Panel Transcript: Immigration’s Impact on Health Care Reform

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Transcript by
Federal News Service
Washington, D.C.

MARK KRIKORIAN: Good morning. My name is Mark Krikorian. I’m executive director of the Center for Immigration Studies think tank here in Washington that examines and critiques the impact of immigration on the United States. As our name suggests, we don’t have views on things other than immigration. The center has no stance supporting or opposing any kind of reform on health care.

Our staff and board almost certainly have a pretty wide variety of views on health care, as well as a variety of other issues. But health care, being such a big part of the economy and such an important thing, obviously, in people’s lives, there’s a significant intersection between the work that center does on immigration and something like health care. And there, I think, we do have a contribution to make.

There has been some discussion already of the immigration aspects of the health-care issue. From our perspective, that’s been limited, though, because it’s been mainly about the issue of legal status – in other words, will illegal immigrants be subsidized by some taxpayer-funded health-care program. And that’s an important aspect of the issue and our speakers will touch on it to some degree or another.

But the important thing, I think, is to understand that the problem, if you see it as a problem, of immigration as it relates to health care is not strictly one of legal status. It’s not limited to illegal immigration, as important as that is; it’s the question of immigration overall and the impact it has on health care because illegal immigrants are not different species. They’re people like anybody else. They come from the same countries as legal immigrants, same families – in fact, a lot of times, they’re the same people flipping back and forth and back and forth between legal and illegal status.

So to understand, to use – to coin a phrase “comprehensively” – the impact of immigration on the health-care issue, you need to look at all immigration, not just illegal immigration, as important as that is. And that’s what we aim to do here today. Our first speaker is probably one of the nation’s leading experts on the issue of immigration, Steven Camarota, the research director here at the Center for Immigration Studies.

Second speaker will be James R. Edwards, Jr. Jim is a fellow with CIS, co-author of “The Congressional Politics of Immigration Reform,” and for many years, has worked in both immigration policy field, but also in the health policy field. And so he’ll have a lot to be able to bring to this discussion.

And last but not least is Robert Rector from the Heritage Foundation, probably the nation’s leading scholar on the issue of welfare reform, and over the past several years, has been doing significant research on the issue of immigration and its effects on public services and costs and what have you. So the three speakers will say their piece and then we’ll take Q&A from people if anybody has any questions. Steve?

STEVE CAMAROTA: Thanks, Mark. As Mark said, I’m Steve Camarota. I’m director of research at the Center for Immigration Studies here in Washington. Now, as Congress and the nation debate health-care reform, the impact of immigration is or should be an important part of component of that debate. Now, whether illegal immigrants get access to some new government program or public option has been discussed to some extent, but the overall impact of immigration has not really been discussed.

As Mark pointed out, we at the Center for Immigration Studies don’t have a position on what form health-care reform should take. I am personally sympathetic to some of the president’s proposals, but that’s not the focus of my discussion. Instead, I’m going to discuss what the data tell us about the impact of immigration on the nation’s health-care system. I’m going to primarily rely, in this discussion, on data collected by the government, and what I think that data is going to show is that it is very difficult to imagine getting our health-care house in order without getting our immigration house in order, if you will.

In my presentation, as I said, I’m going to rely primarily on government data – the Current Population Survey from 2008, which is the most recent data available. It asks about your health insurance coverage in the previous year – the previous calendar year. So that would be how much coverage you had in 2007. The survey is collected by the U.S. Census Bureau and is really, in most ways, our primary source of information on health insurance coverage in the United States for any population. Let me also point out that most of the information that I’ll cover today is also available at our Web site,

Now, in 2007, 33 percent of immigrants – of all immigrants, legal and illegal – did not have health insurance, compared to about 13 percent of native-born Americans. Immigrants by themselves account for 27.1 percent of all U.S. residents without health insurance. We can see this in Figure 1, which is to my right, right here. Figure 1 shows that immigrants are 12.5 percent of the nation’s total population, but they are 27.1 percent of the uninsured. Again, this is just the immigrants themselves.

If we can keep the camera on Figure 1 just a little longer, let me discuss some additional information. Of course, the impact of immigration is not just confined to the immigrants themselves. Immigrants, of course, also have children whom they are often unable to provide health insurance for. If the children who are born here – the U.S.-born children of immigrants who are under the age of 18 – are included with their immigrant parents, then together, as Figure 1 shows, they comprise 31.9 percent of all those without health insurance.

Now, to place this figure in context, Figure 1 also shows that immigrants and their kids are about 16.8 percent of the total population – so about twice their share of the uninsured, relative to their share of the total population. Put simply, this means that about one out of every three people in America without health insurance is either an immigrant, legal or illegal, or the U.S.-born child of an immigrant.

The total number of immigrants and their children without health insurance is 14.5 million in 2007. Why is that so important? Because what it tells us, just obviously, is that when we’re talking about the uninsured in this country, which is a big part of the current debate we’re having, immigration is a very large part of that story, but of course, it’s not the whole story; it’s just a large fraction of it that is often not adequately acknowledged.

There is another way of thinking about the impact of immigration on the size of the uninsured population. We can look at how much of the growth of the uninsured, or increase in the uninsured, is from immigration. Now, the government reports that, since 1999, the number of uninsured people is up in the United States about 6.4 million.

In 2007, there were 5 million immigrants who had arrived in the United States since 1999 who didn’t have health insurance. So if we just take the 5 million and divide it by 6.4 million, what we find is that 78 percent of the growth in the uninsured is attributable to these newly arrived immigrants – or it equals 78 percent of that growth. And if we add in their U.S.-born children who are uninsured, then that figure gets to be over 85 percent. In other words, if we’d had no immigration after 1999, most of the growth in the uninsured would not have occurred.

Now, immigration does not only impact the size of the uninsured population when we think about the health-care system; it also plays a role in the Medicaid system. Medicaid is the primary government program that provides health insurance to people with low incomes. Now, it goes by different names – like in California, you may have heard of Medi-Cal, but it’s really just Medicaid. And in some parts, there’s also a special program for children referred to sometimes as SCHIP, but again, it’s all Medicaid. So when we talk about, here, Medicaid, we’re talking about the big program, whatever name we talk about it under.

