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 yearhttp://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

10%

18%

23%

14%

22%

36%

55%

26%

0%

20%

40%

60%

NHWs Blacks Hispanic Asians

% u

nins

ured

US citizens

Non-citizens

Racial/ethnic disparities in insurance coverage by citizenship status

0

5

10

15

20

25

30

35

Chinese Filipino Indian Japanese Korean Vietnamese

% U

nin

sure

d

Health Coverage in NYC% of Uninsured Adults

Naturalized

Citizens

21%

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 inU.S.-born vs. Foreign-born Persons United States, 1991-2001

0

5000

10000

15000

20000

1991 1993 1995 1997 1999 2001

U.S.-born Foreign-born

No

. o

f C

ases

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