DREDF Comment Opposes Federal Attempts to Strip Immigrants of Public Benefits

Download the PDF version

The Honorable Robert F. Kennedy, Jr.
Secretary
U.S. Department of Health and Human Services
200 Independence Ave SW
Washington, DC 20201

Re: Notice: Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA); Interpretation of “Federal Public Benefit”

The Disability Rights Education & Defense Fund (DREDF) writes in opposition to the harmful new interpretation the Department of Health and Human Services (HHS) is taking in regard to the definition of a “Federal public benefit” under the Personal Responsibility and Work Opportunity Reconciliation Act.

DREDF is a cross-disability national civil rights law and policy center led by individuals with disabilities and parents who have children with disabilities. Our mission is to advance the civil and human rights of people with disabilities, including immigrants of all ages and their families, through legal advocacy, training, education, public policy and legislative development.

DREDF has persistently fought for the right of people with disabilities to be fully integrated within all aspects of community life. Our work is based on the knowledge that people with disabilities are capable of contributing to their communities with access to needed services and supports, protection from discrimination, and the reasonable accommodations and modifications enshrined in U.S. law.

We write out of deep concern for our immigrant community members including the up to 10% of immigrants who have disabilities, disabled people who are family members of immigrants, or who receive caregiving services from disabled or non-disabled immigrants. Nearly half of non-elderly immigrants with disabilities already live on low family incomes, with 3 in 10 working in such critical service occupations as cleaners and life-sustaining personal care attendants for disabled people.[1] All people in need must have access to programs that provide support for mental health services, services for youth and their caregivers in foster care, and essential health services and supports.

The Department of Health and Human Services’ (HHS) is initiating a change to nearly 30 years of legal interpretation that will affect millions of immigrants and their families’ ability to access critical health and other safety-net programs funded by HHS, and potentially will impose burdensome new requirements on state and local governments.

Enacted in 1996, the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) made a range of federal public benefit programs available only to “qualified immigrants,” subject to certain exceptions. The law defines qualified immigrants as those who fall in a defined list of immigration categories, including those with Lawful Permanent Resident Status, refugees, persons granted asylum, certain immigrants from Cuba, Haiti and Pacific Island nations, certain survivors of domestic violence and trafficking, and other specific categories. Some people who are lawfully present in the US were not included on the list, including individuals with Temporary Protected Status, people with nonimmigrant visas, and individuals granted deferred action, including Deferred Action for Childhood Arrivals (DACA). Thus, the PRWORA always excluded some but not all individuals who are lawfully present, and not only undocumented immigrants.

In 1998, HHS issued a Notice that interpreted the term “Federal public benefit” to explain which Department programs met the definition and would thus be limited to qualified immigrants (1998 Notice).^[2] This notice identified 31 programs that excluding undocumented and other lawfully present but “not qualified” immigrants from programs such as Medicare, Medicaid, Temporary Assistance for Needy Families, and a range of cash-assistance programs. However, HHS determined that some programs were not Federal public benefits under the law. All immigrants, whether they were in a “qualified” category or not, were included in access to programs that were recognized as serving the broader community. The notice provided a reasoned interpretation of the statutory definition to explain the manner in which these programs were identified.

On July 14, 2025, the Department disavowed the 1998 Notice interpretation and identified 13 additional programs as restricted Federal public benefits (2025 Notice).^[3] These programs include Head Start, the Title X Family Planning Program, and the Health Center Program (e.g. federally qualified health centers funded by the Health Resources and Services Administration) among others. These programs provide critical services and limiting access to them will have negative effects on the health and welfare of not only immigrant populations, but communities as a whole.

HHS’ unnecessary reinterpretation of the definition of “Federal public benefit” in PRWORA of 1996, contravening nearly three decades of established policy, will cause further harm to the health and well-being of immigrant families who already have limited access to essential programs and services. Indeed, the barriers that immigrant families have faced in securing services that are essential to health, safety, and economic security and mobility have harmed not only persons directly barred from these programs but also mixed-status families and broader communities.