In 2007, 19 percent of immigrants and their U.S.-born children were on Medicaid. And we can actually combine the share who were on Medicaid with the share who were uninsured. And Figure 2 over to my left has some pie charts that does that. What Figure 2 shows is that 47.6 percent of immigrants and their U.S.-born children were either uninsured or on Medicaid. That means that almost half of immigrants and their children have no health insurance or have it provided to them by the government.

In comparison, the bottom of Figure 2 shows – if you could see it, and I don’t know if you can – that about 25 percent – so about one-fourth – so that’s one-half of immigrants and about one-fourth of natives and their children don’t have health insurance or have it provided by Medicaid. Now, the question you’re probably all wondering is why are so many immigrants in the United States lacking in health insurance? The large share of immigrants without health insurance is partly explained by the large share who have very low levels of education.

About one-third of all immigrants, legal and illegal, did not complete high school in their home country, which means that they typically work at jobs that don’t provide insurance, and their resulting low incomes, from their lower levels of education, means that they often can’t afford it on their own. In fact, among illegal immigrants, we estimate that about 55 percent didn’t graduate from high school in their own home country. Among all immigrants, legal and illegal, it’s about a third.

We can see the importance of immigration to this question by just looking at some simple statistics. If we look at college-educated immigrants, 15 percent are uninsured; if we look at immigrants who didn’t graduate high school, half are uninsured. So a big part of this story is education. But it’s not just education; cultural and other factors also seem to play a role. If we look at affluent immigrants who have a college degree and compare them to affluent natives who have a college degree, the immigrants are still two-and-a-half times more likely not to have health insurance. So something else is going on – these are people – when I say affluent, it depends on your definition, but I was looking at households of $75,000 or more.

So these are people who should be able to afford health insurance. They have a college degree so they should be able to recognize its importance and why they might want to have it. But again, the immigrants in that position are much less likely to have insurance than natives in that position. Now, there are some other reasons for this. And that is that immigrants often come from countries where health insurance is not that common, or they often come from countries where it’s provided by the government automatically. And I think these two factors also play some significant role in why immigrants who would seem very likely to have it, given their education and income, still often choose not to.

Now, one thing that we can also say is lack of health insurance among immigrants is not caused by immigrants’ unwillingness to work. In 2007, about three-quarters of all immigrants held a job, and that’s exactly the same percentage as, you know, adult natives. There’s no fundamental difference in the share who worked. This is not being caused by immigrants, say, you know, sitting home and not being willing to work. Again, rather, the reason so many don’t have health insurance is their low educational attainment.

There is not single better predictor of how an immigrant is going to do in the modern American economy than their education levels, and this is true whether we were to look at welfare use, income, home ownership or health insurance coverage. Now, so far, we’ve only talked – or I’ve only talked – about all immigrants and their kids, but what about legal status? In an earlier study, we’ve estimated that 64 percent of illegal immigrants are uninsured and they account for about one out of seven people in the United States without health insurance. And if we were to count their U.S.-born children, then it’s more like one out of every six people without health insurance in the United States is an illegal immigrant.

So these are some big numbers, but it’s not, again, the whole story. Again, about 7 million uninsured illegal immigrants; that number is about 8 million when we count their U.S. children. Now, what about the costs because that’s what, I think, a lot of folks are concerned about? Now, we here are in the process of trying to develop some more precise estimates, but right now, our best estimate is that we’re spending about $4 billion a year providing health care to illegal immigrants.

Now, that is just public expenditures: $4 billion; it’s a little more if you count their U.S.-born children. Now, it is also important to note that uninsured illegal immigrants use significantly less in health care than uninsured native-born Americans. They’re just dramatically more likely to be uninsured in the first place. This is because they tend to be younger than native-born Americans. And so health-care costs generally rise with age; the illegals are relatively young, so they tend to cost less than uninsured natives. They’re just much more likely to be uninsured in the first place.

Also, although the stereotype is that illegal immigrants go to emergency rooms all the time – very often – this is not really correct. The problems illegal immigrants create for emergency rooms is not so much that they go more often than the rest of the population; rather, it is that when they go, they are much more likely not to pay, and that’s why it’s a problem. Remember, 13 percent of native-born Americans are uninsured, so they pay the vast majority of the time.

But more than 60 percent of illegal immigrants are uninsured, so they often don’t pay. Thus, when illegal immigrants use emergency health care, there is often no corresponding stream of revenue gong to the emergency room to offset all the costs they create. This is the reason emergency rooms get so overcrowded in areas with lots of illegal immigrants. Illegal immigrants are using the system without paying for the system at much higher levels.

We can also calculate the cost to taxpayers of the whole thing – of what legal and illegal immigrants cost, and if we put in their U.S.-born children who are uninsured as well, and that’s about $11 billion a year from public coffers. Now, charity and the illegals themselves – and the immigrants themselves – pay on top of that, but the cost to taxpayers from all immigrants who are uninsured and their U.S.-born children we’re estimating at about $11 billion a year, and this takes into account that the immigrants tend to be younger and use less care, but are all of course much more likely to be uninsured in the first place.

Now, what if we tried to provide Medicaid to, say, uninsured immigrants? In that case, the cost would be very high indeed. If we decide to cover just the uninsured illegal immigrants with Medicaid, even taking into account their much younger age on average, it would still cost about $15 to $30 billion a year to provide them directly with Medicaid. Now, providing Medicaid to all uninsured immigrants and their children would, of course, be enormously expensive – perhaps $60 billion a year.

Now, what about an amnesty, or what some folks like to call legalization of illegal immigrants? Would that solve our problem? That’s an interesting question. The president has made statements that suggest that he thinks an amnesty would solve our problem. But the answer is no, it almost certainly would not. Remember, lack of health insurance is very common among legal immigrants – people who are here legally.

In 2007, more than one-fourth of those with a green card – that is, a legal resident who’s not a citizen – did not have health insurance. That’s more than twice the rate for native-born Americans. If we look at green-card holders who don’t have a lot of education, which then is analogous to the illegal immigrants, or what the illegal immigrants would become if we gave them legal status, 35 percent are uninsured.

