Trump Says Covering All Immigrants Would Bankrupt Our Healthcare System. That’s a Lie.

Covering undocumented immigrants under Medicare for All isn’t just morally right—it’s also economically sound.

Adam Gaffney February 7, 2020

We must confront Trump’s State of the Union lies about immigrants’ healthcare. (Photo by Mark Boster/Los Angeles Times via Getty Images)

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. 

Including immigrants in an insurance system, in other words, makes it more actuarially sound.

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.

Adam Gaffney is a physi­cian and writer with a focus on health­care pol­i­tics, pol­i­cy and his­to­ry. He is an instruc­tor in med­i­cine at Har­vard Med­ical School and a pul­monary and crit­i­cal care physi­cian at the Cam­bridge Health Alliance. His writ­ing has appeared in the New Repub­lic, Los Ange­les Review of Books, Salon, CNN​.com, USA Today, Jacobin and else­where. He’s a board mem­ber of Physi­cians for a Nation­al Health Pro­gram, a sin­gle-pay­er advo­ca­cy orga­ni­za­tion. The views expressed are his own.
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