Documenting the Undocumented Tough Questions: What about the undocumented?

1. Documenting the UndocumentedTough Questions:What about the undocumented? PNHP Annual Meeting- 2007 Olveen Carrasquillo, MD, MPH Director, Columbia Center for the Health of Urban Minorities

4. 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)

5. 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 year http://pewhispanic.org/files/execsum/61.pdf

6. 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).

10. How do they get here? 50% of undocumented immigrants entered US legally

11. Some do cross the border!!!

12. 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."

13. States with largest undocumented populations

15. 14.6 million in unauthorized families

20. 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

21. 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.

22. 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.

23. 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

24. 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.

25. Local Data: Wash DC 22% Unauthorized

26. 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.

28. Back to Health Care

29. Racial/ethnic disparities in insurance coverage by citizenship status

31. Health Coverage in NYC% of Uninsured Adults Source: LANYC Immigrant Survey/ Urban Inst.

32. 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

33. 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

34. 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

35. 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

36. Am J Pub Health 2005:95;1431-1438

37. Scare Tactics:Your Family will get sick!!! • Tuberculosis / Resistant Tb • Malaria • Childhood Infections • Pandemic Influenza

38. Number of TB Cases inU.S.-born vs. Foreign-born Persons United States, 1991-2001 No. of Cases

39. Foreign-born vs. US-born cases of tuberculosis in Northern Manhattan N Eng J Med 2002; 346: 1453-1458

40. Will Single Payer Cover the Undocumented?

41. Single Payer’s Dirty Little Secret: It will!!!

42. 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

43. 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

44. 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

45. LNHI Update

46. 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

47. 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