Health Care and Undocumented Immigrants
by Samuel Metz, MD, 1 August 2013
If immigration reform isn’t tough enough, watch the fireworks when we include the health care needs of undocumented immigrants. For many Americans, subsidizing health care of the undocumented by higher taxes and more expensive insurance policies is intolerable. We surely cannot afford the expense of providing more care at greater cost to a population of uninvited outsiders.
This is where immigration reform efforts run aground. Above all, we must protect our already endangered health care system from the ruinous expense of caring for the undocumented as well.
Or so goes the argument. Is it true?
The answer is not trivial. The future of both immigration reform and our family’s access to health care rests on getting this right. We run grave risks if we base immigration policy on intuition, no matter how appealing that intuition might be.
The argument against including the undocumented in our health care system rests on assumptions: (1) immigrants consume more health care dollars than native born Americans, (2) the cost of their health care exceeds what they pay in taxes; (3) providing free health care only encourages more illegal immigration (and further drains our public resources), and (4) excluding them will reduce health care costs for the rest of us.
None of these assumptions are correct.
Of the 25 million immigrants in the US (8% of the population), 12 million are undocumented. A 2005 study estimated these 25 million immigrants consume $39 billion annually in health care, (less than 2% of the $2.6 trillion spent by all Americans). The Pew Hispanic Center found 40% of the undocumented already own private insurance policies, and thus pay their own way.
The remaining seven million immigrants who are both undocumented and uninsured consume miniscule amounts of health care, about $4.3 billion annually. Per capita, they consume less than one tenth of what native born Americans spend. This is not statistical flim-flam: multiple studies corroborate that immigrants consume fewer health care dollars per person than native born Americans. No evidence refutes this.
Even so, does this small amount of health care exceed what undocumented immigrants pay in taxes? No. Immigrants subsidize the rest of us. A recent article in Health Affairs found that Medicare receives $16 billion more in taxes from undocumented immigrants than is spent on their care. The Social Security administration discovered immigrants generated $12 billion in payroll taxes for benefits they will never receive.
In sum, immigrants inject $30 billion in taxes each year without receiving any services in return.
Perhaps excluding immigrants might still reduce overall health care spending. Again, evidence says No.
The absolute amount of health care savings by excluding undocumented immigrants is small, less than 2% of total health spending.
But even this small savings disappears when we include enforcement costs of such a policy. The Government Accounting Office found efforts to exclude undocumented immigrants from Medicaid were expensive – very expensive: states on average spent $100 on administration to save 14 cents in health care.
Worse, these efforts to verify residency resulted in delay or denial of Medicaid to many US citizens unable to produce the required documentation.
States are not the only agencies that lose by excluding immigrants. Smaller communities also pay heavily when they restrict health care access. Studies from the University of Pennsylvania and the Commonwealth Fund showed that as an area’s uninsured population grows, access and quality of care for the insured go down. If a community wants to protect its health care, extending care to all residents (including the undocumented) appears the better choice.
Still, some argue that providing health care to undocumented immigrants encourages more illegal immigration. Unlikely. Immigrants come here for jobs, not health care. Undocumented Latinos, for example, primarily immigrated to states with employment opportunities; family and housing were secondary considerations. In contrast, data from the California Immigrant Policy Center shows readily accessible public health care played no role: instead, those states with the least generous public health care benefit programs showed the fastest rise in immigrant population.
Parenthetically, we should note that 40% of our undocumented immigrants entered the US legally and then overstayed their visas. Erecting physical barriers or withholding free services to prevent illegal entry to the US is of limited value in reducing the overall number of undocumented immigrants.
Regardless of economic arguments, some insist we should punish criminals (i.e., people who enter the US illegally) by denying them health care. This runs contrary to a legal principle: The only people in the US constitutionally entitled to medical care at public expense are those in prison. (Shockingly, we find stories of native born Americans committing crimes solely to get care they could not afford as free citizens but would receive as convicted felons.) Should undocumented immigrants who pay more in taxes than they receive in public benefits be excluded from health care while convicted felons who pay no taxes are included? It’s hard to find an economic justification for this conclusion.
Absent economic and legal reasons, is there a moral reason to deny health care to undocumented immigrants? Many citizens, despite financial reasons to the contrary, cannot tolerate their tax dollars serving undocumented immigrants.
Such an argument cannot be refuted. Moral disputes are about ideals, not facts. However, we must acknowledge the real costs of implementing this argument as public policy. Denying health care to undocumented immigrants costs us money, increases our taxes, and reduces our access to health care.
What is the best solution to immigration reform? No answers are easy, but let’s not make hard answers harder. Immigration reform is simpler, our health care more accessible, and our taxes lower when we extend health care to everyone, including undocumented immigrants.
The late Senator Paul Wellstone expressed this well: “We all do better when we all do better.”
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