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Jon Feere is the legal policy analyst at the Center for Immigration Studies.
In his first year in office, President Obama lifted an entry ban on foreigners with HIV. In his final year in office he will lift the entry ban on three more sexually transmitted diseases (STDs). The president's own Health and Human Services department says this guarantees more infections in the United States, proving once again that immigration is the defining issue for politicians like Obama. Increased immigration trumps all other concerns.
First, some background. In 1993, a clause specifically designed to reduce the spread HIV/AIDS into the United States was added to the Immigration and Nationality Act. It passed the Senate with a vote of 76 to 23. It reads:
Any alien who is determined (in accordance with regulations prescribed by the Secretary of Health and Human Services) to have a communicable disease of public health significance, which shall include infection with the etiologic agent for acquired immune deficiency syndrome [AIDS] ... is inadmissible.1
Though the law is clear that AIDS is to be considered "a communicable disease of public health significance", today it is the responsibility of the Department of Health and Human Services (HHS) to determine whether a disease meets that threshold. This is due to a law signed by immigration advocate President George W. Bush in 2008.2 The Obama administration picked up the ball and ran with Bush's open-border vision and decided in 2009 that HIV is not a "communicable disease of public health significance".3
Despite the declaration that HIV was no longer a communicable disease of public health significance, the CDC estimates that approximately 50,000 people in the United States are newly infected with HIV each year and that over 1.2 million persons in the country are HIV positive. The United States has the highest prevalence of HIV infection of any developed country.4
HHS provided some estimates of the effect of this rule change and found that every year anywhere from 1,073 to 6,409 HIV-infected immigrants would be granted legal permanent residency.5 The analysis ignored the additional unknown number of people infected with HIV who would enter on a temporary basis; in other words, the number of people with HIV granted admission would be much larger. And this doesn't include people who sneak across the border, of course.
The National Institutes of Health (which falls under HHS) noted that if HIV screening is not part of the immigration examination, the new immigrants "will add to the numbers of those who are HIV-positive yet are unaware of their infection", potentially leading to "a larger population of persons with undiagnosed HIV ... who are more likely to transmit the infection to others, likely within their own immigrant communities." 6 HHS put it quite bluntly: "The main cost of this rule is the potential for onward transmission to U.S. residents who are not infected with HIV."
HHS also estimated that after five years approximately 170 to 1,014 people in the United States would become infected as a result of the policy change, costing anywhere from $4 million to $22 million in health care expenditures for this "onward transmission". This estimate assumed a low-end new infection rate of 1.51 percent — meaning that every 100 HIV-infected persons will infect 1.51 persons. But HHS noted that it could be higher, explaining that the "most recent estimate of average onward transmission, when limited to sexual transmission, in the United States is 3.02 per 100 HIV positive immigrants."
HHS estimated that after the first five years of this rule change, there may have been 3,956 to 23,622 HIV-infected new immigrants in the United States. Again, this focused only on lawful permanent resident immigrants. Any HIV-infected border-jumpers or tourists who overstay their visas were not included in this estimate.
Overall, the estimated healthcare cost of removing HIV from the travel ban may have ranged from $19 million to $173 million in the first year alone. HHS explained that this would obviously double the second year as a new wave of immigrants arrives, triple the third year, and so on. HHS estimated that after five years the healthcare cost would be $86 million to $513 million. But not to worry, HHS noted that the cost to taxpayers is "likely to be small given the restrictions on federal benefits to new immigrants." Of course, these estimates were made in 2009, before Obamacare.
Recently, President Obama made some more changes, opening our borders to more STDs. Yet only a single special-interest news outlet has even noticed.7
Prior to 2009, HHS listed eight diseases as "communicable diseases of public health significance": tuberculosis, leprosy, Human Immunodeficiency Virus (HIV), syphilis, chancroid, gonorrhea, granuloma inguinale, and lymphogranuloma venereum. After the first two on the list, the remainder are all sexually transmitted diseases. After the administration dropped HIV from the list, only five STDs remained: syphilis, chancroid, gonorrhea, granuloma inguinale, and lymphogranuloma venereum.
