Panel Transcript: Health Care for Illegal Immigrants

What would it cost?


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C-Span Video


How Much Would It Cost to Provide Health Insurance to Illegal Immigrants?

The Cost of Immigrant Medicaid Coverage Under Current Policy

Event Summary

The Center released two reports as part of a October 10, 2019 panel discussion on the cost of granting healthcare benefits to illegal immigrants.


Mark Krikorian
Executive Director
Center for Immigration Studies

Jason Richwine
Independent Policy Analyst

Steven Camarota
Director of Research
Center for Immigration Studies

Christopher Pope
Senior Fellow
Manhattan Institute

MARK KRIKORIAN: Good morning. My name is Mark Krikorian. I am executive director of the Center for Immigration Studies.

And the Democrats in one of their debates this summer were asked whether the taxpayer should fund healthcare for illegal immigrants, and all 10 participants raised their hand and said yes. That’s an arguable position. There are arguments you can make for and against that. But the first question you need to answer in this, as in any other policy proposal, is what is this going to cost, and there simply hasn’t been very much interest or exploration in this question. And so that’s why we’re releasing the two papers we’re releasing today and having this panel discussion, is precisely to get a sense of what it could cost. It’s not definitive. These are estimates. Maybe there will be different – other people have other estimates. We’d love to see them. But nobody really has offered some concrete examination of what the consequences for taxpayers would be of these proposals.

And so today we’re going to be – we’re releasing two papers to look at that. The first is a look at what the current costs to taxpayer are under current policy. The second is what the likely under a couple different scenarios costs would be. And this is – this is a topic that needs to be injected into this debate if the debate is actually going to be constructive and meaningful.

And so participating in the panel are going to be some of the authors and a commenter. And the first will be Jason Richwine. He’s an independent policy analyst who’s written on immigration as well as other issues. He did the paper on what the current costs are. Jason’s a Ph.D. in policy analysis from Harvard who’s published not just on immigration, but other issues – for instance, education funding recently at the – published at The Wall Street Journal and elsewhere.

Next will be Steven Camarota, director of research at the Center for Immigration Studies. He’s the lead author on the paper estimating what the likely costs in the future would be if illegal immigrants were to be covered under healthcare. Steve is – for more than two decades has been one of the top analysts of the immigration issue. His Ph.D. is from UVA in policy analysis.

And then our commenter, discussant if you will, is Chris Pope, who is a senior fellow at the Manhattan Institute. And he’s going to be responding to the two papers and then maybe more generally to the issue of the effect on taxpayers of covering illegal immigrants for healthcare.

So if we could kick it off, Jason?

JASON RICHWINE: Thanks very much, Mark.

So I want to talk to you about the – sort of the baseline, the current situation with immigrants both legal and illegal in terms of how much they cost the Medicaid program. I would say this is also relevant not just to the Democratic presidential candidates, but also to the presidential proclamation that happened – was it last Friday? The proclamation that said that immigrants applying under certain visas will have to show that they have health insurance before they’re allowed to enter. And of course, the reaction to this was, as you might expect, from certain quarters – I have to say sort of as an aside I do find the media’s reaction to this whole issue kind of humorous.

Before the Trump administration, groups like the Center for Immigration Studies would put out reports that say, you know, we tabulated some Census data and we found that immigrants do, in fact, use means-tested antipoverty programs, and in some cases they use them at higher rates than natives. And the response from a lot of people in the media was to say: that’s absurd; immigrants don’t use welfare. In fact, apparently you guys have never even heard of something called the public charge rule, and the public charge rule says that you can’t be here if you’re – as an immigrant if you are on welfare.

Well, as soon as the Trump administration became serious about enforcing the public charge rule, suddenly overnight the talking points changed considerably, and in fact this was criticized because it was too draconian; it would affect two-thirds or three-quarters of all immigrants. It’s difficult for me to keep all the talking points straight. But we don’t give you talking points here. We’re going to give you just the facts here.

So certainly immigrants do use Medicaid. There are some restrictions, of course. Not all immigrants are eligible. In fact, generally speaking, if you’re an immigrant who wants to use Medicaid you have to be a legal permanent resident. That means not a temporary immigrant like someone on a student visa. And you also have to have lived here for five years, generally speaking. But there are, of course, exceptions to those rules, as there always are. Humanitarian immigrants, for example – refugees, asylees – they can access medical care immediately. Generally speaking, children and pregnant women also do not have to wait the five years to get coverage. And emergency services are available for everyone, regardless of whether you’re legal, illegal, or anything else. And another exception, if you want to call it that, is that U.S.-born children of immigrants are fully eligible for Medicaid and every other program that citizens are eligible for, and we’ll get into why that matters in a second.

So let’s dive into some results here. I won’t belabor the methodology. We can bring that up in the Q&A if you’d like. This is from the Medical Expenditure Panel Survey, and this is just enrollment rates that we’re looking at right now. And I’d like you to focus on the individual row at first. You can see that despite the legal restrictions on which immigrants are allowed to use Medicaid, overall immigrants still use Medicaid on an individual level at about the same rate as natives, at 23 percent. And you can also see that I’ve divided immigrant into some interesting subcategories, and there are – less-skilled immigrants tend to be on Medicaid more often, which is not too surprising.