With one in four children in the U.S. living with at least one immigrant parent, including those with qualified and nonqualified statuses, its impact will reach beyond those newly excluded from specific programs.^[4] Under PRWORA, millions of non-qualified immigrants are already excluded from federal public benefits, including full scope Medicaid, Medicare, Temporary Assistance for Needy Families (TANF) and a host of other anti-poverty and social welfare programs. Even qualified immigrants, such as green card holders who are just one-step removed from U.S. citizenship, often face a five-year bar before they can access federal benefits. This structure has made it difficult if not impossible for many immigrant families to pull themselves out of poverty, access higher education, access affordable health care, and thrive in the U.S.

Existing restrictions in PRWORA and accompanying regulations create a chilling effect that deters eligible immigrants and citizen family members from seeking essential programs. For example, when parents are barred access from federal health care programs, they are less likely to enroll eligible children in health care programs. From 2016-2019, participation in programs such as Medicaid, CHIP, and the Supplemental Nutrition Assistance Program among citizen children with noncitizen household members fell twice as fast as those with only U.S. citizen households due to fear and uncertainty caused by changes in immigration policy.^[5] In 2023 nearly 60% of adults in mixed status families, including those with disabled members, reported experiencing material hardship such as food insecurity, and unmet need for medical care.[6] Inadequate access could lead to exacerbation of chronic health conditions or increased disability leading to severe illness or death. This new rule reinterpreting the definition of federal health benefits will only exacerbate these chilling effects, causing harm to families across this country.

While PRWORA exempts nonprofit charitable organizations from verification requirements, it does not exempt state and local governments that already expend extraordinary resources on verifying eligibility for programs like Medicaid and the Supplemental Nutrition Assistance Program (SNAP). Any new requirements for state and local governments to verify eligibility for programs newly deemed to be Federal public benefits would be an unfunded mandate and force them to develop new policies, technology, and training procedures for each one. Prior to the enactment of H.R. 1, state budgets were already facing increasing fiscal stressors. The Administration’s policies and H.R. 1 have slashed federal funding to states and will shift further costs to states for Medicaid and SNAP. Any new requirements would be even more unaffordable.^[7]

Red tape already is a major barrier to effective utilization for federally funded programs to all who want to participate. Low-income families utilizing the programs targeted by HHS already face “time poverty” driven by excessive paperwork requirements that stem from federal regulations like the ones that this notice may create.^[8] Federal paperwork already costs 10 billion hours and $276.6 billion annually and we expect to see rising costs to states to implement the H.R. 1 mandated work requirements.^[9] When Arkansas temporarily introduced work requirements the state and federal government spent $26.1 million in administrative expenses with no gain in employment for people who had relied on Medicaid before being pushed off. Georgia spent more than $40 million in its first year of Medicaid work requirements with a majority of the money going to administrative and consulting fees and less time for staff to focus on the provision of essential healthcare and supports services.[10]

As the notice acknowledges, PRWORA does not require nonprofit charitable organizations that administer Federal public benefits to conduct eligibility verifications. This provision ensures that nonprofits and their clients are not subject to the paperwork costs borne by government agencies described above. However, the notice also indicates that, despite this important exception, the agency expects that they, “should pay heed to the clear expressions of national policy,” under President Trump’s anti-immigrant executive orders.

This statement of expectation is not appropriate for an official federal document and may confuse nonprofit organizations. They may be concerned about adverse actions against them, particularly given this administration’s attempts to force private actors to comply with its demands without a statutory basis, such as its abuse of the college accreditation system and threats to cut transportation funding for cities that do not facilitate mass deportations.^[11] HHS should clarify that no nonprofit will be adversely affected if they, as is their legal right, do not divert funds and staff time to force their clients to fill out paperwork.

Expanding the definition of “Federal public benefit” to include essential health programs, such as Title X and the Health Center Program, threatens public health, 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 health care.^[12] Restricting these services will significantly reduce access to contraception, STI testing, cancer screenings, and prenatal care.^[13]

Similarly, Community Health Centers (CHCs) provide primary and preventive care services, which are crucial for managing chronic conditions and promoting overall health. CHCs can be the closest healthcare provider who can verify a person’s medical need for devices such as respirator machines, wheelchairs, or other durable medical equipment needed by people with disabilities. Confusion about eligibility and fear of immigration consequences 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 health care system they depend on.^[14]

Denying access to preventive care does not eliminate peoples’ need for services, it shifts the burden to hospital emergency departments and, ultimately, to state systems and taxpayers. People who are unable to access preventive health care inevitably enter the health care system at more complex and expensive points. Delayed treatment leads to worse health outcomes, including rising STI rates, increase in late-stage cancer diagnoses, and poor maternal and infant health, all of which require more intensive, costly interventions.

