Increased Medicaid coverage for immigrants linked to reversal of ‘public charge’ rule

Once a Trump-era rule was rescinded in March 2021, Nevada Medicaid saw a sharp increase in the number of immigrants enrolling.(Photo by Roger Brown from Pexels)

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Medicaid enrollment among Nevada’s immigrant population has risen dramatically during the COVID-19 pandemic, a development officials attribute not only to extended pandemic eligibility during the health emergency, but also to the Biden administration rolling back the Trump-era “public charge” rule that deterred immigrants from seeking medical and housing benefits.

During the Trump administration, immigrants who used noncash public benefits — like housing vouchers, food assistance, or Medicaid— could be deemed a public charge and denied residence or citizenship status.

The Trump rule also included provisions that made entering the U.S. or obtaining a green card harder for low-income immigrants who had not used any benefit programs at all but were expected to use noncash public benefits.

Pres. Joe Biden issued an executive order a few weeks after his inauguration which ended enforcement of the public charge restrictions.

Nearly 41,ooo legal permanent residents—a record number—have health coverage through Nevada Medicaid, as enrollments surged since the start of the pandemic, according to recent data from the Nevada Department of Health and Human Services.

Between March 2020 and February 2022, more than 12,000 legal permanent residents enrolled in the program—a 43% increase, the data shows. 

Ineligible immigrants enrolled in Nevada Medicaid, who only qualify for emergency services, had the second largest numerical increase, from 2,923 in March of 2020 to 4,576 recipients in February 2022. 

Refugees were the third largest growing immigrant population to enroll in Nevada Medicaid, from 2,865 in March of 2020 to 3,630 recipients during that same time period.

The significantly higher enrollment among Nevada’s immigrant population is likely driven by two main factors, say state health officials: the end of Trump-era changes to the federal public charge rule, and a federal requirement that states keep Medicaid beneficiaries enrolled until the end of the public health emergency.

In Nevada, Medicaid enrollment among the general population has climbed overall amid a pandemic-induced recession and more people qualifying under relaxed eligibility requirements.

“Medicaid populations across the board increased substantially during the pandemic,” said Robert Thompson, administrator for the Nevada Division of Welfare and Supportive Services.

But state health officials say Nevada Medicaid enrollment data among immigrants has also closely followed changes to the federal public charge rule which broadened the government’s definition of benefits to include widely used “non-cash public benefits” like Medicaid and food assistance.

In 2018, in the wake of stricter public charge rules proposed under the Trump administration, enrollment in Nevada Medicaid among immigrants fell by about 2% in the state.

Once the Trump-era rule was rescinded in March 2021, Nevada Medicaid saw a sharp increase in the number of immigrants enrolling. Within the first six months of the rule change the state health department logged a nearly 15% increase among the immigrant population.

“We don’t get personal with our customers and ask why they enrolled or didn’t,” Thompson  said. “But we can look at those time frames and we can see that the time frames correlate with when releases were sent out by the federal government relaxing the messaging regarding public charge.”

Prior to the statewide shutdown caused by the pandemic, health officials began outreach to inform immigrant communities the public charge rule had been rescinded, including partnerships with grocery stores, however the operation was shut down soon after due to the growing pandemic.

State health officials say the increase in non-citizens enrolling in Nevada Medicaid is likely also related to the state’s choice to maintain eligibility for Medicaid recipients in exchange for increased federal funding.

Medicaid enrollment among the general population in Nevada increased by about 35% from February 2019 to January of 2022, less than the increase among immigrants but still substantial.

Before the pandemic, Nevada Medicaid evaluated the eligibility of beneficiaries each year, removing people who no longer qualified, but the federal government agreed to increase Medicaid matching funds if states pledged not to disenroll anyone from Medicaid while the public health emergency was in full force.

That deal expires with the end of the federal public health emergency, meaning states will once again remove Medicaid recipients who are no longer eligible for the program.

“We do expect there to be a drop in caseloads,” Thompson said, but by how much is unclear.

After the chaos of the pandemic, many Medicaid recipients have neglected to update paperwork and income changes to the agency. Medicaid managers also fear they might not have current addresses for recipients with so many people moving during the pandemic, meaning that requests for income information might go unanswered.

State health officials say the immigrant population may be especially difficult to reach, so they are working to keep those gains in health care coverage among the population. 

While many of the newly enrolled Medicaid recipients will remain eligible, others are at risk of losing health care coverage, an eventuality Nevada health officials are preparing to mitigate by working with partners to ensure a smooth transition for those who will need to find alternative healthcare.

“We are looking at new technologies that will be able to assist us and do some automatic eligibility,” Thompson said. “The computer systems will be able to do automatic referrals to the Nevada Health Link exchange if we deny or terminate someone due to income limits.”

Since the Biden administration the U.S. Citizenship and Immigration Services has announced the use of benefits will not determine eligibility for U.S. citizenship. That change in tone was an important factor in establishing trust with immigrant populations, said Rico Ocampo, an organizer for the immigrant rights group Make the Road Nevada.

“The underlying tone or rhetoric that came from the previous administration set a lot of immigrants sitting on needles,” Ocampo said.

The rule change also had a cooling effect on immigrants with U.S. citizen children who are eligible for benefits, even among their own members, said Ocampo.

“Many times we’ve seen families having to choose whether to get services for their U.S. citizen children or risk running into the public charge rule,” Ocampo said. “It’s had a big impact on communities that are in need of these resources and services.”

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