It was a rare moment of total agreement in the Democratic debates last week. On the second night, when asked whether public health insurance should cover undocumented immigrants, every presidential hopeful there raised his or her hand.
"Our country is healthier when everybody is healthier," Indianan mayor Pete Buttigieg said. "We do ourselves no favors by having 11 million undocumented people in our country be unable to access health care."
President Donald Trump condemned the idea quickly, on Twitter. Later, while answering questions from reporters, he said: "If you look at what they're doing in California, how they're treating people, they don't treat their people as well as they treat illegal immigrants." California had just expanded its Medicaid program, Medi-Cal, to cover undocumented youth up to age 26. "It's crazy. And it's mean, and it's very unfair to our citizens," Trump said of the policy.
The president's statements suggest that covering the undocumented hurts citizens—and perhaps, though he didn't mention them, legally present residents of America, who are also eligible to buy plans on the Obamacare exchanges, and many of whom can apply for Medicaid and Medicare. So is it true that letting unauthorized immigrants in would mean worse care for everyone else?
The question of costs to others doesn't answer moral arguments for or against covering undocumented immigrants: that all people deserve health coverage and care, or that they don't deserve government-sponsored help because of their illegal residence. But looking at the research shows when politicians make claims based on evidence—or just conjecture.
There's a limited amount of data on the undocumented. Health studies rarely ask people's immigration status because scientists fear it would scare people away from participating. The data we do have suggests covering those in the country without papers could actually lower everyone's insurance costs. It can get difficult, however, to predict what would happen to costs under every possible undocumented-coverage scenario, especially with increasing government support for the needy.
The main reason that undocumented residents are expected to lower insurance costs is that immigrants tend to be younger and healthier than the American population as a whole, and to visit both a regular doctor and the emergency room less often, as analyses of California's Latinx population have found. It's thought that a combination of their better health and barriers, like fears that they don't qualify for care or will be deported for seeking help—which may be reduced if they're on a state plan—keeps immigrants away from clinics and emergency rooms.
Undocumented immigrants tend to be even healthier than recent documented immigrants, and to use health care even less. After all, it's often only the young and hale who are willing and able to make a perilous, unauthorized journey into the United States.
Add these folks to an insurance program, and they could lower premiums for all, particularly if the plan is to allow unauthorized immigrants simply to buy Affordable Care Act marketplace plans, without any government subsidies. There's evidence this has already happened with private insurance: One recent analysis, published in the journal Health Affairs, found that immigrants with private plans pay more in premiums than they get out in benefits.
"They pay premiums, they lower the risk of the insurance pool, and so basically everybody benefits," says Alexander Ortega, an epidemiologist who studies Latinx and immigrant health at Drexel University. Of course, how many folks will want to buy a marketplace plan, without financial help, is up in the air.
It's possible that, once undocumented people are all covered, they'll start going to the doctor more often, racking up costs to whatever public-health plan they're on. Still, researchers like Ortega and Leah Zallman, director of research at the Institute for Community Health, believe that covering the undocumented would lead to savings in the long run, because people would catch health problems earlier on, when they're cheaper to treat. That would mean fewer folks would visit hospital emergency rooms that must, under law, stabilize everyone who comes in who's severely ill, regardless of their immigration status or ability to pay. Who pays when that happens? It's complicated, but eventually the price tag hits taxpayers, Ortega says: "Those costs generally trickle down."
In general, it's better for people's health to get their problems treated early. But there's not a lot of specific research on whether, for undocumented immigrants, that would save the health-care system money overall. In 2004, the Government Accountability Office concluded it couldn't calculate how much undocumented immigrants cost to hospitals in uncompensated emergency treatment. Zallman points to one 2018 study, which found that the care of undocumented immigrants with kidney failure, who got only emergency hemodialysis, was far pricier than starting dialysis sooner, which doctors recommend: Emergency-care-only kidney-failure patients spent 10 times as many days in acute care as their counterparts who got treatment sooner. They were also 14 times more likely to die within five years.
What if a politician proposes not only to allow undocumented immigrants to buy full-priced public insurance plans, but also to offer them subsidies based on need, just like those that citizens and lawfully present immigrants get? We don't know how that balance sheet works out because there's simply not enough data on undocumented immigrants, Zallman says.
Regardless of national rules—like the one passed during the Obama administration that barred undocumented immigrants from buying into the Obamacare exchanges, even at full price—some states and localities are covering at least some undocumented residents anyway, as if they were any other low-income resident. A few states, including Oregon, Illinois, and New York, allow undocumented children and pregnant women to join Medicaid.
As Trump alluded to, California, which has a budget surplus this year, just made its Medicaid program available to undocumented youths up to age 26. Democrats in the state had wanted Medicaid available to undocumented people of all ages, but Governor Gavin Newsom pushed back, out of concern for cost, though he said he planned eventually to give every California resident insurance, the Associated Press reports.
At a rally on Monday, Newsom made the same argument as health researchers, saying that extending health insurance to all is "the right thing to do and it's the fiscally responsible thing to do."