The road to health care reform is peppered with landmines that threaten to derail passage of truly comprehensive legislation. Some of these landmines are predictable: cost projections that go beyond $1.6 billion; controversy over new taxes and a public plan; worries about rationing and a government-takeover of health insurance.
There are other, less obvious, issues that conservatives can use to ignite controversy. Abortion, which I’ve written about here, is one divisive issue that could delay progressive reform. Another potential deal-breaker is health coverage for immigrants—an issue that has simmered just below the surface for a while now. A recent move by legislators in Massachusetts to drop some immigrants from that state’s health care roll could be a harbinger of what’s to come in federal health reform efforts.
A New “Lesson” From Massachusetts
Here’s the background: Earlier this month, the Massachusetts legislature decided to drop state-subsidized health coverage for 30,000 legal immigrants—those who have green cards but have been residents for less than five years. Dropping the immigrants—non-disabled adults who are 18 to 65 years old—is expected to save the state $130 million next year.
Some commentators both inside and outside the state tried to portray the immigrants as illegal aliens who were “freeloading” off the state for health benefits. In fact, they are documented, permanent residents who are able to work and live in our country legally. Like American citizens, they pay taxes and can join the military to fight our wars—many go on to become citizens.
In justifying the legislature’s decision to cut coverage for this group, State Treasurer Tim Cahill told the State House News Service (a subscription service) that immigrants may be receiving the message, “Come to Massachusetts and we’ll cover you.” Cahill went on to say, "That's not really protecting our own citizens who have grown up here and spent their lives here and want to either raise a family or keep their family here, like I'm trying to do."
Governor Deval Patrick, facing a budget crisis tied to a $3.2 billion drop in state revenue, but wanting to keep his commitment to universal coverage, proposed restoring $70 million to the $28 billion state budget to cover some of these immigrants. The latest news is that Massachusetts legislators decided to restore about $40 million in funding, but it’s not clear what benefits this will pay for.
State legislators are not willing to budge any more and the public seems to agree. In an editorial in the Boston Globe entitled “Who Comes First in the State,” columnist Joan Vennochi sees cutting coverage for immigrants as a necessary evil:
“The $70 million Patrick wants to restore is a tiny piece of a $28 billion state budget. But if I were being asked to do it, I would first consider the big picture. The Massachusetts healthcare reform law was passed in 2006 without a dedicated revenue stream to support its costs and with the expectation that serious cost containment measures would be implemented.
“Until then, there isn’t enough money to pay for the universal coverage promised by the law. Until then – as cold as it sounds – the most vulnerable Massachusetts citizens should come first.”
Much has been written about the fundamental problems Massachusetts faces in financing its grand scheme to achieve universal health coverage. Trudy Lieberman’s series, “Health Reform Lessons from Massachusetts” for the Columbia Journalism Review is a great resource for learning more about the topic. But besides the lack of cost-control and the lack of a steady source for financing universal coverage, a new lesson from the Massachusetts experience is that, when it comes to health care, apparently immigrants are expendable.
Naturalized Citizens, Legal and Illegal Immigrants Contribute to the Economy
Before we can talk about immigrants and health care reform we need to specify which kind of immigrants we’re talking about. According to the Census Bureau, in 2006 there were 37.5 million immigrants living in the U.S., some 12.5% of the population. About 40% of those who were foreign-born are naturalized citizens (i.e. they fulfilled the necessary requirements for U.S. citizenship). Then there are the illegal immigrants. Although it’s hard to know for sure, the government estimates that about 11.5 million immigrants are living here illegally. The rest (my math gives me about 13 million) are legal immigrants who have been in the country for varying amounts of time—but work and pay taxes.
Whatever their legal status, our country’s economy depends on immigrants of all types. They comprise some 15.6% of the workforce, many of them employed in lower-paying jobs in the service, agricultural and construction industries. Contrary to charges made by foes of immigration, these newer arrivals contribute more than they take from our economy.
The Massachusetts Immigrant and Refugees Advocacy Coalition, (which opposes the coverage cuts for legal immigrants in Commonwealth Care) points to the recent report “Massachusetts Immigrants by the Numbers: Demographic Characteristics and Economic Footprint,” to highlight valuable contributions immigrants make to the state’s economy:
“The report shows conclusively that the state’s immigrant population ‘countervails the net out‐migration from Massachusetts to other states’ and offsets the aging of our native‐born workforce. Indeed, immigrants represent a larger percentage of the workforce (17 percent) than they do of the general state population (14 percent). The report also shows that ‘immigrants pay into the state income tax system at a higher rate than their percentage of the population.’”
Although they clearly contribute to our economy, immigrants are more likely to be uninsured than any other segment of the population. Approximately 47% of non-citizens lack health insurance, compared to 15% of U.S. citizens. While undocumented immigrants are the least likely to be insured because they do not receive coverage through their employers and do not qualify for any public programs, legal permanent residents—those we’ve admitted into the country on a permanent basis who work, pay taxes, serve in the military, become U.S. citizens—are also ineligible for federal programs (like Medicaid) for at least 5 years.
Immigrants Are Not a Drag On Our Health Care System
Immigrants are often portrayed as being a huge drain on our health care system. Conservatives write about emergency rooms overflowing with undocumented aliens, clamoring for free care that hospitals must provide under EMTALA laws. They spin scary stories about “medical tourists,” sick immigrants who come to America specifically to get treatment once they are admitted through the ER.
