FROM SAFETY NET TO SOLID GROUND Many Immigrant Families with Children Continued to Avoid Public Benefits in 2020, Despite Facing Hardships Jennifer M. Haley, Genevieve M. Kenney, Hamutal Bernstein, and Dulce Gonzalez May 2021 In 2020, immigrant families faced several overlapping crises. Many faced greater risks of exposure to the novel coronavirus because of their jobs and living circumstances (Artiga and Rae 2020; Gelatt 2020). The associated economic recession also affected households with noncitizen family members even more severely than other households (Gonzalez et al. 2020). At the same time, some immigrant families were also excluded from initial relief efforts, such as the Coronavirus Aid, Relief, and Economic Security, or CARES, Act.1 In addition, families with immigrants continued to be affected by the immigration policies and rhetoric of the Trump administration. In 2018, the administration moved to expand the “public charge” rule to consider use of noncash public benefits, such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, or housing assistance, in applications for green cards or temporary visas. Research found “chilling effects,” or avoidance of public programs out of fear of immigration-related consequences, even before the new public charge rule was implemented in 2020 (Barofsky et al. 2020; Bernstein et al. 2019, 2020; Haley et al. 2020; Straut-Eppsteiner 2020; Tolbert, Pham, and Artiga 2019)2 and during the pandemic (Bernstein et al. 2021). Many immigrant families were confused about the details of the rule, and chilling effects extended beyond those who would be directly affected, including to some who reported avoiding children’s benefits even though the new rule would not have considered children’s program enrollment in their parents’ public charge determinations (Haley et al. 2020). Moreover, avoidance of programs by other family members could affect children in both the short and long terms, especially given the extent of the current economic crisis and the importance of parents’ physical and emotional health and family financial stability to children’s well- being.3 This analysis uses data from the Urban Institute’s Well-Being and Basic Needs Survey (WBNS), a nationally representative internet-based survey conducted in December 2020 to assess the chilling effects, hardships, and financial concerns reported by adults in immigrant families living with children under 19. We build on research using WBNS data from December 2019 (Haley et al. 2020), but we more comprehensively identify program avoidance by assessing a wider range of immigration-related reasons for avoiding public benefits. Our analysis also shows how the experiences of adults in immigrant families with children vary by the citizenship and immigration statuses of family members in the household (box 1). The 2020 survey sample included 1,168 nonelderly adults who speak English or Spanish, were born outside the US (foreign born) or live with one or more foreign-born family members, and live with children under age 19 (hereafter called adults in immigrant families with children). Our main findings are as follows: ◼ One in 5 adults in immigrant families with children (20.0 percent) and almost 3 in 10 of those in low-income immigrant families with children (28.8 percent) reported that they or a family member avoided one or more noncash public benefits or other help with basic needs in 2020 because of concerns about green card status or other immigration-related reasons. ◼ Adults in immigrant families with children were more likely to report chilling effects than their counterparts without children (20.0 percent versus 15.0 percent). ◼ Adults in immigrant families with children reported that their families most often avoided SNAP (7.7 percent), followed by Medicaid and the Children’s Health Insurance Program (CHIP) (6.3 percent). Chilling effects extended beyond programs specified in the new public charge rule. ◼ Chilling effects varied by families’ immigration and citizenship statuses, and among adults in immigrant families with children, those with nonpermanent residents were most likely to report that they or a family member experienced chilling effects (42.3 percent). This subgroup would have been more likely than other immigrant families to be affected by the public charge rule and is likelier to face risks of immigration enforcement. However, chilling effects extended to other immigrant families as well. ◼ Adults in immigrant families with children reported that their families avoided public programs, even as many faced significant financial concerns. Nearly half of adults in immigrant families with children (45.1 percent) reported someone in the family lost work or income because of the pandemic. In the past 12 months, 28.0 percent experienced food insecurity in the household, and more than 1 in 6 experienced problems paying rent or a mortgage or utilities. In addition, more than 3 in 10 adults in immigrant families with children reported being worried about having enough to eat in the next month, being able to work as many hours as they wanted, or being able to pay rent or a mortgage, utilities, or debts in the next month. ◼ Adults in immigrant families with children reported significant health needs in the household, with 40.7 percent reporting someone in the household had a chronic condition or disability. Almost 3 in 10 of such adults (29.9 percent) reported that someone in the family had missed 2 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS out on needed health care because of cost or that they were having trouble paying medical bills. More than 3 in 10 (31.8 percent) had an uninsured family member. ◼ Hardships and financial worries were especially common for those in families with nonpermanent residents, the group of immigrant families with children also most likely to report avoiding programs because of immigration concerns. For example, more than one- quarter of such adults had experienced problems paying rent or a mortgage or utilities in the prior year, more than one-third had experienced food insecurity in the prior year, nearly half worried about having enough to eat or being able to pay utility bills in the next month, and more than half reported worrying about being able to pay debts or the rent or mortgage or reported that someone in the family was uninsured. We find that many immigrant families with children faced hardships in 2020, and immigration concerns led some to avoid safety net programs. Moreover, hardships were more prevalent in families with nonpermanent residents, who were more likely to report chilling effects than other immigrant families. Research has also found persisting program avoidance among immigrant families more generally in 2020 (Bernstein et al. 2021). Reluctance to use public benefits among families with children could have both short- and long-term consequences, because food insecurity, financial hardships, and problems accessing needed health care can affect children’s health and well-being both immediately and as they grow. And given the greater financial risks and needs for assistance for noncitizens during the pandemic, program avoidance may also be particularly harmful (Artiga and Rae 2020; Gonzales 2020). The Biden administration expressed opposition to and ordered a review of the expanded public charge rule, and the rule was vacated nationwide as of March 2021; the government has returned to the 1999 field guidance. Together with other actions by the new administration, such as several executive orders reversing other Trump administration immigration policies,4 these steps may eventually increase immigrant families’ trust in public institutions. And provisions of the American Rescue Plan (ARP) Act, enacted in March 2021, could help reduce hardships among some immigrant families with children. But effective communication will be needed about the rule’s new status, including specific messaging encouraging eligible immigrant families to use safety net benefits, so that public program avoidance does not make it harder to mitigate families’ hardships during the economic downturn. Not meeting the basic needs of immigrant families with children, especially during the current crisis, could have lasting repercussions for them, their families, and their communities. Background More than 18 million children—about 1 in 4 children in the United States—live with at least one foreign-born parent.5 The vast majority of children in immigrant families are US-born citizens who have at least one foreign-born parent; only about 1 in 8 children in immigrant families are noncitizens. 