Comments from Richard Besser, MD, on the Trump Administration Reinterpretation of the Term “Federal Public Benefit”
The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (hereinafter “RWJF” or “the Foundation”) President and CEO, in response to the U.S. Department of Health and Human Services (HHS) Notice (hereinafter “the HHS Notice” or “the Notice”) published in the Federal Register on July 14, 2025, regarding the Administration’s new interpretation of the term “Federal public benefit.”
RWJF is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work side-by-side with communities, practitioners, and institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right.
Our comments are grounded in the perspectives and expertise of our grantees, who include organizations seeking to advance immigrants’ access to healthcare programs and other social safety net programs as well as academic researchers who have significant experience identifying how immigrants’ lack of access to healthcare and public programs damages health and creates health disparities. For instance, RWJF has supported substantial work documenting the ways in which immigration status is a social determinant of health and the ways that immigrant eligibility restrictions harm health equity.
RWJF strongly opposes the expanded definition of “Federal public benefit” contained in the HHS Notice. This broadened interpretation would significantly restrict access to vital programs and services that play a key role in community-wide health and would particularly harm immigrants and their families. Further, the Notice would place unnecessary new burdens on providers administering the HHS programs subject to the Notice, including Head Start, Community Health Centers, the Title X Family Planning Program, and the Community Services Block Grant, among others. These new burdens would compromise providers’ ability to serve all their clients—citizen and noncitizen alike—and keep their communities healthy. We encourage HHS to rescind this Notice and instead work to ensure that public benefit programs are available to all people in the U.S. regardless of immigration status. Overall community health is improved when everyone has access to the supports and services they need to thrive.
Background
Under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), only a narrow category of "qualified immigrants" may access "Federal public benefits." Federal agencies may define which programs fall under the term "Federal public benefits." For nearly three decades, HHS and other agencies have generally interpreted these provisions to exclude many community-focused programs, such as mental health and substance use disorder treatment at Community Behavioral Health Clinics; low-income preschool services via Head Start; and prevention programs through Title IV-E, which helps prevent children from entering the foster care system by enabling them to stay with their families instead (1998 Interpretation).
As noted in HHS’ 1998 Notice, Federal public benefits “do not include benefits that are generally targeted to communities or specified sectors of the population (e.g., people with particular physical conditions, such as a disability or disease; gender; and general age groups, such as youth or elderly).” That Notice recognized the difference between an authorizing statute that identified populations with “specific characteristics” to clarify the types of services provided but did not authorize using those characteristics as a basis for determining eligibility. And other programs may provide a mix of services, including some services provided to communities or specified sectors of a population while also provided to an individual, household, or family eligibility unit. Further, as recognized by the 1998 Notice, programs primarily designed to target and provide services to communities—including all of the programs now listed in the current notice—should not have to be burdened with verification procedures merely because they may include some services that flow more directly to an individual, household, or family eligibility unit.
The new HHS Notice substantially reinterprets the term “Federal public benefit,” expanding the list of restricted programs and narrowing access for lawfully present immigrants who are not considered “qualified” under PRWORA. The HHS Notice took effect immediately, though it allowed for a 30-day public comment period after the effective date.
This reinterpretation has significant implications. It newly designates at least 13 additional programs—including Head Start, Community Health Centers, the Title X Family Planning Program, and the Community Services Block Grant—as “Federal public benefits,” potentially barring many immigrants from accessing services that have long been understood to be broadly available regardless of immigration status. This includes individuals with Temporary Protected Status, Deferred Action for Childhood Arrivals (DACA recipients), asylum applicants, and other immigrants who have been granted work authorization or deferred action but are not classified as “qualified immigrants.”
While HHS affirms that nonprofit organizations administering these programs are not required to verify immigration status, the Notice does not clarify how verification might otherwise be conducted. Nor does it address how this shift could affect program operations or public health outcomes, despite acknowledging potential harm to immigrant communities and broader public health.
Added Burdens and Confusion for Immigrants
HHS’ reinterpretation of the definition of “Federal public benefit” contravenes nearly three decades of established policy and will result in significant harm to the health and wellbeing of both lawfully present and undocumented immigrant families who already face limited access to essential programs and services. Indeed, the barriers that immigrant families have faced accessing services that are essential to health, safety, and economic security and mobility have negatively impacted not just individuals explicitly barred from these programs but also those in mixed-status families and broader communities. When providers administering these programs are burdened with rules that require additional verification, documentation, and data sharing, providers are forced to spend more time complying with paperwork requirements and are pulled away from their core mandate of offering care and supporting the health of people, families, and communities.
