As President Donald Trump continues his crackdown on immigration, Nevada Medicaid is predicting a dramatic drop-off in lawful permanent residents enrolling in public assistance — a change the department says could help neutralize budgetary shortfalls. 

Late last month, Nevada Medicaid discovered a nearly $66 million budget hole after failing to account for cost inflation among managed care organizations, which have contracts to provide care for beneficiaries. To meet those shortfalls, Nevada Medicaid suggested amending its budget in several ways, including cracking down on Medicaid enrollees who moved out of state and pulling from an old budget surplus. 

Another option: to subtract $38 million from the budget to reflect “federal immigration policy changes” as Congress considers expanding the public charge rule — a policy to deny legal status to people relying on public benefits.

Over the next two years, Nevada Medicaid expects there to be a 15 percent reduction in Medicaid caseloads from mixed-status families because of “increased federal scrutiny.” Although lawfully present immigrants — including asylum seekers and green card holders — have been allowed to enroll in Medicaid since the ‘90s, the state Office of Analytics predicts there will be increased concerns among beneficiaries about deportations and how receiving aid could affect their immigration status. 

Undocumented immigrants, meanwhile, are already typically ineligible for federal Medicaid benefits, except in the case of emergency medical care. Less than 1 percent of total Medicaid spending goes to covering those emergency costs, according to some estimates. 

“We know that there will be some fears around enrolling in public assistance programs,” Nevada Medicaid Director Stacie Weeks said during a budget hearing in front of the Assembly Committee on Ways and Means and Senate Committee on Finance last week.

The implications of these Medicaid changes could be huge in Nevada, which has the largest share of mixed-status families in the nation and is home to some 130,000 lawful permanent residents. Some lawmakers and public health officials have raised concerns that the assumption in the budget amendment is misguided and that it is hard to quantify how many people will actually disenroll. 

“There's no guarantee that that's actually true. We don't want to put ourselves in a position where we are under budgeting,” said Sen. Fabian Doñate (D-Las Vegas), chair of the Senate Health and Human Services Committee.

Weeks, however, said that the analysis was based on prior studies on how federal immigration policy has affected Medicaid, specifically the “public charge rule,” which allows the government to deny visas or green cards to immigrants who are deemed likely to become dependent on public benefits. 

In 2019, Trump broadened that rule to include health, nutrition and housing programs, leading to the number of immigrants enrolled in Medicaid to decrease by as much as 35 percent, according to the nonprofit health policy organization KFF, before the Biden administration reversed that change in 2021. 

But the public charge rule could be reimplemented. The House Republican budget, passed in late February, calls for bringing it back, and Senate leaders are making strides to vote on the plan as soon as this Friday. 

In a justification for the budget amendment, Nevada Medicaid lists “concerns over the effects of receiving aid on immigration status” as another potential deterrent for immigrants seeking Medicaid.

“I don’t know how likely it is that the changes will be reinstated,” Drishti Pillai, the associate director of the Racial Equity and Health Policy Program and director of Immigrant Health Policy at KFF, said in an interview. “However, if they are, the chilling effects of the rule may be even larger during this term due to compounding fears associated with increased enforcement activity.” 

Doñate, who is bringing forth a bill that would expand certain Medicaid benefits to undocumented people, said that the government should ensure they are “doing their due diligence to actually dispel misinformation” to folks who are actually eligible to enroll. 

“It seems to me that they would qualify for it. We’re talking about U.S. citizens being fearful of getting government services when they need it most,” Doñate said about planning for an enrollment drop-off. 

One of Doñate’s bills, SB234, proposes going in the opposite direction and leaning into coverage of immigrants. The bill, set to be heard Tuesday afternoon, would expand emergency Medicaid coverage for undocumented people who are diagnosed with cancer and renal disease, with prior approval from the Department of Health and Human Services. It would also cover emergency medical transportation and the cost of care in certain outpatient facilities. 

That bill would result in more than $5 million in general fund expenditures, according to a fiscal note from Nevada Medicaid, as the program already faces budget uncertainty. The rest of the expenditures would be paid for with more than $16 million in federal funds. 

Lowered Medicaid enrollment rates already have some public health officials worried that immigrants will have to increasingly rely on emergency room visits to access medical care, which under federal law, are required to treat patients regardless of their ability to pay. 

Without preventative care, many say that medical situations can quickly escalate to something that is life-threatening. 

“If people are afraid to sign up for Medicaid because they're afraid of getting deported, then they're not going to show up for doctor's appointments or for pharmacy or for anything,” said Dr. Joey Adashek, president of the Nevada State Medical Association.