The 2026 public charge rule and long-term health impacts among NYC immigrants: a simulation study

ImportanceThe 2026 public charge rule could discourage immigrants from accessing health coverage programs, creating a chilling effect that potentially leads to negative health outcomes; However, its long-term health impact is poorly understood. ObjectiveTo model potential impacts of the 2026 public charge rule on primary care and premature mortality among immigrants in New York City (NYC). Design, Setting, and ParticipantsThe simulation used a deterministic compartmental model with Ordinary Differential Equations (ODEs) using 2023 NYC Vital statistics data and American Community Survey, and estimates obtained from 2 previous studies about effects of healthcare access on primary care and Medicaid expansion on premature mortality. Main Outcomes and MeasuresRates of primary care outcomes (access, doctors visits) in 5 years, and premature mortality in 5 and 20 years, projected by the model under conservative, moderate, and aggressive scenarios of avoidance/disenrollment due to the public charge rule, known as the "chilling effect". Effects of the avoidance/disenrollment on primary care outcomes and premature mortality were obtained from 2 previous studies. Projected rates of the outcomes under each scenario were compared with counterfactuals to estimate the health impacts of the chilling effect. ResultsImplementation of the public charge rule was projected to decrease the primary care access rate by 4.1% (conservative) to 9.9% (aggressive) over 5 years, relative to the counterfactual scenario without the rule. The rate of doctors visits was projected to decrease over 5 years by 5.1% (conservative) to 12.2% (aggressive). Premature mortality was projected to increase by 4.4% (conservative) to 10.6% (aggressive) in 5 years and 7.4% (conservative) to 17.4% (aggressive) in 20 years. Legal noncitizens and Black immigrant New Yorkers were predicted to experience higher burdens of premature mortality attributed to the chilling effect, compared with other immigrant groups and racial/ethnic groups, respectively. Conclusions and RelevanceThis study demonstrates adverse health consequences of federal public charge rule changes among immigrants in NYC. The model projected a decrease in primary care visits and increase in premature mortality across various scenarios. These findings suggest urgent reconsideration of a regulatory change that disproportionately increases risk of premature mortality among immigrants in NYC. Key PointsO_ST_ABSQuestionC_ST_ABSWhat are the long-term impacts of the 2026 public charge rule on primary care and premature mortality among immigrants in New York City? FindingsIn this simulation study, under the scenario of a large-scale avoidance or disenrollment of public health services due to the rule vs. no such rule, the primary care access rate was projected to decrease by 10% over 5 years, and premature mortality rate was projected to increase by 17% in 20 years. MeaningThe findings suggest urgent reconsideration of a regulatory change that has devastating public health consequences.