One in four children in the U.S. lives with at least one immigrant parent, including those with qualified and nonqualified statuses. Thus, the number of individuals harmed by this Notice will be far greater than the individuals who are newly excluded from specific programs.1 Under PRWORA, millions of immigrants are already excluded from accessing many Federal public benefit programs, including full-scope Medicaid, Medicare, Temporary Assistance for Needy Families (TANF), and a host of other economic security programs. Even “qualified immigrants,” such as green card holders who are just one step removed from the long path to U.S. citizenship, often face a five-year bar before they can access federal benefits. As intended by the Clinton Administration, this structure created significant barriers for many immigrant families in accessing opportunities such as higher education, affordable healthcare, and pathways to economic inclusion and hindering their ability to fully thrive in the U.S.
Existing restrictions through PRWORA and accompanying regulations create a chilling effect such that even those immigrants who are eligible for programs are less likely to access them.2 For example, when parents are barred from federal healthcare programs, they are less likely to enroll their eligible children in healthcare programs. From 2016–2019, participation in programs such as Medicaid, the Children’s Health Insurance Program (CHIP), and the Supplemental Nutrition Assistance Program (SNAP) among citizen children with noncitizen household members fell twice as fast as those with only U.S. citizen household members due to fear and uncertainty caused by changes in immigration policy.3 This new Notice reinterpreting the definition of “Federal public benefit” will exacerbate these chilling effects, causing harm to families and communities across this country.
While the Administration’s stated intention is to ensure the integrity of federal public benefit programs and prioritize access for U.S. citizens and “qualified immigrants,” it is important to recognize the racist historical context of U.S. immigration policy and its direct, real-world consequences for benefit access and public health. Fear of detention and deportation—including among lawfully present individuals and their families—creates a widespread chilling effect that discourages eligible immigrants from using essential public services, even when permitted by law. This dynamic is magnified by experiences of discrimination, profiling, and racially disparate enforcement, which contribute to significant health inequities and barriers to wellbeing for entire communities.
Rather than advancing the country toward comprehensive immigration reform or promoting integration and economic security, the current approach—embodied in the HHS Notice—deepens exclusion for millions of immigrants, including among lawfully present individuals and their families.
Added Burdens on State and Local Governments
The reinterpretation of PRWORA adds additional administrative burden on state and local governments, who already expend extraordinary resources on verifying eligibility for health and human services programs like Medicaid and SNAP. Any new requirements for state and local governments to verify eligibility for programs newly deemed to be Federal public benefits would require additional staff hours for verification and would likely be an unfunded mandate and force them to develop new policies, technology, and training procedures for each program. The result would be a diversion of federal funding from provision of services to verification, further limiting the reach of the newly included programs.
Prior to the enactment of H.R. 1, the One Big Beautiful Bill Act, state budgets were already facing increasing fiscal stressors. Now that the Administration’s policies have cut federal funding to states and will shift further costs to states for Medicaid and SNAP, any new requirements following from the HHS Notice would be even more unaffordable and further strain state and local government budgets.4
Research from the HHS Assistant Secretary for Planning and Evaluation found that requiring applicants to verify immigration status creates administrative complexity and additional documentation burdens.5 State and local program administrators report that these requirements add significant obstacles, slow down processing, and result in many eligible families losing access to health and human services programs or being deterred from applying altogether. Requirements to verify immigration status have impacts beyond immigrant families, as many citizen individuals and families—including married women who have changed their name and African American elders who lack official birth documentation as a direct consequence of systemic discrimination during the Jim Crow era and beyond—may lack the credentials to verify their status and ultimately have challenges accessing services.
Exemption from Verification by Nonprofit Organizations
PRWORA includes a specific provision (8 U.S.C. § 1642(d)) that exempts nonprofit charitable organizations that administer federal, state, or local public benefits from conducting eligibility verifications. This provision ensures that nonprofit organizations and their clients are not subject to the paperwork costs borne by government agencies described above. However, the HHS Notice indicates that, despite this important exception in PRWORA, HHS expects that nonprofit organizations “should pay heed to the clear expressions of national policy” under President Trump’s anti-immigrant executive orders.