6 Compared with other children, children in immigrant families face additional barriers to their well- being. For example, they are more likely to be uninsured and to be in families with low incomes, which MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 3 may make it harder for their families to meet their needs (Linton, Green, and Council on Community Pediatrics 2019). Immigrant families also have more limited access to public safety net programs. Though US-born citizen children in immigrant families qualify for programs such as Medicaid and CHIP on the same basis as other citizen children, 16 states bar noncitizen children from Medicaid/CHIP during their first five years with a green card, and only 7 states use state funds to offer Medicaid/CHIP to undocumented immigrant children, who are barred from federal coverage (Brooks et al. 2020). Moreover, immigration status restrictions on eligibility for federal safety net programs are more stringent for adults: eligibility for SNAP, Medicaid, and many other safety net benefits is restricted for most adults who are not citizens or green card holders with more than five years’ permanent residency (NILC 2020),7 and undocumented immigrants are ineligible for most major federal safety net programs, which can reduce the benefits available to the whole family (Broder, Moussavian, and Blazer 2015; Siskin 2016).8 But even for families who qualify for public benefits, such as mixed-status families with citizen children, barriers like language access, misinformation or lack of information about benefits, logistical challenges, and worries that participation will harm their immigration status or expose them to enforcement authorities keep many families from enrolling (Chaudry, Fortuny and Pedroza 2014; Fix and Zimmerman 1999; Fortuny and Chaudry 2011). And following years of anti-immigrant rhetoric and policy during the Trump administration, fear and uncertainty about accessing safety net programs have increased (Gomez and Meraz 2021; Pierce and Bolter 2020). As noted, a key driver of chilling effects was the Trump administration’s significant changes to the public charge rule, part of the process for obtaining permanent residency or temporary visas. The changes to the rule expanded the criteria by which applicants may be denied green cards for having received noncash benefits or being deemed likely to receive public benefits in the future.9 Since the law has been vacated, the government has returned to the 1999 field guidance in place before Trump’s expansion.10 However, studies have found that chilling effects around the stricter public charge rule began long before it took effect in February 2020, as families learned about the proposed changes during the government rulemaking process starting in 2018 (Barofsky et al. 2020; Bernstein et al. 2019, 2020; Straut-Eppsteiner 2020; Tolbert, Pham, and Artiga 2019). Our research found that in the context of the new rule, one in five adults in immigrant families with children reported that someone in the family avoided a noncash public benefit for fear of risking future green card status in 2019 (Haley et al. 2020). The expanded public charge rule did not consider a child’s benefit use in a parent’s public charge determination, applied only to adults who were not yet green card holders, and included only certain safety net programs, but many families were confused about the rule, leading to chilling effects extending beyond those who would be directly affected (Haley et al. 2020). If immigrant families continue to avoid benefits out of persistent fear and confusion, their access to health care, nutrition, 4 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS and financial stability could decrease, which could harm their abilities to meet children’s immediate needs and ensure their growth and healthy development (American Academy of Pediatrics 2016; Carlson and Neuberger 2017; Carlson et al. 2016; Paradise and Garfield 2013; Sommers, Gawande, and Baicker 2017). The consequences could extend to later life, potentially impeding children’s long- term educational attainment and health (Cohodes et al. 2014; Goodman-Bacon, forthcoming; Gundersen and Ziliak 2015; Lipton et al. 2016; Miller and Wherry 2019; Murphey 2017; Wherry, Kenney, and Sommers 2017).11 And even if parents are avoiding benefits for themselves and not their children, the consequences could extend to the entire family, given the spillover effects of parents’ health and well-being on their children.12 Immigrant families are reluctant to participate in public programs at a time when needs for assistance have likely increased because of the pandemic and economic crisis (Page et al. 2020). The economic downturn is adversely affecting immigrant families; estimates from 2020 indicate immigrant workers were especially hard hit by rising unemployment,13 and Hispanic families with noncitizens have disproportionately experienced hardships, including high rates of food insecurity (Gonzalez et al. 2020).14 In addition, some immigrant families were initially excluded from relief efforts, such as the CARES Act, including citizen children in families with a mix of immigration statuses (NILC 2020).15 Further, immigrants are overrepresented in jobs with higher potential COVID-19 exposure; this is particularly concerning for those with underlying health conditions that exacerbate COVID-19 risks and could potentially lead to greater health care needs in immigrant communities (Artiga and Rae 2020; Clark et al. 2020; Gomez and Meraz 2021). In this brief, we first assess chilling effects related to immigration concerns reported for the past 12 months by adults in immigrant families with children in December 2020. We assess chilling effects overall, for those in families with low incomes (below 200 percent of the federal poverty level), and according to family citizenship and immigration status. Finally, we report on families’ financial hardships and concerns and health care needs and affordability overall and according to family citizenship and immigration status. We conclude with a discussion of policy implications. An accompanying brief examines chilling effects and hardship among adults in low-income immigrant families (Bernstein, Gonzalez, and Karpman 2021). Our methods vary from those used in our previous research on chilling effects among adults in immigrant families with children using the WBNS (Bernstein, Gonzalez, Karpman, et al. 2019, 2020, 2021; Haley et al. 2020). We expanded our definition of chilling effects to include avoidance of not only noncash government benefit programs but also other sources of help for meeting basic needs. We also include in our estimates of chilling effects anyone who reported they or a family member avoided benefits because of concerns not only about green card status but also about immigration status or enforcement. These broader measures better reflect the reality that multiple immigration- related concerns deter immigrant families from program participation (FRAC and NILC 2020; Straut- Eppsteiner 2020). MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 5 BOX 1 Family Citizenship and Immigration Status For this brief, family citizenship and immigration status categories are constructed around such statuses of the foreign-born family members in a household.a We define each category as follows: ◼ Adults in families with naturalized citizens live in households where all foreign-born family members are naturalized citizens. Such families may include US-born family members (including the respondent). ◼ Adults in families with green card holders live in households where all noncitizen family members are permanent residents. Such families may include US-born and foreign-born family members who are naturalized citizens (including the respondent). ◼ Adults in families with nonpermanent residents live in households where at least one noncitizen family member is not a permanent resident. Such families may include US-born and foreign-born family members who are naturalized citizens or permanent residents (including the respondent). Nearly all adults in immigrant families with children (96 percent) report having one or more US- citizen children in the family. a In our sample of adults in immigrant families with children, 39.9 percent were in families with naturalized citizens, 35.2 percent were in families with green card holders, and 24.9 percent were in families with nonpermanent residents. Findings One in 5 adults in immigrant families with children (20.0 percent) and almost 3 in 10 of those in low-income immigrant families with children (28.8 percent) reported that they or a family member avoided one or more noncash public benefits or other help with basic needs in 2020 because of concerns about green card status or other immigration-related reasons. Overall, 20.0 percent of adults in immigrant families with children reported that they or someone in the family had avoided a noncash government benefit program (e.g., Medicaid/CHIP, SNAP, or housing subsidies) or other assistance (e.g., help with basic needs including rent, food, or medical care) because of green card concerns or other immigration-related reasons.16 Program avoidance due to concerns about green card status or immigration status or enforcement, called chilling effects, were larger among those with low family incomes (28.8 percent).17 Focusing on those reporting avoiding help because of green card concerns specifically, we find that 15.5 percent of adults in immigrant families with children and 21.4 percent of those in low-income immigrant families with children reported someone in the family avoided a noncash benefit in December 2020 (figure 1). 