HEALTH POLICY CENTER Immigration Concerns Continued to Deter Immigrant Families with Children from Safety Net Programs in 2021, Compounding Other Enrollment Difficulties Jennifer M. Haley, Dulce Gonzalez, and Genevieve M. Kenney December 2022 In 2018, the Trump administration proposed expanding the "public charge" rule to consider use of noncash public benefits, such as the Supplemental Nutrition Assistance Program (SNAP), Medicaid, and housing assistance, in applications for green cards or temporary visas. The rule was implemented in February 2020, but it was halted in March 2021 after the Biden administration stopped defending the rule following a federal court order vacating it (Protecting Immigrant Families 2021).1 Research found that even before the Trump-era public charge rule was implemented, it was associated with "chilling effects," or avoidance of public programs among immigrant families, including among those not affected by the rule (Barofsky et al. 2020; Bernstein, Gonzalez, and Karpman 2021; Bernstein et al. 2019, 2020, 2021; FRAC 2021; Haley et al. 2020; Haley, Kenney, Bernstein, et al. 2021).2 Moreover, although the rule did not apply to citizen children in immigrant families or include children's benefits use in their parents' public charge determinations, immigrant families with children were even more likely to report chilling effects than those without children (Haley et al. 2020; Haley, Kenney, Bernstein, et al. 2021). In this analysis, we build on research using the Urban Institute's Well-Being and Basic Needs Survey (WBNS), a nationally representative, internet-based survey of nonelderly adults conducted in December 2021 that assessed avoidance of public benefits among adults in immigrant families (Bernstein, Gonzalez, and Karpman 2021; Bernstein et al. 2019, 2020, 2021; Haley et al. 2020; Haley, Kenney, Bernstein, et al. 2021).3 Here we assess the responses of adults in families with incomes below 400 percent of the federal poverty level (FPL) 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").4 Where relevant, we compare the experiences of adults in immigrant families with those of adults in all-US-born families, in which all members were born in the US. Because the WBNS was conducted in English and Spanish, it may not fully capture the experiences of adults who speak other languages. Our main findings from December 2021 are as follows:  Among adults in immigrant families with children who had family incomes below 400 percent of FPL, just over 3 in 10 (31.4 percent) reported avoiding noncash government benefits in the past 12 months because of one or more immigration-related concerns. Specifically, they worried benefits would disqualify them or a family member from obtaining a green card (24.4 percent), had other worries about immigration status or enforcement (18.4 percent), were not sure if they were eligible because of their or a family member's immigration status (15.3 percent), or were asked to provide a Social Security number or other proof of citizenship or immigration status when applying for a family member (14.1 percent).  Avoidance of public programs due to immigration-related concerns compounded other difficulties enrolling in safety net programs and interacting with program staff. » More than half (51.3 percent) of adults in immigrant families with children who had family incomes below 400 percent of FPL and had applied for or participated in one or more safety net programs in the prior year reported an enrollment difficulty, including having trouble figuring out if they were eligible (37.1 percent), having trouble providing required documentation or completing paperwork (29.9 percent), and/or not getting benefits as soon as they were needed (34.9 percent). » Among those who had also interacted with program staff, almost half (47.8 percent) had difficulties interacting with staff, including 39.3 percent who reported never or only sometimes being treated with courtesy and respect, 37.3 percent who reported never or only sometimes getting the information or help they needed, and 17.6 percent who felt treated or judged unfairly because of their racial or ethnic background. » In addition, 17.3 percent of adults in immigrant families with children who had interacted with program staff were never or only sometimes able to find program information in their preferred language. » Adults in immigrant families with children were more likely than adults in all-US-born families with children to report problems providing required documentation or completing paperwork and feeling they were treated or judged unfairly by program staff because of their racial or ethnic background. » Adults in immigrant families with children were also more likely than their counterparts in families with only US-born members to report receiving help from a community organization when applying for benefits (21.5 versus 10.7 percent). 