The Notice’s statement to “pay heed” is not appropriate for an official federal document and may confuse nonprofit organizations. While a Notice cannot overrule a statute, many of the organizations providing services covered by the Notice may not have the legal knowledge to understand this technical interpretation. Indeed, the inclusion of the “pay heed” statement would likely be understood by a non-legal audience that the Notice has a broader application than it actually does. Nonprofit organizations may be concerned about adverse actions against them. HHS should clarify that no nonprofit will be adversely impacted if they do not divert funds and staff time to force their clients to fill out paperwork, which is consistent with their rights under PRWORA.
Impact on Health, Healthcare Delivery Systems, and Economies
Decreased access to public benefits will likely result in higher rates of preventable illness, rising healthcare costs, shorter lifespans, and deepened health inequities, resulting not only in harm for immigrants and low-income families, but also in undermining population health and resilience for entire communities.6
Community Health Centers (CHCs) provide primary care and preventive services, which are crucial for managing chronic conditions and promoting individual and population health. CHCs are the main source of primary health care for people with limited or no insurance, providing vital care to 1 in 10 people nationwide, 32.5 million people annually, and more than 9 million children.7 Confusion about eligibility and fear of harms related to immigration status may discourage even eligible individuals, including U.S. citizen children, from accessing needed care. Limiting access to these health centers will further isolate underserved families from the healthcare system and jeopardize population health for whole communities.
New analysis8 from KFF underscores that the proposed policy would bar significant numbers of immigrants—both lawfully present and undocumented—from accessing a broad range of vital health and social services, including those provided by the federally funded network of CHCs.9 Survey data show that CHCs are especially important for immigrant populations, with nearly one in three immigrant adults—and an even higher share of undocumented immigrants (42%) and individuals with limited English proficiency (39%)—relying on a CHC as their usual source of care in 1,300 medically underserved communities nationwide.
Reflecting their broad community health mandate, CHCs play pivotal roles as frontline first responders, bridging public and population health obligations with patient care in the most disadvantaged areas. During the COVID-19 pandemic, CHCs mobilized to support the HHS response by providing tens of millions of COVID-19 tests and vaccines, at-home tests, and N-95 masks.10 Communities served by CHCs had fewer COVID-19 infections and deaths compared to areas without CHCs.11 Additionally, CHCs have been instrumental in addressing the nation’s opioid epidemic,12 supporting public health screening, and addressing the needs of their local communities in the wake of natural disasters.13 Depriving certain immigrant populations of CHC services therefore has consequences not only for the health of individuals, but also community- and population-wide implications.
Likewise, expanding the definition of “Federal public benefit” to include the Title X Family Planning Program threatens public health, healthcare delivery systems, and the broader economy. Title X is the only federal program dedicated to providing individuals with low incomes access to affordable family planning care. In many areas, it is the only available source of essential healthcare. Restricting these services will significantly reduce access to contraception, testing for sexually transmitted infections, cancer screenings, and prenatal care.
Head Start provides high-quality and comprehensive services for families in need and has transformed the lives of countless families by providing free early childhood education and childcare to 40 million children across the country since 1965. The effects of Head Start are well-documented: Head Start significantly improves the health, educational outcomes, and financial prospects of participating families.14,15 The program increases the probability that participants graduate from high school, attend college, and receive a post-secondary degree, license, or certification.16 In fact, participation in Head Start is associated with a 39% increase in college completion17,18 and a 29% reduction in likelihood of relying on public assistance in the future.19 Head Start also plays a key role in social, emotional, and behavioral development that leads to adulthood self-control, self-esteem, and positive parenting practices, all outcomes that are crucial for long-term community wellbeing. Head Start is also highly cost effective: estimates for the return on investment range from $7 to $9 for every $1 invested, or as high as 13% annually.20,21 Head Start ensures that children are prepared for K–12 education, and the sudden recategorization to limit access to the program would plunge millions of families and children into uncertainty.
The Notice would restrict access to critical primary care, mental health, family planning, and early childhood education services, compounding barriers already faced by immigrant families. By narrowing eligibility for these services, the HHS Notice not only jeopardizes the health and stability of immigrant communities but is likely to worsen long-term outcomes and increase the demand for uncompensated care. Hospitals, particularly in rural and medically underserved areas, will absorb this uncompensated care, threatening their financial viability. Additionally, people with advanced health issues who may be forced to go without care are less likely to be able to continue working and supporting their families. This will have broader impacts on communities given immigrants’ essential role in the workforce.22 Restricting access to critical health and human services programs not only contradicts the agency’s commitment to health and public safety but also threatens to destabilize the broader healthcare system.
