POLICY: Wrong, but wrongly influential

At the recent PRI meeting, one loony lambasted me for failing to agree with her that all the problems of the US health care system were due to all that care bing wasted on illegal immigrants. I asked her to provide me with photographic evidence of cancer patients swimming the Rio Grande…

But a UCLA study has found that even adjusted for age and health status:

Illegal immigrants from Mexico and other Latin American countries are 50% less likely than U.S.-born Latinos to use hospital emergency rooms in California, according to a study published Monday in the journal Archives of Internal Medicine.

Of course this isn’t news to us wonks, but here’s a quiz for ya; which one of me and the loony will be voting in the Republican primary? That tells you lots about our health care policy options.

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  1. I do agree that the study should probably have compared illegals to the overall sample not just legal immigrants or US Born Latinos. Why they chose to compare with US born Latinos is a curious decision. They could easily run the numbers against any other group as well.
    I think that any data they have on illegals is legitimate, based on the reasons I’ve given above. Now, whether or not the data on non-illegals is legitimate, that is another question. I would say that it is legitimate.
    The logic is thus: if the (honest reporting) illegals reported fewer hospital visits, then the dishonest illegals (who said they’re legal) would presumably also have reported fewer hospital visits. No reason to assume they would answer any differently just because at the end of the survey they were afraid to mention their immigrant status. If they, are, in turn, lumped in with the (honestly reported) legal immigrants or US Born Latino data, then this would bias the sample of Hispanics / legal immigrants to be closer to the illegals, not further away from them. Basically, if there are illegal immigrants erroneously in the sample of US-born Latinos, then it would actually make them look more like the illegal sample, not less.
    From your earlier point on overestimating the native borns educational levels and or talent and skills “Your assessment of our native borns as high-skilled or mostly college degreed is charitable, and inaccurate.” I thought I’d mention that In the US more than 52% of the population (of all races) has at least some college education, including associates, bachelors and advanced degrees. I’m sure the numbers for native borns will be even higher, since this is from Census data that counts almost everyone ( U.S. Census Bureau, Current Population Survey, 2006 Annual Social and Economic Supplement). I would say we do have a talented, skilled group of native born Americans.
    At any rate, I’ve enjoyed the conversation and now have to get back to my real life. Thanks for your point-of-view Alex.

  2. 2&3) The study measured illegals compared to US born Latinos and other populations. The findings regarding those who self-report being undocumented is skewed when the undocumented report as legal citizens. This is where I have zero faith in the validity of self-reporting surveys, particularly with this population and on these questions. It’s also why I believe the completion rate and the point at which folks dropped off are very much relevant.
    4) “Illegal immigrants from Mexico and other Latin American countries are 50% less likely than U.S.-born Latinos to use hospital emergency rooms in California, according to a study published Monday in the journal Archives of Internal Medicine.”
    Those are the first words in the article which is why I referenced EDs specifically. I cannot determine from the study itself how the children of illegals are reflected as use since the findings reference the CHIS, but provides no direction on that question which is an important one. I’m ready to believe that illegals indeed use less health care, but this particular claim (not just less but WAY less) doesn’t even pass the laugh test.
    On immigration generally, there is nothing in your post that I even mildly disagree with. I happen to believe that government sanction part is pretty damn important though given the current size and scale of immigration compared to immigration waves of the past. That I disagree with the findings of the study has little to do with my beliefs on immigration and much to do with my belief that this is a flawed study