2 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021  Though many immigrant families with children with incomes below 400 percent of FPL avoided public benefits because of immigration concerns and reported substantial barriers interacting with safety net programs, we find that immigrant families with children overall experienced higher rates of many material hardships than did all-US-born families with children. » Among all immigrant families with children, 28.8 percent reported food insecurity in the household, 23.2 percent reported unmet needs for medical care in the family because of costs, 18.3 percent reported problems paying utility bills, 18.7 percent reported problems paying rent or the mortgage, 14.6 percent reported problems paying family medical bills, and 7.8 percent had had their utilities suspended during the past 12 months. In 2021, many immigrant families both with and without children continued to avoid public programs because of immigration-related concerns, despite the Trump-era public charge rule having been vacated early that year (Bernstein et al. 2022). And though the 2022 rule now in place clarifies that benefits use by family members,5 including children, will not affect the immigration statuses of other family members, this analysis shows that chilling effects among families with children persisted in 2021, limiting access to benefits that can address families' basic needs. Thus, it will be important to continue to monitor the persistence of such barriers under the 2022 rule; future research will assess WBNS data during December 2022. This research also identifies other difficulties adults in immigrant families with children faced enrolling in safety net programs and interacting with their staff, which such families often experienced at higher rates than did their counterparts in all-US-born families, and the concerning material hardships reported by these families. Avoidance of public benefits due to immigration-related concerns or other barriers could result in families not being able to meet their basic needs, which could adversely affect the health, stability, and well-being of parents, their children, and their communities. Findings Among adults in immigrant families with children with family incomes below 400 percent of FPL, more than 3 in 10 (31.4 percent) reported avoiding noncash government benefits in the past 12 months because of at least one of four immigration-related concerns. This is a higher rate than that among immigrant families without children. As shown in table 1, nearly one-quarter (24.4 percent) of adults in immigrant families with children with family incomes below 400 percent of FPL did not apply for one or more noncash government benefit programs because they worried it would disqualify them or a family member from obtaining a green card. An estimated 18.4 percent did not apply because they had other worries about immigration status or enforcement. In sum, 28.8 percent did not apply for benefits for at least one of those two reasons. In addition, 15.3 percent did not apply for one or more benefits because they were not sure if they were eligible because of their or a family member's immigration status. And about 14.1 percent avoided applying for benefits because they were asked to provide a Social Security number or other proof of citizenship or immigration status when applying for a family member. AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 3 Overall, an estimated 31.4 percent of adults in immigrant families with children avoided public benefits for at least one of the four reasons listed here. When asked about which programs they or their family members had avoided because of such concerns, they reported a range of programs, including housing subsidies, SNAP, unemployment insurance, and Medicaid or the Children's Health Insurance Program (CHIP; data not shown).6 Adults in immigrant families with children were also more likely than adults in immigrant families without children to report avoiding benefits because they worried it would disqualify them or a family member from obtaining a green card, had other worries about immigration status or enforcement, or were asked to provide a Social Security number or other proof of citizenship or immigration status when applying for a family member or for any of the specified reasons. TABLE 1 Share of Adults in Immigrant Families with Family Incomes Below 400 Percent of FPL Who Did Not Apply for One or More Noncash Government Benefits Because of Select Immigration-Related Concerns, by Presence of Children under Age 19 in the Household, December 2021 Adults in immigrant Adults in immigrant families with families without children children Worried it would disqualify them or a family member from obtaining a green card (%) 24.4 14.8*** Had other worries about immigration status or enforcement (%) 18.4 13.0** Was not sure if they were eligible because of their or a family member's immigration status (%) 15.3 11.3 Was asked to provide a Social Security number or other proof of citizenship or immigration status when applying for a family member (%) 14.1 7.1*** Avoided benefits for any of the above reasons (%) 31.4 22.8** Avoided benefits because they worried it would disqualify them or a family member from obtaining a green card or had other worries about immigration status or enforcement (%) 28.8 18.7*** Sample size 730 537 Source: Well-Being and Basic Needs Survey, December 2021. Notes: FPL = federal poverty level. Adults are ages 18 to 64. See the Data and Methods section for details on question wording. */**/*** Estimate differs significantly from that for adults in immigrant families living with children under age 19 at the 0.10/0.05/0.01 level, using two-tailed tests. More than half of adults in immigrant families with children who had applied for or participated in programs in the prior year reported additional enrollment challenges. Nearly half of adults who interacted with program staff reporting difficulties doing so, and more than one in six adults reported having problems finding information in their preferred language. 