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
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 [8-11]
because they are healthier. 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
In sum, immigrants inject $30 billion in taxes each year without
receiving any services in return.
excluding immigrants might still reduce overall health care spending.
Again, evidence says No.
absolute amount of health care savings by excluding undocumented
immigrants is small, less than 2% of total health spending.
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
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.[14,15] 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.[19-21]) 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
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.” 
Sommers, BD. Stuck between
Health and Immigration Reform — Care for Undocumented Immigrants. N
Engl J Med, July 24, 2013.http://www.nejm.org/doi/full/10.1056/NEJMp1306636?query=TOC
Preston J. 11.2 Million Illegal Immigrants in U.S. in 2010, Report
Says; No Change From ’09. New York Times. February 1, 2011. http://www.nytimes.com/2011/02/02/us/02immig.html
Goldman DP, et al.
Immigrants And The Cost Of Medical Care. Health Affairs.
Ku L. Health Insurance
Coverage and Medical Expenditures of Immigrants and Native-Born Citizens
in the United States. Am
J Public Health. 2009;99(7):1322–8.
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