New Public Charge Guidance: How the State Department’s Expanded Health and Financial Review May Affect Visa Applicants

Recent reporting confirms that the U.S. Department of State (DOS) has issued new internal guidance—via a cable distributed to consular posts worldwide—significantly expanding how consular officers evaluate visa applicants under the public charge ground of inadmissibility (INA §212(a)(4)). Although the statute itself has not changed, this directive reshapes the analysis by placing far heavier weight on medical conditions, financial self-sufficiency, education, and employability than past practice.

This development has major implications for anyone applying for an immigrant visa or certain nonimmigrant visas abroad.

A Shift Toward Predictive Economic Assessment

Traditionally, the public charge determination focused on whether a person was likely to become primarily dependent on U.S. government support. But the new DOS guidance expands this review by asking consular officers to look beyond immediate health or financial issues and consider the future financial impact of chronic medical conditions—even when those conditions are not grounds for medical inadmissibility.

This includes conditions that previously played little or no role in visa decision-making.

The DOS cable reportedly instructs officers to:

• Scrutinize medical exams for any chronic physical or mental health conditions, even Class B conditions (which are not grounds for denial under INA 212(a)(1)).
• Return medical exams to the panel physician (via 221(g)) if the doctor has not provided detailed analysis of the applicant’s likely disability level, anticipated medical needs, or risk of eventual institutionalization.
• Evaluate whether these conditions could lead to future financial strain, inability to work, or reliance on public assistance.

This represents a fundamental shift: the focus of the medical exam is no longer only about communicable diseases or public health risks, but also projected long-term healthcare costs.

Medical Conditions Flagged for Public Charge Review

According to the AILA Practice Alert, the DOS cable specifically highlights several health conditions—some of which have never been a basis for inadmissibility—as potential indicators of future public charge risk. Among the conditions reportedly flagged:

• Obesity
• Diabetes
• Hypertension
• Arthritis and joint disorders
• Breathing problems, asthma, sleep apnea
• Gallbladder disease and gallstones
• Mental health concerns such as depression or anxiety
• Cancer or other chronic systemic illnesses

These are not Class A or Class B medical grounds for visa denial. But DOS now frames them as potential contributors to a finding that the applicant may not be able to financially manage future care, and thus could become a public charge.

This blurs the line between medical inadmissibility and financial inadmissibility in a way immigration practitioners have not previously seen.

Expanding Consideration of Other Factors: Education, English Ability & Employment

The cable goes well beyond medical analysis. Consular officers are instructed to stretch the “totality of circumstances” test to identify all possible derogatory factors, including:

• Limited English proficiency
• Low-skilled employment history
• Educational background inconsistent with economic self-sufficiency
• Past receipt of public benefits—including outside the United States
• Weak financial resources or savings

Although the Foreign Affairs Manual (9 FAM 302.8) already lists these factors, the new guidance encourages a more aggressive and less forgiving approach, treating them as early warnings of financial instability.

Notably, even a strong Affidavit of Support (Form I-864) is no longer treated as a decisive factor. Officers are directed to consider the sponsor’s income but not view it as dispositive.

Applies to Both Immigrant & Certain Nonimmigrant Visas

The guidance clarifies that INA 212(a)(4) applies to:

• Immigrant visa applicants (family-based, employment-based, etc.)
• Nonimmigrants whose categories are not subject to INA 214(b) — including H-1B and L-1 applicants

While officers are still encouraged to use INA 214(b) to deny tourist visas and other intent-based categories when appropriate, the cable reminds consular staff that public charge can apply even where 214(b) does not.

This could significantly impact employment-based nonimmigrant applicants who previously had little concern about public charge issues.

No Waiver Exists for 212(a)(4) in Consular Processing

One of the most significant consequences of this policy shift is that:

There is no waiver for public charge for immigrant visas processed abroad.

Humanitarian categories (such as refugees, asylees, and VAWA applicants) remain exempt, but family-based and employment-based immigrant visa applicants have no safety valve if denied.

This dramatically increases the stakes for applicants with chronic conditions or limited financial means.

What Applicants Should Expect

Applicants preparing for consular processing should be ready for:

• More intrusive medical questioning, even about non-contagious or well-managed chronic conditions.
• Requests for evidence of health insurance, long-term treatment plans, or employer-based insurance coverage.
• Greater scrutiny of financial resources, including savings, employment prospects, tax history, and support networks.
• Detailed review of educational history, English fluency, or work experience to determine future employability.

Applicants should not attempt to conceal medical conditions—doing so can result in misrepresentation findings under INA 212(a)(6)(C), which are far more damaging.

Practical Guidance for Applicants With Chronic Conditions

If you or a family member is preparing for a medical exam or a consular interview and you have a chronic health condition:

1. Document your ability to manage your condition
   – medical stability, treatment plan, fitness to work, etc.
2. Gather evidence of financial ability
   – income, employment, support from the U.S. sponsor, private insurance, savings, assets.
3. Prepare for officer questions about employability, especially if English proficiency or skills may be questioned.
4. Consult an experienced immigration attorney
   – particularly before the medical exam or interview.

This new guidance changes the risk calculus for many applicants, especially those who – under prior practice – would have passed the public charge review without issue.

Conclusion

The new State Department cable expands the scope of the public charge analysis in unprecedented ways—directing officers to consider chronic medical conditions, financial capacity, English skills, and employability far more aggressively than before. Although the statute has not changed, the way it is being applied has shifted dramatically, and the lack of a waiver for overseas immigrant visa applicants makes this a high-stakes development.

Anyone applying for a visa—especially with chronic medical conditions—should approach the process with careful preparation, strong documentation, and, ideally, professional legal guidance.