A new directive from Donald Trump’s administration has sparked anger and alarm after it emerged that foreigners applying for visas to live in the United States could be refused entry if they are judged too likely to become a financial burden on the health-care system because of conditions such as obesity, diabetes and heart disease. The guidance, circulated in a cable from the US State Department to embassies and consulates around the world and first reported by KFF Health News, instructs consular officers to weigh common chronic illnesses and applicants’ ability to pay for long-term treatment when deciding whether to grant visas.
The cable tells officials they “must consider an applicant’s health” and lists a broad range of non-communicable conditions that can now count against would-be immigrants, including cardiovascular and respiratory diseases, cancers, diabetes, metabolic and neurological disorders, and mental health conditions. It goes on to say that these illnesses “can require hundreds of thousands of dollars’ worth of care”, and explicitly urges officers to take obesity into account because it can lead to asthma, sleep apnoea and high blood pressure, all of which may require expensive, long-term treatment.
Under US immigration law, people seeking to enter or settle in the country can be refused if officials decide they are likely to become a “public charge” – somebody who will depend on certain government benefits. That standard has existed for more than a century, but has historically been applied narrowly, focusing on factors such as poverty and, in health terms, on contagious diseases that pose a direct risk to the public. The new guidance significantly broadens that interpretation, asking visa officers not just to look at applicants’ current health but to make judgements about their future need for medical care and the possible cost to US taxpayers.
In practice, the change gives frontline consular staff far more discretion over who is allowed to cross the border. Alongside the expanded list of medical conditions, officers are instructed to carry out a kind of lifetime affordability test, asking whether an applicant has “adequate financial resources to cover the costs of such care over his entire expected lifespan without seeking public cash assistance or long-term institutionalisation at government expense”. The cable also directs them to consider the health of dependants, including children and older relatives, and to ask whether caring responsibilities might prevent an applicant from maintaining employment in the US.
The policy does not operate as an outright ban on people who are overweight or who live with chronic conditions, and the guidance stresses that decisions must still be made case by case. However, immigration lawyers and public-interest groups say it opens the door to far more rejections for people whose health issues are common across much of the world’s population. About 10% of people globally have diabetes, according to figures cited in coverage of the directive, and cardiovascular diseases remain the leading cause of death. Obesity rates have also risen sharply; in the United States more than 40% of adults are classified as obese and many other countries, including key US allies, report rising levels.
Critics argue the guidance could allow consular staff, who are not medically trained, to make decisions based on incomplete information or personal bias. Charles Wheeler, a senior attorney with the Catholic Legal Immigration Network, told reporters that the cable appears to conflict with the State Department’s own Foreign Affairs Manual, which instructs officers not to deny visas based on speculative “what if” scenarios. He warned that asking officials to form “their own thoughts about what could lead to some sort of medical emergency or sort of medical costs in the future” was troubling precisely because they lacked specialist knowledge and could end up making inaccurate or discriminatory assessments.
Other legal experts have raised concerns that the guidance effectively treats some foreign nationals as potential liabilities simply because they are older or live with conditions that are widespread in the US itself. Erin Corcoran, a professor of immigration and human rights law at the University of Notre Dame, said similar rules introduced during Trump’s first term had already signalled a shift towards viewing immigrants as a financial burden rather than contributors to society. She and others argue that this latest expansion of the “public charge” standard could deter people from applying for visas or from seeking medical help even when they are lawfully present, for fear that treatment records might later be used against them or their relatives.
Supporters of the move inside the administration frame it as part of a broader effort to reduce immigration and limit taxpayer spending. The directive follows a series of measures under Trump aimed at tightening both legal and irregular migration, including earlier attempts to expand the definition of “public charge” to cover a wider range of welfare programmes. Officials argue that the US is entitled to prioritise applicants who are unlikely to need publicly funded support and who can demonstrate financial self-sufficiency, especially as healthcare costs rise and new weight-loss drugs and cancer treatments stretch insurance and government budgets.
The immediate practical impact of the guidance is still uncertain. Many visa categories already involve medical examinations by approved doctors, and communicable diseases such as tuberculosis have long been grounds for further scrutiny or denial. Under the new system, however, conditions that are not contagious but are expensive to treat may play a much larger role. Immigration specialists say that could affect a wide range of people, from retirees hoping to join family members in the US to skilled workers with chronic illnesses and students with mental health histories. It may also intersect with existing inequalities, as applicants from poorer countries or with lower incomes are less likely to have comprehensive private insurance or savings that can reassure visa officers.
The directive has drawn particular attention from advocacy groups representing disabled people and those with long-term illnesses, who warn that it risks embedding stigma in immigration decisions. They point out that the cable explicitly highlights disabilities and “special needs” among dependants as factors that could reduce a primary applicant’s ability to keep a job, potentially counting against families who provide care for children with developmental conditions or older parents with dementia. Campaigners argue that such language runs counter to international efforts to promote inclusion and equal treatment for disabled people, and could encourage other countries to adopt similarly restrictive approaches.
The controversy has been amplified on social media, where posts distilling the complex guidance into shorthand claims about “bans” on overweight people have been widely shared and criticised. Users have highlighted the contrast between the focus on the health of prospective immigrants and Trump’s own history, noting that his weight was a subject of scrutiny during previous presidential terms. Others have argued that the policy effectively tells people with common conditions that they are not welcome, even as the US continues to recruit foreign workers for industries such as healthcare, technology and academia. While some supporters of the administration contend online that it is reasonable to protect public finances, the reaction from many viewers and commentators has been sharply negative, with accusations of “fat-shaming” and discrimination against people with disabilities.
For now, the State Department has not offered detailed public justification beyond what is contained in the cable, and spokespeople have declined to comment further when contacted by reporters. That leaves many practical questions unresolved, including how officers will access and interpret medical information, what evidence applicants will need to provide to demonstrate they can pay for treatment, and whether there will be any formal appeals process for those refused on health grounds. Immigration lawyers expect that the new rules will be tested in US courts, where previous iterations of the “public charge” policy have faced legal challenges on the basis that they were arbitrary, capricious or inconsistent with congressional intent.
The debate around the directive is unfolding against a backdrop of broader concern about migration and healthcare in the United States. As campaigns ramp up ahead of future elections, Trump has repeatedly promised tougher action on immigration and has portrayed his opponents as favouring what he calls “open borders”. At the same time, soaring medical costs, disputes over insurance coverage and political fights over programmes such as Medicaid have kept healthcare at the centre of domestic politics. The new visa guidance sits at the intersection of those arguments, turning long-running anxieties about the price of treatment into a formal criterion for deciding who can cross the US border.
For people outside the United States who are older, overweight or living with chronic illness, the change introduces a new layer of uncertainty into an already complex process. Consular officers around the world now have explicit instructions to weigh conditions like obesity and diabetes in their calculations of future cost, and to ask whether applicants can pay for care without help from the American state. How strictly they will apply those rules – and how many people will see their travel or migration plans derailed as a result – will become clear only as cases begin to filter through embassies, consulates and, in all likelihood, the US courts.