6 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS FIGURE 1 Share of Adults in Immigrant Families with Children Who Reported That They or a Family Member Avoided Noncash Government Benefits or Other Assistance in the Past Year Because of Immigration Concerns, December 2020 All incomes Family income below 200% of FPL 28.8% 21.4% 20.0% 15.5% Avoided noncash benefits or other help with basic needs Avoided noncash benefits because of concerns about because of green card status or other immigration green card status concerns URBAN INSTITUTE Source: Well-Being and Basic Needs Survey, December 2020. Notes: FPL = federal poverty level. Adults are ages 18 to 64. Immigration concerns are concerns about green card status or immigration status and enforcement. See the data and methods section for details on question wording. Adults in immigrant families with children were more likely to report chilling effects than their counterparts without children (20.0 percent versus 15.0 percent). As shown in figure 2, adults in immigrant families with children were more likely to experience chilling effects than those without children, consistent with patterns in 2019 (Haley et al. 2020). That adults in families with children are more likely to report chilling effects could owe to more safety net programs being targeted toward children and families, broader eligibility rules for children (e.g., higher income thresholds and fewer restrictions based on immigration status), or differences in household size or other characteristics. MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 7 FIGURE 2 Share of Adults in Immigrant Families with and without Children Who Reported That They or a Family Member Avoided Noncash Government Benefits or Other Assistance in the Past Year Because of Immigration Concerns, December 2020 20.0% 15.0%** Adults in immigrant families with children Adults in immigrant families without children URBAN INSTITUTE Source: Well-Being and Basic Needs Survey, December 2020. Notes: Adults are ages 18 to 64. Immigration concerns are concerns about both green card status or immigration status and enforcement. See the data and methods section for details on question wording. */**/*** Estimate for those without children differs significantly from the estimate for those with children at the 0.10/0.05/0.01 level. Adults in immigrant families with children reported that their families most commonly reported avoiding SNAP, followed by Medicaid/CHIP. Chilling effects extended beyond the programs specified in the new public charge rule. As shown in table 1, the 7.7 percent of adults in immigrant families with children who reported someone avoided SNAP represent 38.5 percent of all adults in such families who avoided any of the programs we discuss. An estimated 6.3 percent of adults in immigrant families with children reported they or a family member avoided Medicaid/CHIP, and 5.0 percent reported the family avoided housing subsidies. Chilling effects extended to programs not included in the expanded public charge rule, such as unemployment insurance (6.2 percent); the P-EBT (Pandemic Eletronic Benefits Transfer) program, which provides electronic benefit transfers to purchase food to replace school-based meals during distance learning (5.6 percent); other free or low-cost medical care for the uninsured (5.4 percent); emergency cash assistance (5.2 percent); emergency rental assistance (5.2 percent); WIC, or the Special Supplemental Nutrition Program for Women, Infants, and Children (4.1 percent); and free and reduced-price school lunches (4.1 percent). And 3.8 percent of adults in immigrant families with children, or nearly 1 in 5 of those reporting chilling effects, reported avoiding Medicaid/CHIP for a child, though children’s use of public health insurance would not have been considered in the expanded public charge rule. 8 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS Overall, 10.1 percent of adults in immigrant families with children reported someone in the family avoided a food or nutritional assistance program, 8.0 percent reported someone avoided a health program, and 7.2 percent reported someone avoided a housing program. Many who reported chilling effects reported avoiding more than one program (data not shown). TABLE 1 Adults in Immigrant Families with Children Who Reported That They or a Family Member Avoided Noncash Government Benefits or Other Assistance in the Past Year Because of Immigration Concerns, December 2020 Adults in Immigrant Families with Children Those who reported All chilling effects Share reporting avoiding the following benefits or assistance (%) Health Medicaida or CHIP for someone in the family 6.3 31.3 Medicaid or CHIP for a child 3.8 19.2 Free or low-cost medical care through a local 5.4 26.8 clinic or health center for people without health insurance Any health program above 8.0 40.2 Food and nutrition SNAPa 7.7 38.5 P-EBT 5.6 28.1 WIC 4.1 20.4 Free or reduced-price school lunches 4.1 20.3 Emergency food assistance 3.9 19.5 School-provided replacements for school meals 3.4 17.1 Any food/nutrition program above 10.1 50.4 Housing Housing subsidiesa 5.0 25.0 Emergency rental assistance 5.2 26.2 Any housing program above 7.2 36.2 Unemployment insurance 6.2 30.8 Emergency cash assistance 5.2 25.8 Sample size (N) 1,168 330 Source: Well-Being and Basic Needs Survey, December 2020. Notes: CHIP = Children’s Health Insurance Program; P-EBT = Pandemic Electronic Benefits Transfer; SNAP = Supplemental Nutrition Assistance Program; WIC = Special Supplemental Nutrition Program for Women, Infants, and Children. Adults are ages 18 to 64. Immigration concerns are concerns about both green card status or immigration status and enforcement. School- provided replacements for school meals include meal delivery, grab-and-go meals, or any combination thereof. See the data and methods section for details on question wording. a Usage considered in public charge determinations under the revised rule in effect in 2020. Chilling effects varied by families’ immigration and citizenship statuses, and among adults in immigrant families with children, those with nonpermanent residents were most likely to report that they or a family member experienced chilling effects (42.3 percent). This subgroup would have been more likely than other MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 9 immigrant families to be affected by the public charge rule and is likelier to face risks of immigration enforcement. However, chilling effects extended to other immigrant families as well. Among adults in immigrant families with children, 42.3 percent of those in families with nonpermanent residents (42.3 percent) reported someone in the family experienced chilling effects in December 2020 (figure 3). This may owe to worries about the new public charge rule or other immigration- related concerns. But chilling effects also extended to other immigrant families with children; the shares of adults avoiding public benefits were 9.5 percent in such families with naturalized citizens and 16.2 percent in families with green card holders. FIGURE 3 Adults in Immigrant Families with Children Who Reported That They or a Family Member Avoided Noncash Government Benefits or Other Assistance in the Past Year Because of Immigration Concerns, by Family Citizenship and Immigration Status, December 2020 42.3%***/^^^ 16.2%* 9.5% Adults in families with naturalized Adults in families with green card Adults in families with nonpermanent citizens^ holders residents URBAN INSTITUTE Source: Well-Being and Basic Needs Survey, December 2020. Notes: Adults are ages 18 to 64. Immigration concerns are concerns about both green card status or immigration status and enforcement. See the data and methods section for details on question wording and box 1 for definitions of family citizenship and immigration status categories. */**/*** Estimate differs significantly from that for adults in families with naturalized