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Kaushal N, Muchomba FM. Cost of Public Health Insurance for US-Born and Immigrant Adults. JAMA Netw Open 2023; 6:e2334008. [PMID: 37713197 PMCID: PMC10504616 DOI: 10.1001/jamanetworkopen.2023.34008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 08/08/2023] [Indexed: 09/16/2023] Open
Abstract
Importance The immigrant population in the US has low health insurance coverage. Surveys find that approximately one-half of the US population is opposed to public health insurance of immigrants, and there is a widely held belief that immigrants are a state fiscal liability. Objective To estimate the cost of providing public health insurance to immigrants in the US. Design, Setting, and Participants This serial cross-sectional study used restricted data from the 2011 to 2019 Medical Expenditure Panel Survey (and data from 2011-2020 in supplemental analyses). The data are nationally representative of the US civilian noninstitutionalized population. Participants included adults aged 19 to 64 years with family incomes below 138% of the Federal Poverty Level, the population that benefited from the Medicaid expansions. Data analysis was performed from November 2022 to August 2023. Exposures State Medicaid expansion. Main Outcomes and Measures The primary outcomes were insurance coverage, total health care expenditures, expenditures categorized by payment source (paid by self or family and paid by others), expenditures by major health care type (office based, inpatient, and prescription), and health care utilization (number of office-based visits, outpatient facility visits, emergency department visits, hospital discharges, dental care visits, home health clinician days, and prescription medicine refills). A difference-in-differences method was used to compare the health care cost and utilization by low-income, working-age US-born and immigrant adults in states that adopted the Patient Protection and Affordable Care Act (ACA) Medicaid expansions with the corresponding change in nonexpansion states before and after the policy implementation. Results Among the study sample of 44 482 individuals (mean [SD] age, 38.5 [14.0] years; 25 221 female individuals [56.7%]; 34 052 [76.6%] US born), 46% of immigrant adults (1953 participants) and 70% of US-born adults (9396 participants) had insurance coverage in the pre-ACA period. Medicaid expansions increased insurance coverage of both groups by 7 percentage points (95% CI, 3 to 11 percentage points). The resulting change in health care increased total expenditures (self-paid plus insurer paid) by $660 (95% CI, $79 to $1242) and insurer-paid expenditures by $745 (95% CI, $141 to $1350) per US-born adult. For immigrant adults, the corresponding changes in total ($266; 95% CI, -$348 to $880) and insurer-paid ($308; 95% CI, -$352 to $968) expenditures were small and not statistically significant. Estimates suggest that providing insurance to immigrants costs the health care system approximately $3800 per person per year, less than one-half the corresponding cost ($9428 per person per year) for US-born adults. Conclusions and Relevance These findings suggest that the direct cost of providing public health insurance to immigrants is less than that for the US born, and immigrants' health care utilization, upon coverage, remains comparatively modest, thus refuting the notion that providing insurance to immigrants imposes a heavy fiscal burden.
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Affiliation(s)
- Neeraj Kaushal
- Columbia School of Social Work, Columbia University, New York, New York
| | - Felix M. Muchomba
- School of Social Work, Rutgers, The State University of New Jersey, New Brunswick
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Park JK, Yale-Loehr S, Kaur G. DACA, public health, and immigrant restrictions on healthcare in the United States. LANCET REGIONAL HEALTH. AMERICAS 2023; 21:100493. [PMID: 37122970 PMCID: PMC10131123 DOI: 10.1016/j.lana.2023.100493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/27/2023] [Accepted: 03/30/2023] [Indexed: 05/02/2023]
Affiliation(s)
- Jin K. Park
- Harvard Medical School, 260 Longwood Avenue, Suite 168, Boston, MA 02115, USA
| | | | - Gunisha Kaur
- Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
- Corresponding author.