Now, this is better than the 64 percent that we estimated for illegals, so in that sense, we think that more illegal immigrants would have health insurance. But there’s a catch: If we, again, look at those less-educated green-card holders, in addition to 35 percent being uninsured, another 28 percent on Medicaid – the health-insurance program for the poor that’s very costly for the government, which means we haven’t really solved the cost problem because we didn’t solve the underlying problem, which was that illegal immigrants are overwhelmingly unskilled – not in every case; there’s certainly skilled immigrants. But we think that about 80 percent, say, for example have no education beyond college – the majority haven’t even – I’m sorry, no education beyond high school. And we think that a majority haven’t even graduated high school – about 55 percent. And about 80 percent are either high-school dropouts or have only a high-school education.

In conclusion, we have to ask the question, can we have health-care reform without immigration reform? Put a different way, can you let illegal immigrants stay and avoid the large cost for taxpayers? The answer is almost certainly no. If the illegals stay, the costs will stay as well. In short, we either enforce the law and reduce the illegal population over time, or we just accept the costs, which is another alternative.

Now, if one still favors an amnesty or a legalization – whatever you’d like to call it – then we have to be honest and make it clear that in areas like health care, the costs are significant for letting the illegals stay and may actually get quite a bit bigger if we legalize them. It doesn’t solve the cost problem. As for legal immigration, obviously legal immigrants already here are free to stay, of course. But in the future, we have to decide whether it makes sense to continue to allow in so many legal immigrants who don’t have a lot of education.

Depending on how you calculate it, some research shows a quarter of legal immigrants haven’t graduated high school, and some research shows a third haven’t graduated from high school. So a very large fraction of the legal immigrant flow is what can be described as quite unskilled. At present, most legal immigrants are allowed in the country because they have a relative here. This means that most legal immigrants are selected without regard to their education or their impact on taxpayers or the health-care system.

If we want to avoid large costs for taxpayers in the health-care system, we would need to significantly reduce the number of legal immigrants who are allowed in, in the future, who have very little education. Now, I think there’s still one final point that bears mentioning. The large share of legal immigrants on Medicaid or the large share of illegal immigrants without health insurance should not be seen as some kind of moral defect on the part of immigrants. The vast majority of immigrants, legal or illegal, do not come to the United States to get free health care or to sign up for welfare programs, though that often does happen.

And of course, as I’ve already pointed out, the vast majority of immigrants, including those here without health insurance, hold a job – they work. Rather, the problems I have discussed are an unavoidable consequence of allowing in large numbers of immigrants who work but have very little education and, as a result, they, or often their children, are uninsured or use a welfare program like Medicaid. If we want to reduce the uninsured population and avoid large costs for taxpayers in the health-care system, we need to enforce immigration laws and reduce the number of illegal immigrants in the country.

And on legal immigration, moving forward in the future, we would need to allow in many fewer immigrants who have little education. Barring those two changes, immigration will continue to have a very large impact on our health-care system, creating lots of folks who are uninsured, lots of folks who need Medicaid with a cascading series of consequences for the system. Thank you.

MR. KRIKORIAN: Thank you, Steve. Jim?

JAMES R. EDWARDS, JR: Well, I think it’s evident from Steve’s talk that immigration will affect and be affected by the health reform legislation that’s being crafted in both the House and the Senate with 12 to 15 million uninsured immigrants, as was discussed, their mere presence means that every provision of the legislation that’s designed to extend health coverage to those without insurance will potentially expand, as Steve highlighted, the taxpayers’ cost by billions if not tens of billions or even more.

And many immigrant households have children who are automatically eligible for government health care of various sorts even if their parents are here illegally. Bear in mind, government agencies and nonprofits often only look at things like income levels and other similar qualifiers when they’re enrolling new beneficiaries in public programs like Medicaid and SCHIP. They often overlook one’s immigrant status, even though that could disqualify someone from program participation.

Well, today, I’ll focus my remarks on the main immigration implications of the House and Senate health committee bills. I’ll also make a couple of observations about the Senate finance committee’s legislation, although there’s no legislation from that committee yet; it’s all being negotiated, and I’ll base my remarks on the finance committee effort – on its outline of health reform put out just a few weeks back.

Well, health reform legislation, particularly H.R. 3200, contains a number of provisions that open the door to taxpayer funding of immigrants’ health care. That’s for illegal aliens, for legal aliens who are supposed to rely on their sponsor for financial assistance during their first five years in the country and for certain immigrants who sponsor other immigrants. First, let’s look at the taxpayer-funded premium subsidy.

H.R. 3200’s Title II of Division A relates to coverage. This section, or title, of the bill creates a government agency to regulate health insurance. Individuals and employers will have to go there through its exchange arm for government-approved health insurance. It will run the public option and it will operate a graduated subsidy program. Well, section 242A defines who’s eligible for the premium subsidy and how many credits that they can receive to determine the amount of that premium subsidy.

The bill apparently qualifies all lawful permanent residents, regardless of their sponsor’s pledge financial responsibility or the required 5-year bar for most means-tested programs. Section 242D excludes receipt of these premium subsidy payments from counting as welfare. Taxpayers will subsidize households earning up to 400 percent of the poverty level. So Section 242 generously subsidizes many people, including the foreign-born, well into the middle class.

On the House bill count, that would be up to about $88,000 income a year for a family of four. The money doesn’t count as welfare payment, as I mentioned, which might potentially risk deportation as a public charge or jeopardize their ability to sponsor other immigrants. And the credits are available to sponsored legal immigrants and foreign-born immigrant sponsors themselves. The Senate Finance outline indicates that bill will subsidize insurance costs up to three times the poverty income level.

Let me talk briefly about public charge doctrine, which I’ve mentioned a couple of times. Public charge doctrine is a longstanding U.S. policy dating to colonial times and has been vigorously a part of our immigration policy throughout our history. It’s supposed to protect the country from importing people who become a burden on society. Would-be immigrants are denied visas on public charge grounds – they have too little income or whatever – or have certain other factors that would cause us to not give them a visa, and this goes on continually.