citizens at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^ Estimate differs significantly from that for adults in families with green card holders at the 0.10/0.05/0.01 level, using two-tailed tests. Adults in immigrant families with children reported that their families avoided public programs, even as many faced significant financial concerns. At the same time that many immigrant families with children reported avoiding public assistance because of immigration concerns, nearly half of adults in such families reported the pandemic had negatively affected their family’s finances: an estimated 45.1 percent of adults in immigrant families with children reported losing work or income because of the pandemic (figure 4). This includes 19.1 10 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS percent for whom the respondent or a spouse or partner lost or was laid off from a job and 26.0 percent who experienced other negative impacts on family employment (data not shown). FIGURE 4 Adults in Immigrant Families with Children Who Reported Negative Effects of the Pandemic on Family Employment, Hardships in the Prior Year, and Worries about Meeting Basic Needs in the Next Month, December 2020 Hardships in the prior 12 months Lost work or work-related income because of the 45.1% pandemic Food insecurity 28.0% Problems paying rent or mortgage 17.4% Problems paying utility bills 18.2% Worries in the next month Having enough to eat 31.2% Being able to pay utility bills 36.8% Being able to pay rent or mortgage 38.2% Being able to work as many hours as wanted 41.7% Being able to pay debts 42.2% URBAN INSTITUTE Source: Well-Being and Basic Needs Survey, December 2020. Notes: Adults are ages 18 to 64. Worries refer to being “somewhat” or “very” worried about having difficulty in the next month. See the data and methods section for details on question wording. Moreover, many adults in immigrant families with children reported that their households experienced hardships during the prior year. More than one in four—28.0 percent—reported that their households experienced food insecurity, 17.4 percent reported problems paying their rents or mortgages, and 18.2 percent reported problems paying utility bills during the past 12 months. In addition, many adults in immigrant families with children also reported being very or somewhat worried about their abilities to meet their family’s needs during the following month, including having enough to eat (31.2 percent), being able to pay utility bills (36.8 percent), being able to pay the rent or mortgage (38.2 percent), being able to work as many hours as desired (41.7 percent), and being able to pay debts (42.2 percent). Not surprisingly, such concerns were much higher among adults in immigrant families with children whose family members lost work or income because of the pandemic than those in such families who did not lose work or income. The shares of adults who experienced food insecurity in the past year or reported being worried about being able to pay the rent or a mortgage, utilities, or debts MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 11 or having enough to eat in the next month were nearly twice as high as such shares for adults in immigrant families who had not lost work or income. And the shares who reported having problems paying rent or the mortgage or utility bills and being concerned about being able to work as many hours as desired were more than twice as high (data not shown). Adults in immigrant families with children reported significant health needs in the household, with 40.7 percent reporting someone in the household had a chronic condition or disability. Almost 3 in 10 of such adults (29.9 percent) reported that someone in the family had missed out on needed health care because of cost or that they were having trouble paying family medical bills. More than 3 in 10 (31.8 percent) had an uninsured family member. Respondents also reported both high needs for health care in the household and challenges meeting the family’s health needs (figure 5). For about 4 in 10 adults in immigrant families with children (40.7 percent), someone in the household had either a chronic health condition (39.0 percent; data not shown) or a disability (11.4 percent; data not shown), indicating that someone in the household likely needed ongoing health care. FIGURE 5 Share of Adults in Immigrant Families with Children Who Reported Having a Household Member with Health Issues, Experiencing Family Health Care Affordability Issues, or Having an Uninsured Family Member in the Prior Year, December 2020 40.7% 31.8% 29.9% Someone in the household has a Problems paying family medical bills or Someone in the family chronic health condtion/disability unmet need for medical care in the is uninsured family URBAN INSTITUTE Source: Well-Being and Basic Needs Survey, December 2020. Notes: Adults are ages 18 to 64. See the data and methods section for details on question wording. Nearly 3 in 10 adults in immigrant families with children (29.9 percent) indicated their family experienced challenges accessing and affording health care; such adults had problems either meeting needs for medical care because of costs (20.7 percent; data not shown) or paying family medical bills (19.4 percent; data not shown). And challenges accessing and affording care were likely even more 12 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS difficult for those whose households included someone with a chronic health condition or disability than for those whose households did not (39.8 percent versus 23.0 percent; data not shown). Problems with health care affordability may also be related to a lack of health insurance coverage, especially given that 31.8 percent of adults in immigrant families with children reported that someone in the family was uninsured.18 Hardships and financial worries were especially common for adults in immigrant families with nonpermanent residents, the group also the most likely to report avoiding programs because of immigration concerns. Financial hardships, worries about meeting the family’s basic needs, and health care access and affordability among immigrant families with children varied by family citizenship and immigration status (table 2). Hardships and concerns were prevalent among adults in immigrant families with children and especially prevalent among those in families with nonpermanent residents. For instance, though 19.2 percent of adults in such families with naturalized citizens reported food insecurity during the prior year, 31.8 percent in families with green card holders and 36.8 percent in families with nonpermanent residents had experienced food insecurity. Likewise, 21.0 percent of those in families with naturalized citizens reported worrying about having enough to eat in the next month, but this rate was higher among those in families with green card holders (32.5 percent) and nearly doubled among those in families with nonpermanent residents (45.9 percent). However, those in families with nonpermanent residents were also more likely to report someone in the family avoided food or nutrition programs over immigration-related worries (21.7 percent; data not shown) than those in families with green card holders or naturalized citizens (21.7 percent versus 9.0 percent and 3.8 percent; data not shown). This finding suggests families with nonpermanent residents were more likely to be both worried about having enough to eat and reluctant to seek assistance. Problems paying either (1) the rent or mortgage or (2) utility bills in the prior year among adults in immigrant families with children also varied by family immigration and citizenship status. Such problems were less common among those in families with naturalized citizens (11.8 and 13.0 percent) and with green card holders (16.8 and 18.7 percent) than they were for those in families with nonpermanent residents (27.1 and 25.8 percent). And though just over one-quarter of adults in such families with naturalized citizens (27.3 percent) reported worrying about paying their rent or mortgage in the next month, 4 in 10 adults in such families with green card holders (40.9 percent) and more than 5 in 10 in families with nonpermanent residents (52.0 percent) were worried about paying the rent or mortgage. At the same time, adults in families with nonpermanent residents also reported they or their family members commonly avoided housing programs (data not shown). Overall, more than half of adults in families with nonpermanent residents, who were most likely to report chilling effects, reported the family lost work or income because of the pandemic. More than one-third of such adults also reported the houshold experienced food insecurity, and more than one- quarter