4 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 Table 2 shows that enrollment difficulties were reported by 51.3 percent of adults in immigrant families with children who applied for or participated in public programs. An estimated 37.1 percent had trouble figuring out if they were eligible, 29.9 percent had trouble providing required documentation or completing paperwork, and 34.9 percent did not get benefits as soon as needed. Adults in immigrant families with children were more likely than those in families with only US-born members to report problems providing required documentation or completing paperwork. TABLE 2 Share of Adults in Families with Children with Family Incomes below 400 Percent of FPL Reporting Challenges Enrolling in Safety Net Programs in the Past 12 Months, by Family Nativity Status, December 2021 Adults in immigrant Adults in all-US-born families with children families with children Had trouble figuring out if they were eligible (%) 37.1 30.4 Had trouble providing required documentation or completing paperwork (%) 29.9 23.5* Did not get benefits as soon as needed (%) 34.9 29.1 Had any of the above difficulties (%) 51.3 43.5 Sample size, adults with incomes below 400% of FPL whose families applied for or participated in one or more programs 466 1,065 Source: Well-Being and Basic Needs Survey, December 2021. Notes: FPL = federal poverty level. Adults are ages 18 to 64. Estimates include adults who reported their families applied for or participated in one or more of the following programs in the past 12 months: Medicaid or the Children's Health Insurance Program, the Supplemental Nutrition Assistance Program, unemployment insurance benefits, rental assistance, Supplemental Security Income, Social Security Disability Insurance, and Temporary Assistance for Needy Families or other cash assistance. See the Data and Methods section for details on question wording. */**/*** Estimate differs significantly from that for adults in immigrant families living with children under age 19 at the 0.10/0.05/0.01 level, using two-tailed tests. In addition, almost half (47.8 percent) of those who applied for or participated in one or more public programs and interacted with program staff reported difficulties engaging with staff: 39.3 percent reported never or only sometimes being treated with courtesy and respect, 37.3 percent reported never or only sometimes getting the information or help they needed, and 17.6 percent felt they were treated or judged unfairly because of their racial or ethnic background (table 3). Overall, adults in immigrant families with children were also more likely than adults in all-US-born families to report having such difficulties or feeling they were treated or judged unfairly by program staff because of their racial or ethnic background. Furthermore, 17.3 percent of adults in immigrant families with children reported never or only sometimes being able to find program information in their preferred language. This rate is higher-23.6 percent-when restricting the analysis to Spanish and bilingual English and Spanish speakers only (data not shown). But these rates likely understate immigrants' challenges with language access given that AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 5 the survey may not represent the experiences of adults in immigrant families with children who speak languages other than English and Spanish.7 TABLE 3 Share of Adults in Families with Children with Family Incomes below 400 Percent of FPL Reporting Challenges Interacting with the Staff of One or More Safety Net Programs in the Past 12 Months, by Family Nativity Status, December 2021 Adults in immigrant Adults in all-US-born families with children families with children Staff never or only sometimes treated respondent with courtesy and respect (%) 39.3 31.7 Staff never or only sometimes gave respondent the information or help the respondent needed (%) 37.3 35.6 Respondent ever felt treated or judged unfairly because of their racial/ethnic background (%) 17.6 10.2* Respondent experienced any of these difficulties (%) 47.8 41.1* Respondent was never or only sometimes able to find program information in their preferred language (%) 17.3 – Sample size, adults with incomes below 400% of FPL and whose families applied for or participated in one or more programs and interacted with program staff 396 852 Source: Well-Being and Basic Needs Survey, December 2021. Notes: FPL = federal poverty level. – indicates sample is too small for analysis (only people who are Spanish speakers or bilingual Spanish and English speakers received the question about language access). Adults are ages 18 to 64. Estimates include adults who reported their families applied for or participated in one or more of the study programs and interacted with program staff in the past 12 months. The study programs are Medicaid or the Children's Health Insurance Program, the Supplemental Nutrition Assistance Program, unemployment insurance benefits, rental assistance, Supplemental Security Income, Social Security Disability Insurance, and Temporary Assistance for Needy Families or other cash assistance. See the Data and Methods section for details on question wording. */**/*** Estimate differs significantly from that for adults in immigrant families living with children under age 19 at the 0.10/0.05/0.01 level, using two-tailed tests. Though most adults in immigrant families with children did not report receiving application assistance from a community organization when applying for safety net programs in the past 12 months, they were more likely to do so than other adults. An estimated 21.5 percent of adults in immigrant families with children who had applied for or participated in such programs received assistance, compared with 10.7 percent of adults in all-US-born families with children (figure 1). 