The cost of providing access to healthcare to undocumented immigrants

Lost amid the current scandal-plagued presidential election campaign is a simple-sounding, relatively new policy touted by former Secretary of State and Democratic presidential candidate Hillary Clinton: Expand access to affordable healthcare to families regardless of immigration status.

Obviously influenced by the views of former Democratic presidential candidate Senator Bernie Sanders (D-VT), such a policy is grounded on two beliefs: that healthcare is a basic human right and that the federal government should ensure the provision of healthcare for all, including undocumented immigrants.

Providing access to healthcare—most likely through an expansion of Medicaid for the nation's undocumented immigrants—would go beyond the Affordable Care Act (ACA), which did not change the eligibility rules for Medicaid and required verification of citizenship status to determine eligibility for the federal premium credits of the health insurance exchanges.

What would be the cost of expanding public healthcare coverage to the nation's undocumented immigrants? In simple terms, one could estimate the financial tab as the product of the number of undocumented immigrants times the average per person cost of healthcare.

The Number of Undocumented Immigrants
How many illegal immigrants are in the United States? At the low end of the range, the U.S. Department of Homeland Security, the Center for Immigration Studies, and the Center for Migration Studies—all citing estimates from the Pew Research Center—hold that there are about 11 million undocumented immigrants in the country. Pew's estimates are based solely on the responses by immigrants to U.S. Census Bureau surveys. Pew attempted to factor in the reluctance of illegal aliens to answer government surveys by adding about 10 percent to its population estimate, but no empirical data validating that assumption has been provided by Pew.

At the high end of the range, businessman and Republican presidential candidate Donald Trump has said that he's heard that the illegal immigrant population is "30 million, it could be 34 million." Although Trump has not cited a source for his claim, it may not be a totally unfounded assertion, as there are examples in which census surveys and government estimates pertaining to illegal aliens have been proven significantly wrong. For example, the Special Agricultural Worker program of the Immigration Reform and Control Act, which became law in 1986, was expected to grant legal status to 350,000 illegal immigrants. Instead, more than 1.3 million illegal immigrants applied for this amnesty, with most of them using phony documents in what has been labeled one of the greatest immigration frauds in our nation's history.

In between the Pew estimate and Trump's assertions is a 2005 Bear Stearns study, which used remittances, school enrollments, housing statistics in immigrant enclaves and Border Patrol apprehension data, estimating the undocumented immigrant population at 20 million.

Average Per Person Cost of Healthcare
According to the Kaiser Family Foundation, in 2011, average Medicaid spending per enrollee—across aged (65 years and older), adults and children—was $5,790. Applying the distribution of those three groups for the legal immigrant population to the undocumented immigrant population as well as actual and projected inflation rates for 2012 thru 2017 yields average Medicaid spending per enrollee of $3,702 for the coming year.

Total Cost Projections
Given that estimate for average Medicaid spending per enrollee, providing Medicaid to 11 million undocumented immigrants would cost $40.7 billion, and the financial tab would swell to $111.1 billion to cover 30 million undocumented immigrants.

As a kind of sanity check and point of reference, in 2013, the United Kingdom's Home Office estimated that Britain's National Health Service and schools spent £4,250 (about $5,200) per undocumented immigrant per year.

The $40.7 to $111.1 billion cost projection does not take into account the fact that the U.S. healthcare system already spends an estimated $4.3 to $10.7 billion annually to care for undocumented immigrants. Thus, the incremental annual cost to add this subpopulation to the rolls of Medicaid could be as little as $30 billion to as much as $106.8 billion.

Conclusion
Expanding access to healthcare to undocumented immigrants is a politically popular idea in some circles that would go beyond the ACA. Because of the undocumented nature of this subpopulation of American society, the total cost of a coverage expansion could vary greatly. Caveat emptor!

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