A Summer of Continuing the Fight: Defending Coverage, Demanding Health Equity

This month marks the 30^th anniversary of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996, referred to at the time as “welfare reform.” This misguided and deeply harmful legislation redefined who can access vital safety-net programs when they need it most — not based on necessity, but whether they can prove they “deserved” help. The law imposed a new five-year waiting period for lawfully present immigrants to become eligible for Medicaid and other vital public benefit programs that keep families healthy, sorted immigrants by “qualified” and “not qualified” status to determine who could access critical services, and tied access to public benefits to work requirements. The implications of that law have reverberated through generations, and underly today’s Medicaid work reporting requirements and further immigrant eligibility restrictions established under H.R. 1 and through administrative rulemaking.

Families USA opposed PRWORA and fought throughout the 90’s to ensure that all people can access affordable health coverage, and that fight continues today. In our current environment that vision faces historic roadblocks from federal actions that have expanded the scope of PRWORA’s immigrant eligibility restrictions and created new barriers for working families to health coverage, threatening to deepen long-standing health disparities, including:

• New immigrant eligibility restrictions: On top of enacting the largest health care cuts in history, estimated to strip coverage from millions and leave millions more at risk, H.R. 1 tightened the definition of who is a qualified immigrant for Medicaid/CHIP and Marketplace coverage eligibility that is estimated to leave more than 1.3 million lawfully present immigrants uninsured. This new restriction doesn’t replace PRWORA’s five-year waiting period for lawfully present immigrants, it builds on top of it. CMS’s guidance notes that among the immigrants H.R. 1 leaves eligible for Medicaid after October 1 — lawful permanent residents (LPRs), Cuban/Haitian entrants, and COFA migrants — only LPRs are subject to the same waiting period imposed by PRWORA three decades ago; the other two groups remain exempt. Separately, H.R. 1 leaves untouched a longstanding state option under the 2009 Children’s Health Insurance Program Reauthorization Act (CHIPRA), which allows states to waive the five-year waiting period for lawfully present children and pregnant individuals – an option roughly three quarters of states currently use.
• Repeated chilling effects on immigrant families: The administration’s new public charge regulation is imposing fear among eligible immigrants from participating in programs like Medicaid — the same chilling effect set in motion by PRWORA when it first classified what type of immigrants could access health coverage and other basic needs, and reinforced during the first Trump administration’s 2019 public charge rule. The Trump administration’s 2026 final rule acknowledges its impact reaches far beyond immigrants it targets directly, with ripple effects extending to hospital systems, pharmacies, and the broader economy.
• New work reporting requirements: In another damaging result of H.R. 1, beginning January 1, 2027, nationwide federal work reporting requirements — burdensome paperwork that historically has led to eligible people losing Medicaid despite meeting the requirements — will take effect for certain Medicaid expansion participants. These work reporting requirements carry their own racial equity implications, layered on top of the barriers immigrant families already face.

Championing Bold Health Equity Legislation

Despite these threats, Families USA, our partners across the health equity movement, and champions in Congress continue to fight back — reimagining a health care system that works for all people, regardless of who they are, where they’re from, or where they live. Together, we are working to advance the following policy solutions that would collectively restore access to care and undo the harm:

• Health Equity and Accountability Act (HEAA) of 2026: This summer, the Congressional Tri-Caucus — a coalition of the Congressional Black Caucus, Congressional Hispanic Caucus, and Congressional Asian Pacific American Caucus — reintroduced HEAA, the most comprehensive legislative blueprint for eliminating racial and ethnic health disparities. HEAA includes provisions to increase federal support for Medicaid weakened by H.R. 1, remove citizenship and administrative barriers to health coverage rooted in PRWORA, and expand access to culturally competent and linguistically appropriate care.

• The Protect American Values Act of 2026: Under the Trump administration’s new public charge rule, immigrant families who are otherwise fully eligible for Medicaid and other critical safety-net programs will face immigration-related penalties simply for accessing them, starting September 18. When a similar rule took effect in 2019 under the first Trump administration, fear and confusion rippled through communities: eligible families — including U.S. citizens — avoided medical care and other critical supports. The Protect American Values Act would prevent funding from going to implement this harmful rule.

• Lifting Immigrant Families Through Benefits Access Restoration (LIFT the BAR) Act: A five-year waiting period enacted under PRWORA continues to bar lawfully present immigrants from accessing Medicaid and other federal safety-net programs — a barrier that will grow more severe with the implementation of new federal immigration restrictions on Medicaid under H.R. 1 that take effect on October 1.

• Seamless, Accountable, and Fair: A Civil Rights Agenda for Reconstructing Insurance Affordability Programs: In July, Families USA joined UnidosUS, NAACP, the National Council of Negro Women, the National Urban League, and other leading civil rights and health care advocacy organizations to publish the report, showing how the massive rollback in health coverage and access disproportionately impacts people of color. It lays out concrete recommendations, including restoring Medicaid eligibility for lawfully present immigrants, eliminating burdensome paperwork requirements, and protecting access to health coverage from counting against immigrants in public charge determinations.

Keep the Movement Going

Call on Congress to support health equity–driven policy solutions, including the evidence-based policies in HEAA, the LIFT the BAR Act, and the Protect American Values Act — to reduce long-standing health disparities, respond to historic cuts to Medicaid, and eliminate xenophobic policies that harm children and families.

Amplify the Civil Rights Agenda: Share Seamless, Accountable, and Fair across your networks to drive conversations about the equitable health care system our communities deserve.

Share the Protecting Immigrant Families (PIF) Coalition Public Charge Toolkit. Beginning September 18, 2026 immigration officials gain broad discretion to weigh benefits like Medicaid and food assistance against green card applicants, reviving the standard PRWORA set 30 years ago. PIF’s updated toolkits can help you and your networks understand the changes.

Thirty years ago, Congress decided that genuine need alone wasn’t enough — they decided that people needed to prove they met a discriminatory standard of “deserving help” before they could receive it. That decision still shapes our health care system today in terms of who gets covered, who gets left behind, and who lives in fear of seeking care they’re entitled to when they need it most. Today, as we see new restrictions and administrative burdens build on PRWORA’s faulty foundation, current and future Members of Congress must face the same choice they did in 1996: organize a fragmented health care system around burdensome requirements or build one that is equity-centered and focused on need.

Families USA remains dedicated to working with advocates across the country to make sure they make the right choice. Together, we can build a health care system that works for all of us.