Limited Comment Period and Lack of Program-Specific Information
HHS states that the Notice is effective immediately and only provides 30 days for public comments. For a revision of nearly 30 years of precedent potentially impacting thousands of organizational recipients of federal funding across many programs and millions more people by putting our nation's health at risk, the lack of time for public input is inadequate and deeply concerning. Together, these programs comprise over $27 billion in federal funding for fiscal year 2025.
The Notice also fails to provide sufficient program-specific information to adequately respond. Program-specific information is critical to understand the impact of the Notice, particularly how the Administration proposes to implement verification and who will have the responsibility to verify. Without that detailed information, it is impossible to provide fulsome comments on the full implications of the new interpretation. Further, the Notice imposes immediate and extensive compliance requirements, compelling entities subject to the Notice to rapidly overhaul service delivery, eligibility screening, and funding allocation models while managing complex operational challenges. These entities will need time to plan and minimize the negative impacts of the Notice.
Conclusion
We strongly urge the Department to withdraw the Notice entirely and refrain from issuing any further guidance, regulations, or reinterpretations of PRWORA. If the administration is unwilling to withdraw the Notice, HHS should at a minimum pause all implementation efforts given the significant and immediate consequences of this Notice. This pause must provide sufficient time for a comprehensive analysis of the Notice’s full impact. We would appreciate the opportunity to work with the Department and other partners so that instead of restricting access to healthcare, we ensure that everyone has access to affordable, quality health and human services.
We have included numerous citations to supporting research, including direct links to the research. We direct HHS to each of the materials we have cited and made available through active links, and we request that the full text of each of the studies and articles cited, along with the full text of our comment, be considered part of the formal administrative record for purposes of the Administrative Procedure Act. If HHS is not planning to consider these materials part of the record as we have requested here, we ask that you notify us and provide us an opportunity to submit copies of the studies and articles into the record.
1 Drishtii Pilla, Akash Pillai, and Samantha Artiga, Children of Immigrants: Key Facts on Health Coverage and Care, KFF (Jan. 15, 2025), https://www.kff.org/racial-equity-and-health-policy/issue-brief/children-of-immigrants-key-facts-on-health-coverage-and-care/.
2 Leighton Ku and Matt Broaddus, Coverage of Parents Helps Children, Too, Center on Budget and Policy Priorities (Oct. 20, 2006), https://www.cbpp.org/research/coverage-of-parents-helps-children-too.
3 Drishti Pillai and Samantha Artiga, Expected Immigration Policies Under a Second Trump Administration and Their Health and Economic Implications, KFF (Nov. 21, 2024), https://www.kff.org/racial-equity-and-health-policy/issue-brief/expected-immigration-policies-under-a-second-trump-administration-and-their-health-and-economic-implications/. See also 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 (Dec. 2020), https://www.migrationpolicy.org/news/anticipated-chilling-effects-public-charge-rule-are-real.
4 Wesley Tharpe, Roundup: State Budgets Increasingly Strained as House, Senate Republican Plans Would Impose Major Costs, Center on Budget and Policies Priorities (June 24, 2025), https://www.cbpp.org/sites/default/files/6-24-25sfp.pdf.
5 Krista M. Pereria et al., Barriers to Immigrants Access to Health and Human Services Programs, ASPE (May 24, 2012), https://aspe.hhs.gov/reports/barriers-immigrants-access-health-human-services-programs-0.
6 Daniel M. Finkelstein et al., Economic Well-Being and Health: The Role of Income Support Programs in Promoting Health and Advancing Health Equity, Health Affairs, Vol. 41, No. 12 (Dec. 2022), https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00846.
7 National Association of Community Health Centers, America’s Health Centers: By the Numbers, NACHC (Oct. 31, 2024), https://www.nachc.org/resource/americas-health-centers-by-the-numbers/.
