The following are Human Rights Watch’s comments in response to the US Department of Homeland Security (DHS) and US Citizenship and Immigration Services (USCIS) proposed rule, “Inadmissibility on Public Charge Grounds,” published October 10, 2018 (DHS Docket NO. USCIS-2010-0012, RIN 1615-AA22). Human Rights Watch is in strong opposition to the proposed rule because it is likely to chill access to a broad range of programs that support individuals’ basic health, nutrition, and housing needs, for potentially millions of people, including US citizens and legal residents, with a particularly damaging impact on vulnerable populations, including pregnant women, children, people with disabilities, and older people.
Human Rights Watch has documented numerous rights violations within the US immigration system, as well as the impact of governmental policies in the US and elsewhere that violate the basic rights of women, children, people with disabilities, and older people. For the reasons detailed in the comments that follow, DHS and USCIS should immediately withdraw their current proposal and have longstanding principles clarified in the 1999 field guidance remain in effect.
Human Rights Watch writes in response to the Department of Homeland Security’s (DHS, or the Department) Notice of Proposed Rulemaking (NPRM or proposed rule) to express our strong opposition to the changes regarding “public charge,” published in the Federal Register on October 10, 2018. The rule is likely to have a devastating impact on families in the United States by chilling access for millions, including US citizens and legal residents, to a broad range of programs that support individuals’ basic health, nutrition, and housing needs. It will have a particularly damaging impact on vulnerable populations, including pregnant women, children, people with disabilities, and older people. It will also exacerbate the failures of a broken immigration system in which 11 million people are unauthorized and subject to serious abuses. We urge that the rule be withdrawn in its entirety, and that long standing principles clarified in the 1999 field guidance remain in effect.
Human Rights Watch is a nonprofit, nongovernmental human rights organization. We operate in 90 countries and have been investigating, documenting, and exposing human rights abuses around the world for four decades. We have published numerous reports on abuses within the US immigration system. We have also documented the impact of governmental policies in the US and elsewhere that violate the basic rights of women, children, people with disabilities, and older people.
The proposed rule makes a dramatic change to the longstanding public charge test. Under current policy, a public charge is defined as an immigrant who is “likely to become primarily dependent on the government for subsistence.” The proposed rule radically expands the definition to include any immigrant who simply “receives one or more public benefits.”
Additionally, under longstanding guidance, only cash “welfare” assistance for income maintenance and government funded long-term institutional care can currently be taken into consideration in the “public charge” test – and only when it represents the majority of a person’s support. If the rule is finalized, immigration officials could consider a much wider range of government programs in the “public charge” determination, including most Medicaid programs, housing assistance, SNAP (Supplemental Nutrition Assistance Program, formerly Food Stamps) and assistance for seniors who have amassed the work history needed to qualify for Medicare and need help paying for prescription drugs.
The rule also makes other major changes, such as introducing an unprecedented income test and weighing negatively many factors that have never been relevant. For example, the proposed rule details how being a child or a senior, having a large family, or having a medical condition could be held against immigrants seeking permanent legal status. The rule also indicates a preference for immigrants who speak English.
These massive changes are not justified by any rationale. In fact, the NPRM itself acknowledges that the proposed rule would cause great harm to individuals, families, and communities, although it fails to quantify this harm and therefore largely ignores it.
- The proposed rule would significantly chill families’ access to programs that help provide for their basic health, nutrition, and housing needs.
The proposed regulation would make—and has already made—immigrant families afraid to seek programs that support their basic needs, including programs that are not even included in the proposed public charge test. These programs play a key role in reducing poverty and hunger and improving health and economic security.
If millions of families decide not to access these programs, the severe cost of increased poverty, hunger, unstable housing, and financial insecurity will resound not only the individuals themselves, but on their communities and the entire country.