had experienced problems paying the rent or mortgage or utilities. More than half reported worrying about being able to pay debts or their rent or mortgage or being able to work as many hours as they wanted, and nearly half were worried about paying utilities or having enough food. Moreover, MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 13 nearly 4 in 10 reported problems affording medical care for the family and more than 5 in 10 had an uninsured family member. These findings indicate families experienced severe family financial hardships and troubles meeting health needs alongside significant reluctance about accessing needed assistance through the safety net. TABLE 2 Adults in Immigrant Families with Children Who Reported Hardships and Concerns in the Family Related to Employment, Meeting Basic Needs, and Health Care, by Family Citizenship and Immigration Status, December 2020 Adults in Immigrant Families with Children with Green card Nonpermanent Naturalized citizens holders residents Share reporting the following in the prior 12 months (%) Lost work or work-related income because of the pandemic 41.0 45.6 50.8* Food insecurity 19.2 31.8*** 36.8*** Problems paying rent or mortgage 11.8 16.8 27.1** Problems paying utility bills 13.0 18.7 25.8*** Share worried about the following in the next month (%) Having enough to eat 21.0 32.5*** 45.9***/^^ Being able to work as many hours as wanted 30.1 44.0*** 57.0***/^^ Being able to pay rent or mortgage 27.3 40.9*** 52.0***/^^ Being able to pay utility bills 25.6 40.2*** 49.6*** Being able to pay debts 33.1 43.8** 54.6***/^^ Shares reporting health problems, health care affordability, and uninsurance (%) Someone in the household has a chronic health condition or a disability 40.4 44.0 36.5 Unmet need for medical care in the family because of costs or problems paying family medical bills 22.2 31.9*** 39.2***/^ Someone in the family is uninsured 19.4 29.1* 55.2***/^^^ Sample size (N) 380 420 368 Source: Well-Being and Basic Needs Survey, December 2020. Notes: Adults are ages 18 to 64. Worries refer to being “somewhat” or “very” worried about having difficulty in the next month. See box 1 for definitions of family citizenship and immigration status categories and the data and methods section for details on question wording. */**/*** Estimate differs significantly from that for adults in families with naturalized citizens at the 0.10/0.05/0.01 level, using two-tailed tests. ^/^^/^^^ Estimate differs significantly from that for adults in families with green card holders at the 0.10/0.05/0.01 level, using two-tailed tests. 14 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS Discussion In December 2020, many adults in immigrant families with children reported their families experienced hardships during the prior year or worried about their abilities to meet their basic needs in the next month. These problems included losing income or employment because of the pandemic; experiencing food insecurity or difficulties paying the rent or mortgage or utilities in the prior year; experiencing unmet health care needs, trouble paying medical bills, or uninsurance among family members; being worried about not having enough to eat; and being worried about not being able to pay housing costs, utilities, or debts or work as many hours as desired in the next month. At the same time that adults in immigrant families with children were experiencing these economic difficulties and hardships, one in five said they or a family member had avoided a noncash benefit program, such as Medicaid or SNAP, or other help meeting basic needs for fear of jeopardizing their or a family member’s future green card status or because of other immigration concerns. Adults in such families with nonpermanent residents were more likely than adults in other immigrant families with children to report their families had avoided public benefits or other assistance and had experienced hardships or concerns about meeting basic needs. But even adults in families in which all noncitizens were green card holders or in which all foreign-born family members were naturalized citizens reported program avoidance, hardships, and financial worries, though at lower rates. Below we suggest several possible strategies for increasing benefit usage and reducing hardships among immigrant families with children. Increasing immigrant families’ use of needed benefits will require sustained, targeted outreach through trusted sources. Key to reducing hardships will be encouraging more immigrant families with children to use the assistance to which they are legally entitled. Such families will also need to be reassured that use of public benefits will not have any bearing on their abilities to obtain a green card or become a citizen.19 To earn such trust will likely require sustained and culturally and linguistically effective outreach and enrollment investments tailored to individual communities. In prior research, we found that many immigrant families with children trusted sources such as federal, state, and local government agencies and legal professionals for information about how public benefit use could affect immigration status (Haley et al. 2020). This suggests that disseminating information through these sources—including clarifying definitively that the Trump administration’s expanded public charge rule has been rescinded—could help reduce families’ worries about using available benefits. Collaboration with trusted community partners, such as schools, early childhood educators, and health care providers, may also be needed for outreach, enrollment, and retention efforts to successfully counteract chilling effects. Though immigrant families have historically tended to participate in public programs at lower rates than other families, under prior efforts to encourage Medicaid/CHIP enrollment among their children, participation gaps for children with noncitizen parents reduced relative to those with citizen parents, suggesting targeted enrollment efforts to immigrant families could boost program participation (Fortuny and Chaudry 2011; Kenney, Haley, and Wang 2018). MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 15 ARP provisions and other actions could help reduce hardships among some immigrant families with children. Though the pandemic has had adverse health and economic impacts, the ARP includes new assistance that could help reduce hardship among immigrant families with children. A wide range of relief funds could be targeted to fill gaps in immigrants’ access to benefits, but state and federal governments will need to ensure immigrant families are aware of new relief programs and that their immigration-related fears are mitigated.20 Relative to prior pandemic-related assistance, the ARP broadened eligibility for economic impact payments to include some families with mixed immigration statuses, including those in which a child has a Social Security number but the parents do not. 21 The ARP also includes other temporary enhancements that could reduce poverty and uninsurance rates among some immigrant families with children. The ARP’s child tax credit expands the income available to families with children, including immigrant families with citizen children, by increasing the amount of the tax credit, expanding the scope of the credit to include children under 17 (as opposed to under 16), and making the credit advanceable and fully refundable. 22 Other key measures include rental, homeowner, and utilities assistance to alleviate housing hardship, extending an increase in the maximum SNAP benefit through September 2021, extending universal free lunches through the 2021–22 school year, and extending the P-EBT program through the summer of 2021.23 Further, the ARP provides WIC with funding to support broad-based innovations and modernizations in technology, outreach, and enrollment, which could be used to reach out to and inform families that using WIC benefits does not negatively affect immigration status (Rosenbaum et al. 2021). The ARP also expanded the subsidies available based on income for purchasing health insurance coverage through the Affordable Care Act’s Marketplaces, including for immigrants with lawful status (Pollitz 2021). The enhanced subsidies will offer cost savings for current Marketplace insurance holders and a lower-cost option for many uninsured individuals, and access to these subsidies will be available through a special enrollment period operating through August 2021.24 And some women, including immigrants with lawful status, could benefit from the law’s option for states to extend postpartum Medicaid/CHIP for a full year starting in April 2022.25 Medicaid and CHIP coverage remains available to many uninsured citizen children in mixed-immigration-status families, as well as to some of their parents. Increasing insurance coverage among immigrant families could reduce their high rates of unmet health care needs due to costs during the current health crisis. Further, enrollment and tax filing support tailored to the cultural and language needs of immigrant families can help ensure such families benefit from these provisions. The Biden administration recently announced it will expand grants for health insurance navigators by $80 million;26 these funds could help with outreach, education, and enrollment assistance for eligible individuals, including those in immigrant families. 