8 Drishtii Pilla and Samantha Artiga, New Policy Bars Many Lawfully Present and Undocumented Immigrants from a Broad Range of Federal Health and Social Supports, KFF (July 21, 2025), https://www.kff.org/policy-watch/new-policy-bars-many-lawfully-present-and-undocumented-immigrants-from-a-broad-range-of-federal-health-and-social-supports/.
9 National Association of Community Health Centers, America’s Health Centers: By the Numbers, NACHC (Oct. 31, 2024), https://www.nachc.org/resource/americas-health-centers-by-the-numbers/.
10 Jessica Sharac et al., Data Note: Findings from 28 months of Data from HRSA’s Health Center COVID-19 Survey, Geiger Gibson Program in Community Health (Sept. 1, 2022), https://geigergibson.publichealth.gwu.edu/data-note-findings-28-months-data-hrsas-health-center-covid-19-survey.
11 Bailey Spates, Community Health Centers: A Vital Resource for COVID-19 Vaccination in the Era of Commercialization, NACHC (Oct. 5, 2023), https://www.nachc.org/chcs-a-vital-resource-for-covid-19-vaccination-in-the-era-of-commercialization/.
12 Julia Zur et al., The Role of Community Health Centers in Addressing the Opioid Epidemic, KFF (July 2018), https://files.kff.org/attachment/Issue-Brief-The-Role-of-Community-Health-Centers-in-Addressing-the-Opioid-Epidemic.
13 Jessica Sharac et al., The Recovery of Community Health Centers in Puerto Rico and the US Virgin Islands One Year after Hurricanes Maria and Irma, KFF (Sept. 19, 2018), https://www.kff.org/medicaid/issue-brief/the-recovery-of-community-health-centers-in-puerto-rico-and-the-us-virgin-islands-one-year-after-hurricanes-maria-and-irma/.
14 Diane Whitmore Schanzenbach and Lauren Bauer, The long-term impact of the Head Start program, Brookings (Aug. 19, 2016), https://www.brookings.edu/articles/the-long-term-impact-of-the-head-start-program/#:~:text=Consistent%20with%20the%20prior%20literature,esteem%2C%20and%20positive%20parenting%20practices.
15 National Head Start Association, 60 Years of Head Start: Facts and Impacts, NHSA (2024), https://nhsa.org/resource/facts-and-impacts/.
16 Diane Whitmore Schanzenbach and Lauren Bauer, The long-term impact of the Head Start program, Brookings (Aug. 19, 2016), https://www.brookings.edu/articles/the-long-term-impact-of-the-head-start-program/#:~:text=Consistent%20with%20the%20prior%20literature,esteem%2C%20and%20positive%20parenting%20practices.
17 Martha J. Bailey, Shuqiao Sun, and Brenden Timpe, Prep School for Poor Kids: The Long-Run Impacts of Head Start on Human Capital and Economic Security, University of Michigan (Dec. 16, 2020), https://websites.umich.edu/~baileymj/Bailey_Sun_Timpe.pdf.
18 Martha J. Bailey, Shuqiao Sun, and Brenden Timpe, Evaluating the Head Start Program for Disadvantaged Children, National Bureau of Economic Research (Apr. 1, 2021), https://www.nber.org/digest/202104/evaluating-head-start-program-disadvantaged-children.
19 Meg Hassan, Study Shows Head Start Reduces Likelihood of Adult Poverty, First Five Years Fund (Jan. 2, 2019), https://www.ffyf.org/resources/2019/01/new-study-shows-head-start-reduces-likelihood-of-adult-poverty/.
20 National Head Start Association, Head Start’s Return on Investment, NHSA, https://olis.oregonlegislature.gov/liz/2024R1/Downloads/PublicTestimonyDocument/105491.
21 National Head Start Association, 60 Years of Head Start: Facts and Impacts, NHSA (2024), https://nhsa.org/resource/facts-and-impacts/.
22 Drishti Pillai and Samantha Artiga, Employment Among Immigrants and Implications for Health and Health Care, KFF (Jun. 12, 2023), https://www.kff.org/racial-equity-and-health-policy/issue-brief/employment-among-immigrants-and-implications-for-health-and-health-care/.
About the Robert Wood Johnson Foundation
RWJF is a leading national philanthropy dedicated to taking bold leaps to transform health in our lifetime. Through funding, convening, advocacy, and evidence-building, we work side-by-side with communities, practitioners, and institutions to get to health equity faster and pave the way together to a future where health is no longer a privilege, but a right.