The Lancet: Psychiatry

US policy of public charge inadmissibility and refugee suicides

by Awaad, R., Dailami, M. & Noureddine, N.

An immigration ruling of inadmissibility on public charge grounds, announced by President Donald Trump in August, 2019, has caused anguish for some of the most vulnerable people residing in the USA. We have found that within days of the announcement, two refugees and an asylum seeker from the same county died by suicide, all citing this ruling as the reason for feeling unsafe and fearing extradition. In fact, refugees and asylum seekers are exempt from the public charge ruling and their unfortunate misinterpretation highlights the confusion surrounding this new policy. We must question whether we are witnessing the advent of a national mental health crisis and impending suicide cluster among the most vulnerable immigrant populations in the USA.According to the US Citizenship and Immigration Services website, immigrants who use public benefits, including cash welfare, food stamps, housing aid, Medicaid, or public mental health services, are considered to be dependent on government assistance and deemed to be so-called public charges. The ruling also states that legal immigrants classified as public charges will become inadmissible for American citizenship and prevented from obtaining a Permanent Resident Card (green card).¹ The policy was scheduled for implementation on Oct 15, 2019, but district judges in five states have issued injunctions blocking its expansion. On Jan 27, 2020, the US Supreme Court lifted the injunctions, thereby allowing this ruling to go into full effect on Feb 24, 2020.The Trump administration states that its goal for this policy is to encourage so-called self-sufficiency. Unfortunately, the result is that even short-term use of public benefits could have major consequences for immigrants.² The likelihood of being classified as a public charge is increased for individuals with persistent medical and mental health conditions, less education, limited English proficiency, lower income, and unsteady employment.¹ Therefore, this policy targets the most vulnerable immigrants and implicitly discourages immigration by denying immigrants the most basic services necessary to live a physically and mentally healthy life.A negative effect of the new ruling is that even those who are exempt from its application have started disenrolling from Medicaid and food benefits, owing to language barriers, widespread fears, and a lack of clarity surrounding the policy. One study found that disenrolment from health services by immigrants would amount to 538 000 fewer clients in a year, demonstrating that a large number of individuals will be left without health services as a result of this policy.² In the context of other policies that discriminate against immigrants,³ there is an implicit assumption that the cost of public benefits is not worth the contributions that immigrants make to the nation’s economy. However, the literature indicates that between 2005 and 2014, refugees and asylum seekers contributed US$63 billion more to government revenues than they used in public services.⁴The USA accepts fewer immigrants, refugees, and asylum seekers, and offers these populations fewer public services than many lower-income countries. Increasing clarity and awareness of services available to refugees and asylum seekers would provide them with proper health care that would increase their economic contribution. Furthermore, refugees and asylum seekers often have traumatic experiences before arriving in the USA. Untreated trauma is frequently compounded in the resettlement and acculturation process;⁵ therefore, it is imperative that this vulnerable population be encouraged, not deterred, from accessing mental health services. As highlighted by the three deaths by suicide within days of its announcement, the expansion of the public charge policy will inevitably have a considerable negative effect on the physical and mental safety of the most vulnerable individuals in our country.