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Ku L. Who Pays for Immigrants' Health Care in the US? JAMA Netw Open 2022; 5:e2241171. [PMID: 36350655 DOI: 10.1001/jamanetworkopen.2022.41171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Leighton Ku
- Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
- Center for Health Policy Research, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia
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Ommerborn MJ, Ranker LR, Touw S, Himmelstein DU, Himmelstein J, Woolhandler S. Assessment of Immigrants' Premium and Tax Payments for Health Care and the Costs of Their Care. JAMA Netw Open 2022; 5:e2241166. [PMID: 36350650 PMCID: PMC9647478 DOI: 10.1001/jamanetworkopen.2022.41166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
IMPORTANCE Some worry that immigrants burden the US economy and particularly the health care system. However, no analyses to date have assessed whether immigrants' payments for premiums and taxes that fund health care programs exceed third-party payers' expenditures on their behalf. OBJECTIVE To assess immigrants' net financial contributions to US health care programs. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional analysis used 2017 data from the Medical Expenditure Panel Survey (MEPS) and the Current Population Survey (CPS) and 2014 to 2018 data from the American Community Survey. The main analyses used data from the calendar year 2017. Data from the calendar years 2012 to 2016 were also reported. Data were analyzed from June 15, 2020, to August 14, 2022. Participants comprised 210 669 community-dwelling respondents to the MEPS and CPS (main analysis) and nursing home residents who were included in the American Community Survey (additional analysis). EXPOSURES Citizenship and immigration status. MAIN OUTCOMES AND MEASURES Total and per capita payments for premiums and taxes that fund health care as well as third-party payers' expenditures for health care in 2018 US dollars. RESULTS Among 210 669 participants, 51.0% were female, 18.3% were Hispanic, 12.3% were non-Hispanic Black, 60.3% were non-Hispanic White, and 9.2% were of other races and/or ethnicities. A total of 180 084 participants were respondents to the 2018 CPS, and 30 585 were respondents to the 2017 MEPS. Among the 180 084 CPS respondents, immigrants accounted for 14.1% (weighted to be nationally representative), with the subgroup of citizen immigrants accounting for 6.8%, documented noncitizen immigrants accounting for 3.7%, and undocumented immigrants accounting for 3.6%; US-born citizens constituted 85.9% of the population. Relative to US-born citizens, immigrants were more often age 18 to 64 years (79.6% vs 58.3%), of Hispanic ethnicity (45.0% vs 14.0%), and uninsured (16.8% vs 7.4%); similar percentages (51.4% vs 50.9%) were female. US-born citizens vs immigrants paid similar amounts in premiums and taxes ($6269 per capita [95% CI, $6185-$6353 per capita] vs $6345 per capita [95% CI, $6220-$6470 per capita]). However, third-party expenditures for immigrants' health care ($5061 per capita; 95% CI, $4673-$5448 per capita) were lower than their expenditures for the care of US-born citizens ($6511 per capita; 95% CI, $6275-$6747 per capita). Immigrants, in general, paid significantly more per person (net contribution, $1284; 95% CI, $876-$1691) than was paid on their behalf. Most of this surplus was accounted for by undocumented immigrants, whose contributions exceeded their expenditures by $4418 per person (95% CI, $4047-$4789 per person). US-born citizens collectively paid $67.2 billion (95% CI, -$2.3 to $136.3 billion) less in premiums and taxes than third-party payers paid for their care. This deficit was mostly offset by the $58.3 billion (95% CI, $39.8-$76.8 billion) net surplus of payments from immigrants, 89% of which ($51.9 billion; 95% CI, $47.5-$56.3 billion) was attributable to undocumented immigrants. CONCLUSIONS AND RELEVANCE In this study, immigrants appeared to subsidize the health care of other US residents, suggesting that concerns that immigrants deplete health care resources may be unfounded.
