Health Care Spending: Why Immigrants Aren’t the Problem

I recently wrote a piece highlighting research that shows that immigrants actually strengthen the Medicare program, because they pay more money into it than they spend. But many of you may have noticed that one of the reasons for that is that undocumented immigrants, and legal immigrants with less than 5 years as U.S. residents are not eligible for public programs like Medicaid or Medicare. This doesn’t phase critics of immigration, however. Instead, they claim, immigrants take a toll on the American taxpayer through the use of high levels of uncompensated care and crowd our emergency departments.

The great thing about data, though, is that it does a tremendous job of poking holes in these empirically unfounded, albeit widely held, assertions. A research group out of the University of Nebraska, headed by Jim Stimpson recently published some interesting findings in the July issue of Health Affairs. They report that, from 2000 to 2009, all U.S. immigrants (legal and illegal) accounted for a total of $96.5 billion in health care spending, while native-born U.S. citizens accounted for more than $1 trillion in health care spending. Of course, this simply underscores that immigrants are a relatively small proportion of the population. In fact, undocumented immigrants account for less than 1.5% of total U.S. health care spending. In the grand scheme of things, that is practically a rounding error.

The authors also report that while nearly one-third of native-born U.S. citizens benefit from public health care programs, fewer than 8% of undocumented immigrants do so. Moreover, the average amount of the benefit is markedly different: $1,385 for native-born citizens, compared to $140 for undocumented immigrants). And that emergency room crowding issue? Native-born citizens spend an average of $138 a year on emergency room care, compared to just $54 among undocumented immigrants. It’s easy for us to blame “others” for our problems, but these data demonstrate rather clearly that when we do so, we are merely fooling ourselves into avoiding the reality that we–the native-born sons and daughters of the United States of America–are the ones bleeding this country dry.

 

Health Inequality And Modern Day Slavery

“They never took me to the doctor when I was ill.” These are the words spoken by Merieme Mint Hamadi when asked about her life as a slave. Merieme, one of an estimated half a million people in Mauritania who are enslaved, lives in some of the world’s worst conditions. Her country, which has a population estimated to rival Chicago, was the last country in the world to make slavery a crime. However, since that 2007 law was passed – almost 150 years since Abraham Lincoln issued the Emancipation Proclamation in the US – only one person has been successfully prosecuted for owning another human in Mauritania. The health and human rights violations that exist there today have led to the UN ranking Mauritania at 155 out of 187 countries on its 2013 inequality-adjusted Human Development Index.

The UN estimated that in 2012 for every 100,000 live births in the country, 510 women die from pregnancy, with significant disparities between the death rates of Black slaves and Arab owners. Of even greater concern is that due to female slaves being forced to have children with owners, an estimated 71.3 births per 1,000 live births are to adolescents who suffer extreme mental and physical abuse. In John Sutter’s captivating CNN coverage of oppression, Slavery’s Last Stronghold, he reports that, “In Mauritania, the shackles of slavery are mental as well as physical.” He goes on to describe the political and societal methods through which the lighter-skinned Arabs maintain their ownership of the dark-skinned peoples.

Kevin Bales, an expert on modern day slavery, wrote in his book Disposable People that even if someone of bondage attempts to leave an owner, “for most, freedom means starvation.” He claims that because slaves are, “immediately recognizable by color, clothing and speech” they will not be given shelter or proper care by others. Further, Mr. Bales asserts that on the streets of Mauritania, “ there are already a good number of beggars, many of them disabled, to remind slaves of where they almost certainly end up” if they were to leave their masters.

“Mauritania is a country with scarce resources – including access to medical care. The health needs of slave owners come first in Mauritania; the health needs of slaves come last. Slave children are chronically malnourished. Slave women are frequently victims of sexual assault by their owners and the devastating health problems that result.” says Sean Tenner, Co-Founder of the Abolition Institute, an organization focused on ending Mauritanian slavery and a veteran of numerous public health campaigns.

Despite the country’s open system of ownership, to date, the US has not taken a stance against the practice. The country, located on the western fringe of the Sahara, is not densely populated, and therefore practices of the owners are not easily monitored by the government. Further, the country’s ruling elite makes no attempt to fight slavery, as they claim to the UN that slavery does not exist.