Consequently, hospitals, especially in rural and underserved areas, will absorb more uncompensated care, threatening their financial viability. Additionally, those with advanced health issues 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.^[15]

Restricting access to critical health care programs not only contradicts the agency’s commitment to health equity and public safety, but also threatens to destabilize the broader health care system. In addition, any delay in diagnosis or healthcare treatment for a person with a disability with chronic mental health or other conditions, or those who are in acute crisis, can lead to costly and life-threatening outcomes.

With a growing mental health crisis and a shortage of behavioral health specialists, those seeking mental health treatment often face long wait times to obtain care. In a study on how clinic congestion affects mortality for veterans experiencing mental health emergencies, longer waiting times make it more likely that patients miss their follow-up mental health visit, consequently increasing the probability that they permanently disengage from care.

According to the notice, the following programs, that were previously excluded given their focus on helping entire communities, will be newly considered Federal public benefits. Each one’s addition to the list of prohibited federal public benefits would be harmful if they are not determined to be exempt.

Programs providing Mental Health and other Healthcare Supports

The Certified Community Behavioral Health Clinics, Community Mental Health Services Block Grants, Health Center Program, Projects for Assistance in Transition from Homelessness Grant Program, and Programs administered by the Substance Abuse and Mental Health Services Administration each provide critical services for people with mental illness. Many people are being held in detention centers. Lawfully present people that are able to make their way back into the community have a high likelihood of experiencing mental health problems.[16] Anxiety, depression and post-traumatic stress disorder are commonly reported both during and following detention. One study found a 18.5% chance of a lifetime mental health diagnosis after detention.[17] Immigrants with preexisting mental health disabilities may face additional trauma, isolation, and medical and health neglect leading to worsening of their disabilities.[18] Access to mental health supports for all is crucial and should not be restricted. Additional background on each program is provided.

• Certified Community Behavioral Health Clinics – Certified Community Behavioral Health Clinics (CCBHCs) are specific clinics that provide critical and comprehensive mental and behavioral health services to all – regardless of insurance, ability to pay, or diagnosis history. In order to meet the needs of the vulnerable populations that access care at CCBHCs, these clinics receive an enhanced Medicaid reimbursement rate. CCBHCs connect people to life-saving quality care. CCBHCs should not be defined as a federal public benefit and remain statutorily exempt, as the abrupt change in access to mental health care will upend lives and cause lasting damage to individuals and communities.
• Community Mental Health Services Block Grant – The Community Mental Health Services Block Grant is awarded to mental health service providers that work in communities with complex and comprehensive needs. Specifically, the block grant funds providers that serve adults with serious mental illnesses and children with serious emotional disturbances. The Community Mental Health Services Block Grant should not be defined as a federal public benefit and remain statutorily exempt, as this critical program is among the few funding options available for reaching those with the most vulnerable and complex mental health needs.
• Community Services Block Grant – The Community Services Block Grant (CSBG) is an anti-poverty, federally-funded block grant that connects states and localities to life-saving funding for underserved communities. CSBG funding has been used for critical programming, including housing, nutrition, and education services. According to HHS’s Administration for Children & Families, CSBG-funded programs serve over 9 million vulnerable children and adults each year.^[19] Community Services Block Grant funding should not be defined as a federal public benefit and remain statutorily exempt, as millions of children and families across the country rely on the critical programming to live and thrive. Restricting access would put vulnerable populations at risk of increased insecurity and poverty.
• Health Center Program – For decades, federally-funded health centers have connected communities to low-cost, high-quality, comprehensive dental, medical, and mental health services. Each year, health centers connect tens of millions of people across the country to life-saving health care. In 2023 alone, more than 31 million individuals were able to access care at health centers, including 585,000 pregnant women, over 400,000 veterans, and more than 24.7 million patients who were uninsured, or received Medicaid or Medicare.^[20] The Health Center Program should not be defined as a federal public benefit and remain statutorily exempt, as this program is often the only lifeline for millions who otherwise have virtually no options for quality, affordable health care. The effects of limited access to care are well documented – to restrict access to health care is to upend entire families and communities.
• Projects for Assistance in Transition from Homelessness Grant Program – The Projects for Assistance in Transition from Homelessness (PATH) grant funds services for people with serious mental illness experiencing homelessness — an extremely vulnerable population that otherwise has little to no access to care. In 2021, PATH grantees were able to reach over 100,000 people, and connected over 50,000 individuals to critical services including but not limited to screening and diagnostic treatment, habilitation and rehabilitation, community mental health supports, and housing services.^[21] The Projects for Assistance in Transition from Homelessness (PATH) Grant Program should not be defined as a federal public benefit and remain statutorily exempt. People who are experiencing homelessness and simultaneously struggling with severe mental illness are among the most underserved and unsupported populations in the United States. To restrict access to some of the only services available would place an even larger burden on the providers trying to connect these extremely vulnerable individuals with critical care.
• Mental Health and Substance Use Disorder Treatment, Prevention, and Recovery Support Services Programs administered by the Substance Abuse and Mental Health Services Administration. There is a public health crisis in the United States, and SAMHSA’s programming offers a vital lifeline to the millions of individuals affected by mental health and/or substance misuse seeking preventative treatment, care, and rehabilitation. Mental health and substance use disorder treatment, prevention, and recovery support services programs administered by SAMHSA should not be defined as federal public benefits and remain statutorily exempt. Any additional barriers to SAMHSA’s offerings will prove to be destabilizing and destructive for those actively receiving or seeking care, as well as for providers.