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Affiliation(s)
| | - Lynsie R. Ranker
- Department of Community Health Sciences, Boston University School of Public Health, Boston, Massachusetts
| | - Sharon Touw
- Institute for Community Health, Malden, Massachusetts
| | - David U. Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Jessica Himmelstein
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Steffie Woolhandler
- School of Urban Public Health, City University of New York at Hunter College, New York
- Department of Medicine, Cambridge Health Alliance, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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Squires A, Thompson R, Sadarangani T, Amburg P, Sliwinski K, Curtis C, Wu B. International migration and its influence on health. Res Nurs Health 2022; 45:503-511. [DOI: 10.1002/nur.22262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Allison Squires
- Rory Meyers College of Nursing New York University New York New York USA
- Grossman School of Medicine New York University New York New York USA
| | - Roy Thompson
- Sinclair School of Nursing University of Missouri Columbia Missouri USA
| | - Tina Sadarangani
- Rory Meyers College of Nursing New York University New York New York USA
| | - Polina Amburg
- School of Nursing Monmouth University Long Branch New Jersey USA
| | - Kathy Sliwinski
- School of Nursing, Center for Health Outcomes and Policy Research University of Pennsylvania Philadelphia Pennsylvania USA
| | - Cedonnie Curtis
- School of Nursing La Salle University Philadelphia Pennsylvania USA
| | - Bei Wu
- P50 Center for Asian Health Promotion and Equity, Rory Meyers College of Nursing New York University New York New York USA
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Guo H, Zou M. Do non-citizens migrate for welfare benefits? Evidence from the Affordable Care Act Medicaid expansion. Front Public Health 2022; 10:955257. [PMID: 36249197 PMCID: PMC9562776 DOI: 10.3389/fpubh.2022.955257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 07/21/2022] [Indexed: 01/24/2023] Open
Abstract
We explore if low-educated noncitizens, who have a considerably high uninsured rate, internally migrate to states with more generous public insurance benefits. We utilize the state-level variation in accessing Medicaid benefits and employ a difference-in-differences methodology that compares in-migration and out-migration rates of non-citizens in states that adopted Medicaid expansion, both before and after the policy implementation, to the outcomes of non-citizens in states that did not adopt the expansion. We find that interstate in-migration (out-migration) rates of Medicaid expansion states did not increase (decrease) relative to that of non-expansion states after the expansion.
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Affiliation(s)
- Hao Guo
- Li Anmin Institute of Economic Research, Liaoning University, Shenyang, China
| | - Miaomiao Zou
- School of Economics, Nanjing Audit University, Nanjing, China,*Correspondence: Miaomiao Zou
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Page KR, Genovese E, Franchi M, Cella S, Fiorini G, Tlili R, Salazar S, Duvoisin A, Cailhol J, Jackson Y. COVID-19 vaccine hesitancy among undocumented migrants during the early phase of the vaccination campaign: a multicentric cross-sectional study. BMJ Open 2022; 12:e056591. [PMID: 35301211 PMCID: PMC8931801 DOI: 10.1136/bmjopen-2021-056591] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
STUDY OBJECTIVES The marginalisation of undocumented migrants raises concerns about equitable access to COVID-19 vaccination. This study aims to describe migrants' hesitancy about the COVID-19 vaccination during the early phase of the vaccination campaign. SETTING This multicentric cross-sectional survey was conducted in health facilities providing care to undocumented migrants in the USA, Switzerland, Italy and France in February-May 2021. PARTICIPANTS Eligibility criteria included age >16 years, being of foreign origin and living without valid residency permit in the country of recruitment. A convenience sample of minimum 100 patients per study site was targeted. PRIMARY AND SECONDARY OUTCOME MEASURES Data were collected using an anonymous structured questionnaire. The main outcomes were perceived access to the local COVID-19 vaccination programme and demand for vaccination. RESULTS Altogether, 812 undocumented migrants participated (54.3% Geneva, 17.5% Baltimore, 15.5% Milano and 12.7% Paris). Most (60.9%) were women. The median age was 39 years (interquartile range 1). Participants originated from the Americas (55.9%), Africa (12.7%), Western Pacific (11.2%) Eastern Mediterranean (7.9%), Europe (7.6%) and South-East Asia (4.7%). Overall, 14.1% and 26.2% of participants, respectively, reported prior COVID-19 infection and fear of developing severe COVID-19 infection. Risk factors for severe infection were frequently reported (29.5%). Self-perceived accessibility of COVID-19 vaccination was high (86.4%), yet demand was low (41.1%) correlating with age, comorbidity and views on vaccination which were better for vaccination in general (77.3%) than vaccination against COVID-19 (56.5%). Participants mainly searched for information about vaccination in the traditional and social media. CONCLUSIONS We found a mismatch between perceived accessibility and demand for the COVID-19 vaccination. Public health interventions using different communication modes should build on trust about vaccination in general to tackle undocumented migrants' hesitancy for COVID-19 vaccination with a specific attention to men, younger migrants and those at low clinical risk of severe infection.