I would argue, though, that the family row is the more important row in this analysis because immigrants are not – are not individuals in the sense that they have dependents just like anyone else would have dependents when they are living in the United States. And in particular they have U.S.-born children, as I mentioned, who are eligible for Medicaid.

Now, there’s a debate about this. Some people would say U.S.-born children of immigrants should count in the native column. Others say it should count in the immigrant column. I am very much of the view that it should be in the immigrant column, and the reason is this. Parents have a legal obligation to provide basic services to their children. They have to provide them food, they have to provide them shelter, and they have to provide them medical care. So if the government steps in and says we’re going to do that for you, that’s a benefit not just to the child, but to the parent.

So you have a lot of cases where immigrants will be in the country and not on Medicaid themselves, but their children will be put on Medicaid. And you can see from the table there that once you look on a family basis, immigrant families are significantly more likely to use Medicaid compared to natives. And in fact, of lesser-skilled immigrants, you have a majority who are actually on Medicaid – I should say at least one member of their family is on Medicaid.

Now, in terms of costs – that’s the next column here, or the next table – you might be thinking, gee, how do we know costs? Do we really go around and ask people, excuse me, how much did you – did you cost the Medicaid system last year? No. So there’s a separate provider survey within this dataset where they actually ask the doctors and the hospitals how much was billed. So it’s a generally more accurate estimate than you might expect from first glance. And unsurprisingly, you see that immigrant families do cost more than native families. This is for everyone. This is like a per capita or per family estimate, so it includes people not on Medicaid – in which case, obviously, their costs are zero. And you can see again that lower-skilled groups like people without a college degree tend to cost more.

Now, when I give this kind of presentation I sometimes get the reaction, or sometimes people accuse me of having the – of stating that immigrants are lazy, immigrants are moochers, immigrants just come here to live off the U.S. taxpayer. No, no, no, that’s not the case. I don’t see that in the data. I don’t see any special appetite for welfare among immigrants. What I do see is that immigrants have certain demographic characteristics that when found among natives also leads natives to be more likely to go on Medicaid. And I’m speaking specifically of two things: lower levels of education and larger families. Whether you’re born in Honduras or Washington, D.C., if you live in the United States and you have a low level of education and you have a lot of mouths to feed, you are likely to be on Medicaid. It’s not a special problem with immigrants; it’s just a fact these are the characteristics that they have.

In fact, I have a little numerical example to show you of that, just a real basic regression analysis. If you look at the cost difference column here, that’s the difference in cost between the average immigrant family on Medicaid and the average Medicaid cost for native families. And that first row is no controls, so that $813 cost difference is the same one we saw in the previous table. But now if we start to control for family size – for example, the number of adults in the family – you see the cost difference go down to $639. And then if you add in a control for children, it goes down to 423 (dollars). And finally, probably most importantly, you control for the education of the head of the family. Then, once you do that, the difference is a very negligible $25. So you can see that we can account for virtually all of the cost difference simply by looking at the education level of the immigrant and also the family size.

The lesson here in terms of immigration policy should be fairly clear. It’s that if we want to reduce immigrant dependency on Medicaid, including their children’s dependency on it, then we want to change the selection criteria such that we have more-skilled immigrants, such that immigrants come in with the kinds of earning power that we know they’re going to be able to support not only themselves but also any children or other dependents they might have when they’re in the United States.

I think certainly the proclamation I mentioned earlier about requiring health insurance for certain immigrants is a step in the right direction. How meaningful it will be remains to be seen in terms of the exact details of the plan, but as I said, a step in the right direction.

A step in the wrong direction would be to expand the eligibility pool among immigrants, especially if you’re expanding it to include even illegal immigrants. And that would be a very costly program. And to give us the cost of that, we have Dr. Camarota.

STEVEN CAMAROTA: Well, thank you, Jason.

MR. KRIKORIAN: And before you start, Steve, I just want to remind people who are here that we have printouts of both papers in the back. And for those watching, both of these reports are online at Steve?

MR. CAMAROTA: Thanks, Mark. And thank you for that introduction, Jason.

My name is Steve Camarota. I’m with the Center for Immigration Studies. I am the Center’s director of research here.

I should mention that the report I’m going to discuss today has two co-authors. One is Jason and the other is Karen Zeigler.

Now, as Mark pointed out, at the June 27th Democratic presidential debate, all the candidates endorsed giving health benefits of some kind, government-provided benefits, to illegal immigrants, but there was no exact discussion about what form this would take. So this research is in response to those proposals.

It is the case that after the debate The Atlantic magazine surveyed the participants and found that Bernie Sanders, Kamala Harris, Elizabeth Warren, Cory Booker, and Julian Castro all would provide benefits to the “undocumented,” in their words. Joe Biden was less clear but seemed to say that he would allow the illegal immigrants to buy insurance on the exchange, presumably unsubsidized. So it looks like that they would just be allowed to buy insurance on the healthcare exchanges, and I’ll go over exactly what that means.

