By Dr. Ashaki Noni Nichols | YourNEWS
WASHINGTON — A sweeping change to the federal government’s “public charge” immigration policy is set to take effect September 18, 2026, triggering lawsuits from states and major American cities and raising questions about healthcare enrollment, food assistance, local hospitals and municipal budgets.
A viral X post shared by Greg Price highlighted New York City Mayor Zohran Mamdani’s warning that as many as 4 million people nationwide could drop their healthcare coverage as a result of the policy.
The underlying issue is real, but the numbers require context.
The Department of Homeland Security finalized a rule rescinding the Biden administration’s 2022 public-charge regulation. Under the Immigration and Nationality Act, certain noncitizens seeking admission to the United States or adjustment to lawful permanent resident status can be found inadmissible if immigration officials determine they are likely to become a “public charge.” The new policy restores significantly broader discretion to immigration officers when making those determinations.
USCIS says the change is intended to align public-charge determinations with congressional intent that immigrants be self-reliant and not dependent on taxpayer-funded benefits. The agency says officers will evaluate the totality of an applicant’s circumstances rather than making decisions based on one factor alone.
Medicaid, Food Assistance and Other Benefits Could Be Considered
The new framework allows immigration officers to consider a wider range of means-tested assistance when evaluating certain applicants.
Federal guidance indicates that potentially relevant programs can include government-funded healthcare, food assistance, public or assisted housing and other means-tested programs. However, receiving one of these benefits does not automatically mean that a green-card application will be denied. Officers are directed to evaluate the totality of an applicant’s circumstances.
The rule also does not apply to everyone living in an immigrant household.
For example, San Francisco’s Human Services Agency notes that the public-charge test does not apply to U.S. citizens and generally does not apply to refugees, asylees and several other humanitarian immigration categories. It principally affects certain noncitizens seeking admission or lawful permanent resident status.
That distinction is important because social-media discussion of the rule can create the impression that millions of immigrants will automatically lose Medicaid, SNAP or other benefits on September 18.
That is not what the rule itself says.
Where Does the “4 Million” Figure Come From?
The figure circulating online appears to correspond closely with modeling by KFF examining what researchers call a “chilling effect” — people withdrawing from benefits because they fear immigration consequences even when they remain legally eligible.
KFF estimates approximately 13.5 million Medicaid or Children’s Health Insurance Program enrollees live in households containing at least one noncitizen.
If 10% to 30% of those individuals disenroll because of public-charge and immigration-related concerns, KFF estimates approximately 1.4 million to 4.1 million people could leave Medicaid or CHIP.
That range includes an estimated 560,000 to 1.7 million U.S.-citizen children.
Therefore, saying that 4 million people will lose or leave healthcare coverage overstates what is currently known.
The more accurate statement is that researchers estimate that disenrollment could reach approximately 4.1 million under a high-end scenario.
DHS itself uses considerably lower estimates. According to KFF’s review of the final rule, DHS estimates more than 600,000 Medicaid enrollees and roughly 60,000 CHIP enrollees could disenroll or forgo enrollment.
Trump Administration Says Policy Protects Taxpayers
The Trump administration describes the policy very differently from its opponents.
USCIS says the previous Biden-era regulation was too restrictive and prevented immigration officers from examining all information relevant to determining whether an applicant was likely to become a public charge.
“The Trump administration is upholding the rule of law and protecting American taxpayers from subsidizing aliens who may become dependent on public benefits,” USCIS spokesperson Zach Kahler said when the final rule was announced.
The administration’s position is therefore that immigration officials should have greater authority to consider whether an applicant is likely to rely on taxpayer-supported assistance.
Opponents argue that the discretion is too broad and could discourage legally eligible families from obtaining healthcare, nutrition and housing assistance.
That disagreement is now headed to federal court.
New York, Chicago, San Francisco and Seattle Go to Court
New York City has joined Chicago, San Francisco, Santa Clara County, Seattle and King County, Washington, in challenging the rule in federal court.
A separate lawsuit includes a coalition of 22 states and the District of Columbia.
The lawsuits contend that DHS exceeded its authority and that the rule violates the Administrative Procedure Act. The Trump administration maintains that the change properly implements federal immigration law.
The legal fight means the ultimate implementation of the policy could still be affected by federal court rulings.
Absent court intervention, however, the rule is scheduled to take effect September 18.
What Could This Mean for New York City?
New York officials argue that the biggest impact may extend beyond people directly subject to public-charge determinations.
Mayor Mamdani has warned that fear surrounding the rule could cause immigrant households — including households containing U.S.-citizen children — to stop using healthcare and other benefits.
New York City officials cite estimates that as many as 4 million people nationwide could leave healthcare coverage and argue that reduced participation could increase pressure on hospitals and other safety-net providers.
