During his State of the Union address on Tuesday, President Trump put Medicare for All in the crosshairs. Single-payer healthcare will “bankrupt our nation by providing free taxpayer-funded healthcare to millions of illegal aliens,” he seethed, “forcing taxpayers to subsidize free care for anyone in the world who unlawfully crosses our borders.” Like so many of the other claims in Trump’s speech, this one was demonstrably false. If anything, the evidence suggests that immigrants actually subsidize healthcare systems — and it is time for advocates to push back.
For proponents, the case for single-payer is fundamentally a moral one: Healthcare should be a right, and everybody should be covered. This argument, however, is up against the rancorous rhetoric of the demagogic Right, which is not only advancing dehumanizing narratives of exclusion, but also bolstering those narratives with factual inaccuracies. According to one CNN poll, some 59% of the American public is opposed to providing public coverage to the undocumented. Changing this opinion means overturning the right-wing narrative. To do so, we have to make the case that Trump’s claim — that including all U.S. residents in a single-payer system will bankrupt it — is wrong.
A fundamental fact about financing healthcare for immigrants is that they are, compared to the native-born population, relatively young, and therefore healthy. As a result, immigrants tend to use comparatively less healthcare (indeed, too little) relative to those born in the United States. At the same time, they still pay into the system — even undocumented immigrants. Precise numbers are hard to come by, but as Paul Van De Water of the Center on Budget and Policy Priorities has noted, undocumented immigrants were estimated to have contributed a net $12 billion into the Social Security system via payroll taxes back in 2007. Something similar plays out in healthcare. As two important studies led by my colleague Dr. Leah Zallman at Cambridge Health Alliance and Harvard Medical School make clear, in healthcare, immigrants subsidize the U.S.-born.
In a 2013 study published in Health Affairs, Zallman and colleagues examined how much immigrants pay into the Medicare trust fund, relative to how much Medicare spends on their healthcare. They found that while immigrants paid some $33 billion in Medicare taxes in 2009, they only used $19 billion in health services — in other words, they subsidized the trust fund to the tune of nearly $14 billion. In a second study, also published in Health Affairs, researchers turned to private insurance, and a similar picture emerged. Premium contributions from immigrants (including the undocumented) exceeded plans’ outlays on immigrants’ healthcare. In contrast, U.S.-born enrollees contributed less than what they used in care — a deficit of about $163 per native-born person.
Including immigrants in an insurance system, in other words, makes it more actuarially sound. “Immigrants subsidize US natives in the private health insurance market,” the researchers concluded, “just as they are propping up the Medicare Trust Funds.”
Evidence from abroad — in particular, Spain — similarly strengthens the economic case for covering everyone. Spain’s universal system dates back to the 1980s, but as health researcher Helena Legido-Quigley of the London School of Hygiene and Tropical Medicine described with colleagues in Lancet Public Health, the nation passed a law in 2011 that “gave an explicit right to free health care for all people living in Spain, both Spanish and migrant, irrespective of their legal status, making Spain one of the most migrant-friendly health systems in Europe.” Still, it hasn’t been a straightforward path. In 2012, a newly elected conservative government reversed this expansion. They were met, however, with a wave of resistance, including civil disobedience. Some 1,300 doctors and nurses pledged to defy the law and treat immigrants regardless of documentation status, as the British Medical Journal reported. After elections in 2018, the new left-wing government of Pedro Sanchez restored coverage to all.
In 2018 (the latest year of data available from the OECD), Spain spent some $3,323 per capita on healthcare — compared to more than $10,000 in the United States. It seems unlikely that the 2019 figures will change that overall picture much. As such, the policy of extending universal healthcare to immigrants has not bankrupted Spain’s system.
Legido-Quigley and colleagues, writing in the British Medical Journal last year, cite other evidence of cost-savings from European nations, including a study in German that found that a policy of limiting healthcare access for asylum seekers and refugees actually led to larger healthcare costs down the road.
Europe, needless to say, faces the same sorts of right-wing populist forces that we contend with in the United States. Recent conservative governments in the United Kingdom, for instance, have taken steps to restrict access to the National Health Service to migrants. Achieving true universal coverage will be no easier here than abroad. But we should see the impediments as political — not economic.
For advocates of Medicare for All, the moral case for universal healthcare will always be paramount. Even if the above realities were not true, we should still include immigrants in universal coverage, on the basis that healthcare is a human right and no one should be left to die because they can’t afford to go to the doctor, regardless of national origin. However, the claim that immigrants would bankrupt the system is an empirical one that can be disproven, and factual inaccuracies should not be allowed to stand, especially when they are used to amplify xenophobic bombast from President Trump and his right-wing backers. The fact that a Medicare for All system that includes immigrants would be economically sound is one of the many data points we can use to make the case to millions of people that it is our moral imperative to build a Medicare for All system that includes everyone.