However, what is most surprising in 2013 is not the lack of Mauritanian action against their own traditions, but the lack of American recognition and action. At a time when the US tries to face its own challenges with inequality, health, human rights and foreign policy, it is saddening to know we also neglect others.

Mauritania is also deeply divided by access to basic human rights such as health. In 2000, it was estimated that only 37% of the country had access to safe drinking water and 33% to adequate sanitation. Life expectancy has hovered around 57 for both sexes for many years, but with great disparities between the slaves and owners.

The US has done nothing to date but overlook the unlivable health conditions and human rights violations in the region for those that are born into bondage.

In the United States however, one group is taking action to make Americans aware of the atrocities faced by the Mauritanian slaves, and the health and human rights violations that exist. The Abolition Institute, founded in Chicago by Mr. Tenner and former Mauritanian slaves, was recently formed to end the practice of slavery in Mauritania, and bring freedom to those suffering under the inhumane circumstances of maltreatment, malnourishment and abuse.

The organization does everything from educating the public on the religious aspects of modern day slavery to informing about the living conditions and health of slaves through noting disparate practices such as “gavaging” in Mauritania, where women of Arab decent try to gain weight to show that they are wealthy elite and not poor slaves with emaciated frames.

However, the devastating effects of slavery run much deeper than the physical effects. The extreme consequences the effects of slavery have on mental health know no bounds.

In Slavery’s Last Stronghold, a leader of an abolition group tells Sutter that many similarities exist between modern slavery in Mauritania and that in the United States before the Civil War, but that the one fundamental difference between the two in his mind is the use of physical restraint. “Chains are for the slave who has just become a slave, who has . . . just been brought across the Atlantic,” Boubacar said. “But the multigeneration slave, the slave descending from many generations, he is a slave even in his own head. And he is totally submissive. He is ready to sacrifice himself, even, for his master. And, unfortunately, it’s this type of slavery that we have today” — the slavery “American plantation owners dreamed of.”

 

The Willing Provider Problem

I spend a lot of time thinking about and researching issues around access to health care. Typically, when we–the American people–think about access to care, we think about one thing: health insurance. And, while it is absolutely true that having health insurance is an important component of access to care, it is not sufficient in and of itself. What insurance does is help address one component of access, namely affordability. For, without insurance, most of us are unable to afford health care, which is generally quite expensive. But assuming you have insurance, there are frequently other barriers to access. For example, many people with insurance are unable to get time off of work to go to a doctor appointment, or they cannot afford child care. Perhaps they have no viable means of transportation to the doctor’s office, or no one speaks their language when they get there. These are examples of what we might call “non-financial” barriers to care, although at their root, many of them actually arise from limited financial resources.

But even beyond these financial and non-financial barriers, there can be other obstacles. One of these is the so-called “willing provider” problem. The short and sweet version of this is that even if you have health insurance and face none of the non-financial barriers to access, you still have to be able to find a provider who is willing to provide care to you. None of us are entirely immune to this problem. In fact, just about a year ago, I remember going to an urgent care clinic that had a sign at the check-in desk informing patrons that they did not accept Harvard Pilgrim health insurance. You see, insurers contract with networks of providers, and some providers refuse to see patients who are insured by a company with whom the providers have not contracted—even when that insurer is a highly touted private firm.

The real concern, though is the willing provider problem in Medicaid. The reason is simple: Medicaid patients can often be in poorer health than the rest of the population, and Medicaid has set very low reimbursement rates. Consequently, many providers opt not to accept Medicaid patients, because they would rather see higher-paying privately insured patients. This, obviously, creates an issue in ensuring that low-income individuals have adequate access to health care—and is very concerning given that the expansion of Medicaid is an integral component of the Affordable Care Act.