Now, under current law illegal immigrants are not allowed to participate in the health insurance exchange established by the Affordable Care Act, also called Obamacare. That’s like the core part of Obamacare. So they cannot receive what’s called the Advanced Premium Tax Credits, which are the subsidies paid to insurance companies to help low-income people afford coverage. Illegal immigrants are also generally barred from participating in Medicaid, the health insurance program for the poor, with some notable exceptions such as minors in some states, pregnant women, and a few other tiny categories. But in general, they’re not supposed to be able to get Medicaid. Now, as I said, the Democratic candidates seemed to envision some significant change from this system.

Now, as a reminder, here’s very briefly how the Obamacare or the ACA works. Those with incomes under 400 percent of poverty – that’s about 83,000 (dollars) for a family of three in 2018 – are eligible for the subsidies that reduce the amount that they pay for health insurance when they buy it on one of these exchanges. Now, the ACA subsidies, of course, are paid for by the government – that is, by taxpayers – to the insurance companies. For the most part, that’s how it works. Now, in general, those purchasing insurance through the exchange are either self-employed or not offered insurance through an employer.

Now, the other aspect of the ACA is that it was originally designed for the lowest-income people, those with under 138 percent of poverty. That’s about 29,000 (dollars), very roughly, in 2018 for a family of three. People below that level would be able to get Medicaid. That’s the free health insurance that you can get, as opposed to the subsidized health insurance from the exchange. However, many states have chosen not to expand Medicaid.

Now, the size of the ACA subsidy – that is, the cost to taxpayers – primarily reflects a person’s age and income, with income measured relative to the poverty threshold. The size of the subsidy goes up, the lower the person’s income. In other words, the poor get the most help, which of course makes sense. Factors such as a person’s overall health or a preexisting condition don’t really matter in terms of the subsidy.

Now, we basically look at, then, two scenarios when we try to figure out what it would cost to provide illegal immigrants with health insurance. The first scenario is basically what if we just made them all eligible for ACA subsidies. That seems to be what the candidates have in mind, and so that’s one possibility. The second scenario is a mix in which the higher-income illegal immigrants – those basically between 138 and 400 percent of poverty – would get the ACA subsidies and the one with the lowest income would get Medicare.

Now, consistent with other research, we estimate that there are about 5 million uninsured illegal immigrants with incomes low enough to get ACA subsidies. Now, there are by most estimates more than twice that number of illegal immigrants in the country, but many either have higher incomes so they couldn’t get the subsides or for the most part they are insured by employers. Now, you might say that’s surprising, but I think there’s a pretty high degree of consensus that very roughly half of illegal immigrants have health insurance.

Now, given their age, we estimate that the average cost of providing an ACA subsidy for illegal immigrants would be about $4,600 a year. While the average cost would be large, that subsidy is actually – for the illegal immigrants is still less than what the average person now gets on the – on the subsidies from the ACA; that is, people who are native born or legal immigrants. This is primarily because illegal immigrants are a relatively young population, so they’d be somewhat less costly to insure with the subsidies.

Now, what would the total cost for that roughly 5 million be? We estimate that if they all signed up, a hundred percent enrollment, it’d be about $22.6 billion a year. That is, if the roughly 5 million got the $4,600 subsidy, then it would be nearly $23 billion.

Now, if you want to place that number in context, this is significantly more than the roughly 17 billion (dollars) spent each year paying cash benefits to poor people under the Temporary Assistance for Needy Families program, referred to as TANF, which is what most people think of as welfare. So the welfare that – the cash welfare that families get is about 17 billion (dollars). The potential cost here for this is about 23 billion (dollars).

Now, another way to think about that is for every 1 million uninsured illegal immigrants who signs up for the ACA insurance and gets the subsidy, the cost to taxpayers is about 4.6 billion (dollars). So you can do your own calculation. Each million – so if you think only 2 million, then it’s 4.6 times two. If you think 3 billion (sic; million), it’s 4.6 times three. So you can do your own estimate.

Of course, many illegal immigrants eligible for the ACA subsidies would probably not sign up. In fact, we estimate that less than half would actually sign up based on other research. So we think the actual cost would not be the nearly 23 billion (dollars), but actually more like 10.4 billion (dollars).

Now, what I think is interesting about this number is that although we think that illegal immigrants are on average cheaper to insure, and we think less than half of them would actually sign up, it’s still the case that in the first year the costs would be over $10 billion. And it might run to over $100 billion in the first 10 years, which is the normal budget horizon used by the Congressional Budget Office when estimating costs of new legislation.

Now, although we consider this ACA-only approach the most likely policy – at least politically – that would be adopted to insure illegals, we also estimate what it would cost if we had a hybrid approach; ACA subsidies, again, for the highest income, Medicaid for the lowest. Now, compared to the ACA-only approach the total cost of the ACA/Medicaid hybrid approach would be about 19.6 billion (dollars), again if everybody enrolled. This is somewhat lower than our ACA-only approach, again assuming a hundred percent enrollment.

Now, the lower cost of a mixed-ACA approach partly reflects our assumption that illegal immigrants on Medicaid consume somewhat less in health care than the average person on that program. By contrast, ACA subsidies, as I mentioned before, are paid to companies, and they mostly just reflect a person’s age and income, not their actual consumption of healthcare. But with Medicaid the government would be insuring people directly, and the tendency of immigrants – including illegal immigrants and Hispanic immigrants – to consume somewhat less in healthcare when on the program, Medicaid – we actually have data on that – we think that would slightly lower the costs.

