The 2026 public charge rule and long-term health impacts among NYC immigrants: a simulation study
Nadhamuni, K., Curcio, E., Solomon, S., Lim, S., Van Wye, G., Parakh, M.
health policy
Quick verdict
A deterministic ODE simulation projecting that the 2026 public charge rule would cut NYC immigrant primary care use and raise premature mortality up to ~17% over 20 years; policy-relevant and transparent, but the headline numbers are assumption-driven point estimates with no uncertainty quantification and an untested symmetric-effect assumption.
Summary
This simulation study from the NYC Department of Health and Mental Hygiene models the 'chilling effect' of the July 2026 federal public charge rule on immigrant New Yorkers. The authors build a deterministic compartmental ODE model of 843,725 NYC immigrants aged 0-64, stratified by age, immigration status (undocumented, legal noncitizen, children in mixed-status households), sex, race/ethnicity, insurance, and chronic conditions, using 2023 NYC vital statistics, ACS microdata, and Center for Migration Studies counts. Under three avoidance/disenrollment scenarios anchored to the 2025 KFF/New York Times immigrant survey (conservative to aggressive: 10-30% for legal noncitizens, 25-42% for undocumented), the model projects primary care access falling 4.1-9.9% and doctors' visits falling 5.1-12.2% over five years versus a no-rule counterfactual; premature mortality rises 4.4-10.6% at five years and 7.4-17.4% at twenty years, with larger burdens projected for legal noncitizens and Black immigrants. Primary care parameters come from an NYC randomized trial; mortality effects are transposed from Medicaid expansion quasi-experiments (Miller et al.) assuming symmetric effects of coverage loss. Limitations include no uncertainty quantification, scenario-driven results, untested symmetry, and inability to isolate the rule from broader enforcement policies.
Review complete
Assessment at a glance
6
risk flags identified
● high 2
● medium 3
● low 1
4 strengths · 5 weaknesses · 5 author questions
Levels reflect verification complexity — not a quality score. Evolve never rates your paper.
Key claims under review
- Implementation of the 2026 public charge rule is projected to reduce NYC immigrant primary care access by 4.1-9.9% and doctors' visits by 5.1-12.2% within five years relative to a no-rule counterfactual.
- Premature mortality among NYC immigrants is projected to rise 4.4-10.6% within five years and 7.4-17.4% within twenty years under the rule's chilling effect.
- Legal noncitizens bear higher projected premature mortality burdens than undocumented adults under moderate and aggressive scenarios (e.g., 20.6% vs 13.0% at 20 years), despite lower assumed avoidance rates, presumably because of their larger insured base.
- Black immigrant New Yorkers are projected to experience slightly larger premature mortality increases than other racial/ethnic groups at both 5 and 20 years.
- These projected harms warrant urgent regulatory reconsideration, though the authors acknowledge the estimates likely reflect combined immigration policy effects rather than the public charge rule alone.
Strengths
Fine-grained population stratification anchored to real data
The compartmental model stratifies 843,725 NYC immigrants (ages 0-64) along six dimensions including immigration status, race/ethnicity, insurance, and chronic condition, drawing on 2023 NYC Vital Statistics, ACS Public Use Microdata, and 2025 Center for Migration Studies counts, enabling subgroup results such as the higher projected burden for Black immigrants and legal noncitizens.
Scenario bounds tied to a concrete empirical source rather than arbitrary guesses
The conservative/moderate/aggressive avoidance and disenrollment rates (10-30% for legal noncitizens; 25-42% for undocumented) are anchored to the 2025 KFF/New York Times Survey of Immigrants, and parameter sourcing is explicit throughout Methods, including the ActionHealth NYC RCT for primary care rates.
Extends the evidence base to a 20-year horizon
High-quality causal anchor for the mortality effect
Weaknesses
No uncertainty quantification of any kind
Headline results largely restate the scenario assumptions
Untested symmetry assumption and cross-population transportability
Internal numerical inconsistency in headline results
Value-laden framing beyond the evidence and acknowledged confounding
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Frequently asked questions
What did the 2026 public charge rule simulation study find about NYC immigrants?
A simulation by NYC Department of Health researchers projected that the July 2026 federal public charge rule could reduce primary care access among NYC immigrants by 4.1-9.9% and doctors' visits by 5.1-12.2% within five years, and raise premature mortality by 4.4-10.6% within five years and 7.4-17.4% within twenty years, compared with a no-rule scenario. These are model projections under conservative-to-aggressive avoidance assumptions, not observed data.
How does the public charge rule create a 'chilling effect' on immigrant health care use?
The rule gives immigration officers more discretion to weigh use of public benefits when deciding immigration petitions. Fearing that enrolling in Medicaid or similar programs could hurt a green card or visa application, some immigrant families avoid or drop benefits they are legally entitled to — even when the benefit use should not count against them. This study models what happens to primary care use and premature mortality if 10-42% of NYC immigrants avoid or disenroll from coverage for this reason.
Are the projected mortality increases in this study reliable?
They are deterministic point estimates with no confidence intervals or probabilistic sensitivity analysis, built by transposing mortality effects from Medicaid expansion studies of U.S.-citizen adults and assuming coverage loss has symmetric opposite effects — an assumption the authors themselves call untested. The scenarios (10-42% disenrollment) are assumptions from a 2025 survey, not post-rule observations. Treat the numbers as illustrative scenario bounds, with the caveat that they may also reflect broader immigration enforcement, not the public charge rule alone.
Which immigrant groups are projected to be most affected by the 2026 public charge rule?
In the model, legal noncitizens show larger projected premature mortality increases than undocumented adults under the moderate and aggressive scenarios (e.g., 20.6% vs 13.0% at 20 years), because they start with much higher public insurance enrollment (84% vs 42%). Among racial/ethnic groups, Black immigrant New Yorkers are projected to experience slightly larger premature mortality increases than other groups at both 5 and 20 years.
Is the model code and data for this public charge simulation available?
Yes. The paper states that model code is publicly available at github.com/nychealth/public-charge-simulation. The inputs are described in the text and appendices (2023 NYC Vital Statistics, American Community Survey microdata, Center for Migration Studies population counts, a KFF/New York Times immigrant survey for scenario assumptions, an NYC randomized trial for primary care rates, and Medicaid expansion studies for mortality effects).
About this review
This is an AI-generated preliminary review by Evolve.Pub, produced from the openly available text of the paper. It is not peer review and does not represent the authors' views. The canonical record of the paper is at the publisher link above.
- Only the main text was available: appendices A1, C, D1, E1, F2 and F3 (population counts, ODE specifications, subgroup tables) were not analyzable, so parameter derivations and subgroup results could not be verified.
- Figure 1 (model schematic) and Figure 2 (mortality trajectories) could not be evaluated from the extracted text; Figure 2's percentage labels were taken from the Results prose only.
- The supplied abstract is truncated mid-sentence in the Results section.
- The paper is a medRxiv preprint (posted September 16, 2026) that has not been certified by peer review.
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