But very few immigrants anymore are deported for the reason of being public charges. So it’s pretty much, once here, you’re safe. Well, the 1996 welfare and immigration reforms strengthened public charge doctrine somewhat. Immigrant sponsors now must sign a legally enforceable affidavit of support. They must have earnings at least 125 percent of the federal poverty level. And their household income is deemed available to the immigrant who’s applying for federal means-tested programs.

Because H.R. 3200’s provisions suspend some of welfare reform’s requirements, it tends to weaken public charge doctrine. The bill creates a situation where sponsors of immigrants and the immigrants themselves can collect taxpayer dollars for health coverage when immigration policy would require that they be more self-reliant.

Section 242 of the bill states “illegal aliens are excluded from receiving federal payments under the affordable credits premium subsidy” but there’s nothing in the bill requiring screening of affordable credit recipients, such as screening them through the SAVE system. Congressman Dean Heller offered an amendment in the Ways & Means Committee to correct that, but it was defeated along party lines. Senate legislation omits the same eligibility verification requirements that would ensure that only lawful immigrants and U.S. citizens benefit under these programs.

Well, now let’s turn to Medicaid and SCHIP provisions. Well, Title VII, under Division B of the House bill H.R. 3200 expands Medicaid eligibility to those earning a third above the official poverty level. Thus, the minimum income that’s required of immigrant sponsors, which I mentioned is 1.25 percent (sic) of the poverty level, that falls below the sponsor’s eligibility for taxpayer-funded health care for the poor at 1 1/3 percent (sic).

The HELP bill expands Medicaid eligibility to 50 percent above the official poverty rate. That leaves an even larger gap for immigrant sponsors who are poor enough to be on Medicaid to still sponsor and bring in additional visa holders. Again, this aspect of the legislation has an undermining effect on public charge doctrine. Section 1702 of H.R. 3200 explicitly prohibits states which administer Medicaid and SCHIP from making further determinations about new Medicaid enrollees’ eligibility.

One such provision requires states to presume someone’s eligibility. In other words, these provisions set up a system that amounts to kind of enroll-first-and-don’t-ask-questions-later. In the Energy and Commerce markup, Congressman Nathan Deal offered an amendment to correct this. The Deal amendment would require a check of the eligibility on immigration and citizenship status of those being signed up for Medicaid. It would apply the same verification standards and use the same existing verification system that’s in the Medicaid statute. This taxpayer protection amendment lost on a largely party-line vote by a single vote. Senate legislation similarly omits any verification requirements of one’s eligibility.

Finally, let’s look at the mandate exemption. The finance committee outline, like the HELP and the House bills, mandates that individuals must carry health insurance, or else face a fine. The finance outline says that illegal aliens will be exempt from the individual mandate. Well, that’s interesting, but it sets up a system where you have Americans and legal immigrants who have to have coverage or else pay a fine, but illegal aliens would escape both the mandate and any fine for being uninsured.

It appears that this sets up for illegal aliens to be free riders, of sorts; they’d still receive taxpayer-funded medical services at health clinics and hospitals required to serve those presenting with medical emergencies. Yet illegal aliens would be free from any responsibility or sanction that other people would bear. So to conclude, essentially, these bills expand government health coverage and taxpayer-funded subsidies for government-controlled private insurance and the public option.

They make it easy to enroll new people in government-run health programs with what amounts to built-in, willful ignorance about characteristics which would be disqualifying, such as being here on a temporary visa or being still under one’s sponsorship requirements or being here illegally. And the bills make no provision at all for ensuring that only lawful U.S. residents and U.S. citizens benefit from these health programs. In short, the health reform plans that are on the table will create new incentives, at least marginally, for illegal immigration, they’ll reward illegal aliens by giving them health care at no expense to themselves, and they’ll further weaken the important public charge doctrine that long served our national immigration policy so well.

MR. KRIKORIAN: Thank you, Jim. Robert?

ROBERT RECTOR: Thank you very much. As we’ve noted here in the previous comments, immigration in the U.S. is primarily and disproportionately lower-skill immigration with one-third of all immigrants lacking a high-school degree, and among illegals, perhaps 55 percent lacking a high-school degree.

Now, if you believe that, in the United States, a person who lacks a high-school degree pays more in taxes than they receive in government benefits, then you would believe that this system is good for the U.S. taxpayer. On the other hand, if you believe that someone who lacks a high-school degree possibly receives a smidgen more in government benefits than they might pay in taxes, then you would recognize that this system, both legal and illegal, is very costly to the U.S. taxpayer.

Another aspect of this is that, since immigrants, both legal and illegal, are disproportionately less educated, they are reducing the average education level of the U.S. workforce. If you believe that reducing the average education level of a national workforce is good for an economy, then you would believe that the current legal and illegal immigration systems are good for the U.S. economy. If, on the other hand, you have an antiquated belief that having a higher-educated workforce is good for economy, you would have to conclude that both legal and illegal immigration is currently unfortunate in terms of quality economic growth.

In the United States today, our country spends over $700 billion on means-tested welfare assistance – that is cash, food, housing, medical care for low-income people. These are programs such as Medicaid, public housing, Earned-Income Tax Credit, Temporary Assistance to Needy Families. Of that, roughly $100 billion-plus goes to lower-skilled immigrants. They are a substantial and significant portion of the U.S. welfare system.

The way that I would characterize our current immigration system, both in its permissive entry of illegals as well as the high level of very low-skilled immigrants that come in through the legal immigration system, it’s as if it’s a transnational welfare outreach. Spending 5 percent of GDP on means-tested welfare is not sufficient; we need to reach out and bring more people into the United States so that they can enroll in this system. The bottom line is that the U.S. has a very generous system of support for less-advantaged individuals and it would be very difficult to provide that level of support to essentially an unlimited inflow of low-skill individuals from the Third World. But that is what our immigration system currently does.