6 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 FIGURE 1 Share of Adults in Families with Children with Family Incomes below 400 Percent of FPL Reporting Receiving Application Assistance from a Community Organization for One or More Safety Net Programs in the Past 12 Months, by Family Nativity Status, December 2021 21.5% 10.7%*** Adults in immigrant families with children Adults in all-US-born families with children URBAN INSTITUTE Source: Well-Being and Basic Needs Survey, December 2021. Notes: FPL = federal poverty level. Adults are ages 18 to 64. Estimates include adults who reported their families applied for or participated in one or more of the following programs in the past 12 months: Medicaid or the Children's Health Insurance Program, the Supplemental Nutrition Assistance Program, unemployment insurance benefits, rental assistance, Supplemental Security Income, Social Security Disability Insurance, and Temporary Assistance for Needy Families or other cash assistance. See the Data and Methods section for details on question wording. */**/*** Estimate differs significantly from that for adults in immigrant families living with children under age 19 at the 0.10/0.05/0.01 level, using two-tailed tests. Many material hardships in the past 12 months were more prevalent among immigrant families with children than among all-US-born families with children. Overall, immigrant families with children were more likely to report several types of material hardships in the past 12 months than other families with children. As shown in figure 2, they were more likely than adults in all-US-born families with children to report food insecurity (28.8 versus 20.9 percent), unmet needs for medical care in the family because of costs (23.2 versus 17.0 percent), problems paying utility bills (18.3 versus 13.6 percent), problems paying rent or the mortgage (18.7 versus 11.4 percent), and suspended utilities (7.8 versus 4.0 percent).8 About one in seven (14.6 percent) adults in both groups reported problems paying family medical bills. AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 7 FIGURE 2 Share of Adults with Children under Age 19 in the Household Who Reported Material Hardships in the Past 12 Months, by Family Nativity Status, December 2021 Adults in immigrant families with children Adults in all-US-born families with children 28.8% Food insecurity 20.9%*** Unmet need for medical care in the family because of 23.2% costs 17.0%*** 18.3% Problems paying utility bills 13.6%* 18.7% Problems paying rent or mortgage 11.4%*** 14.6% Problems paying family medical bills 14.6% 7.8% Utilities suspended 4.0%* URBAN INSTITUTE Source: Well-Being and Basic Needs Survey, December 2021. Notes: Adults are ages 18 to 64. See the Data and Methods section for details on question wording. */**/*** Estimate differs significantly from that for adults in immigrant families living with children under age 19 at the 0.10/0.05/0.01 level, using two-tailed tests. Discussion In 2021, immigrant families with children were more likely to report material hardships than families with only US-born members. At the same time, more than 3 in 10 immigrant families with children with incomes below 400 percent of FPL avoided noncash public programs out of immigration-related concerns, despite the halting of the Trump-era public charge rule earlier that year. Moreover, for those who did apply for or participate in a range of public programs, the majority reported at least one enrollment difficulty, and nearly half who interacted with program staff reported difficulties doing so.9 Immigrant families with children were also more likely to report immigration-related program avoidance than their counterparts without children. Among all children in the US, more than 1 in 4 live in immigrant families, but nearly 9 in 10 are citizens.10 Thus, most of the children in these families are citizens, and although these citizen children would not face immigration-related barriers to program eligibility, their families may avoid enrolling them in Medicaid and CHIP or taking up other public assistance out of concern that it would have adverse immigration-related repercussions. Some of the difficulties adults reported may specifically relate to applying for benefits for citizen children; for instance, some adults said they did not apply for public benefits because they were asked to provide a 8 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 Social Security number or other proof of citizenship or immigration status when applying for a family member, such as another adult or a child. Addressing these concerns may require greater efforts to inform families that the Trump-era public charge rule has been vacated and assure adults that use of safety net benefits for eligible family members will not affect their immigration status-and specifically that children's public benefits participation will not affect their parents' immigration statuses. But these findings suggest that to be fully successful, such measures would likely need to be accompanied by other outreach and enrollment efforts that would increase understanding of eligibility rules, address burdensome documentation requirements, improve treatment by program staff, and expand accessibility of materials and assistance in multiple languages. Many of these measures would also benefit families with children in which all members were born in the US, who also report facing barriers when trying to enroll in or use public assistance programs (Hahn and Adams 2022; Herd and Moynihan 2018; McDaniel et al. 2022; Pratt et al. 2022).11 The Biden administration has released several executive orders on transforming customer service and service delivery processes and advancing