27 Long-term increases in program participation require broadening immigrants’ access to the safety net. In addition to reducing barriers that may keep eligible immigrant families from taking up emergency relief and safety net benefits, state and federal agencies could alter immigration status–related eligibility requirements for these benefits. The COVID-19 crisis has highlighted the exclusion of many immigrants from safety net programs (NILC 2020).28 Though a small number of states and localities have helped support immigrants ineligible for federal relief, such as through cash assistance programs, 16 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS expansion of state tax credits (CBPP 2021), and expansions of eligibility for health care benefits, 29 federal legislation to change immigrant eligibility rules more broadly would be necessary to expand benefit eligibility to more immigrants nationwide.30 Federal proposals to improve the functioning of the immigration system and provide a path to citizenship for many undocumented immigrants could also expand access to benefits, though such proposals face legislative hurdles. Program avoidance among immigrant families with children could have lasting impacts. The prospects for greatly reducing hardships among immigrant families with children, particularly for those with US- citizen family members, are relatively high at the moment, given the public assistance currently available. Yet, difficulties meeting basic needs are likely to persist for immigrant families with children who have noncitizen family members, especially when such members are nonpermanent residents, given the extent of job and income losses they have experienced during the pandemic, the inherent insecurity in lacking citizenship or permanent residence, and constraints in access to public assistance. The hardships that immigrant families with children are experiencing, including food insecurity, financial difficulties, and problems accessing needed health care, could have profound short- and long- term adverse consequences for the health and well-being of their children, their communities, and society as a whole (Cholera, Falusi, and Linton 2020; National Scientific Council on the Developing Child 2014).31 Data and Methods This brief draws on data from a nationally representative sample of adults ages 18 to 64 who participated in the December 2020 round of the Urban Institute’s Well-Being and Basic Needs Survey. The WBNS is an internet-based survey designed to monitor changes in individual and family well- being as policymakers consider changes to federal safety net programs. For each round of the WBNS, we draw a stratified random sample (including a large oversample of adults in low-income households and an additional oversample of noncitizens) from the KnowledgePanel, a probability-based internet panel maintained by Ipsos that includes households with and without internet access. Survey weights adjust for unequal selection probabilities and are poststratified to the characteristics of nonelderly adults based on benchmarks from the Current Population Survey and the American Community Survey. Participants can complete the survey in English or Spanish. For further information on the survey design and content, see Karpman, Zuckerman, and Gonzalez (2018). To assess chilling effects and related issues, we constructed weights for analyzing nonelderly adults who are foreign born or living with a foreign-born relative in their household. The weights are based on the probability of selection from the KnowledgePanel and benchmarks from the American Community Survey for nonelderly adults in immigrant families who are proficient in English or primarily speak Spanish.32 The language criterion is used in the weighting to reflect the nature of the survey sample, because the survey is only administered in English or Spanish. A total of 7,737 adults were in the core sample for the December 2020 WBNS and 433 adults were in the noncitizen oversample. Overall, 2,046 adults in immigrant families participated in the survey. This brief focuses on the 1,168 nonelderly adults in immigrant families living with children under age 19. MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 17 Chilling Effects within a Family We define chilling effects as avoidance of noncash government benefits and other help with basic needs because of concerns about green card status and/or immigration status and enforcement.33 As such, those reporting chilling effects responded “yes” to one or more of the following survey questions: 1. Was there a time in the past 12 months when you or someone in your family decided not to apply for one or more noncash government benefits, such as Medicaid or CHIP, SNAP (or food stamps), or housing subsidies, because you were worried it would disqualify you or a family member or relative from obtaining a green card? 2. Was there a time in the past 12 months when you or someone in your family stopped participating in any noncash government benefits, such as Medicaid or CHIP, SNAP (or food stamps), or housing subsidies, because you were worried it would disqualify you or a family member or relative from obtaining a green card? 3. Was there a time in the past 12 months when you or your family did not apply or participate in noncash government benefits because of other worries about immigration status or enforcement? 4. Was there a time in the past 12 months when you or your family did not get other help with basic needs like rent, food, or medical care because of either worries about obtaining a green card or other worries about immigration status or enforcement? Respondents were asked separately whether (1) they avoided Medicaid or CHIP for someone in the family and (2) they avoided Medicaid or CHIP for a child in the family. We collected information on avoidance of programs that were and were not listed in the public charge rule. A respondent could define family as both their immediate family and other relatives who may live with them or in another household. Respondents may have reported chilling effects for a program for which they were not eligible; some parents likely reported chilling effects on the program participation of a US-citizen child, and higher-income respondents may have reported chilling effects on a relative with lower income. See Bernstein and colleagues (2021) for findings regarding chilling effects among all adults in immigrant families in 2020. Earlier studies (Bernstein et al. 2019, 2020; Haley et al. 2020) used a narrower definition of chilling effects that only considered green card concerns as reasons for avoiding programs. The entire questionnaire is available for all other details on question wording.34 Limitations One limitation of the WBNS is its low response rate, which is comparable with those of other panel surveys that account for nonresponse at each stage of recruitment. However, studies assessing 18 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS recruitment for the KnowledgePanel have found little evidence of nonresponse bias for core demographic and socioeconomic measures (Garrett, Dennis, and DiSogra 2010; Heeren et al. 2008), and WBNS estimates are generally consistent with benchmarks from federal surveys (Karpman, Zuckerman, and Gonzalez 2018). WBNS survey weights reduce but do not eliminate the potential for errors associated with sample coverage and nonresponse, which are likely greater for the subgroup of adults in immigrant families. In addition, because the WBNS is only administered in English and Spanish, our analytic sample does not describe the experiences of the full spectrum of adults in immigrant families. Our study excludes adults with limited English proficiency whose primary language is not Spanish. We estimate that the excluded adults who do not speak English or Spanish represent between 5 and 15 percent of all nonelderly adults in immigrant households as defined for this brief; according to the 2019 American Community Survey, 5 percent of this group speaks English less than well and speaks a primary language other than Spanish. Further, some measurement error is likely for questions related to the citizenship statuses of respondents and relatives in the household, particularly among adults who are undocumented or have been in the US for a short time (Van Hook and Bachmeier 2013). Last, the impacts of the pandemic on survey research, including the findings in this report, are not yet fully understood. Comparing 2020 results with those from earlier years should be approached with caution, particularly for subgroup estimates, which are subject to greater sampling error than estimates for the overall sample of adults in immigrant families. Notes 1 Julia Gelatt, Randy Capps, and Michael Fix, “Nearly 3 Million US Citizens and Legal Immigrants Initially Excluded under the CARES Act Are Covered under the December 2020 COVID-19 Stimulus,” Migration Policy Institute, January 2021, https://www.migrationpolicy.org/news/cares-act-excluded-citizens-immigrants-now- covered. 