If we were to look at the current health-care reform legislation, this takes an unprecedented step in opening up the U.S. welfare system to illegal immigrants. Under the current law, really forever, we have had a system of identity checks that largely prevent adult illegal immigrants from getting onto these means-tested welfare programs. You have to be able to substantiate that you’re in the country legally and you have to be able to substantiate that you, if you’re a legal immigrant, that you’ve been here over the time limits for eligibility.

The health-care reform legislation turns that on its back and tramples it into the dust. It basically says we will not verify; we will not check. We have a complete open door for every illegal immigrant, current and in the future, to simply enroll and receive benefits under this program. We not only will not check them at the door; we will not check them once they begin to receive the benefits. I would say if you’re going to do that with respect to health care, why would you not also establish the same precedent with respect to food stamps, to public housing, to the Earned Income Tax Credit and so forth.

And I believe that is, in fact, the direction that the Congress wants to go to, to allow all welfare benefits to be fully available to all illegal immigrants. This seems to me not only to set up a substantial cost – the cost of that – of providing medical insurance to all of the current uninsured illegals, I believe, is on the tune of close to $200 billion over the next decade – but that it clearly would have a magnet effect, I believe, of drawing even more illegals into the U.S. and into the United States since we will have a precedent of saying come into the U.S., you will get free medical care, we will absolutely not check who you are or whether you are here lawfully.

I would say that this would also create an even further precedent of what I would call medical tourism. What could happen under these bills, if they became law, is that someone could enter the U.S. either illegally in the future or enter the U.S. as a tourist, in the future, who has a significant medical condition that requires health care. They could then declare themselves to be eligible for these programs, enroll in this public option, begin to receive medical care without ever being checked as to whether or not they are in the United States lawfully or eligible for these programs.

I believe that under this legislation, we will begin to draw the seriously ill from all over the world to begin to come here to receive free medical treatment. And once you hook these individuals up to the dialysis machine or whatever it is, we’re very unlikely, as a society, to pull the plug and say get out of here. It is an absolutely mind-boggling precedent that’s being established here. If we look overall at the cost of means-tested welfare – that is, again, aid that is targeted to lower-income people; Medicaid, public housing, food stamps and so forth – what we find that is over the next decade, the United States will spend $1.5 trillion on means-tested welfare for lower-skilled immigrants – those with a high school degree or less: $1.5 trillion.

Half of that, or around $750 billion over the next decade, will be for medical care for lower-skilled immigrants, primarily through the Medicaid program. This is a massive expenditure at a time in which the United States is already going bankrupt as a nation. Now, the health-care reform that is pending in the Congress would add additional cost onto that not only by making the illegals eligible for free medical care, but also by extending medical care to all of the legal immigrants who currently do not have it.

Steve’s numbers here are very good, showing that about a third of the uninsured are immigrants, but I would say that if you looked at the lower-income uninsured, which is where the core of the expenditure will be, that number is probably significantly higher. Perhaps as much as 50 percent of the lower-income uninsured are, in fact, immigrants, both legal and illegal. We are about to, I believe, go into the system of nationalizing U.S. health care, of creating a government monopoly health-care system, primarily – or at least very substantially – in order to provide health coverage to immigrants.

In addition to the health-care reform, we have the fantastic cost associated with the pending amnesty. One of the things that we know about illegal immigrants is that very few of them are elderly. If you are an illegal immigrant, you come here during working age and either, you’re going to find some way of becoming legal or you’re going to go back home by the time you are of retirement age.

One of the clear things that any amnesty bill or earned citizenship bill does is that it, at the point of passage, it immediately takes all of the current illegal immigrants and makes them potentially eligible for Social Security and Medicare – an astonishing out-year cost, all of which is hidden in the normal budgetary calculations, which only calculate the cost of amnesty over, say, a 10-year period.

But you’re going to put all of these individuals – perhaps as many as 12 million individuals – into the Social Security and Medicare systems. Now, the cost of that, once they hit retirement age, which will occur in about two decades, would be around $2.5 trillion. Of that, around $1 trillion would be for Medicare alone. So this is just another aspect of – that not only are we spending enormous sums on the current system, enormous sums on the current low-skilled immigrants, but with health-care reform, we will pile much more money on top of that and if we add amnesty on top of that, we will be adding another trillion dollars in future expenditures, $2.5 trillion if you count Social Security in as well.

The United States of America, in my mind, is now going bankrupt. We are beginning to look like Argentina or something like that in terms of the level of public debt that we are racking up here at an unprecedented rate. A substantial portion of this national debt is due to the fact that we are bringing in very low-skill individuals through both legal and illegal immigration, providing them with a vast array of government services that they do not pay for, and basically piling up the debt on our children in order to pay for those services. Thank you very much.

MR. KRIKORIAN: Thank you, Robert. Steve, did you have a question?

MR. CAMAROTA: Well, I just have a quick point of clarification for Robert and Jim, who’ve studied the legislation itself: So what you’re saying is, in effect, if I’m right, is that they could have – if they have the public option or some new government program, whatever that is – they could have created a situation where, like with other programs, you verify whether the person is eligible. Some legal immigrants are not eligible because they haven’t been here long enough, and illegal immigrants are not supposed to be eligible; their children are, but they’re not.

But they chose explicitly to make them eligible in the sense that they took out the enforcement, but they also said that they weren’t supposed to get it, so it’s kind of like a – would an analogy be a speed limit on a highway and then a pronouncement that police will never patrol that highway? Is that sort of what we’ve kind of done, would you say, in this legislation?

MR. EDWARDS: Yeah, it’s difficult to know the motivation for omitting the verification provisions. You know, I think the one provision that is in there that I mentioned that excludes availability but doesn’t require a way of checking it – yeah, it’s kind of like the highway sign – the highway marker that you mentioned, but it’s also, I guess, similar to – have you ever seen a “no trespassing” sign in the middle of the woods and there’s no fence, there’s no, you know, farmer with a shotgun or whatever. So it’s just there and there’s no enforcement whatsoever.

