By Shefali Luthra

A proposed rule from the White House would make it harder for legal immigrants to get green cards if they have received certain kinds of public assistance — including Medicaid, food stamps and housing subsidies. Green cards allow them to live and work permanently in the United States.

“Those seeking to immigrate to the United States must show they can support themselves financially,” Homeland Security Secretary Kirstjen Nielsen said in a statement.

The proposal, announced Saturday night, marks a new frontier in the administration’s long-term effort to curb immigration, both legal and illegal. It already has spurred intense criticism from Democrats, anti-poverty activists, health care organizations and immigrants’ rights advocates, who call its restrictions unprecedented.

“We are operating in an overall climate of tremendous fear and anxiety as a result of the administration’s overall approach to immigration enforcement and immigration policy,” said Mark Greenberg, a senior fellow at the Migration Policy Institute, which studies migration and refugee policies at local, national and international levels. He is also a former Obama administration official.

But what effect would this proposal have?

It’s a complicated question, touching upon vast government programs, with billions of dollars at stake. While the implications aren’t all immediately clear, Kaiser Health News breaks down some of the key elements.

1. First Thing First: What Is The White House Proposing?

The Trump administration wants to redefine a status known as “public charge”— a category used to determine whether someone seeking permanent resident status is “likely to become primarily dependent on the government for subsistence.”

In the past, people have been at risk of being defined a “public charge” if they took cash welfare — known as Temporary Assistance for Needy Families, or Supplemental Security Income — or federal help paying for long-term care. (Immigrants must be in the country legally for five years before being eligible for TANF or SSI.)

And that “public charge” designation could undermine their applications for permanent residence.

The new rule would expand the list to include some health insurance, food and housing programs. Specifically, it would penalize green-card applicants for using Medicaid, a federal-state health plan for low-income people. (Penalties would not apply for using Medicaid in certain emergencies or for some Medicaid services provided through schools and disability programs.)

Using food stamps, Section 8 rental assistance and federal housing vouchers would also count against applicants. Enrollment in a Medicare Part D program subsidy to help low-income people buy prescription drugs would work against them, too.

The proposal “is definitely a dramatic change from how public charge works today,” said Kelly Whitener, an associate professor at Georgetown University’s Center for Children and Families who specializes in pediatric health benefits and managed-care systems.

A leaked version of the rule from March suggested officials then were also considering penalizing those who receive subsidies to buy health insurance on the Affordable Care Act marketplaces. But that idea was not in the proposal published this weekend. The marketplace subsidies are aimed at people at a generally higher income bracket than the beneficiaries targeted in the Trump plan, Whitener noted.

“They’re really homing in on low-income immigrants,” she added.

Nielsen said the proposed rule is “intended to promote immigrant self-sufficiency and protect finite resources.”

2. Is This As Unprecedented As Critics Say?

Yes.

Public charge is an old idea. In the 1990s, lawmakers expanded it to consider explicitly whether people had received cash-based welfare.

But including programs like Medicaid and food stamps, which are much wider in scope, is a significant change. It would more likely hit working people — the majority of people on Medicaid are themselves employed, and almost 80 percent live in families with at least one working member, according to data compiled by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Children who are American citizens but whose parents are immigrants could be more likely to suffer repercussions, said some experts. When parents opt out of public assistance for fear of their own legal status, their kids are less likely to be enrolled in programs such as the Children’s Health Insurance Program, or CHIP, for which they would qualify.

To be clear, receiving public aid wouldn’t necessarily stop people from getting a green card. But it would tilt the odds against them.

“Another piece is the enormous discretion the administration will have under its proposal in making judgments about who gets admitted to the country and who gets a green card,” said the Migration Policy Institute’s Greenberg.

3. When Will The Policy Shift Take Effect?

This is an early step in the complex federal rule-making process. And a lot could still change.

Once the proposed rule appears in the Federal Register, a 60-day countdown starts, during which anyone can weigh in with comments.

A final rule likely wouldn’t take effect until 2019.

And DHS is still seeking input on some details. For instance, it hasn’t decided whether CHIP would be counted as one of the “public charge” eligible programs.

In the interim, people who had received public benefits before the rule took effect would not be penalized for doing so.

4. Already, Though, The Proposal Is Having Effects.

DHS estimates that 2.5 percent of eligible immigrants would drop out of public benefits programs because of this change — which would tally about $1.5 billion worth of federal money per year. But others expect a much larger impact.

“The chilling effects will be vastly greater than the individuals directly affected,” Greenberg said. “There’s considerable reason to believe that [the White House estimate] may be a significant understatement.”

In the proposed rule, DHS notes that the changes could result in “worse health outcomes,” “increased use of emergency rooms,” “increased prevalence of communicable diseases,” “increased rates of poverty” and other concerns.

Given the complexity of these programs and the proposed rule — and the high stakes at play — low-income immigrants would be much more likely to avoid public benefits altogether, immigration experts said. Millions of immigrants are likely to be affected directly or indirectly, according to the Center for Law and Social Policy, a D.C.-based nonprofit organization.

That could have stark health implications.

Take free vaccines, for which children are often eligible and which would not be subject to the public charge rule. Families afraid of jeopardizing a green card could still be more likely to opt out of that service, Whitener said.

Already, she added, there are reports of people declining federal assistance — even though nothing has yet happened.

“The fear factor cannot be underestimated,” she said.

5. Will People Sue?

Legal action is likely.

Officials such as California Attorney General Xavier Becerra, who has frequently clashed with the White House, are weighing challenges to the rule.

“The Trump Administration’s proposal punishes hard-working immigrant families — even targeting children who are citizens — for utilizing programs that provide basic nutrition and healthcare. This is an assault on our families and our communities,” Becerra said in a statement.

But these actions depend on the final shape of the regulation, which could change through the rule-making process.

“They are likely to receive a very large number of sharply critical comments, and there is no way to know what changes they might make as a result,” Greenberg said.