The vast majority of unauthorized immigrants in the US are not eligible for public benefits. Even lawful permanent residents as a rule are ineligible for benefits for the first five years after gaining resident status. However, millions of non-citizens who may one day apply for permanent resident status live in “mixed-status” families. About 16.7 million people have at least one unauthorized family member living in the same household. More than eight million US citizens have at least one unauthorized family member living with them. More than 6.9 million US citizen children live with at least one family member who is unauthorized. These legal immigrants and citizens, who are fully eligible for these programs, may forego access to these programs–even on a temporary or emergency basis– in order to preserve their loved ones’ path to legal status. Although the public charge test focuses on benefits used by the intending immigrant, widespread confusion about the parameters of this rule are likely to lead to a much broader chilling effect.
There is historical precedent for this scenario. In the wake of welfare reform in the 1990s, there was 25% disenrollment among children of foreign-born parents from Medicaid even though the majority of these children were not affected by the eligibility changes and remained eligible. If the proposed rule leads to disenrollment of just 15 percent, an estimated 2.1 million people could disenroll just among Medicaid/CHIP enrollees, according to the Kaiser Family Foundation. Since welfare reform in the 1990s did not affect immigration status directly, unlike the proposed public charge rule, these estimates may actually underestimate the impact of the rule on benefit usage. Further, the current political climate, with efforts to reduce legal immigration for the first time in decades and increased arrests and deportations, fear of immigration consequences of using public benefits could be even greater.
Already, health and nutrition service providers have noticed an increase in canceled appointments and requests to disenroll from means-tested programs in 2017. Researchers also found that early childhood education programs reported drops in attendance and applications as well as reduced participation from immigrant parents in classrooms and at events, along with an uptick in missed appointments at health clinics. Another recent study found that immigrant families–including those who are lawfully present–are experiencing high levels of fear and uncertainty across all background and locations. In a 2018 survey of health care providers in California, more than two-thirds (67 percent) noted an increase in parents’ concerns about enrolling their children in Medi-Cal (California’s Medicaid program), WIC and CalFresh (California’s SNAP program), and nearly half (42 percent) reported an increase in skipped scheduled health care appointments.
Approximately 25.9 million people would be potentially chilled by the proposed public charge rule, accounting for an estimated 8% of the U.S. population. This number represents individuals with at least one non-citizen in the household who live in households with earned incomes under 250% of the federal poverty level. Of these 25.9 million people, approximately 9.2 million are children under 18 years of age who are family members of at least one noncitizen or are noncitizen themselves, representing approximately 13% of our nation’s child population.
- The proposed rule would have a particularly significant impact on vulnerable populations, including pregnant women, children, people with disabilities, older people, and people with chronic health conditions.
If millions of families were to decide not to access basic programs for which they are eligible, the impact would fall significantly on this country’s most vulnerable populations: pregnant women, children, people with disabilities, and older people.
Women already face significant barriers to health care, and Medicaid plays a crucial role in providing prenatal and obstetric care for women who otherwise do not have health insurance. Prenatal care is crucial for positive pregnancy and birth outcomes for women and their children. When they forego prenatal care, there can be significant negative outcomes for them and their children far into the future. In addition to access to prenatal care, nutrition assistance also helps promote healthy birth outcomes. Researchers comparing the long-term outcomes of individuals in different areas of the country when SNAP expanded nationwide in the 1960s and early 1970s found that mothers exposed to SNAP during pregnancy gave birth to fewer low-birth-weight babies.
Currently more than eight million citizen children with an immigrant parent have Medicaid/CHIP coverage. In 2006, 31 percent of children enrolled in WIC were citizen children of immigrant parents or immigrant children. In 2009 eight percent of all SNAP participants and 17 percent of child participants were citizen children living with noncitizen adults.
A significant proportion of people who receive SNAP or Medicaid have a disability. More than one-quarter of people who use SNAP benefits for nutritional support also have a disability. About one-third of adults under age 65 enrolled in Medicaid have a disability, compared with about 12 percent of adults in the general population. Many of these individuals are eligible for Medicaid, and unable to obtain private insurance, precisely because of their disability. Because private health insurance does not cover home and community-based services, such as meal preparation and household care and maintenance, which are only available through Medicaid, the proposed rule would prevent many people with disabilities from getting needed services that allow them to manage their medical conditions and participate in the workforce.
