Supporting the System — Immigrant Contributions

Part 2, continued: Undocumented and Uninsured – A Health Care Challenge

[Editor’s Note: Click this link for an overview of the series and an interview with the author.]

Tammy Worth — Special correspondent to The Hale Center for Journalism

Immigration policy has become the third rail of politics. During a Congressional address prior to the implementation of the Affordable Care Act, President Obama said the legislation would not be used to provide benefits to people living in the country illegally. In a display of the ire, showing Republican’s frustration with the issue, Sen. Joe Wilson, R-S.C., yelled “You lie!”

But Obama wasn’t lying. Undocumented immigrants were all but left out of health care reform. There are two major provisions of the ACA intended to expand health insurance – Medicaid expansion and the creation of state insurance exchanges – and undocumented immigrants are excluded from both.

There are an estimated 33 million non-elderly adults who would be qualified for Medicaid if states expand eligibility levels. Of those, 3.7 million are undocumented immigrants, who are ineligible to sign up because of their status, according to a report by Lynn Blewett, Division of Health Policy and Management at the University of Minnesota School of Public Health.

Undocumented immigrants are also prohibited from purchasing insurance through the exchanges and ineligible for the income-based subsidies provided to help offset the cost of monthly premiums, even if they pay taxes.

“They went to great lengths to say they won’t help the undocumented,” said Leighton Ku, director of the Center for Health Policy at The George Washington University in Washington, D.C. “There were strong feelings about this in the bipartisan group that developed the legislation. (For undocumented immigrants) There’s not any relief in immediate sight.”

Nubia Estefes’ mother brought her to the United States from Mexico when she was three. The toddler traveled with her mother and sister to California to live with her grandfather who had moved years before and become a U.S. citizen.

Estefes thinks of herself as an American.

“I always kept being undocumented in the back of my head,” she said. “It’s just how you live. You’re not here, not there, just somewhere in between. But this is my home.”

Mixed-status households

Estefes got pregnant at the age of 17 and applied for Healthwave, Kansas’ Medicaid program, but was not eligible without documentation. She had her daughter at the University of Kansas Hospital and got some of the bills reduced because she applied for SOBRA (Sixth Omnibus Budget Reconciliation Act) funds. These are federal Medicaid funds undocumented immigrants in Kansas can use to pay for labor and delivery or life-threatening emergencies.

Shortly after her first child was born, Estefes became a U.S. citizen as are both of her children. But like so many immigrants families, she is part of a mixed-status household: her husband remains undocumented.

Estefes and her husband, who live in Olathe, both work full time, but neither employer offers insurance. Her husband’s employer knows that he is undocumented. They pay income taxes every year but can’t receive benefits like the child tax credit because both parents don’t have Social Security numbers. Her children are covered under Medicaid, so they have health care, but that is all of the assistance her family takes.

“We don’t apply for things (like food stamps) because my husband is undocumented,” she said. “He doesn’t like extra attention. He goes to work and comes home, and that’s it. He keeps below the radar.”

She has been with her husband for seven years and said he hardly ever sees a doctor. He cut his wrist doing yard work a while back and bled for six hours before she could convince him to go to the emergency department.

“He could be dying, and he doesn’t get care,” she said. “Undocumented people don’t demand health care like Americans do. We don’t get checkups; if it’s something bad, we just go to the ER.”

Paying without returns

Like Estefes’ family, many undocumented immigrants are paying into the system – into Social Security and Medicare – without much return.

Francine Lipman, a professor at the William S. Boyd School of Law at the University of Las Vegas, Nevada, has written a handful of studies on the taxation of immigrants. She estimates that undocumented immigrants pay anywhere from $12 billion to $15 billion a year into the Social Security system.

“Particularly in health care, there is fairly compelling evidence that they are paying in a lot and taking out a little,” she said. “One area that is likely they get a large share is free care – but that’s only 3 percent of total health care spending in the United States.”

“Noncitizens, as a group, pay much more money in than they take out,” said Steffie Woolhandler, one of the report’s authors and professor of public health at the City University of New York. “Federal law requires employers to collect Social Security numbers from employees, but the employer isn’t required to verify whether it is valid or not. It means that undocumented immigrants pay payroll taxes into the system, but when it comes time to retire or if they need Medicare they are usually unable to qualify.” Undocumented immigrants’ net contribution to Medicare is estimated to be somewhere around $2.5 billion annually, according to a study released this past June in Health Affairs. Between 2002 and 2009, both undocumented and documented immigrants paid $115 billion more into the Medicare Trust Fund than was spent on their services. The report noted that, in 2009 alone, undocumented immigrants paid in an excess of $10.1 billion. U.S. residents, on the other hand, created a deficit of $30.9 billion to Medicare that same year.

The Social Security Administration has said that undocumented immigrants are helping keep the program solvent. Program administrators estimated that, in 2010 alone, the group paid $12 billion in tax revenue more than they received from the program.

But undocumented immigrants, for the most part, are ineligible for most of the federal aid that citizens can obtain. Immigrant’s eligibility for federal assistance is outlined in the Personal Responsibility and Work Opportunity Reconciliation Act, a bill signed by Bill Clinton in 1996 that dramatically changed the nation’s welfare system.

According to the law, undocumented immigrants and legally residing immigrants who have been in the states for fewer than five years are not eligible for almost any federal aid including: grants, loans, retirement, welfare, health, disability, public housing, higher education, food assistance and unemployment benefits.

Then, in 2009, the Children’s Health Insurance Program Reauthorization Act expanded benefits by allowing states to use state funds to cover lawfully residing immigrant children and pregnant women for fewer than five years. According to the Kaiser Family Foundation, 25 states cover children and 20 cover delivery for pregnant women. Neither Missouri nor Kansas has any such legislation.

The immigrant paradox

Immigrants, particularly ones without documentation, have been shown to use fewer health care services than Americans. And when they do seek care, they typically spend less of the public coffers than citizens.

Between 2000 and 2008, noncitizen immigrants’ expenditures averaged just $1,836 compared to citizens, who spent $4,478, according to a 2012 article from journal of the American Public Health Association. Public health funds spent on noncitizens was 19 percent in 2000 and 2008. Citizens’ publicly funded costs have been on the rise, however, growing from 15 percent in 2000 to 21 percent in 2008.

Steve Wallace, chair of the Department of Community Health Sciences at the University of California, Los Angeles School of Public Health, has studied immigrant health issues since the 1980s. Immigrants cost the system less because they are more likely to put off getting needed care, he said.

“If they take time off to seek health care, they lose a day’s wages, so that is a barrier,” he said. “And in some cases, employers say, ‘If you don’t come back tomorrow, don’t bother coming back at all.’ There are a lot of incentives for people not to use care aside from inability to afford it.”

Another reason recent immigrants use less health care is a trend known as the immigrant paradox. For the first 10 to 15 years immigrants are here, they tend to have fewer chronic conditions, lower mortality rates and healthier babies, Wallace said.

The health degradation occurs after years of adopting the American lifestyle and performing high-stress, physical labor. Mortality rates remain better than citizens, but over time, immigrants’ instances of chronic illness and disability do increase.

“For labor migration, we are basically seeing people coming up who are … physically healthier to make the strenuous journey,” Wallace said. “If you have health problems in Mexico, you aren’t going to take that journey.”

Worth reported this special series during a year-long Association of Health Care Journalists Reporting Fellowship on Health Care Performance supported by The Commonwealth Fund.

Major Funding for Health coverage on KCPT provided by Assurant Employee Benefits and the Health Care Foundation of Greater Kansas City.