At the time I wondered whether some of the other STDs also would be removed from the list since they are not nearly as deadly as HIV. It took him seven years, but recently Obama decided to remove chancroid, granuloma inguinale, and lymphogranuloma venereum as inadmissible health-related conditions for aliens seeking admission to the United States.8
The only remaining communicable diseases considered to be of any "public health significance" are tuberculosis, leprosy, syphilis, and gonorrhea. At least until the leprosy lobby speaks up.
There was one additional change made by the administration pertaining to tuberculosis, however, that is worth noting. Prior to the rule change, federal regulations required that all applicants subject to a chest x-ray, "and for whom the radiograph shows an abnormality suggestive of tuberculosis disease, shall be required to undergo additional testing for tuberculosis." The rule change drops the "shall" requirement. It now reads: "All applicants may be required to undergo additional testing for tuberculosis based on the results of the medical evaluation." It's a subtle change that may have no significant effect; on the other hand, it may mean less stringent protections from tuberculosis.
So what about the costs associated with the new rule change on the three remaining STDs? Don't worry, Obama's HHS secretary ran the numbers and explained in the Federal Register that "The results are not economically significant, i.e. more than $100 million of costs and benefits in a single year."9 In other words, the cost of welcoming in aliens with these STDs will be below $100 million every year.
The secretary argues that there's a "potential" for "a negligible increase in the numbers of disease cases entering the United States", but that "the potential introduction of a very small number of cases will not change the current cost structure associated with the current disease burden." However, the secretary also reports that of these diseases, chancroid is the only one reported to the CDC, meaning that it is difficult to estimate the impact of this rule for the other diseases. In fact, HHS notes that "[d]ata on chancroid, granuloma inguinale, and lymphogranuloma venereum are not systematically collected by any country outside of the United States either by specific countries or regions listed by DHS for aliens, or from the World Health Organization." We don't really know what we're bringing in.
And not to worry, HHS also explains that these "primarily tropical infections can be prevented through improved personal hygiene and protected sex" and that if you do get them, the STDs can be cured "with a short, uncomplicated course of antibiotic therapy." Hopefully they're telling the immigrants that.
The administration argues that this change is beneficial because physicians who would otherwise be administering the exams "will be able to devote more time and training to other, more common and/or more serious health issues." Sound familiar? This is the same argument the Obama administration makes for directing ICE to only focus on deporting "the worst of the worst" criminal aliens. By ignoring the run-of-the-mill illegal aliens, law enforcement can better focus on the most egregious offenders, they claim.10 But it means that plenty of dangerous aliens get a pass and it means that violence has largely become a prerequisite for immigration enforcement. Similarly, the change in STD policies means that many infections are potentially being ignored.
The United States has the highest prevalence of HIV infection of any developed country. The Obama administration's policy change may ensure that the United States keeps that title. In the least, the 2009 and 2016 changes will reduce the ability of our immigration system to protect Americans from communicable diseases.
1 (8 USC § 1182).
2 Jon Feere, "Congress Mulls Lifting HIV Ban", Center for Immigration Studies blog, July 25, 2008.
3 Jon Feere, "Obama Lifts HIV Immigration Ban", Center for Immigration Studies Backgrounder, November 2009.
4 "HIV and AIDS in the Americas: An epidemic with many faces", Pan American Health Organization, 2001.
5 "Medical Examination of Aliens—Removal of Human Immunodeficiency Virus (HIV) Infection From Definition of Communicable Disease of Public Health Significance", Centers for Disease Control, Federal Register notice, November 2, 2009.
6 Susanna E. Winston and Curt G. Beckwith, "The Impact of Removing the Immigration Ban on HIV-Infected Persons", AIDS Patient Care and STDs, 25(12), pp. 709–711, 2011.
7 Matthew Bultman, "HHS Removes 3 STIs From List Barring Immigrant Entry", Law360.com, January 26, 2016.
8 "Medical Examination of Aliens-Revisions to Medical Screening Process: A Rule by the Health and Human Services Department on 01/26/2016", Federal Register, January 26, 2016.
10 Brian Bennett, "High deportation figures are misleading", Los Angeles Times, April 1, 2014.