The rule also includes “health conditions requiring extensive treatment” for those without private insurance as a heavily weighted negative factor. This provision would impact millions of immigrants living with HIV, diabetes, hypertension and many other chronic conditions, many of whom now rely on Medicaid or the federal Ryan White program for HIV care and services. A proposed rule has the potential to decrease willingness to seek, and access to, HIV testing and treatment, causing devastating harm to individuals and families. Moreover, such a proposal undermines the national HIV/AIDS policy of increasing utilization of HIV services nationwide in order to control the HIV epidemic and protect the public health.
Medicare is also a lifeline for many older people, including people who have worked for many years in the U.S. and earned this benefit. Medicare provides coverage for hospital and doctors’ visits, and prescription drugs. However, many Medicare beneficiaries rely on other programs to help them afford out-of-pocket costs. Almost one in three Medicare beneficiaries enrolled in Part D prescription drug coverage access the “Extra Help” program for assistance with their premiums and copays through the low-income subsidy. Nearly 7 million people aged 65 and older are enrolled in both Medicare and Medicaid, and one in five Medicare beneficiaries relies on Medicaid to help them pay for Medicare premiums and cost-sharing. Medicaid is also the key to access to oral health care, transportation, and other critical services Medicare does not cover that older adults could otherwise not afford. In 2015, 832,460, or 62 percent of nursing home residents in the US relied on Medicaid. Low-income seniors also greatly benefit from programs such as Section 8 rental assistance and SNAP to meet their basic needs.
- The proposed rule would exacerbate the failures of the existing immigration system to protect families and protect immigrants from abuses.
Under international human rights law, countries have the right to regulate their borders, but they must do so in a way that protects basic rights, such as the right to due process, the right to family unity, and the right to seek redress from abuses. The proposed rule would exacerbate the existing failures of the US immigration system to protect these basic rights. Rather than addressing and minimizing the barriers longstanding residents face to gaining legal status, the proposed rule will likely bar many unauthorized immigrants, who would otherwise be eligible, from gaining legal status. The proposed rule fails to consider the potential significant costs to families should hundreds of thousands of unauthorized immigrants who are otherwise eligible to gain legal status are unable to do so because of the proposed rule.
A recent analysis by the Migration Policy Institute estimates that among people who gained lawful permanent resident status in the last five years, 69 percent had at least one negative factor under the administration’s proposed expanded test. Only 39 percent had income at or above 250 percent of the federal poverty level, the heavily weighted positive factor. Looking more specifically at the population of unauthorized immigrants in the US now, the Center for Migration Studies estimates 2.25 million unauthorized immigrants have a qualifying relationship to a US citizen or lawful permanent resident living in their household that makes them potentially eligible to gain legal status, but that many have factors that would count negatively against them under the proposed new public charge rule.
Human Rights Watch has long-documented the failure of the US immigration system to protect the right to family unity and the heightened vulnerability of unauthorized immigrants to workplace abuses and crimes. When immigrants are deported under an unfair process that fails to provide individual consideration of a person’s family and community ties to the US, the impact is devastating, not only to the immigrant, but to his or her family and community as well. At the same time, unauthorized immigrants are particularly vulnerable to workplace abuses and crimes. Immigrant workers injured on the job or subject to sexual abuse are often afraid to report the harm they have suffered. Employers who fail to pay wages often tell their workers, “I don’t have to pay you, you’re illegal.” As local law enforcement has become increasingly involved in immigration enforcement, under both state and federal law, immigrants are increasingly afraid to report crimes, which affects the safety of the entire community.
In order to effectively and comprehensively address these failures, we have repeatedly recommended that Congress create a fair and inclusive legalization program that provides legal status for unauthorized immigrants in the US who meet a clearly defined set of criteria and that aims to integrate those with strong family and community ties to the US.
When unauthorized immigrants are deported, their families pay tremendous emotional and financial costs. When unauthorized immigrants are afraid to report workplace abuses and crimes, citizen workers and broader communities suffer as well. The proposed rule fails to consider how these costs could increase under a rule that makes it harder for some unauthorized immigrants to gain legal status.