racial equity that could help improve eligible families' experiences interacting with government programs.12 Given the greater prevalence of enrollment challenges and problems interacting with program staff among immigrant families with children, greater support to community- based organizations that serve immigrants may be needed to help families navigate those processes. Although these measures would help many immigrant families with children meet their basic needs, they would not be sufficient for reaching all immigrant families with children who are facing hardships. Major federal public programs have immigration-related eligibility restrictions that exclude immigrants who are undocumented and many who have authorized status from accessing public benefits.13 States can choose to expand eligibility for some populations under current rules; for instance, by 2022, 35 states had eliminated the bar on Medicaid and CHIP eligibility for lawfully residing immigrant children who had been in the country fewer than five years,14 and some states are using state funds to expand benefits to populations excluded from federal programs, including undocumented residents (Manatt Health 2021).15 Federal legislation has been proposed that would remove length-of-residency restrictions for immigrants with authorized status.16 But broader federal action would be needed to remove federal restrictions on eligibility for undocumented populations. Families' avoidance of multiple types of safety net programs and reported material hardships suggest that many immigrant families with children are struggling with food insecurity, the burdens of paying for housing and utilities, and a lack of affordable access to health care-factors that are affecting their immediate well-being and may have adverse long-term effects on their children (Boudreaux, Golberstein, and McAlpine 2016; Gundersen and Ziliak 2015; Howell and Kenney 2012; Miller and Wherry 2018; Taylor 2018; Thompson 2017; Wherry et al. 2018). Broad solutions including easing families' concerns about public charge considerations, relaxing eligibility restrictions based on immigration status, and improving enrollment and customer service experiences in safety net programs could help more immigrant families with children access assistance to ensure their family's and children's nutritional, housing, health, and other needs are being met. AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 9 Data and Methods Data and Sample This brief draws on data from the December 2021 WBNS, a nationally representative, internet-based survey of more than 8,000 adults ages 18 to 64. The survey is 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) from the KnowledgePanel, a probability-based internet panel maintained by Ipsos that includes households with and without internet access.17 Our analysis centers on adults in families with children under age 19. For most measures, we compare the experiences of adults in immigrant families with children with those of adults in all-US- born families with children. We define adults in immigrant families as those who were born outside the US or live with a relative who was born outside the US. Adults in all-US-born families live in families in which everyone was born in the US, in Puerto Rico, or abroad to US citizen parents. Most of the analysis focuses on adults in families with children with family incomes below 400 percent of FPL, or about $51,500 for a single adult and $106,000 for a family of four in 2021. We use this income range because of the inclusion of safety net programs that have variation in income-based eligibility. When assessing experiences of material hardship, we focus on all adults in families with children regardless of family income. For family-specific measures, the family includes the respondent, their spouse or partner, and any of their children or stepchildren under age 19 living with them. To assess material hardships, barriers to accessing safety net programs, and experiences navigating safety net programs, we constructed weights for analyzing adults in immigrant families and those in all- US-born families. The weights are based on the probability of selection from the KnowledgePanel and benchmarks from the American Community Survey for nonelderly adults who are proficient in English or primarily speak Spanish.18 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. For further information on the survey design and content, see Karpman, Zuckerman, and Gonzalez (2018). Measures We asked adults with annual family incomes below 400 percent of FPL whether they or a family member had participated in or applied for one or more of the following safety net programs in the past 12 months:  Medicaid, CHIP, or any kind of state or government-sponsored health plan based on income or a disability  SNAP 10 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021  a federal, state, or local government housing program that lowers rent, such as a housing voucher or public housing  unemployment insurance benefits  Supplemental Security Income  Social Security Disability Insurance  cash assistance from a state or county welfare program, including Temporary Assistance for Needy Families Adults who reported that they or someone in their family had participated in or applied for one or more of these programs were asked to report their past-year experiences with each program. Respondents were asked how often (never, sometimes, usually, or always) they were treated with courtesy and respect, were given the information or help they needed, and could find information in their preferred language if they spoke Spanish or were