It also may be less burdensome on public coffers to provide Medicaid to the lowest-income illegal immigrants because Medicaid itself is actually slightly cheaper – or not even just slightly cheaper – than the ACA. Medicaid, because the government can negotiate down prices and can command lower fees from doctors and other healthcare providers, it’s actually less costly – people on Medicaid, the typical person – than the typical person now getting the ACA, and that would be true if we gave it to illegal immigrants. Seems kind of counterintuitive: the free health insurance paid for entirely by the government is actually somewhat cheaper. So if we gave illegal immigrants, at least the lowest-income ones, access to Medicaid, it would be somewhat cheaper than if we gave them the subsidies under Obamacare.

Now, like our ACA-only analysis, we do not think that many immigrants would take advantage of an ACA/Medicaid system, again, based on other evidence of enrollment rates. We estimate the cost of a mixed ACA/Medicaid approach would be about 10.7 billion (dollars) annually, or again, though, over $100 billion over 10 years.

So this means, however, if you may have noticed, that once we take into account likely enrollment, the cost of a Medicaid/ACA approach rather than just an ACA approach would be slightly higher, even though the average cost of Medicaid is less than the average cost of ACA. Now, this seems strange. The reason for this is that the likely enrollment rates for Medicaid are so much higher than the likely enrollment rates for the ACA. So, in sum, it costs less to insure each person on Medicaid than with ACA subsidies, but more illegal immigrants would almost certainly take advantage of Medicaid. Remember, Medicaid is free, and if you get ACA subsidies you still have to pay something. And that makes Medicaid enrollment rates generally much, much higher.

Now, in conclusion I would say this. Look, providing illegal immigrants with public health benefits may soon become a reality depending on how the political situation evolves. Of course, the costs of providing health insurance to illegal immigrants would depend heavily on what we choose. But if you look at the current system, the two primary ways in which we deliver free or reduced-cost healthcare insurance to low-income residents are Medicaid and the ACA subsidies. Our analysis indicates that allowing uninsured low-income illegal immigrants access to these programs would likely cost taxpayers $10 or $11 billion, assuming likely enrollment rates, but it’s possible the costs could be up to 23 billion (dollars).

Now, one important caveat about these estimates is we make no assumption about how giving free or subsidized healthcare to illegal immigrants might significantly increase the flow of new illegal immigrants into the country. If low-income people in other countries can come here free and get healthcare, it seems very likely that that could spur at least some additional illegal immigration, creasing new costs, because as you can see from these numbers the value of that free insurance or the value of the subsidized insurance runs into the many thousands of dollars, and that is certainly an attractive option or certainly a very attractive incentive.

Now, the specific costs aside, I think this is maybe the most significant factor. If presidential candidates are advocating spending billions of dollars on people who are in the country illegally, in my view this is significant in its own right because it suggests that allowing in large numbers of less-educated workers inevitably generates political pressure to provide them access to social programs. If there is significant political pressure to provide people who aren’t even supposed to be in the country with benefits that cost thousands of dollars, it seems almost certain that over time pressure will grow to provide health insurance to low-income guest workers or other, quote, “temporary” immigrants as well.

Right now most legal immigrants cannot access Medicaid, for example, at least for the first five years, as Jason said. But if we gave Medicaid to illegal immigrants, surely that would have to change. Surely we’d have to give them access. The legal immigrants certainly would have to get it, and that’s many millions of people potentially as well.

The high cost of providing healthcare to less-educated workers who earn modest wages and whose employers do not provide coverage is a reminder that tolerating illegal immigration or allowing such workers into the country legally is very likely to create a significant burden for taxpayers. But as Jason indicated, that’s not because they’re lazy. That’s not because they didn’t come here to work. Rather, it reflects the educational attainment and the resulting low income, the types of jobs they do, which means they don’t pay a lot in taxes and they will tend to use a lot in services, including potentially this one.

Now, this of course is a big difference from immigration historically and has nothing to do, really, with some sort of difference between the immigrants coming today and now. It has to do with us, our society. We have a well-developed welfare state in which we’re very likely to offer coverage to people once here. Thank you.

MR. KRIKORIAN: Thank you, Steve.

So now Chris Pope from the Manhattan Institute will respond to the papers and maybe more broadly discuss this issue of healthcare for immigrants. Chris?


I think this is an interesting discussion to have. I think in Washington what we tend to have is we have everyone who sort of spends their whole career in a policy silo. I spent all my life in healthcare policy talking with healthcare policy people having the same debates about healthcare policy, and presumably – and not thinking really that much very frequently about immigration. And you guys are all – presumably have something somewhat similar and don’t think that much about the details of healthcare.

And yet, you know, the first thing I think certainly I notice and everyone in my world sort of notices is that healthcare is an enormously complicated sector of policy. The rules, the entitlement rules, the regulations that are associated with health insurance are very, very difficult, and these guys have done really a great job in terms of, like, trying to understand it, trying to penetrate really what’s going on, and trying to interpret and really approach it from an outsider’s perspective. So as someone who spends their whole life trying to work on healthcare policy, I am kind of impressed, like, how well you’ve done really trying to make sense of it all.