When wage earners are arrested, their families suffer significant economic hardships – they lose significant household income and end up experiencing housing instability, difficulty paying bills, and food hardship. Children whose parents are in detention or facing deportation experience emotional challenges and behavioral problems that can affect their performance in school and impact their future success, including earnings as adults. States and localities that have created funds to support deportation defense for residents in their communities have argued such funds are in their communities’ best interest. In New York, for example, advocates for the New York Immigrant Family Unity Project argued New York bore significant collateral costs associated with homelessness, foster care, and reduced tax revenues when New York City residents are deported.
Only a comprehensive immigration overhaul could directly address the costs to families, communities, and state and federal governments associated with deportations, but the proposed rule, in blocking otherwise eligible, long-term unauthorized residents from gaining legal status would only serve to exacerbate those costs.
The Rights at Stake
Right to Health
Under international law, everyone has the right “to the enjoyment of the highest attainable standard of physical and mental health” without discrimination on the basis of sex, age, or other prohibited grounds. The right to health is also inextricably linked to provisions on the right to life and the right to non-discrimination that are included in the International Covenant on Civil and Political Rights (ICCPR), which the US has ratified.
The Committee on Economic, Social and Cultural Rights, the body charged with interpreting and monitoring the implementation of the ICESCR, has identified four essential components to the right to health: availability, accessibility, acceptability and quality. Even though the US is not a party to the ICESCR, the Committee’s interpretation represents a useful and authoritative guide to the steps governments should take to realize and protect the right to health and other human rights.
The health rights of women in particular are addressed specifically in a number of international treaties and other authoritative sources. Article 12 of the Convention on the Elimination of Discrimination Against Women (CEDAW) provides that “[s]tates parties shall take all appropriate measures to eliminate discrimination against women in the field of health care in order to ensure, on a basis of equality of men and women, access to health care services […].” The US has signed, but not ratified, CEDAW. The CEDAW Committee in its General Recommendation 24 affirmed states parties’ obligation to respect women’s access to reproductive health services and to “refrain from obstructing action taken by women in pursuit of their health goals.” As with the ICESCR, even though the US is not a party to CEDAW, the Committee’s interpretation represents a useful and authoritative guide to the steps governments should take to realize and protect the range of human rights addressed under the Convention.
Under the Convention on the Rights of the Child (CRC), children have the right to the highest attainable standard of health, including access to nutritious foods. Although it is a signatory, the US is the only UN member state that has not ratified the CRC, the primary instrument under international law that elaborates the rights of children. However, the Convention is an authoritative and useful tool for understanding the human rights issues children face, and the measures needed to effectively address them. The American Academy of Pediatrics has twice endorsed the CRC.
Rights of Persons with Disabilities
The Convention on the Rights of Persons with Disabilities (CRPD) seeks to “promote, protect, and ensure the full and equal enjoyment of all human rights and fundamental freedoms by all persons with disabilities.” It specifically protects the right of persons with disabilities to live independently in the community; governments are to take appropriate measures to ensure persons with disabilities have access to community support services. The United States has signed but not ratified the CRPD. The Convention is nonetheless a useful and authoritative guide to steps the US government should take to protect and respect the rights of people with disabilities.
Right to non-discrimination
Non-discrimination is a central principal of international human rights law. As a party to the ICCPR, the US is obligated to guarantee effective protection against discrimination. The US also undertakes to eliminate racial discrimination and guarantee everyone, without distinction, the right to public health, under the International Convention on the Elimination of all Forms of Racial Discrimination. The treaty obligates governments to address both intentional racial discrimination by laws and policies and practices that result in disparate racial impact.
This proposed rule would disproportionately impact vulnerable populations, including women, children, people with disabilities, older people, and people with chronic health conditions.
Thank you for the opportunity to submit comments on the proposed rulemaking. Please do not hesitate to contact Grace Meng, senior US researcher at Human Rights Watch, at email@example.com or at (323) 694-5181 if you have any questions.
 Alison Siskin, Congressional Research Service, “Noncitizen Eligibility for Federal Public Assistance: Policy Overview,” December 12, 2016, https://fas.org/sgp/crs/misc/RL33809.pdf (accessed December 4, 2018).