In the July issue of Health Affairs, Sandra Decker provides us with estimates of the scope of the willing provider problem in Medicaid. She finds that, on average, 29.9 percent of physicians do not accept new Medicaid patients. While there are some places, like community health centers, where the refusal rates are as low as 5.8 percent, there are also particular specialties where the rates are alarmingly high. For example, 43.6 percent of internal medicine physicians do not accept new Medicaid patients. For orthopedists, the figure is 40.0 percent. For dermatologists, it’s 44.5 percent. And, for psychiatrists, it’s 56.2 percent. What this means is that, if you are covered by Medicaid, somewhere between one-third and one-half of the doctors in this country are essentially non-existent to you. When you then begin to think about where the remaining one-half to two-thirds are located geographically, you realize that there are gaps all across the country with no physicians at all.  Or, if there are some willing providers, you have to remember to account for the non-financial barriers once again.

Clearly, the Medicaid expansion alone is insufficient to guarantee access to health care. Just how many barriers will remain, and how bad the problem will be is difficult to predict, but at least we’ve taken a step in the right direction.

 

As They Age: Women Know What They Do Not Know

The need for health care varies greatly over a lifespan, with older adults having significantly more health-related needs and costs than younger individuals. Women, in particular, often face a myriad of health problems as they transition through menopause. Sadly, despite the fact that every woman will go through menopause, very little is understood about the physical and mental changes that occur during this period of life. In addition, women may struggle to find pharmaceutical solutions, which can safely provide proven relief without the worry that those available will increase their likelihood of other health and mental complications.

Much is misunderstood about menopause and the changes that are associated with the hormonal fluctuations. This is largely due to the fact this inevitable transition is rarely apart of the conversation, particularly in the context of health care. Further, menopause is expected to be merely “bothersome”; not something one could attribute real health problems to. Although maternity care and issues related to younger women are required in the Affordable Care Act as essential health benefits, nothing of legislative note will improve the knowledge and acceptance of this natural life progression.

Most insurance companies do not even cover basic mediations associated with menopausal symptoms, and conflicting research has women scared about the potential long-term effects associated with hormone replacement therapy. Negative press, little medical literature and low financial assistance often leaves women to suffer through menopause silently, many of whom worry constantly about memory deficits they experience and potential long term changes.

A recent study focused on the memory complaints of midlife women has been receiving a lot of attention. The study, conducted at the University of Illinois- at Chicago (UIC), attempted to determine if women who are experiencing hot flushes during menopause were able to accurately predict their own memory performance.

According to the principal author, Lauren Drogos, “We found that a one-item question: ‘How would you rate your memory in terms of the kinds of problems that you have?’ was the best predictor of verbal memory performance on a list-learning task. We also found that many complaints were related to mood symptoms.”

In the US, the average woman becomes postmenopausal around the age of 51. Common symptoms that occur include hot flushes, sleep disturbances, mood changes and memory problems. However, until recently it was believed that women were unable to accurately describe the current state of their memory and the changes they experience as they progress through menopause.

Despite the difficulty in being taken seriously about the physical and mental challenges that menopause presents, this recent study from Drogos, along with other research, shows that woman are able to accurately describe their current memory abilities. Specifically, a group of sixty-eight women performed a series of memory tests and were then asked, to detail the types of memory problems they were experiencing. The study concluded that women were able to accurately rank themselves on a scale from no memory problems to severe problems.

Using recall of a short story, the deficits seen in memory did not indicate that women were suffering from dementia, nor were they experiencing shortfalls in memory that were impacting daily life. Instead, it was simply indicative that women who experienced memory deficits often recognized the changes occurring.

Previous research focusing on women’s transitions through menopause also found that hot flushes during the nighttime were the best predictors of memory performance in women. This leads researchers within the Women’s Mental Health Research Program at UIC, to believe that sleep disturbances and stress hormones may play integral roles in memory and hot flushes.

The good news for women concerned about the transition through menopause is that the cognitive decline that occurs appears to only be temporary, with performance rebounding early into post-menopause. Further, for those who want to keep both their minds and bodies at peak performance, research indicates that leading a non-sedentary lifestyle, keeping mentally active, and having a healthy diet can be the best preventers of cognitive decline.

 

Delaying the “Employer Mandate”

Much ado has been made about the Obama Administration’s decision this week to delay implementation of what most media sources are calling a “key” part of the law for an additional year, until 2015. The provision under question is not only being proclaimed instrumental to the Affordable Care Act, it is also being misrepresented as the “employer mandate.” I’ve been sick this week, and am just beginning to feel better, so I don’t have the time or the energy to explain all of the politics being played by both sides on this issue. But, I did want to make sure that I took a moment to put some clear information out there.