bilingual in English and Spanish. Respondents could indicate that they did not communicate with program staff for one or more programs. Respondents were also asked whether there was ever a time in the past 12 months when they  had trouble figuring out if they or a family member was eligible for the program,  had trouble providing required documentation or completing other paperwork,  had someone from a community organization (e.g., a navigator or benefit assister) help them or their family apply for the program,  did not get benefits as soon as needed, or  felt treated or judged unfairly because of their racial or ethnic background. We also asked adults in immigrant families whether there was ever a time in the past 12 months when they or someone in their family decided not to apply for one or more noncash government benefits (such as Medicaid/CHIP, SNAP, or housing subsidies) because  they were worried it would disqualify them or a family member or relative from obtaining a green card,  they had other worries about immigration status or enforcement,  they were not sure if they were eligible because of their or a family member's immigration status, or  they were asked to provide their Social Security number or proof of their citizenship or immigration status when they tried to apply for a family member. We construct measures of material hardship in the past 12 months based on questions about food insecurity, problems paying utility bills, problems paying the rent or mortgage, problems paying family medical bills, and utility shutoffs. AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 11 Analysis We estimate the share of adults in immigrant families with children who reported avoiding noncash government programs because of immigration concerns. Among adults with children whose families participated in one or more cash or noncash programs, we assess the share reporting challenges when interacting with the staff of one or more programs by family nativity status. We limit the following estimates to adults who reported communicating with program staff: the shares reporting they were never or only sometimes treated with courtesy and respect, were given the information or help they needed, could find information in their preferred language, and were treated or judged unfairly because of their racial or ethnic background. We also estimate the share of adults in families with children who received assistance applying for one or more programs from a community-based organization by family nativity status. Finally, we assess experiences of material hardship among all families with children regardless of income and by family nativity status. For each measure in which we compare estimates by family nativity status, we tested differences between adults in immigrant and all-US-born families using two-tailed independent sample t-tests. Limitations The analysis has several limitations. First, the WBNS does not capture the experiences of immigrants who do not speak English or Spanish. We estimate these excluded adults represent between 5 and 15 percent of all nonelderly adults in immigrant families (both with and without children) as defined for this brief. In addition, the survey weights reduce but do not eliminate the potential for error associated with sample coverage and nonresponse, which are likely larger for the subgroup of adults in immigrant families. Though the weights are designed to produce representative estimates for nonelderly adults in the US, the survey's design effect increases the sampling error around our estimates. Measurement error is likely for questions related to the immigration and citizenship statuses of respondents and relatives in their households, particularly among adults who are undocumented or have been in the US for a short time (Van Hook and Bachmeier 2013). Further, though studies have found that federal survey respondents generally underreport receipt of public benefits, self-reported participation in the WBNS is slightly higher than in federal surveys such as the American Community Survey and the Current Population Survey (Karpman, Zuckerman, and Gonzalez 2018; Meyer, Mok, and Sullivan 2009; Wheaton 2008). Finally, because we aggregate experiences across programs, we cannot determine whether or how experiences differ for individual programs. 12 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 Notes 1 Inadmissibility on Public Charge Grounds, 84 Fed. Reg. 41292 (Oct. 15, 2019); and US Department of Homeland Security, "2019 Public Charge Rule Vacated and Removed; DHS Withdraws Proposed Rule Regarding the Affidavit of Support," news release, March 11, 2021, https://www.dhs.gov/news/2021/03/11/2019-public- charge-rule-vacated-and-removed-dhs-withdraws-proposed-rule-regarding. 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 See the Data and Methods section of this brief for a description of the WBNS and research methodology. Because the WBNS is conducted in English and Spanish, it does not fully capture the experiences of adults who speak other languages. 4 This analysis builds on Bernstein and colleagues (2022), which assesses patterns for all nonelderly adults. Consistent with other research, here we find that adults in immigrant families with children remained more likely to report chilling effects than their counterparts without children (31.4 versus 22.8 percent; data not shown). 5 US Department of Homeland Security, "DHS Publishes Fair and Humane Public Charge Rule," news release, September 8, 2022, https://www.dhs.gov/news/2022/09/08/dhs-publishes-fair-and-humane-public-charge- rule. 6 Sample sizes for avoidance of specific programs are too small for reporting program-specific estimates with precision. 