2 Randy Capps, Michael Fix, and Jeanne Batalova, “Anticipated ‘Chilling Effects’ of the Public-Charge Rule Are Real: Census Data Reflect Steep Decline in Benefits Use by Immigrant Families,” Migration Policy Institute, December 2020, https://www.migrationpolicy.org/news/anticipated-chilling-effects-public-charge-rule-are- real. 3 Emily M. Johnston, Jennifer Haley, and Genevieve M. Kenney, “Penalizing Immigrants for Obtaining Medicaid Coverage Puts Child and Family Well-Being at Risk,” Urban Wire (blog), Urban Institute, December 6, 2018, https://www.urban.org/urban-wire/penalizing-immigrants-obtaining-medicaid-coverage-puts-child-and- family-well-being-risk. 4 John Hudak and Christine Stenglein, “Biden’s Immigration Reset,” Fixgov (blog), Brookings Institution, February 19, 2021, https://www.brookings.edu/blog/fixgov/2021/02/19/bidens-immigration-reset/. 5 Cary Lou, Gina Adams, and Hamutal Bernstein, “Part of Us: A Data-Driven Look at Children of Immigrants,” Urban Institute, March 14, 2019, https://www.urban.org/features/part-us-data-driven-look-children- immigrants. MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 19 6 “Children in US Immigrant Families,” Migration Policy Institute, accessed May 13, 2021, https://www.migrationpolicy.org/programs/data-hub/charts/children-immigrant-families. 7 Amanda Salami, “Immigrant Eligibility for Health Care Programs in the United States,” National Conference of State Legislatures, October 19, 2017, https://www.ncsl.org/research/immigration/immigrant-eligibility-for- health-care-programs-in-the-united-states.aspx; “Kelly Whitener, “COVID-19 and Immigrant health.” Say Ahhh! (blog), Georgetown University Center for Children and Families, April 10, 2020, https://ccf.georgetown.edu/2020/04/10/covid-19-and-immigrant-health/; and Johnston, Haley, and Kenney, “Penalizing Immigrants for Obtaining Medicaid Coverage Puts Child and Family Well-Being at Risk,” Urban Wire. 8 Though many noncitizens are ineligible for federal programs, all, regardless of immigration status, are eligible for emergency medical care under Medicaid, public health programs that offer immunizations and treatment of communicable diseases, noncash disaster relief, school breakfast and lunch programs, WIC (the Special Supplemental Nutrition Program for Women, Infants, and Children), charitable food assistance, and assistance through homeless shelters. Further, some noncitizens may be eligible for other programs and supports in certain states or localities. For detailed information about immigrant eligibility rules, see Siskin (2016). 9 For more background on the public charge rule, see Bernstein and colleagues (2020). 10 Chantal da Silva, “Biden Administration Says It Won’t Defend Trump’s ‘Public Charge’ Rule as It Defies ‘Nation’s Values,’” Forbes, May 20, 2021, https://www.forbes.com/sites/chantaldasilva/2021/03/10/biden- administration-says-it-wont-defend-trumps-public-charge-rule-as-it-defies-nations-values/?sh=405b8bec70ea. In addition, the White House issued an executive order requiring federal agencies to review the policy. See the White House, “Executive Order on Restoring Faith in Our Legal Immigration Systems and Strengthening Integration and Inclusion Efforts for New Americans,” February 2, 2021, https://www.whitehouse.gov/briefing-room/presidential-actions/2021/02/02/executive-order-restoring- faith-in-our-legal-immigration-systems-and-strengthening-integration-and-inclusion-efforts-for-new- americans/. The 1999 public charge rule can be found at Field Guidance on Deportability and Inadmissibility on Public Charge Grounds, 64 Fed. Reg. 28689. See also “The ABCs of Public Charge,” Protecting Immigrant Families, March 2021, https://protectingimmigrantfamilies.org/wp-content/uploads/2021/03/THE-ABCS-OF- PUBLIC-CHARGE.pdf. 11 See also Elaine Waxman, “Many Families Are Struggling to Put Food on the Table. We Have to Do More,” Urban Wire (blog), Urban Institute, May 7, 2020, https://www.urban.org/urban-wire/many-families-are- struggling-put-food-table-we-have-do-more. 12 Johnston, Haley, and Kenney, “Penalizing Immigrants for Obtaining Medicaid Coverage Puts Child and Family Well-Being at Risk,” Urban Wire. 13 “US Unemployment Trends by Nativity, Gender, Industry, and More, before and during Pandemic,” Migration Policy Institute, accessed May 13, 2021, https://www.migrationpolicy.org/programs/migration-data-hub/us- unemployment-trends-during-pandemic. 14 Waxman, “Many Families Are Struggling to Put Food on the Table. We Have to Do More,” Urban Wire. 15 Gelatt, Capps, and Fix, “Nearly 3 Million US Citizens and Legal Immigrants Initially Excluded under the CARES Act Are Covered under the December 2020 COVID-19 Stimulus,” Migration Policy Institute. 16 See the data and methods section for question wording. 17 For more detail on chilling effects among adults in all low-income immigrant families, see Bernstein, Gonzalez, and Karpman (2021). Because of sample size constraints, we cannot conduct all comparable analyses for the subset of adults in low-income immigrant families with children. 18 Most sampled adults from families in which someone is uninsured reported that they are uninsured (65 percent). A majority of these adults also reported that someone else in the family is uninsured (58 percent). 19 On April 12, 2021, Tracy L. Renaud, senior official at the US Citizenship and Immigration Services, released a statement to interagency partners seeking help in clarifying the policy change to the public; see https://www.uscis.gov/sites/default/files/document/notices/SOPDD-Letter-to-USCIS-Interagency-Partners- on-Public-Charge.pdf. 20 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 20 Center on Budget and Policy Priorities, memo to interested parties, regarding supporting immigrants by maximizing opportunities in the American Rescue Plan, April 15, 2021, https://drive.google.com/file/d/1xMbrP8hH2WQQaHydMzctJ85yu0yVT0ZD/view. 21 “Immigrant Eligibility for Public Programs during COVID-19,” Protecting Immigrant Families, March 26, 2021, https://protectingimmigrantfamilies.org/immigrant-eligibility-for-public-programs-during-covid-19/. 22 US Department of the Treasury, “FACT SHEET: The American Rescue Plan Will Deliver Immediate Economic Relief to Families,” news release, March 18, 2021, https://home.treasury.gov/news/featured-stories/fact- sheet-the-american-rescue-plan-will-deliver-immediate-economic-relief-to-families. 23 Laura Reilly, “USDA Extends Universal Free Lunch through Next School Year, Bringing Relief to Millions of Food-Insecure Families,” Washington Post, April 20, 2021, https://www.washingtonpost.com/business/2021/04/20/usda-extends-universal-free-lunch/; and US Department of Housing and Urban Development, “Fact Sheet: Housing Provisions in the American Rescue Plan Act of 2021,” accessed May 13, 2021, https://www.hud.gov/sites/dfiles/Main/documents/Factsheet_Housing_Provisions_American_Rescue_Plan_Ac t-2021.pdf. 24 US Department of Health and Human Services, “2021 Special Enrollment Period Access Extended to August 15 on HealthCare.gov for Marketplace Coverage,” news release, March 23, 2021, https://www.hhs.gov/about/news/2021/03/23/2021-special-enrollment-period-access-extended-to-august- 15-on-healthcare-gov-for-marketplace-coverage.html. 25 Stacey McMorrow, Jennifer M. Haley, and Emily Johnston. “The American Rescue Plan Contains an Evidence- Based Policy Win for New Mothers,” Urban Wire (blog), Urban Institute, March 19, 2021, https://www.urban.org/urban-wire/american-rescue-plan-contains-evidence-based-policy-win-new-mothers. 