Transcript Health Insurance Coverage of Immigrants

Documenting the Undocumented
Tough Questions:
What about the undocumented?
PNHP Annual Meeting- 2007
Olveen Carrasquillo, MD, MPH
Director, Columbia Center for the Health
of Urban Minorities
Demographics
• In March 2006, the population in the United
States included 35.1 million foreign born,
representing 12 % percent of the U.S.
population.
• This includes 21.6 million non-citizens
(7.4% of US pop)
Unauthorized Immigrants
(aka illegal, undocumented etc)
• A person who resides in the US but who is not a
U.S. citizen, has not been admitted for permanent
residence, and is not in a set of specific authorized
temporary statuses permitting longer-term
residence and work
• The Pew Hispanic Center estimates that there are
currently 11.5 to 12 million unauthorized migrants
living in the United States in March 2006
• Increasing about 500,000 per year
http://pewhispanic.org/files/execsum/61.pdf
How do we know how many
undocumented?
“Residual Method”
• Subtracts the estimated legal-immigrant
population from the total foreign-born
population and treats the residual as a
source of data on the unauthorized migrant
population (Passel, Van Hook, and Bean
2004).
How do they get here?
50% of undocumented immigrants entered US legally
Some do cross the border!!!
• If I were in their shoes, I'd be doing the
same thing--coming across that border and
trying to better things for myself and my
family."
States with largest undocumented
populations
14.6 million in unauthorized families
Do undocumented pay taxes?
• About half of undocumeted work using fradualent SS#
and thus pay federal, social security, Medicare, and
state taxes
• Social Security Administration has estimated that three
quarters of undocumented immigrants pay payroll
taxes, and that they contribute $6-7 billion in Social
Security funds that they will be unable to claim (Porter
2005).
• Any extension of legal work authorization—whether
temporary or permanent— would give a substantial
boost in tax revenue
Do undocumented pay taxes?
• Undocumented immigrants pay the same
real estate taxes—whether they own homes
or taxes are passed through to rents—and
the same sales and other consumption taxes
as everyone else.
• The majority of state and local costs of
schooling and other services are funded by
these taxes.
• Contrary to the public's perception, when all levels of
government are considered together, immigrants
generate significantly more in taxes paid than they cost
in services received.
• This surplus is unevenly distributed among different
levels of government, however, with immigrants (and
natives) generating a net surplus to the federal
government, but a net cost to some states and most
localities.
– Feds will not pay Medicare or SS costs
– States and localities absorb most health care costs and
education
• This disparity has intensified over the past decade, as
federal support for the few federal programs targeted to
immigrants and to the communities in which they settle
has declined sharply.
• When these trends are viewed in the light of the
growing concentration of the immigrant
population in six states and in the nation's already
stressed urban areas, they raise serious questions
about institutional capacity, fiscal fairness, and the
direction of immigration policy.
• All of these concerns suggest that questions of
intergovernmental fiscal equity—an important
aspect of immigrant policy—require attention
http://www.urban.org/publications/305184.html
• Recent analyses by government agencies
interested in "recovering" the public sector
costs of immigrants and nonprofit groups
committed to reducing levels of
immigration uniformly find that immigrants
impose fiscal burdens on governments and
on native-born taxpayers.
Local Data: Wash DC
22% Unauthorized
Models assume that only 55 percent of unauthorized
individuals pay Social Security, Medicare, and federal, state,
and local income taxes, since many of them work under the
table and are paid in cash.
Back to Health Care
Racial/ethnic disparities in insurance
coverage by citizenship status
60%
55%
US citizens
Non-citizens
% uninsured
40%
36%
26%
23%
22%
18%
20%
14%
10%
0%
NHWs
Blacks
Hispanic
Asians
35
30
% Uninsured
25
20
15
10
5
0
Chinese
Filipino
Indian
Japanese
Korean
Vietnamese
Health Coverage in NYC
% of Uninsured Adults
Naturalized
21%
Citizens
Permanent residents 41%
Refugees /Assylees 41%
Undocumented
79%
Source: LANYC Immigrant Survey/ Urban Inst.
Single Payer and Disparities
• NHI will not end disparities in health or health
care
– nor it will end racism in the US
• NHI needs to be the fist and most important step
towards addressing healthcare disparities
• Other Barriers that need to be addressed
–
–
–
–
–
Cultural Competency Issues
Language Issues
Workforce Diversity
Racism / Discrimination
Undocumented Issues
Why cover immigrants (aka non
citizens / undocumented)
• Humanitarian Reasons
– No even the most right wing will let child die from
appendicitis
– ? Bleed to death from MVA
– ? Thombolysis to AMI
– ? Dialysis
• Social Justice
– They are paying their way
Economic Reasons
• Some health care is cost saving vs CE
– immunizations
– Will pay for diabetic amputation
– But not management DM/ CV risk factors
• Keeping work force (current + future)
healthy is good for our economy
• Costs little to care for immigrants
Healthy Immigrants
• Despite diabetes similar/lower rates of
cardio-vascular disease and stroke
• Overall lower cancer incidence
• Similar/ infant mortality as NHWs
• 33% lower odds of LBW and 11% lower
odds of pre-term births
Am J Pub Health 2005:95;1431-1438
Scare Tactics:
Your Family will get sick!!!
•
•
•
•
Tuberculosis / Resistant Tb
Malaria
Childhood Infections
Pandemic Influenza
Number of TB Cases in
U.S.-born vs. Foreign-born Persons
United States, 1991-2001
20000
15000
10000
5000
0
1991
1993
1995
U.S.-born
1997
1999
Foreign-born
2001
Foreign-born vs. US-born cases of
tuberculosis in Northern Manhattan
N Eng J Med 2002; 346: 1453-1458
Will Single Payer Cover the Undocumented?
Single Payer’s Dirty Little Secret:
It will!!!
Why Single payer must require
coverage of non citizens
• 50% are already covered
• Some of the other 50% already get care from
costly and inefficient safety net
• Administrative costs of developing
mechanisms to bar 6 million from low cost
coverage
Why Single payer must require
coverage of non citizens
• Hospital Global Budgeting..
– Every one in no one out
– Vs maintenance of billing offices
• Providers…
– Safety net providers will want to be paid for
care of undocumented
– Cost of maintaining for safety net for 6 million
Challenge to Single Payer Advocates
• Do we openly and vocally acknowledge that we
will cover undocumented
• Will need to… when we speak to Latino groups
• ? Being silent when we speak to some other
minority groups
• Will incur wrath of right wing but also may
moderate Democrats
• Many people would gladly pay much more to
ensure we screw undocumented
LNHI Update
Latinos for a National Health
Insurance : Update
• LNHI’s mission is to serve as a Latino
focused advocacy group to establish a
comprehensive, universal, accessible,
equitable and affordable program of
national health insurance covering every
person living in the United States.
• It will do this through coalition formation
and education
LNHI Update: Status
• Finally incorporated
• More talks
–
–
–
–
Lincoln Hospital Conference
Testimony to NYS Commission
Media work
Stuff Jaime has done
• Need money!!!
– 503c
– Need money to raise money
• Sources of Funds
–
–
–
–
Birthday Party- raised . $1000K
NIH giving us about $1000 K (they do not know it)
Fancy Schmancy Meeting with NYC Latinos VIPs hosted by Union
Got a $2000 Match