 University of Southern California Center for Immigrant Integration and Center for American Progress, “Keeping Families Together: Why All Americans Should Care What Happens to Unauthorized Immigrants,” March 16, 2017, https://www.americanprogress.org/issues/immigration/reports/2017/03/16/428335/keeping-families-together/ (accessed December 3, 2018).
 Neeraj Kaushal and Robert Kaestner, “Welfare Reform and Health Insurance of Immigrants,” Health Services Research, 40(3), June 2005, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361164/pdf/hesr_00381.pdf (accessed December 4, 2018).
 Samantha Artiga, Raphael Garfield, and Anthony Damico, Kaiser Family Foundation, “Estimated Impacts of the Proposed Public Charge Rule on Immigrants and Medicaid,” October 11, 2018, https://www.kff.org/disparities-policy/issue-brief/estimated-impacts-of-the-proposed-public-charge-rule-on-immigrants-and-medicaid/ (accessed December 4, 2018).
 Jeanne Batalova, Michael Fix, and Mark Greenberg, Migration Policy Institute, “Chilling Effects: The Expected Public Charge Rule and Its Impact on Legal Immigrant Families’ Public Benefits Use,” June 2018, https://www.migrationpolicy.org/research/chilling-effects-expected-public-charge-rule-impact-legal-immigrant-families (accessed December 4, 2018).
 Jennifer Laird et al., Columbia Population Research Center, “Foregoing Food Assistance Out of Far Changes to ‘Public Charge’ Rule May Put 500,000 More U.S. Citizen Children at Risk of Moving into Poverty,” April 5, 2018, https://static1.squarespace.com/static/5743308460b5e922a25a6dc7/t/5af1a2b28a922db742154bbe/1525785266892/Poverty+and+Social+Policy+Brief_2_2.pdf (accessed December 4, 2018).
 Hannah Matthews et al., The Center for Law and Social Policy, “Immigration Policy’s Harmful Impacts on Early Care and Education,” March 2018, https://www.clasp.org/sites/default/files/publications/2018/03/2018_harmfulimpactsece.pdf (accessed December 4, 2018).
 Samantha Artiga and Petry Ubri, Kaiser Family Foundation, “Living as an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health,” December 3, 2017, https://www.kff.org/disparities-policy/issue-brief/living-in-an-immigrant-family-in-america-how-fear-and-toxic-stress-are-affecting-daily-life-well-being-health/ (accessed December 3, 2018).
 The Children’s Partnership and California Immigrant Policy Center, “Healthy Mind, Healthy Future: Promoting the Mental Health and Wellbeing of Children in Immigrant Families,” August 2018, https://www.childrenspartnership.org/wp-content/uploads/2018/08/Healthy-Mind-Healthy-Future-Report-Promoting-the-Mental-Health-and-Wellbeing-of-Children-in-Immigrant-Families.pdf.pdf (accessed December 4, 2018).
 2012-2016 5-Year American Community Survey Public Use Microdata Sample (ACS/PUMS); 20122016 5-Year American Community Survey (ACS) estimates accessed via American FactFinder; Missouri Census Data Center (MCDC) MABLE PUMA-County Crosswalk. Custom Tabulation by Manatt Health, October 11 2018, https://www.manatt.com/Insights/Articles/2018/Public-Charge-Rule-Potentially-Chilled-Population (accessed December 4, 2018).
 Douglas Almond, Hillary Hoynes, and Diane Schanzenbach, “Inside the War on Poverty: The Impact of Food Stamps on Birth Outcomes,” The Review of Economics and Statistics, 93(2), May 2011, https://www.mitpressjournals.org/doi/pdfplus/10.1162/REST_a_00089; and Hilary Hoynes, Diane Whitmore Schanzenbach, and Douglas Almond, “Long-Run Impacts of Childhood Access to the Safety Net,” American Economic Review, 106(4):903–934, April 2016, https://pdfs.semanticscholar.org/c94b/26c57bb565b566913d2af161e555edeb7f21.pdf.
 Samantha Artiga & Anthony Damico, Kaiser Family Foundation, “Nearly 20 Million Children Live in Immigrant Families that Could Be Affected by Evolving Immigration Policies,” Apr. 18, 2018, https://www.kff.org/disparities-policy/issue-brief/nearly-20-million-children-live-in-immigrant-families-that-could-be-affected-by-evolving-immigration-policies/ (accessed December 4, 2018).