26 US Department of Health and Human Services, “HHS Announces the Largest Ever Funding Allocation for Navigators and Releases Final Numbers for 2021 Marketplace Open Enrollment,” news release, April 21, 2021, https://www.hhs.gov/about/news/2021/04/21/hhs-announces-the-largest-ever-funding-allocation-for- navigators.html. 27 Reducing immigrants’ worries about repercussions following their interactions with public authorities could also help encourage receipt of COVID-19 vaccines. See Gonzalez, Karpman, and Bernstein (2021) and Akilah Johnson, “For Immigrants, IDs Prove to Be a Barrier to a Dose of Protection,” Washington Post, April 10, 2021, https://www.washingtonpost.com/health/2021/04/10/covid-vaccine-immigrants-id/. 28 “COVID-19 Highlights the Need to Support Immigrants Now and into the Future,” Grantmakers Concerned with Immigrants and Refugees, May 15, 2020, https://www.gcir.org/news/covid-19-highlights-need-support- immigrants-now-and-future. 29 “Coverage for Immigrant Seniors,” Illinois Department of Healthcare and Family Services, accessed May 13, 2021, https://www.illinois.gov/hfs/Pages/CoverageForImmigrantSeniors.aspx. 30 Federal legislation includes Health Equity and Access under the Law, the HEAL Act, which would remove the five-year bar for Medicaid and CHIP for all federally authorized immigrants who would otherwise be eligible. It would also give undocumented immigrants access to health insurance through the Marketplaces. See “The HEAL for Immigrant Women and Families Act,” National Asian Pacific American Women’s Forum, accessed May 13, 2021, https://www.napawf.org/heal. 31 Hamutal Bernstein and Archana Pyati, “Expanding the ‘Public Charge’ Rule Jeopardizes the Well-Being of Immigrants and Citizens,” Urban Wire (blog), Urban Institute, October 3, 2018, https://www.urban.org/urban- wire/expanding-public-charge-rule-jeopardizes-well-being-immigraents-and-citizens. 32 We define adults with English proficiency as those who speak English at least well, as classified in the American Community Survey. Adults with limited English proficiency are those who speak English less than well. This is a broader measure than is commonly used to define English proficiency; in most analyses, a person must speak English very well to be classified as proficient in English (Wilson 2014). We use the following measures for weighting: gender, age, race and ethnicity, educational attainment, presence of children under age 18 in the household, census region, homeownership status, family income as a percentage of the federal poverty level, MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 21 access to the internet, and family composition. We benchmark non-Hispanic respondents who are not white or Black by two categories: (1) other race born in Asia and (2) either multiple races or other race not born in Asia. 33 To define chilling effects, we drew on measures developed by researchers at the University of California, Los Angeles, for an immigrant follow-up survey to the California Health Interview Survey. 34 For the exact wording of all questions on the Well-Being and Basic Needs Survey, see the survey questionnaire at https://www.urban.org/sites/default/files/2021/02/16/wbns_2020_questionnaire.pdf. 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Tolbert, Jennifer, Olivia Pham, and Samantha Artiga. 2019. Impact of Shifting Immigration Policy on Medicaid Enrollment and Utilization of Care among Health Center Patients. San Francisco: Kaiser Family Foundation. Van Hook, Jennifer, and James D. Bachmeier. 2013. “How Well Does the American Community Survey Count Naturalized Citizens?” Demographic Research 29 (1): 1–32. https://doi.org/10.4054/DemRes.2013.29.1. Wherry, Laura R., Genevieve M. Kenney, and Benjamin Sommers. 2017. “The Role of Public Health Insurance in Reducing Child Poverty.” Academic Pediatrics 16 (3 suppl.): S98–S104. Wilson, Jill H. 2014. Investing in English Skills: The Limited-English Proficient Workforce in US Metropolitan Areas. Washington, DC: Brookings Institution. 24 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS About the Authors Jennifer M. Haley is a research associate in the Urban Institute’s Health Policy Center. Haley’s current work includes assessing ways states and communities can improve health equity in response to the COVID-19 pandemic, barriers to enrollment in publicly subsidized health insurance coverage, coverage gaps for postpartum women, and challenges to accessing the safety net for children in immigrant families. She also conducts research on other issues related to Medicaid, the Children’s Health Insurance Program, and coverage and care for children and families. Haley holds an MA in sociology from Temple University. Genevieve M. Kenney is a senior fellow and vice president of the Health Policy Center. She has been conducting policy research for more than 25 years and is a nationally renowned expert on Medicaid, CHIP, and broader health insurance coverage, health care, and health issues facing low-income children and families. Kenney has led a number of Medicaid and CHIP evaluations and published more than 100 peer-reviewed journal articles and scores of briefs on insurance coverage, access to care, and related outcomes for low-income children, pregnant women, and other adults. In her current research, she is examining impacts of the Affordable Care Act, implications of the COVID-19 pandemic, and health and health care equity. She received a master’s degree in statistics and a PhD in economics from the University of Michigan. Dulce Gonzalez is a research associate in the Health Policy Center. She forms part of a team working on the Urban Institute’s Well-Being and Basic Needs Survey. Gonzalez conducts quantitative and qualitative research focused primarily on the social safety net, immigration, and barriers to health care access. Her work has also focused on the impacts of the COVID-19 pandemic on nonelderly adults and their families. Before joining Urban, Gonzalez worked at the Georgetown University Center for Children and Families and at the nonprofit organization Maternal and Child Health Access. Gonzalez holds a BA in economics from California State University, Long Beach, and a master’s degree in public policy from Georgetown University. Hamutal Bernstein is a principal research associate in the Income and Benefits Policy Center at the Urban Institute, where she leads Urban’s program on immigrants and immigration. Her research focuses on the well-being of immigrant and refugee families and workers. Her areas of expertise include immigration and integration, workforce development and training, and human services. She is a mixed-methods researcher, with experience in policy analysis, program monitoring and evaluation, technical assistance, design of qualitative and survey data collection, and qualitative and quantitative data analysis. She is a principal investigator on the Annual Survey of Refugees for the US Department of Health and Human Services. Before joining Urban, Bernstein was a program officer at the German Marshall Fund of the United States and a research associate at the Institute for the Study of International Migration at Georgetown University. Bernstein received her BA in international relations from Brown University and her PhD in government from Georgetown University. MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS 25 Acknowledgments This brief was funded by the David and Lucile Packard Foundation. Funding from the Robert Wood Johnson Foundation and the Bernard and Anne Spitzer Charitable Trusts also supported the 2020 Well-Being and Basic Needs Survey. We are grateful to them and to all our funders, who make it possible for Urban to advance its mission. The views expressed are those of the authors and should not be attributed to the Urban Institute, its trustees, or its funders. Funders do not determine research findings or the insights and recommendations of Urban experts. Further information on the Urban Institute’s funding principles is available at urban.org/fundingprinciples. The authors appreciate helpful feedback from Michael Karpman, Emily Ruskin, David Kallick, and Elaine Waxman and excellent editorial assistance from Rachel Kenney and Devlan O’Connor. ABOUT THE URBAN INSTITUTE The nonprofit Urban Institute is a leading research organization dedicated to developing evidence-based insights that improve people’s lives and strengthen communities. For 50 years, Urban has been the trusted source for rigorous analysis of complex social and economic issues; strategic advice to policymakers, philanthropists, and practitioners; and new, promising ideas that expand opportunities for all. Our work inspires effective decisions that advance fairness 500 L’Enfant Plaza SW and enhance the well-being of people and places. Washington, DC 20024 Copyright © May 2021. Urban Institute. Permission is granted for reproduction of www.urban.org this file, with attribution to the Urban Institute. 26 MANY IMMIGRANT FAMILIES WITH CHILDREN AVOIDED BENEFITS DESPITE HARDSHIPS