MR. RECTOR: Well, I would say the motivation is clear. I mean, it couldn’t help but be clear. This is such an unprecedented step within the U.S. welfare system, to basically say, oh, you are not eligible but we will not check, wink, wink, nod, nod. We’ve never done that, okay. And, gee, I wonder why that provision is in there, especially since, on two occasions, they deliberately voted down amendments that said, well, why didn’t you apply the traditional checks that are on – by the way, these are on over 71 different federal welfare programs, okay – you use this type of check to determine whether the person is eligible?

I mean, that’s what you do. It’s not only just a check for illegals; it’s also a check for employment verification, okay. So if you say that you come in and you have income of X, well, we – the government determines whether your income is in fact that low, or whether you are, in fact, eligible. This bill says no, we ain’t checking nothing, okay? You come in – it’s self-proclaimed; if you proclaim that you’re eligible for this, we’re going to let you in. And if you proclaim that you’re a U.S. citizen or that you’re otherwise eligible, you’re in and we will never check you. There’s only one reason for doing that, and it’s because they deliberately intend all illegal immigrants, both current and future, to receive free medical care at the expense of the U.S. taxpayer.

MR. KRIKORIAN: Thank you. We’ll take questions from the audience now. Yes, ma’am?

Q: Hi, I’m Penny Star with CNS News. When you referred, Mr. Rector, to the $1.5 trillion in the next decade for those lower-skilled immigrants, are you talking about all – I mean illegal and legal?

MR. RECTOR: Yes, that’s all. It would be higher – much higher if you granted amnesty to the illegals, but under the current system, recognizing the lower-skill immigrants take about 15 percent of total means-tested aid – that’s cash, food, housing and medical care – that would be at least $1.5 trillion over the next decade.

Q: And which immigrants, again, was that?

MR. RECTOR: It’s basically those with a high-school degree or less.

Q: But are they legal or illegal?

MR. RECTOR: Probably the majority of that is for those that are currently legal.

MR. KRIKORIAN: Thank you. Yes, sir, and if you could speak up and identify yourself, please.

Q: Frederick McKenna with RTT News. Two quick questions, please, one for Mr. Camarota: Did you find anything – any difference between illegal immigrants and legal immigrants in terms of their paying back the use of emergency services? You mentioned that illegal immigrants tend not to pay for that, and do you think that, that might potentially change, were they legalized? And the second question is for Mr. Edwards. Have you looked at the agricultural visa worker and the provisions – how health-care reform might affect that segment of the low-skilled population – you know, your guest workers, that sort of thing?


MR. CAMAROTA: Yeah, well, the statistics I gave were what taxpayers pay – remember, uninsured people still pay billions of dollars for their care – they go to the doctor; they go to the emergency room – they just don’t pay most of it, and the total sum of what taxpayers pay is though to be around $43 billion. Around $4 billion of that is going to illegals. Somewhat more might be going to legal immigrants.

I don’t think we have a good body of research showing that legal immigrants are more likely to pay for services – I don’t know of any that says that – when they’re uninsured. What we do know is that legal immigrants who are unskilled tend to be more likely to have health insurance than illegals who are unskilled, but the big difference seems to be Medicaid – that what happens is they get insurance, but they get it entirely at the taxpayer expense. They move from being uninsured to Medicaid.

So if your concern was they didn’t have insurance, then now they do, so that’s positive. That might improve their health-care outcomes. If your concern is the taxpayer, then that’s very bad because being on Medicaid is much more expensive to taxpayers than being uninsured.


MR. EDWARDS: One of the bills – I believe it’s the Senate bill, but I may be mistaken on my recollection – states that lawful permanent residents and U.S. citizens – one of the other bills, maybe the House bill – I may have that reversed – says that it’s – and so that’s a permanent immigrant visa holder. The other says that – it includes pretty much anybody who’s here under color of law, which includes everybody who’s legally here on temporary protected status, non-immigrant visas and so forth.

So one of the bills does contemplate separating and not extending coverage, but again, without checking and verifying that non-immigrant visa holders – temporary visa holders – would not qualify, whereas the other does say anybody who’s here legally, even temporarily.

MR. KRIKORIAN: And that would include foreign students as well as farm workers, illegal aliens given temporary status – all kinds of people. And there’s actually millions of immigrants here that we describe as immigrants, but are not green-card holders, are not illegal immigrants – they’re legally here, but temporarily. Next question? Yes, sir. No, you there – yeah.

Q: In reading the memorandum, the second bullet point says, “Immigrants account for 21 – 27 percent of those without health insurance.” And then, at the bottom, it says “legal immigrants account for 27 percent” and the one up before it says “64 percent of illegal immigrants are uninsured.” Can you explain this?

MR. CAMAROTA: Yeah, they are two different statistics. One is, what fraction of immigrants don’t have health insurance; the other is, we’re trying to measure their impact on the system. If there are only 10 immigrants in the United States, just 10 people, and half didn’t have insurance, they would be a trivial fraction of the uninsured. But there are lots of immigrants. So one statistic is, how many people, of immigrants, are uninsured. The other is what fraction of the total they comprise.

So in the case of immigrants and their children, the two statistics are somewhat close. But the point here is about 33 percent of all immigrants – just immigrants now, not their kids – 33 percent don’t have health insurance. And they comprise 27 percent of all people without health insurance. Do you see the difference? A third don’t have it and they make up a fourth of the total.

So they’re two different measures that are important to know; you can’t just know one without really thinking about the other. And that’s why the two statistics – maybe we could say it a little clearer here, you know, make it clear we’re talking about total versus what fraction don’t have it. But that’s how it works.

MR. KRIKORIAN: Next question. Yes, sir.

Q: Michael McLaughlin, American Council for Immigration Reform.

MR. KRIKORIAN: Speak up, please.

Q: Okay. A comment for Mr. Rector, as well as a question. First of all, I enjoyed your importation of poverty, a book of charts, which to me is a seminal work on the impact of immigration on this country. Second of all, when you talked about the impact of amnesty, you mentioned that it would cost an out-year cost, 2.5 trillion (dollars) roughly for impact on Social Security, Medicare, et cetera.

But in your analyze of the Hagel-Martinez bill in 2006, you estimated that in addition to the legalization of the 12 to 20 million, that there would be at least over 60 million people who would come into this country would be sponsored through chain migration or family unification. So is that amount included in your 2.5 trillion for the out-years or not?

