How should healthcare reform treat foreigners living in the United States?
The question is a sensitive one because Americans experience so many confusing emotions when it comes to immigration. But it’s one that policy makers will inevitably have to face because of the sheer numbers of foreigners without insurance who have taken up residence in the US. There are something like 9.2 million non-citizens who lack health insurance, about one-fifth of the total of 46 million people without insurance in the United States.
As Nancy Folbre points out in the New York Times blog Economix today, the common sense interpretation of statements talking about giving “Americans” health insurance implies citizenship. Ignoring the distinction doesn’t help anyone because eventually we’ll have to make a decision about who will be covered by the plans under consideration on Capitol Hill. And if lawmakers don’t make the decision explicitly, it will be made by federal courts. Regardless, we’re going to have to face the decision about how to cover resident foreigners.
If past practice is any guide, we should probably restrict non-citizen access to government supported health care plans. As Folbre writes:
The Personal Responsibility and Work Opportunity Act of 1996 excluded most legal immigrants who have been in this country for less than five years from eligibility for public assistance. As a result, Medicaid coverage for adult noncitizens declined.
Only two weeks ago the Massachusetts legislature voted to exclude legal immigrants with less than five years’ residency from the state’s subsidized health insurance program — a program widely considered a model for proposed national reforms.
On the one hand, a robust health plan covering all residents might be easier to administer. Employers mandated to provide insurance wouldn’t have to distinguish between those they are required to cover and those they are not.
Non-citizen participation would also help avoid the public health problem of having a subsegment of the population without easy access to the healthcare system. Contagious conditions don’t discriminate based on citizenship, and foreign workers are probably more likely to come in contact with diseases and viruses introduced abroad. We might all be better off if these are caught early rather than left to simmer beneath the radar of public health officials.
Folbre also argues that there is no evidence that, if we put aside illegal immigrants, legal immigrants might drive up costs of health insurance. In fact, they could drive down costs because they are relatively healthy and good earners. “Including them in the pool of those insured would likely lower average medical costs,” Folbre writes. Unfortunately, discriminating between legal and illegal immigrants both cuts into the administrative savings (because employers are stuck figuring out who is covered and who isn’t) and much of the public health benefits. But if you include illegal immigrants, you will drive up average medical costs because they are less healthy and can afford to contribute less than average.
More importantly, including immigrants–legal or illegal–in mandatory insurance could affect the quality of immigrants moving to the country. By increasing taxes to pay for the plan and increasing the welfare state benefits, healthcare reform dramatically changes the incentives for immigration. So it could be very deceptive to rely on the healthcare costs of immigrants under our current system to predict the costs under the new system. (Like assuming that people getting mortgages during the housing bubble would not default more than earlier history implied.)
“Because it is one thing to have free immigration to jobs,” Milton Friedman famously said. “It is another thing to have free immigration to welfare. And you cannot have both. If you have a welfare state, if you have a state in which every resident is promises a certain minimal level of income, or a minimum level of subsistence, regardless of whether he works or not, produces it or not. Then it really is an impossible thing.”
To the extent we want to encourage assimilation and citizenship by foreigners living in the US, including them in subsidized healthcare plans could be counter-productive. It levels the playing field between citizenship and non-citizenship, taking away an incentive for immigrants to seek citizenship. (Note: we may not want to encourage assimilation and citizenship; it’s feasible we just want temporary workers who later go back home or a disenfranchised underclass to do jobs Americans won’t do.)
Unfortunately, much of this policy debate is clouded by overheated rhetoric that assumes all scepticism about incuding immigrants in healthcare reform is rooted in hatred. Folbre becomes almost hysterically hateful herself, describing those who would exclude non-citizens as akin to the crazed “birthers” who deny that Barack Obama is a US citizen.
“When Mr. Rove implies that we shouldn’t be concerned about them, he feeds the same animosities as the so-called ‘birthers‘ who challenge the president’s own citizenship. These animosities continue to shape United States social policy,” Folbre writes.
That’s hardly the kind of discussion likely to lead to wise policy-making. Unfortunately, it seems that the term “birthers” have entered the arsenal–along with phrases like “a nation of immigrants” and “nativism”–of those who want to destroy debate about immigration and citizenship.u
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