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Affiliation(s)
- Kathleen R Page
- Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eleonora Genovese
- Laboratory of Healthcare Research and Pharmacoepidemiology, Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Matteo Franchi
- Medical Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - Silvano Cella
- Laboratory of Clinical Pharmacology and Pharmacoepidemiology, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | | | - Rim Tlili
- Infectious and Tropical Diseases Department, Hôpital Avicenne, Bobigny, France
| | - Sebastian Salazar
- School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Aline Duvoisin
- Center for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Geneva, Switzerland
| | - Johann Cailhol
- Infectious and Tropical Diseases Department, Hôpital Avicenne, Bobigny, France
- Laboratoire Education et Pratiques de Santé, Universite Paris 13 Nord, Bobigny, France
| | - Yves Jackson
- Department of community health and medicine, University of Geneva, Geneva, Switzerland
- Division of primary care medicine, Geneva University Hospital, Geneva, Switzerland
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Bustamante AV, Chen J, Félix Beltrán L, Ortega AN. Health Policy Challenges Posed By Shifting Demographics And Health Trends Among Immigrants To The United States. Health Aff (Millwood) 2021; 40:1028-1037. [PMID: 34228519 DOI: 10.1377/hlthaff.2021.00037] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Since the 1960s the immigrant population in the United States has increased fourfold, reaching 44.7 million, or 13.7 percent of the US population, in 2018. The shifting immigrant demography presents several challenges for US health policy makers. We examine recent trends in immigrant health and health care after the Great Recession and the nationwide implementation of the Affordable Care Act. Recent immigrants are more likely to have lower incidence of chronic health conditions than other groups in the US, although these differences vary along the citizenship and documentation status continuum. Health care inequities among immigrants and US-born residents increased after the Great Recession and later diminished after the Affordable Care Act took effect. Unremitting inequities remain, however, particularly among noncitizen immigrants. The number of aging immigrants is growing, which will present a challenge to the expansion of coverage to this population. Health care and immigration policy changes are needed to integrate immigrants successfully into the US health care system.
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Affiliation(s)
- Arturo Vargas Bustamante
- Arturo Vargas Bustamante is a professor in the Department of Health Policy and Management at the UCLA Fielding School of Public Health, and faculty director of research at the UCLA Latino Policy and Politics Initiative, University of California Los Angeles, in Los Angeles, California
| | - Jie Chen
- Jie Chen is a professor in the Department of Health Policy and Management, School of Public Health, University of Maryland, in College Park, Maryland
| | - Lucía Félix Beltrán
- Lucía Félix Beltrán is a research assistant in the Department of Health Policy and Management, UCLA Fielding School of Public Health
| | - Alexander N Ortega
- Alexander N. Ortega is a professor in the Department of Health Management and Policy, Drexel University Dornsife School of Public Health, in Philadelphia, Pennsylvania
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Zallman L, Finnegan KE, Himmelstein DU, Touw S, Woolhandler S. Care For America’s Elderly And Disabled People Relies On Immigrant Labor. Health Aff (Millwood) 2019; 38:919-926. [DOI: 10.1377/hlthaff.2018.05514] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Leah Zallman
- Leah Zallman is director of research at the Institute for Community Health, an assistant professor of medicine at Harvard Medical School, and a primary care physician at Cambridge Health Alliance, in Cambridge, Massachusetts
| | | | - David U. Himmelstein
- David U. Himmelstein is a professor of health policy at Hunter College, City University of New York, in New York City, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School
| | - Sharon Touw
- Sharon Touw is an epidemiologist at the Institute for Community Health
| | - Steffie Woolhandler
- Steffie Woolhandler is a professor of health policy at Hunter College, City University of New York, and a lecturer in medicine at Cambridge Health Alliance/Harvard Medical School
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