The thing that – I think just as sort of in a policy world we sort of have these independent silos in terms of how policy – as policy analysts we’re able to think about different policy sections, it’s true also of candidates and people making public policy. When they develop immigration policy, they don’t think that much about healthcare policy. And when you develop healthcare policy, you don’t really think that much about immigration policy. And obviously, this is not entirely possible. Like, we have these overlap between the policy areas, and this is a pretty good example of one.

The public charge rule, which is sort of long established and obviously has an intuitive support for it from many voters that care about it, hasn’t always been thought of as a healthcare policy issue. But we’re in a pretty different world now. Fifty, 60 years ago, healthcare was not – was not dominating the welfare state the way it is today. Healthcare – health insurance premiums were less than a thousand dollars not that long ago. Only a decade or two ago, that was, like, a fairly standard amount that people would pay. And now we’re talking about tens of thousands of dollars for family coverage. It looms large in terms of family budgets, especially for people who are low down the income scale. If you’re earning around the minimum wage and then also have a healthcare benefit that’s sort of worth potentially $20,000 for family coverage, that healthcare benefit is an enormous – is sort of an enormous feature relative to your compensation.

And it’s also true with respect to the public – the public sort of spending side of things. If you look at CBO data, even in 2008 healthcare was 52 percent of means-tested federal programs. By 2028 it’s going to be 71 percent. So healthcare – if you’re talking about a public charge, if you’re talking about public entitlements, you’re kind of really talking about healthcare just in crude numbers. It’s not really possible to talk about this issue without talking about healthcare. A hundred years ago, absolutely it was possible to talk about this issue without talking about healthcare. Healthcare was not really that important a thing. But really these days when you’re talking about burdens on taxpayers, it’s really all about healthcare that we’re talking about.

So the other thing that I think really has changed recently – and again, this is really from a healthcare perspective – is what happened with the Affordable Care Act. Prior to the Affordable Care Act, we obviously had the Medicare program, which is for elderly and certain qualifying disabled individuals, people who had paid into the program over large periods of time. We had the Medicaid program, which prior to the Affordable Care Act had really been for various sections of what’s called categorically eligible beneficiaries – so low-income disabled, low-income families, different low-income elderly sort of supplement to Medicare. Really for able-bodied working-age adults, the Medicare program didn’t really do that much. In a few states they were – they were sort of – sort of tangentially covered, but for the most part, like, able-bodied working-age adults weren’t in Medicaid.

The Affordable Care Act really changed that. The Affordable Care Act ensured that the Medicaid program was expanded to able-bodied working-age adults under the – earning less than 138 percent of the federal poverty level, which is probably about $15,000 for an individual and then for a family it increases sort of depending on the amount – on the amount of people in the household it sort of increases. So it could be like 20(,000), 30(,000), 40,000 (dollars) depending on household size. This means that you get the coverage if you earn less than that, but you don’t get the – you’re not entitled to the coverage if you earn more than that.

That straightaway creates a whole host of complications that were never really involved in healthcare policy before the Affordable Care Act. It creates work incentive issues. It creates questions of people coming in and claiming access to benefits in a way that really was never – was never really an issue that policymakers had to grapple with to anything like the same extent.

Nonetheless – and I think this is sort of like a big caveat, I would suggest – is that the Affordable Care Act, the entitlement expansion of the Affordable Care Act, is only about 10 percent of healthcare spending, and for some of the reasons that were touched on earlier. The Affordable – able-bodied working-age adults that earn low incomes tend to be fairly young, which means they tend to be fairly healthy. They’re not – they’re not consuming as many healthcare services as people on Medicare.

So that’s why it’s sort of like this strange – this strange phenomena of public policy that I certainly feel as a healthcare guy, is that when you throw out a big number it sounds really huge in almost every context, and then in a healthcare context it’s like, oh, well, that’s actually not that big of a number. Compared to the amount of money that the public purse is spending on, like, TANF, on welfare benefits, even on food stamps – these are enormous, enormous numbers, but in terms of, like, when you talk about – there was an estimate in the public charge rule of $30 billion per year. That’s a big, big number, but it’s 3 percent of healthcare spending. So there is a sense in which, like, what does this mean?

In terms of a sort of concern and criticism, is the number actually potentially bigger than that? I think there are some reasons to think it might be.

Firstly, there is the issue of employer-sponsored insurance. Now, a big reason why not that much is spent in terms of exchange subsidies is because, like, 90 percent of Americans that get health insurance through private insurance get it through their employers, and they’re not entitled to exchange subsidies or to Medicaid if employers are providing it. If the offered rate of employer-sponsored insurance to noncitizens is greater than it is to citizens, you might see a larger proportion claiming ACA subsidies or claiming Medicaid than you just kind of might assume from the general population.

Secondarily, there was sort of the issue with Medicaid that was touched on. I think a lot of Medicaid looking relatively cheap relative to other payers is because the cost is a little bit hidden. So, like, if you’re a hospital, if you accept Medicaid, you get a lot of tax advantages on the backend. You get a lot of discounts from drug companies on the backend. And so the extent to which the actual dollar figure of Medicaid actually represents your true fiscal cost of enrolling an individual on Medicaid, that’s a little bit uncertain.