  3. 1) In theory, RDD dials mobile phones as well as residential, but, yes, phone interviewing does have a bias towards landline phones, especially in this day and age when more and more people are dropping landlines in favor of cell phones. I’ve seen some studies that show that while it does have a bias, this doesn’t necessarily translate into drastically different responses. The cell phone bias crosses demographic boundaries, as I understand it.
    2) Illegals reporting as legal may affect findings as they pertain to the legal responses, so perhaps the data on legal immigrants or legal residents or even citizens overall will be corrupted a bit. However, they do NOT affect the findings with regards to illegals, since they have admitted to being undocumented. It gives a good look at the behavior of people who actually claim to be undocumented. There’s no reason why they would be lying since they don’t even know they will be asked their status until the end of the survey anyways.
    3) I don’t believe the completion rate is an issue in this study. If they were able to complete a certain amount of interviews among reported illegals, the completion rate is inconsequential (other than costing them more to get the completed interviews).
    4) I believe that this study looks pretty rigorous, although it wasn’t designed specifically to analyze the illegal population. I would agree that we might get some valid information through intercept studies of people who go into ERs. Still, this only gives us a snapshot of people who go to ER’s not of the people who don’t go to the ER. You can’t determine what percentage of people drive cars or don’t drive cars by interviewing people who go into a car dealership as this would bias results towards drivers. It is possible that in certain areas the majority of people going into the ER are undocumented, especially when the ER is located in an area where there are lots of undocumented people. If you were to go to a primarily non-immigrant location and make an assessment of how many uninsured people visit the ER, your assessment would be that non-immigrants are the ones who use the ER most.
    Alex, no one should believe in unfettered immigration legal or otherwise. I just think our immigration system should reflect the realities of labor in this country and allow in the amount of people necessary (and none more) to reflect that. In reality this is already happening, but without the government’s sanction. People don’t immigrate to a country if there aren’t jobs waiting for them. People don’t take a huge gamble and risk their lives and spend upwards of 10 grand to come here if they don’t know that there is a job waiting for them. Immigrants make the hard decision of coming here only when they have heard from friends / family that there are openings / jobs wherever it is they are going. This, incidentally, happened with the Okies in the western expansion (Grapes of Wrath, anyone?) and eventually, when news hit that employers were turning people away, people stopped coming. Why don’t we charge them $1500 to come in, use that money to secure the borders and keep tabs on all the people who come in legally. Then when there is less demand for labor, we start letting less people in. As it is right now, unskilled laborers have virtually no chance of getting in legally (something less than 1000 people per year).

  4. 1) You know more about RDD than I do, but my understanding is that the high rate of mobile phone use as a primary phone by the illegal population complicates telephone surveys. My experience with it has been in the Medicaid population where contact presents massive problems and the widespread use of cell phones (and the tunrover of the numbers) presents problems.
    2) How exactly do we determine the honesty of responses? How does an illegal reporting as legal not affect the outcome of a study measuring use by legal/illegal status?
    3) Completion rate is less of an issue if you are measuring public opinion. It matters more in a study in which you are measuring usage of a service and the reason that people opt to not complete matters as well, especially when dealing with the illegal population which is notoriously difficult to get information from.
    4) As I said, their thesis may very well be true, but I don’t think their study is a very good one for proving it. I happen to believe that medical debts do cause bankruptcies, but I also believe some of the studies on it have been close to fraudulent. These figures get repeated over and over again and become axioms regardless of their truth. There is a much better way to measure the use of health care by illegal immigrants. Go to many ERs, sit there, interview the people there, record the results.
    Unfettered illegal immigration is not capitalism. Regulation of our borders is not socialism. Your assessment of our native borns as high-skilled or mostly college degreed is charitable, and inaccurate.

  5. Actually Alex, you’re wrong on several points.
    1) RDD (random digit dialing) does not rely on listed phone numbers. It’s generated by a randomized dialer, so it does not exclude anything.
    2) Yes, this could be an issue, but in the other direction. It makes the pool of illegals to analyze in this study smaller, not bigger. If not all the respondents answered honestly, then they simply aren’t included in the findings about legals / illegals so it shouldn’t affect the findings. They obviously had a large enough percentage of respondents who did report their undocumented status, so the analysis stands. If anything, it makes it more robust, rather than less.
    3) Completion rate? What do you mean by this? All surveys have low completion rates. That’s how surveys work. Not everyone has the patience to sit through a 30 minute interview. Yes, this makes surveys less than perfect, but there is no such thing as a study that is perfect (in science or otherwise).
    4) Your points about reflecting “accurate picture of immigrants health care” I agree with. I’m just not sure what you mean by “it’s not because their study proved it”
    Lastly, your point on wages needing to rise to reflect that demand is debatable. The demand for labor (or cheap labor as you put it) is what’s driving immigration and the outsourcing of jobs to other countries. Frankly, I’d rather have these capitalists import labor from Mexico than send the jobs to India or China (along with marketing, management and all the other jobs that are generated when manufacturing / production occurs here). If you want to impose a socialist planning model on our capitalist system, then you can force higher wages on the employers. This will slow our progress, stifle innovation and cause inflation. Still, it would never be enough to attract native-born people… most of whom have college degrees, technical skills and/or other talent we need. Do you really want your skilled talent working unskilled jobs? I’d rather they be creating, producing, inventing and innovating.