7 Importantly, only people who are Spanish speakers or bilingual Spanish and English speakers received the question about language access; their experiences may not represent the experiences of speakers of other non- Spanish languages, who generally face even higher barriers to language access (Bernstein, McTarnaghan, and Islam 2021). 8 When restricting the analysis to only those with incomes below 400 percent of FPL, the sizes of the differences are reduced, and some are no longer statistically significant. Among immigrant families with children with family incomes below 400 percent of FPL, 36.7 percent reported food insecurity, 27.5 percent reported unmet needs for medical care in the family because of costs, 22.8 percent reported problems paying utility bills, 23.1 percent reported problems paying rent or the mortgage, 16.1 percent reported problems paying family medical bills, and 9.6 percent had had utilities suspended during the past 12 months. Among all-US-born families with children with incomes below 400 percent of FPL, 32.4 percent reported food insecurity, 22.8 percent reported unmet needs for medical care in the family because of costs, 20.4 percent reported problems paying utility bills, 17.4 percent reported problems paying rent or the mortgage, 20.2 percent reported problems paying family medical bills, and 6.3 percent had had utilities suspended during the past 12 months. Rates were statistically significantly lower for adults in immigrant families with children for problems paying family medical bills and higher for unmet needs for medical care in the family because of costs and problems paying rent or the mortgage. 9 Other research finds that these difficulties were common among adults applying for or enrolling in safety net programs overall (McDaniel et al. 2022). 10 "Children in U.S. Immigrant Families," Migration Policy Institute, accessed December 3, 2022, https://www.migrationpolicy.org/programs/data-hub/charts/children-immigrant-families. 11 "Addressing Persistent Medicaid Enrollment and Renewal Challenges as Rolls Increase," State Health Access Data Assistance Center blog, September 2, 2020, https://www.shadac.org/news/addressing-persistent- medicaid-enrollment-and-renewal-challenges-rolls-increase. 12 Exec. Order No. 13985, 86 CFR 7009 (2021); Exec. Order No. 14058, 86 CFR 71357 (2021). 13 Tanya Broder, Gabrielle Lessard, and Avideh Moussavian, "Overview of Immigrant Eligibility for Federal Programs," National Immigration Law Center, updated October 2022, https://www.nilc.org/issues/economic- support/overview-immeligfedprograms/. AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 13 14 "Medicaid/CHIP Coverage of Lawfully-Residing Immigrant Children and Pregnant Women," Kaiser Family Foundation, updated January 1, 2022, https://www.kff.org/health-reform/state-indicator/medicaid-chip- coverage-of-lawfully-residing-immigrant-children-and-pregnant-women/. 15 "Medical Assistance Programs for Immigrants in Various States," National Immigration Law Center, October 2022, https://www.nilc.org/wp-content/uploads/2022/10/med-services-for-imms-in-states-2022-10-1-1.pdf. 16 LIFT the BAR Act of 2021, H.R. 5227 (2021). 17 Adults without internet access are provided free web-enabled devices and internet access to facilitate participation in the KnowledgePanel. 18 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 having English proficiency. 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, 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. References Barofsky, Jeremy, Ariadna Vargas, Dinardo Rodriguez, and Anthony Barrows. 2020. "Spreading Fear: The Announcement of the Public Charge Rule Reduced Enrollment in Child Safety-Net Programs." Health Affairs 39 (10). https://doi.org/10.1377/hlthaff.2020.00763. Bernstein, Hamutal, Dulce Gonzalez, Paola Echave, and Diana Guelespe. 2022. "Immigrant Families Faced Multiple Barriers to Safety Net Programs in 2021." Washington, DC: Urban Institute. Bernstein, Hamutal, Dulce Gonzalez, and Michael Karpman. 2021. "Adults in Low-Income Immigrant Families Were Deeply Affected by the COVID-19 Crisis Yet Avoided Safety Net Programs in 2020." Washington, DC: Urban Institute. Bernstein, Hamutal, Dulce Gonzalez, Michael Karpman, and Stephen Zuckerman. 2019. "One in Seven Adults in Immigrant Families Reported Avoiding Public Benefit Programs in 2018." Washington, DC: Urban Institute. ---. 2020. "Amid Confusion over the Public Charge Rule, Immigrant Families Continued Avoiding Public Benefits in 2019." Washington, DC: Urban Institute. Bernstein, Hamutal, Michael Karpman, Dulce Gonzalez, and Stephen Zuckerman. 2021. "Immigrant Families Continued Avoiding the Safety Net during the COVID-19 Crisis." Washington, DC: Urban Institute. Bernstein, Hamutal, Sara McTarnaghan, and Ayesha Islam. 2021. "Centering Race and Structural Racism in Immigration Policy Research." Washington, DC: Urban Institute. Boudreaux, Michel H., Ezra Goldberstein, and Donna D. McAlpine. 2016. "The Long-Term Impacts of Medicaid Exposure in Early Childhood: Evidence from the Program's Origin." Journal of Health Economics 45:161–75. https://doi.org/10.1016/j.jhealeco.2015.11.001. FRAC (Food Research and Action Center). 2021. "New Data Reveal Stark Decreases in SNAP Participation among U.S. Citizen Children Living with a Non-citizen." Washington, DC: FRAC. Gundersen, Craig, and James P. Ziliak. 2015. "Food Insecurity and Health Outcomes." Health Affairs 34 (11). https://doi.org/10.1377/hlthaff.2015.0645. Hahn, Heather, and Gina Adams. 