Programs Providing Supports for Children and Guardians in the Foster Care System

The Title IV-E Educational and Training Voucher Program, Title IV-E Kinship Guardianship Assistance Program, And Title IV-E Prevention Services Program uniquely provide much needed care and supports for disabled immigrants in the foster care system. In 2017, 22% of the children in the U.S. Foster care system had a medical or disability diagnosis requiring additional care. Children with disabilities in foster care (CDFC) have significantly more disruptions and longer stays making them more vulnerable when their support systems are broken.[22] A more recent 2024 study found that CDFCs with specific disabilities were far less likely to achieve a positive outcome like adoption or reunion with family. Children in foster care with intellectual disability, physical disability, and emotional disturbance have a significantly higher risk of death compared to those without disabilities. Disabled children and their guardians need the additional supports and services provided through these programs to access education, healthcare and skill-based programs to remain as healthy as possible and transition into the community as independent adults.[23] Additional background on each program is provided.

• Title IV-E Educational and Training Voucher Program – Title IV-E Education and Training Vouchers (ETV) assists young adults in or formerly in foster care with their postsecondary educational needs by providing up to $5,000 per year for costs associated with postsecondary education and training. The program is administered by the states, and implementation of the program and the interpretation and application of the eligibility criteria can vary widely. The ETV Program should not be defined as a federal public benefit and should remain statutorily exempt. Limiting access to this program imposes yet another barrier for a population of youth that are already at risk of experiencing disruptions in their education.
• Title IV-E Kinship Guardianship Assistance Program – Title IV-E Kinship Guardianship Assistance are formula grants that assist States and Tribes (Indian Tribes, Tribal Organizations, and Tribal Consortia) who provide guardianship assistance payments for the care of children by relatives who have assumed legal guardianship of eligible children for whom they previously cared as foster parents. As of January 2025, 56 Title VI-E Agencies (42 states, DC, 2 Territories, 11 Tribes) have approved Title VI-E plan amendments that enable them to make claims for this support.^[24] The Title IV-E Kinship Guardianship Assistance Program should not be defined as a federal public benefit and remain statutorily exempt. To impose a new definition and place sudden restrictions on this program will prove to be a destabilizing force for foster care providers, children, and entire families.
• Title IV-E Prevention Services Program – Title IV-E Prevention Services provide optional time-limited prevention services for mental health, substance abuse, and in-home parent skill-based programs for children or youth who are candidates for foster care, pregnant or parenting youth in foster care, and the parents or kin caregivers of those children and youth. The Title IV-E Prevention Services Program should not be defined as a federal public benefit and remain statutorily exempt. This program provides enhanced support to children and families within the foster care system. To impose new restrictions will make it even more difficult to connect those either in foster home placements or who are caring for children within the foster care system to the care they need.