Then there is the issue which I think is, like, really came out of the debate, which – it’s hard to imagine that this is a serious proposal – which is to provide universal coverage to anyone who essentially shows up. That’s not – that’s not a policy that any country in the world does, and I think that there is no way it would actually happen. And the reason is quite – is simply this. Like, we have a lot of medical therapies in the United States that aren’t available around the rest of the world, a lot of cutting-edge drug therapies that cost $100,000, $200,000. Now, there’s no way – this is almost separate from immigration policy. Like, there’s no way that we would set up an entitlement that would provide – where U.S. taxpayers would pay for drugs that aren’t available in European countries – for Europeans who have cancer to come over, claim the drug spending, get all the treatment, and then go back. Like, aside from all the questions of how that interrelates with the Third World and sort of where we’re actually sort of seeing the greater flows of immigration. But it does sort of raise the same question.

So it’s – and that sort of raises one more point, which is the interaction between the immigration proposals and the single-payer debate, which is these things sound really, really expensive if they interact with the existing public law, with the existing Affordable Care Act. How would they interact with a single-payer system where there are no premiums, no out-of-pocket costs, where everything is essentially funded by taxes? That, I think, was the strangest thing of the debate, was that you can almost to some degree come up with a number, as you guys have done, for how immigration interacts with existing healthcare law; I don’t know how you even come up with a number for how it would interact with what’s proposed on single payer, with the caveat that some of the – some of the candidates don’t entirely endorse single payer. So Biden’s proposal you could actually say has an actual number attached to it, but the Bernie Sanders kind of end of the spectrum I just don’t think you could even cite a number with that.

And the final point that I would make is really how does – sort of thinking again about, like, the feedback between the policy areas – is that to the extent that we have an expanding healthcare system, to the extent that we have a more universal healthcare system, there’s a big demand for labor. Healthcare is an incredibly labor-intensive industry and there’s a lot of essentially low-skilled labor that goes into it, especially if we think about long-term care issues. If you think about, like, the aging of the Baby Boom generation – in a few years people are going to be going into their 80s – they are going to need round-the-clock nursing care. They’re going to need home health assistants. In terms of the native workforce, traditionally that has not been where the work has come from for that. Traditionally you’ve had a very large share of immigrant workers that are responsible for providing these home health services. And to the extent that spending on healthcare increases – and you see this in single-payer countries around the world – with physician fees controlled, with wages controlled, with kind of real tight budgetary controls, it really does tend quite often – you see this in Germany, you see this in England – it tends to feed back into immigration policy really just under the pressure of workforce challenges, of really keeping the trains running on time in terms of the healthcare system.

MR. KRIKORIAN: Thank you, Chris. That last point was kind of interesting because I guess the increase in healthcare costs will create pressure to bring in immigrant workers who won’t be paid very much, who will then create political pressure to provide healthcare to those people, which – I mean, it’s almost a vicious cycle.

I just wanted to raise the first issue, and I guess for anybody. Steve, something you had brought up, but I think it’s worth underlining. A lot of the lobbyists for expanded immigration, especially those from the, you know, business – the corporate side and the libertarians, say that it’s possible to have a kind of “immigration si, welfare no” approach – we let in lots and lots and lots of people regardless of their skills and education, and somehow that’s not going to create any cost to taxpayers. And it obviously goes beyond the healthcare issue, but I mean, we’ve tried this before in creating a kind of wall around public services; it hasn’t really worked very well. I was just wondering if maybe just briefly you could talk a little more about that, the experience of welfare reform.

MR. CAMAROTA: Yes. So we do have – we do have restrictions on new legal immigrants and illegal immigrants are not supposed to get stuff. But when you look at all the data the government collects in the Current Population Survey or the Survey of Income and Program Participation, it’s clear that a very large fraction of immigrant families do use these programs, even those who are in the country illegally. And the reason is it doesn’t cover all programs. There’s a lot of pressure, right, as I like to say. Think about the Women, Infants, and Children Nutrition Program. Just say the name and it kind of answers the question of whether we’re going to keep anybody off that program. We’re not, right? But that, obviously, runs into the billions of dollars. So you just have to accept that if the person’s here they’re going to get it.

Other things that matter is states have sometimes taken under their own initiative to provide services. As Jason mentioned, what’s very common in immigrant families is for the family to receive the benefit on behalf of the U.S.-born child, and that’s very common just generally. That program I mentioned of TANF, a very large fraction are what’s called child-only households. So the family gets a check, but technically the adults in the family don’t, just the children, which of course is kind of a difference without a – a difference without any meaningful –

MR. KRIKORIAN: Distinction.

MR. CAMAROTA: – distinction, yeah. But nonetheless, that’s sort of what happens.

And so I think that – other things, of course, is that political pressure tends to move the ball back. You say, look, we’re going to be tough, we’re going to restrict, but then over time when no one’s looking you write regulations – and that’s sort of what’s happened with welfare reform as well, the regulations themselves tend to walk back a lot of the restrictions. And the reason that all happens is that a very large fraction of immigrants are low income, and so you could argue they need these services. Once here, it’s very hard to prevent that from happening.

And what these proposals for illegal immigrants remind us is even people who aren’t supposed to be in the country, you can still create a lot of political pressure to spend money on them because they are here. They do work. So it becomes very hard to avoid that political pressure. And again, it’s a very different situation than existed during our last great wave of immigration a hundred years ago, when we didn’t have a well-developed welfare state.