2022. "Strategies for States to Improve Safety Net Program Access and Efficiency." Washington, DC: Urban Institute. Haley, Jennifer M., Genevieve M. Kenney, Hamutal Bernstein, and Dulce Gonzalez. 2020. "One in Five Adults in Immigrant Families with Children Reported Chilling Effects on Public Benefit Receipt in 2019." Washington, DC: Urban Institute. 14 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 ---. 2021. "Many Immigrant Families with Children Continued to Avoid Public Benefits in 2020, Despite Facing Hardships." Washington, DC: Urban Institute. Haley, Jennifer M., Genevieve M. Kenney, Robin Wang, and Clare Wang Pan. 2021. "Citizen Children with Noncitizen Parents Experienced Health Insurance Coverage Losses between 2016 and 2019." Washington, DC: Urban Institute. Herd, Pamela, and Donald Moynihan. 2018. Administrative Burden: Policymaking by Other Means. New York: Russell Sage Foundation. Howell, Embry M., and Genevieve M. Kenney. 2012. "The Impact of the Medicaid/CHIP Expansions on Children: A Synthesis of the Evidence." Medical Care Research and Review 69 (4). https://doi.org/10.1177/1077558712437245. Karpman, Michael, Stephen Zuckerman, and Dulce Gonzalez. 2018. "The Well-Being and Basic Needs Survey: A New Data Source for Monitoring the Health and Well-Being of Individuals and Families." Washington, DC: Urban Institute. Manatt Health. 2021. "Supporting Health Equity and Affordable Health Coverage for Immigrant Populations: State- Funded Affordable Coverage Programs for Immigrants." Princeton, NJ: State Health and Value Strategies and Manatt Health. McDaniel, Marla, Michael Karpman, Genevieve M. Kenney, Heather Hahn, and Eleanor Pratt. 2022. "Customer Service Experiences and Enrollment Difficulties Vary Widely across Safety Net Programs." Washington, DC: Urban Institute. Meyer, Bruce D., Wallace K. C. Mok, James X. Sullivan. 2009. "The Under-Reporting of Transfers in Household Surveys: Its Nature and Consequences." NBER Working Paper 15181. Washington, DC: National Bureau of Economic Research. https://doi.org/10.3386/w15181. Miller, Sarah, and Laura R. Wherry. 2018. "The Long-Term Effects of Early Life Medicaid Coverage." Journal of Human Resources 54 (3): 785–824. https://doi.org/10.3368/jhr.54.3.0816.8173R1. Pratt, Eleanor, Marla McDaniel, Heather Hahn, Jennifer M. Haley, Dulce Gonzalez, Soumita Bose, Sarah Morriss, and Laura Wagner. 2022. "Improvements in Public Programs' Customer Service Experiences Could Better Meet Enrollees' Needs and Help Build Trust in Government." Washington, DC: Urban Institute. Protecting Immigrant Families. 2021. "Public Charge Update: What Advocates Need to Know Now." Washington, DC: Protecting Immigrant Families. Taylor, Lauren A. 2018. "Housing and Health: An Overview of the Literature." Washington, DC: Health Affairs. Thompson, Owen. 2017. "The Long-Term Health Impacts of Medicaid and CHIP." Journal of Health Economics 51: 26–40. https://doi.org/10.1016/j.jhealeco.2016.12.003. 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. Wheaton, Laura. 2008. Underreporting of Means-Tested Transfer Programs in the CPS and SIPP. Washington, DC: Urban Institute. Wherry, Laura R., Sarah Miller, Robert Kaestner, and Bruce D. Meyer. 2018. "Childhood Medicaid Coverage and Later-Life Health Care Utilization." Review of Economics and Statistics 100 (2): 287–302. AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 15 About the Authors Jennifer M. Haley is a senior research associate in the Health Policy Center at the Urban Institute, where she studies maternal, child, and parental health and health care; Medicaid and the Children's Health Insurance Program; challenges to accessing the safety net among immigrant families; barriers to enrollment in publicly subsidized health insurance coverage; opportunities for improved collection and use of data on race and ethnicity; health equity; and other issues related to coverage and care for children and families. She holds an MA in sociology from Temple University. 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. Genevieve M. Kenney is a vice president and senior fellow in the Health Policy Center. She is a nationally renowned expert on Medicaid, the Children's Health Insurance Program (CHIP), and health insurance coverage; health care access and quality; and health outcomes for low-income adults, children, and families. She has played a lead role in several Medicaid and CHIP evaluations, including multiple congressionally mandated CHIP evaluations, and has conducted state-level evaluations of the implementation of managed care and other service delivery reform initiatives and policy changes in Medicaid and CHIP. Currently, she is leading a project focused on health equity that involves working with a community advisory board. Her prior work has used mixed methods to examine Medicaid expansions for pregnant women, parents, and children; Medicaid family planning waivers; and a range of policy choices related to Medicaid and CHIP. She received a master's degree in statistics and a doctoral degree in economics from the University of Michigan. 16 AVOIDANCE OF PROGRAMS AMONG IMMIGRANT FAMILIES WITH CHILDREN IN 2021 Acknowledgments This brief was funded by the David and Lucile Packard Foundation. Support from the Robert Wood Johnson Foundation and the Bernard and Anne Spitzer Charitable Trusts also supported the 2021 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 thank Hamutal Bernstein and Michael Karpman for helpful feedback. 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 and 500 L'Enfant Plaza SW enhance the well-being of people and places. Washington, DC 20024 Copyright © December 2022. Urban Institute. 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