(UNITED STATES) The U.S. State Department has expanded the use of health-based grounds to refuse visas, directing consular officers worldwide to weigh a broad range of chronic conditions when deciding if an applicant is likely to become a public charge. The guidance, circulated to embassies and consulates in 2025 under the Trump administration and in effect as of November 2025, reaches into family immigration, including cases involving spouses of U.S. citizens. Immigration lawyers say the shift has already led to more visa denials and leaves families scrambling to prove they can privately cover long-term medical costs without public assistance.
What changed and why it matters
Under the new approach, officers are instructed to consider whether an applicant, and any dependents, have adequate resources to pay for medical care throughout their expected lifespan without relying on government-funded programs or long-term institutional care.
This represents a pivot from prior practice, which focused primarily on communicable diseases and vaccination compliance. The updated guidance:
- Places sharper focus on projected lifetime costs of care.
- Expands scrutiny to common chronic conditions such as:
- Diabetes
- Cardiovascular disease
- Obesity
- Respiratory diseases
- Cancers
- Metabolic and neurological disorders
- Mental health conditions
These conditions can now trigger additional scrutiny and may tip a case toward refusal if private means for long-term care are not clearly documented.
Scope: who is affected
- The guidance applies across nearly all visa categories, including immigrant visas for spouses.
- It explicitly extends to family members planning to immigrate with the principal applicant.
- If a child or elderly parent has a disability or chronic illness that could reduce the principal applicant’s ability to work, officers are directed to factor that into the public charge assessment.
Lawyers warn that the policy’s breadth means even well-prepared families can face difficult questions at consular interviews, especially when future medical needs are uncertain.
Practical effects at interviews
Medical exams have long been part of the visa process, but the emphasis on chronic conditions and projected costs changes the stakes:
- Officers now request detailed evidence of assets, private insurance, and other resources to cover long-term treatment.
- Attorneys report officers are being asked to make complex, lifetime medical cost projections—tasks beyond typical consular training.
“This guidance asks consular officers and panel physicians to make complex, lifetime medical cost projections,” said attorney Sophia Genovese. “They’re not trained for that, and families are left trying to prove the unknowable.”
Charles Wheeler of the Catholic Legal Immigration Network described the policy as “troubling,” noting officers lack the medical expertise to accurately predict future health needs.
Direct impact on spouses of U.S. citizens
- A spouse’s visa can now be denied based solely on a chronic health condition if the officer finds the applicant is likely to require costly care and cannot prove the ability to pay privately for the long term.
- There is no automatic exemption for family unity, and standards do not relax because the petitioner is a U.S. citizen.
- The burden of proof rests with the applicant, who must demonstrate substantial private means to avoid a public charge finding.
Transparency and oversight concerns
- The State Department has not publicly released the exact text of the diplomatic cable that underpins the changes.
- KFF Health News and multiple immigration law firms have reviewed the contents, according to attorneys who have seen the materials.
- That partial visibility, combined with large consular discretion, makes it unclear what evidence will satisfy an officer’s concerns at a given post.
Documentation challenges
Even with private insurance, families face hurdles:
- Premiums, deductibles, and coverage limits differ widely between plans.
- Matching plan details to an officer’s expectations about high-cost conditions (e.g., cancer, advanced diabetes) is difficult.
- For illnesses with unpredictable courses, building a credible financial plan that satisfies a consular officer is often not straightforward—even for applicants with savings.
Legal advocates report no dedicated appeal pathway specifically for health-based refusals. Applicants can reapply with new evidence, but consular discretion is broad and there’s no sign of a formal review mechanism tied to these determinations.
What lawyers and advocates recommend
Applicants and petitioners are increasingly taking practical steps to prepare:
- Working with private insurers and financial planners to assemble documentation.
- Collecting detailed letters from treating physicians.
- Showing proof of sustained insurance coverage.
- Producing records that demonstrate liquid assets sufficient to pay for potential high-cost care.
According to VisaVerge.com analysis, families report inconsistent experiences across consulates, with some posts applying stricter readings of public charge factors than others. That variability can affect outcomes for identical medical profiles depending on where the case is processed.
Real-world examples described by attorneys
- A U.S. citizen petitioner expecting a straightforward immigrant visa process for a spouse with controlled Type 2 diabetes was instead asked detailed questions about costs for specialists, medications, and possible complications decades ahead.
- A principal applicant faced a likely refusal because a parent’s neurological disorder raised concerns that the applicant would become a full-time caregiver, reducing employability and tipping the public charge analysis toward denial.
In both examples, the health-based grounds assessment became decisive, even where all other eligibility elements were satisfied.
Legal context and government resources
Official materials note that public charge decisions involve a totality of circumstances, including:
- Age
- Health
- Family status
- Assets and resources
- Financial status
- Education or skills
But attorneys say the latest guidance places unusual weight on health and projected costs, reshaping outcomes across visa categories. For an overview of the government’s framework, see the State Department’s public charge page: https://travel.state.gov/content/travel/en/us-visas/immigrate/public-charge.html.
Criticism and political context
- Critics argue the change will hit hardest families with modest means or from countries where advanced medical care is less accessible.
- Supporters of stricter screening say the U.S. should ensure immigrants are self-sufficient and will not add costs to public programs.
- Some lawmakers and policy analysts warn this approach could force mixed-status families into impossible choices, noting that listed medical conditions do not on their own predict lifetime costs or employability.
“Chronic disease is not destiny,” said one attorney, arguing the policy conflates diagnosis with dependency.
What to expect and next steps for applicants
- No automatic bar exists for any single condition; success often depends on private coverage, employment records, and documented assets.
- The requirement to predict and pay for a lifetime of care sets a high bar and, without clear standards, officers may default to caution—raising the chance of visa denials where doubt remains.
Practitioners’ recommended checklist before consular interviews:
- Obtain detailed medical letters from treating physicians explaining prognosis and treatment plans.
- Provide proof of continuous private insurance with clear summaries of covered services.
- Document liquid assets and accessibility (bank statements, investment accounts).
- Supply explanations from financial planners if available, tying assets and insurance to potential high-cost scenarios.
- Be prepared to answer detailed questions about who pays for care and how resources will cover potential high-cost events.
If a refusal is issued on public charge grounds tied to health, reapplication with substantial new documentation is the main recourse. Advocacy groups are monitoring cases as refusals tied to chronic conditions rise and are urging families to seek legal advice early.
Bottom line
With the policy live and no immediate revision apparent, practitioners advise assembling the strongest possible financial record before attending consular interviews. That includes consistent insurance coverage, proof of accessible assets, and clear medical explanations. While the law still calls for a holistic review, the expanded health-based grounds have become central to consular public charge assessments—and families are experiencing the effects in real time.
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This Article in a Nutshell
The State Department’s November 2025 guidance directs consular officers worldwide to weigh common chronic conditions and projected lifetime medical costs when assessing public-charge risk across nearly all visa categories, including spouses. The change increases denials and requires applicants to provide private insurance documentation, medical letters, and proof of liquid assets. Attorneys warn officers are being asked to make complex cost projections beyond their training. Families should assemble thorough financial and medical documentation before consular interviews.