Jason, you want to say something on that?

MR. RICHWINE: Your answer was so comprehensive. I was looking for an in; I just didn’t have one.

MR. KRIKORIAN: I mean, one point I would just add to that, Steve, is that we have, for instance, the requirement – the federal requirement that anyone asking for treatment in an emergency room be cared for.


MR. KRIKORIAN: And I mean, that’s federal law, and frankly, I’m not sure how many voters there are outside the Cato Institute or Reason magazine who would actually be willing to have people even if they’re illegal aliens die on the steps of a hospital.

MR. CAMAROTA: Absolutely, right.

MR. KRIKORIAN: It’s just not going to happen, I mean, just to reinforce your point.


MR. KRIKORIAN: Any questions for any of the panelists? Yes, sir. Oh, we have a – yeah, wait for the microphone.

Q: Well, thank you so much for organizing this panel. Very interesting. I’m Alex Segura from Agencia EFE, the largest newswire in Spanish.

This is a question for Mr. Camarota or maybe Krikorian. What do you expect from the release of these two studies? Do you – do you expect Democrat candidates to kind of change their promises regarding this issue, or at least give some more details about, you know, their healthcare plans and regarding immigration as well? Thank you.

MR. CAMAROTA: Yeah, I just hope it informs the debate. And maybe it would help them flesh out, help them say, look, you know, here we think this proposal based on this research and drawing in other evidence would cost $10 (billion) to $20 billion so the taxpayers can decide.

As Chris pointed out, something that costs $20 billion, sure, that’s an enormous sum. It’s bigger than the gross national product of lots of countries. But in reality, relative to what we spend on healthcare in other things, you could argue it’s not that big.

And so – but you shouldn’t – I think it’s always a bad idea to have a policy proposal out there without some sense of what it’s going to cost, and I hope that that’s what we get out of this study.

MR. KRIKORIAN: Yeah. And as far as, you know, what effect it’ll have, I have no idea. But part of that is up to reporters from EFE and AP and the Post and the Times and et cetera to actually ask candidates, you know, there’s an estimate that this is going to cost X, what’s your response to that. I mean, so in some sense it really does depend on whether people following the candidates actually confront them about this and try to get some kind of response.

Any other questions? Yes, sir.

Q: Yeah.

MR. KRIKORIAN: Hold on. Wait for the microphone.

Q: Was there ever – was there any consideration given to the potential economic benefit of having a healthier populace so people are more productive and there’s more economic output? How did that factor into your study?

MR. CAMAROTA: Yeah, so we focused in my analysis just on the cost of providing care. There’s certainly evidence that when you give people insurance their healthcare outcomes can improve. Now, they consume a lot more healthcare. People say, well, you know, if you’re sick you only wait, and then you go to the hospital, it costs a lot. But the evidence is pretty clear that that certainly happens, but on balance people just don’t – they put off the care, they do less. So if you give people insurance, expenditures go way up, especially for taxpayers. But it’s possible. Maybe it would make the – make them a little healthier and that would be a positive outcome, you could argue.

Remember, it’s mostly a population of people between the ages of 18 and 45. It’s a relatively young population. So, I mean, there are illegal – remember, we don’t do any costs for the U.S.-born children. There are roughly 5 million minor children of illegal immigrants in the United States, but they’re U.S.-born. We didn’t do anything with that – those figures because they’re all technically eligible for stuff right now. So it’s possible that could be one of the – one of the benefits, is that folks could be a little better off and maybe be a little healthier for them and they’d be more productive.

MR. KRIKORIAN: But I mean, there is a lot of – there are a lot of moving parts here. I mean, as Chris pointed out, some of these estimates might actually be low.


MR. KRIKORIAN: And your – you also observed that it could actually draw more people, so that there’s a lot of sort of dynamic elements to it. But those are – you know, it’s not clear how you’d quantify or where it would end up being, a net plus or a net minus, whereas these numbers are more concrete.

MR. CAMAROTA: Yeah, we do say in the study we don’t deal with those secondary costs or possible other things that we don’t – you know, like increased migration.

MR. KRIKORIAN: Yes, sir. Wait for the mic.

Q: Yes. Fred Lucas with The Daily Signal.

This looks at ACA, current Medicaid. Did you factor in the whole Medicare for All proposal which seems to be part of what the Democratic candidates were talking about?

MR. CAMAROTA: We did not. You could probably get an idea, right? So if there are 5 million people, you have average costs here for Medicaid, you can just look at the tables and figures and you could come up with a number. So that number would probably be something very, very roughly like $20 billion if you said, look, we’re just going to give everybody Medicaid. It’s a little cheaper than the ACA, for just the 5 million illegals.

Q: Right. And Medicaid for All – or Medicare for All, I mean, I think it was estimated to be around 30 trillion (dollars). I mean, would you come back to, say, this 10 billion (dollars) to 24 billion (dollars), would that just be almost a drop in the bucket to the overall 30 trillion (dollars) if that was –

MR. CAMAROTA: Well, that’s not what we spend on Medicare or Medicaid together. Thirty trillion (dollars)? You mean over how many years?

