the invaluable experience and guidance of Siomara’s grandmother – a parent and grandparent to dozens.
I assign myself to a new patient that appears on the trackboard, seven-month-old with fever. The usual wheels are turning as I walk into the room. The listed language preference is Spanish, so the interpreter joins me. The child looks great, smiling and cooing as I intermingle tickles and pokes with my abdominal exam. Ears, check. Nose, check. Skin, check. Throat…there we go, telltale marks pointing to a viral illness – she’ll be fine in a few days.
I share the good news and my usual speech about viruses and encourage the mother to follow up with her pediatrician. She doesn’t have one yet, so we talk a little more about the tarjeta dorada – a vestigial label for the local healthcare system for under- and uninsured patients. I head back to my workstation to take a look at the trackboard.
Elena picked up Siomara and tried to find her way out of the emergency center. She felt only marginally better. She was certain that Siomara would have a fever again once the medicine wore off – they’d both face another sleepless night.
She knew Siomara needed a pediatrician, but this visit alone had already consumed nearly all of their emergency funds. Their asylum hearing was months away, but they’d heard that making use of assistance programs could result in denial – returning to El Salvador was not an option.
She caught a glimpse of the interpreter in the hall and asked her to grab the doctor for one last question.
I saw the interpreter flagging me down, the mother of the kid with a fever wanted to talk to me. I consider the options, probably a last-ditch appeal for antibiotics.
Instead, she asked about the out-of-pocket cost for a primary care visit. I admitted I was unsure but asked why.
“Because we can’t use any public services,” she said.
“Of course, she’s exactly who these services are for,” I replied.
She described her situation. The interpreter paused longer than usual between translations. I understood why as her tragic story was relayed in fragments – tears welling up on both of our eyes as the mother stood – strong, holding her now-sleeping daughter in her arms.
We collectively concluded that we didn’t quite know what to do but recommended a discussion with the social worker and business office for more information.
She thanked us, thanked us, and headed down the hallway.
The new Public Charge Rules go into effect on October 15th. Want to learn more about what this means for patients, and how healthcare providers provide from them? Doctors for Change is hosting a forum on September 26th at 6:30pm.