Maria, an immigrant from Mexico, spends most of her time tending to her sick husband, Gerardo. After a stroke nearly killed him in 2011, she stopped working to bathe him, dress him and shuttle him to three doctors a week across Houston.
The last thing she needs to worry about, she said, is another family member in the hospital. But on Monday morning, she stopped by an aid center to disenroll her 13-year-old daughter from Medicaid.
“My green card expires in two years, and I’m afraid of what could happen if they learn she’s using [Medicaid],” she said, asking that her last name not be used out of fear her residency would not be renewed. “If they deny me, what will happen to my family?”
More immigrants in Texas may do the same, advocates across the state say, after the Trump administration announced a proposal that would make it harder for some noncitizens who use most forms of public assistance to receive visas or permanent residency.
Federal officials say the proposal would save the government money and ensure immigrants are not a drain on taxpayer-funded resources. But critics say it will cause “chilling effects” — especially in Texas — that could also keep U.S. citizens from using benefits they are entitled to, ultimately costing taxpayers more money.
Under the policy, immigrants would not be penalized if their citizen family members rely on safety net programs like Medicaid. That includes Maria’s daughter and husband, who are both U.S. citizens.
But many green card or visa applicants who use — or could be expected to use — housing vouchers, food subsidies, Medicaid, or some parts of Medicare would be considered a “public charge” and effectively ineligible to adjust their status.
Robert Painter, the director of pro bono programs at American Gateways, which offers legal services to immigrants in San Antonio, Austin and Waco, said that the proposal could lead mixed-status families to think that they must choose between staying in the U.S. and accessing basic health and nutrition.
“If they decided it was too big a risk to take, they’re losing out on a supplement to their income that helps their family,” Painter said.
In Texas, which has one of the country’s largest immigrant populations, Painter said the proposed policy feeds into a "climate of uncertainty" that’s expressed itself through state laws like Senate Bill 4, which effectively forces cities and elected officials to cooperate with federal immigration authorities.
“That created a lot of confusion about who they could trust,” Painter said. “Now on top of that, you’re piling on this suspicion that social service departments may have some ulterior motive.”
The “public charge” test has long applied to immigrants who receive cash assistance. But Homeland Security Secretary Kristjen Nielsen said that by including non-cash programs like Medicaid, the proposal will more clearly enforce a long-standing federal rule.
It will “promote immigrant self-sufficiency and protect finite resources by ensuring that they are not likely to become burdens on American taxpayers,” Nielsen said in a statement.
By the department’s estimates, 382,000 non-citizens would be directly affected each year by the proposal, which must still go through a 60-day public comment period.
Advocates say that figure doesn’t account for immigrants who may fear possible repercussions and drop their families out of welfare programs. The Migration Policy Institute estimates that another 2 to 27 percent of non-citizens in Texas could be affected for that reason.
Aid providers across the state said they saw immigrants drop out of welfare programs earlier this year, before the policy had even been formally announced. After the official proposal Saturday, it could only become worse, they said.
The Harris Health System, which serves low-income and uninsured clients in Houston, saw a 10 percent drop in outpatient visits from March 2017 to February 2018 among immigrants, compared to a 7 percent average for all patients.
And Epiphany Community Health Outreach Services, or ECHOS, a Houston nonprofit, said it's seen a 33 percent decrease in the number of families signing up for the Supplemental Nutrition Assistance Program this year. At the same time, the group's food pantry has seen the number of people it serves jump three-fold since the start of the year.
“Because of what they hear on the news, the upcoming public charge considerations and the political climate, they are afraid it may put a target on their back,” said the organization’s director, Cathy Moore.
Jessica Vaughan, the director of policy studies at the restrictionist Center for Immigration Studies, said drops in enrollment are a symptom of the “hysterical overreaction” caused by media reports and warnings from immigration advocates.
Green card holders will likely face no repercussions for using benefits, Vaughan said, and most of those who are applying for a green card or visa from inside the U.S. do not qualify for safety net programs.
But advocates say the policy may have an impact similar to welfare reform in the 1990s, when government guidance said anyone who uses cash benefits, such as Temporary Assistance for Needy Families, could not become a legal permanent resident.
Jeanne Batalova, a senior analyst at the Migration Policy Institute, said that after that guidance was put in place, TANF saw a sharp drop in immigrant enrollment — even among refugees and other groups excluded from the law.
What’s different this time around, advocates said, is that programs like Medicaid and SNAP provide health support for huge swaths of the population — sometimes the majority of it — in low-income, immigrant-heavy pockets of Texas like the border and major metropolitan areas.
Dr. Ryan Van Ramshorst, a San Antonio pediatrician who chairs the Texas Medical Association’s committee on Medicaid, CHIP and the uninsured, said that the policy could leave his patients in Bexar County — about 75 percent of whom rely on a safety net program — with unaddressed health problems.
“Kids are still going to end up needing care,” Van Ramshorst said. “This is going to result in more people going to emergency rooms and taxpayers absorbing the cost.”
When Maria, the Mexican immigrant in Houston, first heard about a draft of the policy six months ago, she dropped her kids out of SNAP, which gave the family about $340 in food assistance each month. Now her daughter has cavities that need filling. And vision that keeps getting worse every year.
She said she can’t afford to go work and leave her husband alone. But she's afraid to use Medicaid to pay for glasses or a trip to the dentist. The risk is too great, she said.
“I don’t know how we’ll pay for all of it,” she said, breaking down into tears. “It’s stressful. So, so stressful.”