Programs Providing Crucial Early Education, Healthcare and Workforce Supports

• Head Start – Head Start provides high quality and comprehensive services for families in need, including families with disabled children, and has transformed lives by providing free early childhood education to 40 million children in every community in every state across the country. During the 2022-23 program year fourteen percent of Head Start cumulative enrollment was made up of children with disabilities, defined as children having special plans under the Individuals with Disabilities Education Act (IDEA). ^[25] The effects of Head Start are well-documented; Head Start significantly improves the health, educational outcomes, and financial prospects of participating families. The children in those families join public classrooms where they are able to contribute to and join in communal learning and socialization. The Head Start program should not be defined as a public benefit and remain statutorily exempt. Head Start ensures that children are prepared for K-12 education, and the sudden recategorization would plunge millions of families and children into uncertainty.
• Title X Family Planning Program – Title X is the only federal program dedicated to providing individuals with low incomes, including those without insurance, access to affordable, high-quality, culturally responsive family planning care. Title X clinics provide a range of essential preventive services, including cancer screenings, STI prevention, HIV services, and contraceptive care and counseling in communities across the country. Title X should not be defined as a federal public benefit and remain statutorily exempt, as Title X services are relied on by millions of people regardless of income, disability or immigration status. Restricting Title X services would cut off people from their only source of reproductive health care and other preventative services, and severely undermine public health.
• Substance Use Prevention, Treatment, and Recovery Services Block Grant – Considered “the cornerstone of States’ substance use disorder prevention, treatment, and recovery systems”, the Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG) program is designed to prevent and treat substance use and abuse.^[26] Grantees must serve specific vulnerable populations (pregnant women and women with dependent children) and offer priority services, including early HIV/AIDS intervention, tuberculosis screenings, and primary preventative care. The Substance Use Prevention, Treatment, and Recovery Services Block Grant (SUBG) program should not be defined as a federal public benefit and remain statutorily exempt. As perhaps the most integral component of the country’s defense against substance use and abuse, it is counterintuitive and cruel to restrict prevention and treatment options. To do so would push thousands further into the dangers of substance use and addiction.
• Health Workforce Programs not otherwise previously covered (including grants, loans, scholarships, payments, and loan repayments). The programs offered by the Bureau of Health Workforce are intended to develop a robust health workforce, by connecting skilled and compassionate providers to communities in need. There are scholarships, loans, and repayment programs available that help foster the growth and career of new providers, as well as grants made available to service-providing organizations for their care. Health Workforce Programs not otherwise previously covered should not be defined as federal public benefits and remain statutorily exempt. Restrictions to these programs will have long-lasting impacts on the quality and size of the country’s health workforce, and undermine attempts to keep our country safe and healthy.

The Health Workforce Program grants, loans and scholarships seek to train professionals providing care for people with opioid and other substance abuse disorders (SUDs), those in rural areas, people needing behavioral or mental health care. The programs also assist community health workers seeking training to address public health emergencies, and reducing burnout in the workforce. People with disabilities are at a higher risk of SUDs, including opioid addiction. Contributing factors include isolation, chronic pain and barriers to accessing healthcare.[27] According to a 2024 National Center for Health Workforce analysis, the United States is experiencing a mental health crisis with increased levels of unmet behavioral needs. There are substantial shortages of mental health counselors, school counselors and other professionals and rural counties are more likely to lack needed providers.[28]  All professionals seeking to provide critical treatment should be supported.

HHS makes this notice effective immediately and only provides 30 days for comments. For a revision of nearly 30 years of precedent potentially impacting hundreds of recipients of federal funding across many programs, this lack of time for public input is deeply inadequate. Together, these programs comprise over $27 billion in federal funding.^[29] This is obviously not a simple administrative decision with limited real-life impact. Supports and services used by millions of children and adults with disabilities are directly implicated in this changed rule. HHS should pause implementation of this reinterpretation immediately and allow for a full stakeholder engagement process including a proper notice and comment period.