 Tracy Vericker, et al., Urban Institute, “Effects of Immigration on WIC and NSLP Caseloads,” September 2018, https://www.urban.org/sites/default/files/publication/29156/412214-Effects-of-Immigration-on-WIC-and-NSLP-Caseloads.PDF (accessed December 4, 2018).
 Curtis Skinner, Columbia University National Center for Children in Poverty, “SNAP Take Up Among Immigrant Families With Children, Columbia University National Center for Children in Poverty” available at http://www.nccp.org/publications/pdf/text_1002.pdf (accessed December 4, 2018).
 See, e.g., Nationwide Adult Medicaid CAHPS, “Health Care Experiences of Adults with Disabilities Enrolled in Medicaid Only: Findings from a 2014-2015 Nationwide Survey of Medicaid Beneficiaries,” November 2017, https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/namcahpsdisabilitybrief.pdf (accessed December 4, 2018).
 USCIS, “Proposed Change to Public Charge Ground of Inadmissibility,” https://www.uscis.gov/legal-resources/proposed-change-public-charge-ground-inadmissibility (accessed December 4, 2018)
 The White House, National HIV/AIDS Strategy for the United States Updated to 2020.
 Kaiser Family Foundation, “Medicare Part D in 2018: The Latest on Enrollment, Premiums, and Cost Sharing,” May 17, 2018, www.kff.org/medicare/issue-brief/medicare-part-d-in-2018-the-latest-on-enrollment-premiums-and-cost-sharing/ (accessed December 4, 2018).
 Kaiser Family Foundation, “Medicaid Enrollment by Age,” https://www.kff.org/medicaid/state-indicator/medicaid-enrollment-by-age/ (accessed December 8, 2018)
 Kaiser Family Foundation, “Medicaid’s Role in Nursing Home Care, by State,” June 7, 2017, https://www.kff.org/infographic/medicaids-role-in-nursing-home-care (accessed December 4, 2018).
 See Justice in Aging, Supporting Older Americans’ Basic Needs: Health Care, Income, Housing and Food, April 2018, www.justiceinaging.org/wp-content/uploads/2018/04/Supporting-Older-Americans%E2%80%99-Basic-Needs_Health-Care-Income-Housing-and-Food.pdf (accessed December 4, 2018).
 Randy Capps et al., Migration Policy Institute, “Gauging the Impact of DHS’s Proposed ‘Public Charge’ Rule on U Immigration,” November 2018, https://www.migrationpolicy.org/research/impact-dhs-public-charge-rule-immigration (accessed December 4, 2018).
 Donald Kerwin et al., Center for Migration Studies, “Proposed Public Charge Rule Would Significantly Reduce Legal Admissions and Adjustment to Lawful Permanent Resident Status for Working Class Persons,” http://cmsny.org/publications/2018-proposed-public-charge-rule/ (accessed December 4, 2018).
 Human Rights Watch, The Deported: Immigrants Uprooted from the Country They Call Home, December 5, 2017, https://www.hrw.org/report/2017/12/05/deported/immigrants-uprooted-country-they-call-home.
Human Rights Watch, Blood, Sweat and Fear: Workers’ Rights in US Meat & Poultry Plants, January 24, 2005, https://www.hrw.org/report/2005/01/24/blood-sweat-and-fear/workers-rights-us-meat-and-poultry-plants (accessed December 4, 2018); Human Rights Watch, Cultivating Fear: The Vulnerability of Immigrant Farmworkers in the US to Sexual Violence and Sexual Harassment, May 15, 2012.
 Human Rights Watch, US/Alabama: No Way to Live, December 2011, https://www.hrw.org/news/2011/12/14/us/alabama-no-way-live-under-immigrant-law.
 Human Rights Watch, No Way to Live, and Human Rights Watch, US: Don’t Call 911, May 19, 2014, https://www.hrw.org/news/2014/05/19/nashville-immigrants-too-scared-call-police.