It is true that certain hospitals in border states like Texas and Florida provide uncompensated care to many immigrants, and the federal government never fully pays them for that care. A court decision in Florida handed down earlier this week illustrates the problem, while pointing to the public’s increasingly hard stance on immigrants. A jury decided that a hospital in Stuart, Florida did not act unreasonably when it chartered a plane and sent a severely brain-injured patient who was an illegal immigrant back to Guatemala without the consent of his legal guardian.
The saga began when the man was hit by a drunk driver and brought to the emergency room in dire shape. Months later, after he was stabilized, the hospital tried to transfer him to a nursing home, but because he didn’t qualify for Medicaid, none would take him. The Guatemalan man ended up “boarding” in the hospital for several years at a cost of more than $1 million. By comparison, the $30,000 the hospital spent to send him back to live in a village with his ailing mother was chump change.
But despite these anecdotes from over-stretched hospitals, and rants from legislators who call for sealing the borders to new arrivals, immigrants are actually not exacting a heavy toll on our health care system.
In a study published in July’s American Journal of Public Health, Leighton Ku, director of the Center for Health Policy Research at George Washington University’s School of Public Health, found that recent immigrants (those who have been in the U.S. for fewer than 10 years) were responsible for only about 1% of public medical expenditures even thought they constituted 5% of the population.
This is not surprising because, as noted before, undocumented and legal immigrants who have been in the U.S. for fewer than 5 years are not eligible for Medicaid (except for emergency coverage or in a few states that mostly provide coverage for pregnant women and children.)
More surprising is that Ku found that recent immigrants who were fully insured over a 12-month period had
medical costs that were half the size of their U.S. born counterparts. Established immigrants had medical costs that were two-thirds the size of U.S.-born citizens. Lu and others have found that immigrants are less likely to have chronic health problems like diabetes, heart disease, hypertension or arthritis and are much less likely to report being in fair or poor health.Finally, as well as seeing doctors far less frequently, recent immigrants have lower rates of hospital admissions and emergency medical visits than native-born Americans.
These figures point to the fact that 1) immigrants are generally healthier than their U.S.-born counterparts, 2) they use fewer medical services and emergency visits and, therefore 3) those that are able to purchase private insurance, end up subsidizing the care of U.S.-born citizens.
In their report, “Health Care: Sharing the Costs, Sharing the Benefits,” the folks from the Immigration Policy Center try to correct some of the major misconceptions Americans have about immigrants and their perceived drag on our overburdened health care system:
“The majority of the growth in the number of uninsured individuals between 2000 and 2006 consisted of U.S. citizens. Citizens made up approximately 80% of the increase, while noncitizens accounted for approximately 20%.”
“Millions of immigrants want the opportunity to purchase affordable health insurance so they can stay healthy, work, and care for their families. Allowing millions of immigrants to purchase affordable health care will result in the payment of billions of dollars in insurance premiums, helping to pay the cost of health reform in America.”
Will Health Care Reform Include Recent Legal Immigrants?
So far, Congress has managed to avoid a confrontation over immigrants and health care reform by maintaining that they comprise two entirely separate, and arguably—equally difficult—issues for legislators. In fact when asked about it directly, Senate Finance Committee Chair Max Baucus answered;
"[W]e're not going to cover undocumented workers. That's too politically explosive.”
President Obama also does not support providing government health coverage for illegal immigrants; except, he told CBS’ Katie Couric, in the case of children who should be offered vaccinations and basic care to prevent the spread of infectious disease.
But Obama did say that he wanted legal residents to be eligible for coverage under a new health care plan. So far, he hasn’t defined which ones will be eligible. Will reform include the recent legal residents who, until now, have been denied federal programs until they’ve been here for more than five years?
How do Americans feel about providing immigrants with health coverage? A poll conducted in June by pollster Rasmussen Reports, found that 80% of voters oppose providing government health care coverage for illegal immigrants; only 11% support it as part of health care reform. The poll—like others–failed to ask the question about recent legal immigrants.
In the end, it looks like Congress will continue to avoid the issue of what to do about illegal immigrants and health care. And judging by public opinion, dodging the issue may not be a bad idea right now. The best legislators can do is follow the example of the SCHIP program and allow immigrants to sign up for benefits with just a social security number, without asking for other proof of citizenship.
Excluding Legal Immigrants Puts a Strain on Safety-Net Hospitals
But providing coverage for all legal immigrants is important. By dropping 30,000 legal immigrants from Commonwealth Care, Massachusetts will only shift the cost back to the “safety net” that is currently in place to deal with the small percentage of residents who remain uninsured. These include community health centers and hospitals that are mandated to offer care without concern about payment. Abby Goodnough, writing in the New York Times lays it out this way:
“If the full $130 million cut survives, hospitals that provide free care to the poor will need to spend an additional $87 million this year treating immigrants who lose their coverage, according to the Massachusetts Hospital Association. That would come on top of a $40 million cut in the state’s Health Safety Net, which reimburses such hospitals, said Tim Gens, the association’s executive vice president.”
On a national scale, the problem only grows larger. The best solution would be for the federal government to reinstate legal immigrants’ eligibility for Medicaid and SCHIP—increasing the number of low-income residents who have health insurance coverage and reducing the strain on safety net services. Meanwhile, if immigrants are allowed the opportunity to purchase insurance through a new health plan, these healthier individuals will end up subsidizing care for the native-born population—further disproving the myth that immigrants represent a drain on our health care system.