We ask you to withdraw this notice and not proceed with any further guidance, regulations or other changes in interpreting PRWORA. Further, we would like our comment, including any articles, studies, or other supporting materials that we have included in our comment as an active link in the text, to be included as part of the formal administrative record for the proposed rule for the purposes of the federal Administrative Procedure Act. Please let us know if HHS is unable for any reason to meet our request and include our linked materials, so we will have the chance to otherwise submit copies of the supporting documents into the record. If you have any questions about anything in the comments or the materials, please contact Silvia Yee, DREDF Policy Director, at syee@dredf.org.

Sincerely,

Silvia Yee
Policy Director

 

[1] Paola Echave, Dulce Gonzalez, Being an Immigrant with Disabilities, Urban Institute. (April 25, 2022) https://www.urban.org/research/publication/being-immigrant-disabilities

[2] 63 Fed. Reg. 41658 (Aug. 4, 1998).

[3] 90 Fed. Reg. 31232 (July 14, 2025).

[4] Drishtii Pilla, Akash Pillai, and Samantha Artiga, Children of Immigrants: Key Facts on Health Coverage and Care, KFF. (January 15, 2025), https://www.kff.org/racial-equity-and-health-policy/issue-brief/children-of-immigrants-key-facts-on-health-coverage-and-care/

[5]  Samantha Artiga and Drishti Pillai, Expected Immigration Policies Under a Second Trump Administration and Their Health and Economic Implications, KFF. (November 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 et al., 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.

[6] Dulce Gonzalez, Hamutal Bernstein, Michael Karpman, and Genevieve M. Kenney, Mixed-Status Families and Immigrant Families with Children Continued Avoiding Safety Net Programs in 2023, Urban Institute (August 2024). https://www.urban.org/sites/default/files/2024-08/Mixed-Status-Families-and-Immigrant-Families-with-Children-Continued-Avoiding-Safety-Net-Programs-in-2023.pdf

[7] 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/research/state-budget-and-tax/roundup-state-budgets-increasingly-strained-as-house-senate; Work Requirements Threaten Health and Increase Costs, Robert Wood Johnson Foundation. (April 24, 2025) https://www.rwjf.org/en/insights/our-research/2025/04/work-requirements-threaten-health-and-increase-costs.html

[8] Celestine Rosales, Can We Afford to be Time Poor? The Hidden Tax of Time Poverty, The Decision Lab. June 18, 2024. https://thedecisionlab.com/insights/society/can-we-afford-to-be-time-poor

[9] Dan Goldbeck, The Hidden Cost of Federal Paperwork, American Action Forum. (October 27, 2021), https://www.americanactionforum.org/insight/the-hidden-cost-of-federal-paperwork/

[10] Robert Wood Johnson Foundation (April 24, 2025).

[11] See Bauer-Wolf, Jeremy, “The Trump Administration Is Wielding Accreditation as Political Weapon Against Columbia University,” New America. (June 5, 2025), https://www.newamerica.org/education-policy/edcentral/the-trump-administration-is-wielding-accreditation-as-political-weapon-against-columbia-university/; Badger, Emily, “Trump Raises New Threat to Sanctuary Cities: Blocking Transportation Dollars,” The New York Times. (January 31, 2025) https://www.nytimes.com/2025/01/31/upshot/sanctuary-cities-trump-transportation-funds.html

[12] Managi Lord-Biggers and Amy Friedrich-Karnik. Factsheet: Features and Benefits of the Title X Program, The Guttmacher Institute (February 2025), https://www.guttmacher.org/fact-sheet/features-and-benefits-title-x-program.

[13] See Sarah D. Compton et al., (2025). Assessing the Impact of Federal Restrictions to the Title X Program on Reproductive Health Service Provision Between 2018 and 2022 in the United States, Contraception, (142), https://www.sciencedirect.com/science/article/abs/pii/S0010782424004335; Amy Friedrich-Karnik & Rachel Easter, Restricting Title X Results in Cascading Harms, Guttmacher Institute. (August. 2024), https://www.guttmacher.org/2024/08/restricting-title-x-results-cascading-harms.