Human Rights Watch, The Deported: Immigrants Uprooted from the Country They Call Home, December 5, 2017, https://www.hrw.org/report/2017/12/05/deported/immigrants-uprooted-country-they-call-home#290612. See also, Human Rights Watch, Within Reach: A Roadmap for US Immigration Reform, May 1, 2013, https://www.hrw.org/video-photos/interactive/2013/05/01/within-reach-roadmap-us-immigration-reform.
 See Ajay Chaudry et al., Urban Institute, “Facing our Future: Children in the Aftermath of Immigration Enforcement,” February 2, 2010, https://www.urban.org/research/publication/facing-our-future/view/full_report (accessed December 4, 2018).
 Center for Popular Democracy, “New York Immigrant Family Unity Project: The Report,” October 29, 2013, https://populardemocracy.org/news/publications/new-york-immigrant-family-unity-project-report (accessed December 3, 2018).
 International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, art. 12(1), https://www.ohchr.org/en/professionalinterest/pages/cescr.aspx (accessed December 4, 2018). The US has signed, but not ratified, the ICESCR and as such is not legally bound by its provisions. In addition, as a signatory, the US has an obligation not to take actions that would defeat the object and purpose of the treaty. Vienna Convention on the Law of Treaties, art. 18(a), May 23, 1969, 1155 U.N.T.S. 331 (entered into force Jan. 27, 1980). Although the United States is not a party to the Vienna Convention, the treaty's provisions are considered to be customary international law.
 International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171, entered into force March 23, 1976, ratified by the United States on June 8, 1992, art. 10, https://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx (accessed December 4, 2018).
 Committee on Economic, Social and Cultural Rights (CESCR), “Substantive Issues Arising in the Implementation of the International Covenant on Economic, Social and Cultural Rights,” General Comment No. 14, The Right to the Highest Attainable Standard of Health, E/C.12/2000/4 (2000), http://www.refworld.org/pdfid/4538838d0.pdf (accessed December 4, 2018), para. 12.
 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), adopted December 18, 1979, G.A. res. 34/180, 34 U.N. GAOR Supp. (No. 46) at 193, U.N. Doc. A/34/46, entered into force September 3, 1981, art. 12, http://www.un.org/womenwatch/daw/cedaw/cedaw.htm (accessed December 4, 2018).
 CEDAW Committee, “General Recommendation 24, Women and Health (Article 12),” U.N. Doc. No. A/54/38/Rev.1 (1999), para. 14, https://www.refworld.org/docid/453882a73.html (accessed December 4, 2018).
 Convention on the Rights of the Child (CRC), adopted November 20, 1989, G.A. Res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), entered into force September 2, 1990, signed by the United States on February 16, 1995, https://www.ohchr.org/en/professionalinterest/pages/crc.aspx (accessed on December 4, 2018). Additionally, the US has an obligation under International Covenant on Civil and Political Rights, art. 24 to provide children with “such measures of protection as are required by [their] status” as children. The Human Rights Committee has noted that these measures of protection can include ESC measures.
 American Academy of Pediatrics, “Health Equity and Children’s Rights,” Pediatrics, April 2010, Vol. 125, Issue 4, reaffirmed October 2013, http://pediatrics.aappublications.org/content/125/4/838 (accessed December 6, 2018).
 Convention on the Rights of Persons with Disabilities (CRPD), adopted January 24, 2007, G.A. Res. 61/106, U.N. Doc. A/61/106 (2007), entered into force May 3, 2008, signed by the United States on July 30, 2009, https://www.un.org/development/desa/disabilities/convention-on-the-rights-of-persons-with-disabilities.html (accessed December 4, 2018). The US has not yet ratified the convention, but as a signatory, may not take actions inconsistent with it.
 CRPD, art.19.
 ICCPR, art. 26.
 International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), adopted December 21, 1965, G.A. Res. 2106 (XX), annex, 20 U.N. GAOR Supp. (No. 14) at 47, U.N. Doc A/6014 (1966), 660 U.N.T.S. 195, entered into force January 4, 1969, ratified by the United States November 20, 1994, art. 5(e)(iv), https://www.ohchr.org/en/professionalinterest/pages/cerd.aspx (accessed December 4, 2018).
 ICERD, art. 1(1).