MR. POPE: So this is –

Q: Yeah – yeah.

MR. POPE: This is probably related to the estimated costs of Medicare for All over 10 years.

Q: Right, right, right, right, right. Yeah.


Q: Right, right, estimated cost for Medicare for All proposal.

MR. KRIKORIAN: But I mean, well, you know, a billion here, a billion there, it starts to add up, you know, I mean. (Laughter.)

MR. POPE: The one – the one thing I would say with that is that the assumption that it would not change the amount of people coming into the country for medical care, that’s when you would see, like, a really big change in that figure. I mean, as I mentioned, like, the therapies that we have in this country, the degree of intensity of care, like the quality, I mean, if you think of, like, people like Arab sheiks that go to the Cleveland Clinic, if it’s not just, you know, the super-rich around the world that are able to come to the Cleveland Clinic or M.D. Anderson, if it’s the U.S. taxpayers are paying that for everybody, all bets are off in terms of numbers if that were ever to happen, which I don’t think there’s any chance it would.

MR. KRIKORIAN: Yes? In the back, ma’am. And then you upfront.

Q: Hi. How are you guys? Emiliana with NTN24.

I know you guys said roughly this could cost 33 billion (dollars) to taxpayers, but I was wondering if you factored in how much it would cost, roughly, an average-income family in their pockets.

MR. CAMAROTA: Oh, you mean so it depends on how much people pay, yeah.

Q: So like individuals, yeah.

MR. CAMAROTA: So you could take the – if you went with the high-range estimate, again assuming away all the secondary costs, you could take that number and divide it by the number of average – households in the United States, and then you could get, you know, a figure – I can’t – I’ve never been great at mental math, but afterwards you can – you can – we can figure it out. You can divide that out.

MR. KRIKORIAN: Yes, ma’am, in the front. You had a – wait for the mic.

Q: Hi. Lisa Ramirez-Branum. I’m with the Congressional Budget Office.

We are curious to get a sense of what you would think on your likely enrollment adjustment. Would you assume – does that factor in the same type of enrollment rate that individuals have in programs already? Because we look at enrollment rates for, say, for example, citizen children of parents who are unauthorized, and their enrollment rate is lower than just the general average Medicaid child. So would you expect the illegal immigrants that would get coverage to have, in a sense, the same enrollment rate as citizen children or the same enrollment rate of the general Medicaid population? Or is there something about this population that you would assume it’s going to be lower?

MR. CAMAROTA: Yeah, so what we assumed was that we could find a surrogate population in the American Community Survey, and then we looked at all 50 states plus the District of Columbia. And we – our surrogate population were eligible Hispanics who – Hispanic citizens who could enroll. And as I recall, for adults it was about 70 percent for Medicaid who seemed to have – fit the income profile and actually enrolled, but it varied enormously by state so we adjusted the number for each state.

For children, under, say – and we actually looked for children under 200 percent of poverty – as I recall, nationally the enrollment rate is very high, like 93 percent. But there aren’t that many illegal immigrant children. There are lots of children of illegal immigrants, but they’re U.S.-born and don’t count in this analysis. So that’s sort of what we did to make an assumption.

Now, the government estimates that a little over 80 percent of all illegal immigrants are Hispanic, so you could argue that, well – and it looks like for the non-Hispanics enrollment’s a little bit different. But we just used one surrogate population and did 51 calculations by age to come up with what we think is a reasonable estimate.

So we think that the enrollment rates will be pretty – relatively high, much higher than the ACA estimates, but lower than they are for some other relevant populations. And that’s how we did it with the – with the American Community Survey.

MR. KRIKORIAN: Thank you. Question back there?

Q: Hi. Megan Boyanton, Cronkite News at Arizona PBS.

You mentioned how the public charge rule has been more enforced underneath the Trump administration. Why didn’t we see the same push underneath Bush?

MR. CAMAROTA: Wow, that’s a great political question. Mark, you want to handle that one? (Laughter.)

MR. KRIKORIAN: Yeah. I mean, I have no idea. I think some of it was inertia. In other words, under the Clinton administration they actually defined what welfare programs – participation in which welfare programs would constitute becoming a public charge. Essentially, they said if you were in public housing and on Medicaid and got food stamps, you were self-sufficient; that didn’t count as welfare. And my sense is that the Bush administration was really not that different. If anything, for most of its tenure they were more lax on immigration, even, than the Clinton administration was. Only toward the end did they tighten up.

So I don’t – I mean, I have no idea what the internal dynamics were, but I expect nobody even thought of the issue, nobody even brought it up under the Bush administration. Which is – which really suggests – again, this is a political point, but where the – where the political demand was for the kind of perspective that Trump as a candidate was offering, that the Republican and Democratic establishments basically had very similar perspectives and so they didn’t really differ that much on immigration.

Any other questions?

You guys have any final points you want to make? Chris?

MR. POPE: No. (Laughter.)

MR. KRIKORIAN: OK. Well, good. I appreciate everybody’s coming. Again, the hard copies are in the back if you’d like them. The reports themselves at on our website at, as is all the rest of our work. And the video and transcript of this will be online within a few days, as well. And appreciate your coming and hope to see you at our next event. Thank you.


Topics: Health Care