The provision, you see, is not an employer “mandate,” but a “penalty.” The details make this apparent: First, it applies only to businesses with more than 50 employees. These are large firms, and upwards of 90% of them already offer their employees insurance. Second, these businesses are not required to provide insurance to their employees. They are merely at risk of having to pay a penalty to the federal government if they do not offer insurance or if they offer insurance that is deemed unaffordable and at least one of their employees then receives a federal subsidy to purchase insurance through the health insurance exchanges. (The Kaiser Family Foundation has an excellent flowchart depicting how all of this works.) Finally, the cost of the penalty is far below the cost of providing insurance, which, combined with the first point that an overwhelming majority of businesses subject to this penalty already provide coverage to their employees, simply underscores that the intent of this provision is not to mandate the provision of insurance, but rather to prevent employers from deciding to stop offering coverage altogether, while letting the health insurance exchanges pick up the slack.

That strategy–known as “crowd-out”–makes sense for businesses if there’s no penalty for the practice. Why not save all of the money being spent on insurance premiums and let Uncle Sam pick up the tab instead? It’s a no-brainer. Thus, the penalty is necessary to discourage it. Does pushing back the penalty by a year really change much? Highly unlikely. Again, most employers with more than 50 employees are already providing coverage. They’re not likely to stop doing that for the single year (2014) when there will be no penalty, but there will be viable health insurance exchanges for their employees to access. The backlash from such an executive decision would be disastrous for most businesses, and not worth the hassle.

Instead, I think this has more to do with the Obama Administration confronting the reality that implementing comprehensive health reform is a massive undertaking, with unintended obstacles encountered as the process progresses. Kudos to them for listening to–and attempting to address–the grievances of American businesses. Well, that, or playing politics with the mid-term elections. Who knows?

 

How Immigrants Strengthen the Medicare Trust Fund

Growing up in the deep south, where most of my family still lives, I can’t tell you how often I hear complaints about all the supposed havoc immigrants are wreaking on our nation. Apparently, they’re taking our jobs, marrying our women, and wringing every last drop of our hard-earned, begrudgingly paid tax dollars from our nation’s public programs. The problem is, no matter what you think about the first two, research clearly demonstrates that that last point is absolutely not true.

A smart group of researchers from Harvard and the City University of New York (CUNY) including Leah Zallman, Steffie Woolhandler, David Himmelstein, David Bor, and Danny McCormick have done the math and concluded that immigrants contributed $115.2 billion more to the Medicare Trust Fund than they took out between 2002 and 2009, and this figure, if anything, may be an underestimate. In 2009 alone, immigrants paid in $13.8 billion more to Medicare than they received in benefits. By contrast, that same year, U.S. citizens “generated a deficit of $30.9 billion,” according to the authors. So, while we’re busy bankrupting ourselves, the immigrants are slowing the bleeding.

If I know anything, it’s that the skeptics among you don’t believe this. “How can it be?” you ask, “Immigrants don’t pay taxes!” And that, my friend, is where you’re wrong. Some immigrants are here quite legally and they do, indeed, pay taxes. Then there are the undocumented immigrants, and they pay taxes, too. According to the study’s authors:

“Undocumented immigrants often pay payroll taxes under Social Security numbers tied to invented names or belonging to someone else, because to comply with federal law employers must obtain a Social Security number from every employee. Less frequently, undocumented immigrants pay self-employment taxes (in lieu of payroll taxes) under individual tax identification numbers, which allows them to claim credit for their contributions should they eventually obtain legal status.”

So, you see, immigrants are bolstering this country’s Medicare Trust Fund, and most believe they are also doing the same for Social Security. With immigration reform on the political agenda, we should be very careful about how we proceed. Opening the floodgates to allow unrestricted immigration is unlikely to solve the problems faced by Medicare and Social Security, but severely restricting immigration could certainly make them much worse than they already are. So, the next time you’re tempted to complain about immigrants, take a moment and thank them for subsidizing the health insurance and retirement income of America’s senior citizens instead.