[14] When sick, lawfully present immigrants, undocumented individuals, and those with limited English proficiency are more likely to access care at ​​clinics or community health centers. Data from the 2023 KFF/LA Times Survey of Immigrants shows that three in ten immigrant adults say a CHC is their usual source of care, with this share rising to about four in ten among likely undocumented immigrant adults (42%) and those with limited English proficiency (39%). See: Drishti Pillai & Samantha Artiga, KFF, New Policy Bars Many Lawfully Present and Undocumented Immigrants from a Broad Range of Federal Health and Social Supports (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/.

[15] Drishti Pillai & Samantha Artiga, Employment Among Immigrants and Implications for Health and Health Care, KFF (June 12, 2023), https://www.kff.org/racial-equity-and-health-policy/issue-brief/employment-among-immigrants-and-implications-for-health-and-health-care/.

[16] von Werthern, M., Robjant, K., Chui, Z. et al. The impact of immigration detention on mental health: a systematic review. BMC Psychiatry 18, 382 (2018). https://doi.org/10.1186/s12888-018-1945-y

[17] Bakely, Leah, et al. Exploring the Association Between Detention Conditions, Detention-Related Abuse, and Mental Health Among Deported Mexican Migrants. Journal of Health Care for the Poor and Underserved, vol. 34 no. 3, 2023, p. 1021-1036. Project MUSE, https://muse.jhu.edu/article/903060

[18] Robin Ritchin, Immigrants with Disabilities Face Barriers in Immigration Court, Human Rights First. (July 19, 2023) https://humanrightsfirst.org/library/you-suffer-a-lot-immigrants-with-disabilities-face-barriers-in-immigration-court/

^[19] Community Services Block Grant (CSBG), Administration for Children and Families (ACF), Department of Health & Human Services (March 25, 2025), https://acf.gov/ocs/programs/csbg

[20] Impact of the Health Center Program, Bureau of Primary Health Care (BPHC), Health Resources & Services Administration (April 2025), https://bphc.hrsa.gov/about-health-center-program/impact-health-center-program

[21] Projects for Assistance in Transition from Homelessness (PATH), Substance Abuse and Mental Health Services Administration (December 12, 2023), https://www.samhsa.gov/communities/homelessness-programs-resources/grants/path

[22] Christine Platt, FNP-c, MSN, Sheila M. Gephart, PhD, RN, FWAN, FAAN, Placement Disruption of Children with Disabilities in Foster Care, Journal of Pediatric Nursing, vol 66. (September – October 2022). DOI:10.1016/j.pedn.2022.05.004.

[23] Children in Foster Care with Disabilities Face Significant Challenges, American Academy of Pediatrics. (September 7, 2024). https://www.aap.org/en/news-room/news-releases-from-aap-conferences/children-in-foster-care-with-disabilities-face-significant-challenges/

^[24] Title IV-E Guardianship Assistance, Administration for Children & Families (ACF), Department of Health & Human Services, (January 10, 2025) https://acf.gov/cb/grant-funding/title-iv-e-guardianship-assistance

^[25] Head Start Program Facts: Fiscal Year 2023, Department of Health & Human Services. (February 27, 2025), https://www.headstart.gov/program-data/article/head-start-program-facts-fiscal-year-2023

[26] Reauthorization of the Substance Use Prevention, Treatment, and Recovery Services (SUPTRS) Block Grant, National Association of State Alcohol and Drug Abuse Directors (January 2023), https://nasadad.org/wp-content/uploads/2023/01/SAPT-Reauthorization_January-Update-final.pdf

[27] Victoria Lynch, Lisa Clemens-Cope, Gaps in Research and Care for Adults with a Disability Who Have Substance

Use Disorders, Urban Institute (December 2024). https://www.urban.org/sites/default/files/2024-12/Gaps-in-Research-and-Care-for-Adults-with-a-Disability-Who-Have-Substance-Use-Disorders.pdf

[28] National Center for Health Workforce Analysis (November 2024) https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/state-of-the-behavioral-health-workforce-report-2024.pdf

[29] Fiscal Year 2025 combined funding for Health Start, Community Mental Health Services Block Grant, Community Services Block Grant, Community Health Centers, Mental and Behavioral Health Programs, Projects for Assistance in Transition from Homelessness, Substance Use Prevention, Treatment, and Recovery Services Block Grant and Title X funding.