MR. RECTOR: No. The 2.5 trillion would simply be the cost of providing earned citizenship to the current illegal population. The bill last time around didn’t have those massive expansions in legal immigration which the bill three years ago did have, which would impose even greater costs.

The bottom line to understand this is to recognize that the U.S. has a very large and robust welfare system. We don’t really recognize that because it’s over 71 different programs. And in order to calculate the cost of those programs, you have to go through a 1300-page budget appendix and count them all up.

Social Security and Medicare appear on two lines in every budget item. In order the find the cost of aiding poor people, you have to go really and really dig. But when you add all of those things together, the cost of aiding the poor, of which medical care is roughly half of it, it is three-quarters of the cost of Social Security and Medicare and has grown as rapidly as Social Security and Medicare over the last three decades.

And virtually no one understands that because this welfare system is like a jigsaw puzzle in which the pieces are never put together. And now the bottom line vis-à-vis immigration is that this system, along with other government systems, constitutes a massive transfer of resources each and every year from the middle class down to the less advantaged. We can barely afford to do that for disadvantaged lower-income Americans, okay?

And what’s happening with immigration is that we are importing huge numbers – both legally and illegally – of people that fall into the eligibility criteria of these programs. You don’t have to sit at home and not work at all; you just have to have a low income in order to generate this flow of income. And the more legal and illegal immigrants that we have of that lower skill status, the greater the cost to the U.S. taxpayer.

On average, an immigrant who does not have a high-school degree receives $20,000 more in government benefits and services than they pay in, in taxes each and every year – and they do pay some taxes. But, by and large, that gap of $20,000 has to be paid from some place. Right at the moment, we are borrowing it. And for the next decade, we’re going to be borrowing it and putting a debt on the future in order to pay for it.

MR. KRIKORIAN: Thank you. Next question. Yes, sir.

Q: (Inaudible, off mike) – University of California journalism program. Mr. Camarota and others talked about how there is a problem with the education level of people coming into the country as immigrants. How do you square that away with the fact that the demand for labor in this country is for low-skilled work, and have you done any cost-benefit analysis on what the benefits to the economy are of that work and also what the cost would be if you didn’t have workers to do it?

MR. CAMAROTA: Yeah, as the level of unskilled immigration has gone up, one of the most troubling trends in the U.S. labor market is that less-educated Americans work less and less. If we look at Americans who don’t have a high school degree, the share who hold a job at any one time, who are in the labor force, has declined dramatically. There are like 7 or 8 million of them now not even in the labor force who are 18 to 65, which a very large fraction should be.

If we look at people who have only a high school degree, especially the young, 18 to 29-year-olds, the share of them holding a job at any one time has declined by several million as well. All totaled, America has 25 million – and even before the recession, about 22, 23 million – people with no education beyond high school who are 18 to 65 not working. Now, the total illegal workforce is 7 to 8 million so it looks like we have this enormous supply. And their situation has deteriorated dramatically.

The other thing is, the other group where we’ve seen this big loss in work is among teenagers. Teenagers used to work at very high rates, say, 16 and 17-year-olds. The last 20 years has seen a massive decline both in their year-long employment and even in their summer employment. And that’s about another 8 million not working at any one time. So roughly speaking, if only one-fourth of the less-educated not working who are native born were to work and then throw in a few teenagers, you could replace the whole illegal workforce of 7 or 8 million people.

Now, the other thing that’s going on in the U.S. labor market that I think most people think is equally as troubling is that wages and benefits for people at the bottom has deteriorated dramatically. So not only are less-educated Americans working less; they are making a lot less. There are some astonishing statistics – let me give you one of my favorites that we’ve come across, which is very well-documented – meat packers, a difficult job generally done by people without a lot of education. Their real wages are 45 percent less today than they were in 1980.

Now, in general, for, say, high school dropouts, wages are about 22 to 25 percent less than they were in 1980. So my take on this is, if we had less unskilled immigration and we paid workers more and we treated workers better, it appears we have a huge supply of unskilled workers to fill those jobs – again, if properly paid and treated. And I think from an equity point of view for our fellow countrymen, that would make a lot of sense. But instead, we’ve sort of adopted this other policy where we flood the unskilled labor market, keep wages very low and allow non-work to become very common among less-educated natives.

Now, there are other issues going on. There are other factors that are negatively affecting less-educated people in this country; it’s not just immigration. But I think immigration is a part of it. And, most importantly, it’s something we can do something about. We can change our immigration policy. Globalization – the Japanese setting up factories in Malaysia and displacing U.S. workers – is tougher to do anything about whereas reducing your immigration level or reducing your unskilled immigration level is at least something that is tangible and we could do something about.

MR. RECTOR: I happen to work on both the issues of welfare and poverty and immigration. And so I get this very paradoxical message that I can go to one group working on welfare and poverty and be told in the morning that there are absolutely no jobs for lower-skilled Americans in Minneapolis or Milwaukee or whatever. And then I can go to another group in the afternoon and be told that we have to have massive, low-skill immigration because Americans won’t take these jobs. We really have to reconcile these things.

If you were to go to any discussion, for example, on black poverty and black family structure in the United States, the overwhelming consensus, particularly in the left, of the major problem is low wages for black male workers and a lack of jobs for black male workers. You could – 20 years, that is the prevailing factor; that is the explanation about why family has declined in the inner city, why we have poverty, why we have welfare and so forth.

And, at the same time, we’re being told that we need to import 7 or 8 million high school dropouts from abroad because we don’t have enough workers to fill these lower-skill jobs. At the same time, when you’re looking at the wages for these less-skilled males, they have almost been flat for several decades. But somehow, we need to have more and more of these workers.

Also, it’s a misnomer to suggest that because immigration makes the economy larger, somehow the average citizen benefits from that. It is true that immigration and low-skill immigration does make sort of a larger pie, but the immigrant eats about 90 percent of that share of the larger pie through his own wages and it does not confer benefits on the rest of us. It does confer costs on the rest of us because almost all of these low-skill immigrants will impose a governmental cost that they cannot finance through their own taxes.