  6. Problems:
    1) Random telephone survey based on numbers available in directory. This is automatically going to hamper the sample, regardless of its size, as it is going to exclude a large percentage of the illegal population.
    2) Self-reporting of immigration status. This is pretty straight forward.
    3) Completion rate.
    The findings of the study may reflect an accurate picture of immigrants use of health care- it makes sense- but it’s not because their study proved it.
    Read the book again. The demand is not for labor, but for cheap labor. When there is demand for labor, wages should rise to reflect that demand. Not wanting to pay these wages, corporations wish instead to increase the supply of cheap labor regardless of the societal impacts. I think most of us can agree that the legal immigration process has ample room to be improved.

  7. I love commenters like Alex who make asinine statements about methodology when they so clearly don’t know that the heck they’re talking about. Yes, I looked at the methodology Alex, and it is most certainly not a joke. First of the all, the question about one’s legal status is only one question out of a 30+ minute questionnaire on healthcare issues in general which was administered to over 40,000 people. The survey captured people all over California of all ethnicities, not just Hispanics, legal or otherwise and focused on many healthcare related topics. The legal residency question is most likely asked at the very end so there is no incentive to underreport one’s healthcare usage in the rest of the 30 minute questionnaire. As a market researcher myself, I would dream of having a sample size this big and a methodology that is so rigorous. If you go to their website there are a good number of documents on their methodology http://www.chis.ucla.edu/methods.html
    It is a shame that our immigration system is so restrictive towards unskilled labor that people are willing to risk life, limb and spend 1000’s of dollars to get into this country, only to be attacked and abused by the very people who benefit from their cheap labor (aka all of us). If our government had some sense, it would make crossing legally a much more efficient affair, and could generate great profits from it by charging $1000 a pop (which is still less than they’re paying coyotes to get over here). Right now, those millions of people who entered illegally are paying $2000 to $10000 to get in. Thats a huge chunk of change that could be paid to our INS who would use the money to strengthen the borders, modernize the system so immigrants are catalogued and documented as they come in and so forth. By some accounts we admit legally less than 1000 unskilled laborers a year legally, yet our economy has been using millions upon millions of them in construction, hospitality, farming etc. Do the math.
    Immigration flows to this country rise and fall with the labor demand. When labor demand is high (aka lots of construction happening, etc.) we should let more people in legally. When it is low, we don’t. Its supply and demand people… When we have growth in this country, we need more unskilled laborers so our more skilled people can go about producing, marketing, creating and inventing. You can read about all this in a little book called the Wealth of Nations by Adam Smith.

  8. I wouldn’t use ER’s either if I felt that I might get reported and deported. At $1000 a month for family coverage, even doubling what illegals are paid wouldn’t enable them to purchase private coverage. It certainly wouldn’t be a public health tragedy if those biggy fries cost $2.00 instead of 79c.

  9. Well tcoyote, maybe if they were paid better wages, they could buy their own health insurance. Would you be in favor of that and willing to pay more for food? I’m not sure you messed up the story line. Matthew said they are 50% LESS likely to use emergency rooms than latino citizens, not that 10 mil. were uninsured. I do agree that border states have a harder time handling the latino uninsured and that the Dems will do no better at insuring them under any universal plan unless we truly go to gov run single-pay. As usual Americans want all the benefits of low wages but none of the responsibility for the outcomes.

  10. Sorry, Mathew, for messing up the story line, but according to the Census Bureau, over 10 million of the 47 million uninsured are not citizens. And of course, that’s a low estimate because if you’re illegal, you’re not going to stand there and answer a Census questionnaire. It isn’t as big a financial risk to the health system as the more than 10 million boomers who are uninsured, but it isn’t negligible either. Illegals are a huge issues for sunbelt hospitals, who are required by EMTALA to treat first and ask coverage questions later. All the Democratic Presidential candidate blather about “universal coverage” is going to prove to be just that- blather. When push comes to shove, if the Democrats cannot get illegals drivers’ licenses, they aren’t going to give them health coverage, are they?

  11. Alex
    Can you post a reference looking at what you decribe. I would be interested in reviewing.

  12. a) did you look at the methodology? It is a joke.
    b) As long as people continue to not count the legally-born babies of illegal immigrants as an expense due to illegal immigration then illegal immigration will not be a primary driver. Once you start adding that up, it becomes a huge factor.