The key issue for cities is therefore not simply immigration enforcement.
It is what happens when residents who would otherwise receive preventive or routine medical care become uninsured and later seek treatment through emergency rooms or publicly supported safety-net systems.
Chicago: Healthcare and Safety-Net Pressure
Chicago is participating directly in the municipal lawsuit challenging the rule, while Illinois Attorney General Kwame Raoul is co-leading the separate multistate challenge.
If significant numbers of eligible residents leave Medicaid or other assistance programs, Chicago and other large metropolitan areas could experience increased pressure on emergency departments, community health centers and locally supported assistance programs.
That potential effect is not unique to Chicago.
States challenging the regulation argue that when people lose or abandon healthcare coverage, some will postpone treatment until medical conditions become more serious — potentially shifting costs rather than eliminating them.
San Francisco: Benefits Outreach Could Become More Important
San Francisco is also challenging the federal rule and has already published guidance explaining who is — and is not — affected.
The city’s Human Services Agency stresses that most immigrants receiving public benefits are not subject to the public-charge rule and that U.S. citizens are not subject to it.
That highlights another potential nationwide consequence: local governments may need to spend additional money communicating complicated eligibility rules to residents.
Without clear information, eligible U.S. citizens or immigrants exempt from public-charge determinations could unnecessarily withdraw from Medicaid, food assistance or other programs.
Seattle and King County: Local Governments Warn of Cost Shifting
Seattle and King County are also plaintiffs.
Officials there have warned that reduced participation in health, food and housing programs could increase homelessness and transfer costs to local hospitals and governments.
Washington State’s attorney general has separately argued that falling Medicaid and SNAP participation could affect healthcare systems, schools and local businesses.
The state points to several possible secondary effects: greater reliance on emergency rooms, reduced SNAP spending at grocery stores and other businesses, and potential complications for school meal programs tied to participation in public-assistance programs.
The Impact Could Reach Cities That Aren’t Suing
The effects of the federal policy would not be limited to New York, Chicago, Seattle or San Francisco.
Cities across Texas, Florida, Georgia, Arizona, Nevada, North Carolina and other states with significant immigrant populations could encounter similar questions even when their state or local governments support the federal policy or choose not to challenge it.
Three competing effects will be important to watch.
First, the administration expects broader public-charge enforcement to reinforce the principle that immigrants seeking permanent residency should be financially self-sufficient and reduce reliance on taxpayer-funded benefits.
Second, healthcare researchers and state and local officials warn of a chilling effect in which people who remain legally eligible — including U.S.-citizen children — leave programs because their families fear immigration consequences.
Third, if substantial numbers of people leave Medicaid or other health programs but continue to need medical treatment, some expenses could shift from federally supported insurance programs toward hospitals, emergency departments, community clinics, charities and local governments.
That means a reduction in federal benefit enrollment would not necessarily translate dollar-for-dollar into lower overall public healthcare costs.
Billions in Federal Spending Could Shift
The financial stakes are significant.
Washington State’s attorney general, citing estimates associated with the litigation, says DHS expects disenrollment or forgone enrollment related to the rule could reduce federal Medicaid and CHIP transfers to states by more than $4 billion annually, along with more than $1 billion in federal SNAP transfers.
Whether those reductions ultimately produce taxpayer savings, additional state and local expenses, increased uncompensated hospital care, or some combination of those outcomes will depend heavily on how many people actually leave programs and what services they subsequently use.
What Happens September 18?
The new public-charge framework is scheduled to apply to affected applications for admission made on or after September 18 and applications for adjustment of status postmarked or electronically submitted on or after that date.
The lawsuits could change that timetable if a federal court blocks or modifies implementation.
For cities across America, the immediate challenge may therefore be separating what the rule actually does from what residents believe it does.
The rule does not automatically terminate Medicaid coverage for 4 million people on September 18.
Instead, it broadens what immigration officials may consider when making public-charge determinations for certain noncitizens. Researchers warn that the uncertainty and fear surrounding those decisions could cause anywhere from roughly 1.4 million to 4.1 million Medicaid and CHIP enrollees in households with a noncitizen to withdraw under modeled scenarios — including many U.S.-citizen children.
Whether those projections materialize — and whether federal courts allow the policy to remain in force — will determine how deeply the change affects hospitals, schools, food-assistance programs and municipal budgets from New York and Chicago to Seattle, San Francisco and cities throughout the rest of the country.
Sources: U.S. Department of Homeland Security/USCIS; Federal Register; KFF; Reuters; New York City Mayor’s Office; Washington State Attorney General; California Attorney General; Illinois Attorney General; San Francisco Human Services Agency.
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