MR. KRIKORIAN: Let’s take a couple more questions. Yes, sir.

Q: Yeah, Perry – (inaudible, off mike) – from the University of California journalism program. This question is for Mr. Camarota and Mr. Rector. Mr. Camarota, you mentioned that immigrants in their home countries don’t have much knowledge of health-care systems – either they don’t have health care or they receive health care from the government. And I’m wondering what the risk of medical tourism is when they are not really aware of the system to go through it to get medical coverage in the U.S.?

MR. CAMAROTA: Yeah, that’s a great question; that’s a reasonable question. I think that I’m not sure about the risk of – it can be a lot of people numerically and it can be millions or even billions of dollars, whether it would be a very large fraction of the whole health-care pie. But remember, obviously, people who would engage in health-care tourism would be mostly the most affluent who find they can’t get insurance in their own country, and they are aware of it and they can afford the plane ticket.

They can afford to navigate the visa process and get one, which obviously millions and millions of people do every year. So what you would not expect is a person who’s not literate in Hindi coming from India and trying to do medical – what you would expect is someone who’s college-educated in India, has a serious condition they can’t afford to treat, and being able to buy a ticket and come.

So you would expect that – that would be more of a phenomenon among the most educated with one very notable exception. Maybe at the border, there would be people who come across the border to get medical care. There are – and that would be another example – there are about 400,000 births to, say, illegal immigrants in the United States each year, comprising about one out of every 10 births in the U.S.

But what percentage are people who arrive pregnant, women who cross the border or overstay a visa pregnant? It could be a large number – 20,000 – and it could cost taxpayers millions and it certainly does, but it’s hard to get a handle on how big that is potentially. But as Robert pointed out, and maybe I’ll – that if you don’t verify, which is what this new bill considers, that could grow much larger than whatever it is now.

MR. RECTOR: I would consider the precedent for medical tourism to be quite strong indeed because we’ve already done this once as a nation, or something very similar. In the 1980s and 1990s we allowed elderly immigrants to come in and get onto a program called supplemental security income. And in fact, elderly immigrants coming to the U.S. to retire on this welfare program – they get supplemental security income and Medicaid – was the fastest-growing element in U.S. welfare.

It was absolutely unprecedented. And what we found – and we had testimony on this as part of welfare reform in 1996 – that all across Southeast Asia, there were actually publications in the native languages – in Chinese or other languages – on how to come to the United States and retire on SSI. In Chinese, okay. And we have testimony before Congress to that effect. Now, one of the things that happened in welfare reform was that welfare reform said you had to be a U.S. citizen to get SSI and that sort of checked that massive inflow. But the idea that no one is aware and are not attracted to these benefits is absolutely historically refuted.

Not only are our people aware of this, but you actually have agencies and organizations set up to inform them and to draw them in. Another aspect of this would be that any legal immigrant who was here would, under this system, have the absolute option of bringing their parents and their grandparents in, declaring them eligible and receiving free medical treatment under this system.

You could retroactively go and try to get some that back. The record of achieving that is absolutely terrible. So what you’re going to do here at the very least is create a mess, which will be exploited and which will ultimately have to be cleaned up at some point in the future after you’ve already spent a lot of money.

MR. KRIKORIAN: Let’s take one final question. Yes ,sir, in the back. If you could speak up please.

Q: I just wanted to ask, in your studies – and they were very interesting studies – but did you consider the cost of not insuring these people who are already here, especially in light of the H1N1 virus and various other viruses such as that? Would it not be less costly to the nation to actually cover these people and not expose the citizenry to even more health costs?

MR. CAMAROTA: Well, let me answer it this way: I do have an estimate – so let’s just take illegal immigrants. If we wanted – right now, we’re spending about $4 billion on their health care. Let’s say we gave them Medicaid. Given, they’re about 7 million but they’re relatively young so they’re not that expensive relative to other people on Medicaid. So you’re still looking at about $15 billion. So it would be much more expensive to cover them on Medicaid but their health-care outcomes might improve.

That would be one thing. Now obviously, vaccines and emergency medical care are still covered, but when you’re talking about communicable diseases, that would be an advantage. The bottom line is people who are uninsured do cost taxpayers money but government insurance costs a lot more. But their health-care outcomes improve, so that’s a balance.

But we’re not going to save any money if we insure folks. That’s what we have to understand because people who don’t have insurance put off care, they don’t go to the doctors, they pay some on their own. Yes, taxpayers spend billions on them as well, but they just don’t get anywhere near what someone with actual insurance like Medicaid.

MR. RECTOR: When Lyndon Johnson launched the war on poverty, welfare spending in 1964 was about – in today’s dollars – about $70 billion a year. It’s now 10 times higher. It went from 1 percent of gross domestic product to 5 percent of gross domestic product. In the next decade it will be 6 percent of gross domestic product.

In each step in that process, we were told that we were spending the additional money in order to save money. (Laughter.) And boy, it’s a good thing we saved all that money. The bottom line is that as long as you have this type of lower skill immigrant in massive numbers in the United States, either legally or illegally, they’re going to cost the U.S. taxpayers a lot of money one way or another. To the extent that you formally incorporate them into these government programs, those costs go up rather rapidly.

MR. EDWARDS: I’ll just make one observation. The congressional Joint Economic Committee just recently came out with a report and it looked at how well cost estimates had done on several of the programs over the past 40 or 50 years – the estimates on the front end of, say, Medicare, front end of various other health programs.

And I believe the Joint Economic Committee’s identification of that cost was that it underestimated in most every incidence by anywhere from 1-to-1.6 ratio, all the way to 1-to-16. So if you’re underestimating anywhere between that and 16 times underestimating, that is a huge risk on unfunded liabilities that you’re potentially going to take on. And this is just one element of adding that.

MR. KRIKORIAN: Well, thank you. Thanks to all the panelists. All of our publications as well as the transcript and video of this event will be on our site at some point relatively soon, which is – C-I-S-dot-O-R-G. And thanks, everyone, for coming. (Applause.)