Good morning, my name is mark, director for the center for Immigration Studies and the democrats in one of their debates this summer were asked whether the taxpayer should Fund Health Care for Illegal Immigrants and all 10 participants raised their hand and said yes. Thats an arguable position, there are arguments you can make for and against that, but the first question you need to answer in this, as in any other policy proposal, is what is this going to cost . And there simply hasnt been very much interest or exploration in this question and so thats why were releasing the twopapers were releasing today and having this panel discussion, is precisely to get a sense of what it could cost us. Not definitive. These are estimates, maybe theyll be different. Other people have other estimates. Wed love to see them, but nobody really has offered some concrete examination of what the consequences for taxpayers would be of these proposals. And so today were going to be were releasing two papers to look at that. The first is a look at what the current cost to taxpayers are under current policy. The second is what the likely, under a couple different scenarios, the cost would be. And this is a topic that needs to be injected into this debate if the debate is going to be constructive and meaningful. And so participating in the panel are going to be some of the authors and the commenter. Ap the first will be jason richwine, hes an independent policy only list whos written on immigration as well as other issues. He did the paper on what the current costs are. Jasons a ph. D. In policy analysis from harvard, published not just on immigration, but other issues, but recently Education Funding he published in the wall street journal and elsewhere. Next will be steven camerota, director of research at the center for Immigration Studies, hes the lead author on the paper estimating what the likely costs in the future would be if Illegal Immigrants were to be covered under health care. Steve is for more than two decades has been one of the top analysts of the immigration issues, ph. D. Is from uva in policy analysis and then our commenter, discussant, if you will, is chris pope, a senior fellow at Manhattan Institute and hes responding to the two papers and maybe more generally to the issue of taxpayer the effect on taxpayers of covering Illegal Immigrants for health care. So if we could kick it off, jason. Thanks very much, mark. So i want to talk to you about sort of the baseline, the Current Situation with immigrants, both legal and illegal in terms of how much they cost the Medicaid Program. I would say this is also relevant not just to the democratic president ial candidates, but also to the president ial proclamation that happened, was it last friday, the proclamation that said that immigrants applying under certain visas will have to show that they have Health Insurance before theyre allowed to enter and of course, the reaction to this was, as you might expect from certain quarters, i have to say sort of an aside. I do find the medias reaction to this whole issue kind of humorous. Before the Trump Administration, groups like center for immigration study would put out reports that shea we tabulated some census data and found that immigrants do in fact use means tested antipoverty programs and in some cases use them at higher rates than natives and the response from a lot of people in the media was to say, thats absurd. Immigrants dont use welfare. In fact apparently you guys have never heard of the public charge rule and the public charge rule says you cant be here as an immigrant if you are on welfare. Well, as soon as the Trump Administration became serious about enforcing the public charge rule, suddenly overnight, the talking point changed considerably and in fact, criticized because it was too draconian. Affecting twothirds or three quarters of all immigrants. Its difficult for me to keep the talking points straight, but we dont give you talking points here. We are going to give you just the facts here. Certainly immigrants do use medicaid. There are some restrictions, of course, not all immigrants are eligible. In fact, generally speaking, if youre an immigrant who wants to use medicaid, you have to be a legal permanent residents. That means not a temporary immigrant like someone on a student visa. And you also have to have lived here for five years generally speaking. There are, of course, exceptions to those rules as there always are. Humanitarians, they can Access Medical care immediately. Generally speaking, children and pregnant women do not have to wait the five years for coverage and Emergency Services available for everyone, regardless whether youre legal, illegal or anything else. And another exception, if you want to call it that, is that u. S. Born children of immigrants are fully eligible for medicaid and every other program that citizens are eligible for, and will get into why that matters in a second. So lets dive into some results here. I wont belabor the methodology. We can bring that up in the q a if you like. This is from medical Expenditure Panel survey and just enrollment rates that were looking at right now. And id like you to focus on the individual row at first. You can see that despite the legal restrictions on which immigrants are allowed to use medicaid, overall, immigrants still use medicaid on an individual level about the same rate as natives, at 23 . And you can also see that ive divided immigrant into some interesting subcategories and there are less skilled immigrants tend to be on medicaid more often, which is not too surprising. I would argue though that the family row is the most important row in this analysis. Immigrants are not individuals in the sense that they have dependents just like anyone else would have dependents when they are living in the United States. And in particular, they have u. S. Born children as i mentioned, who are eligible for medicaid. Theres a debate about this. Some would say u. S. Born children should county in the native column and others in the immigrant column. Im very much of the view it should be in the immigrant column. Parents have a legal obligation to provide basic service toss their children. They have to provide them food, shelter and have to provide them medical care. If the government steps in and says well do that for you, thats a benefit to the parent and not just to the children. And on medicaid and their children would be put on medicaid. You can see from the table there, that once you look on a family basis, immigrant families are significantly more likely to use medicaid compared to natives and in fact, lesser skilled immigrants you have a majority who are actually on medicaid. I should say at least one people of their family is on medicaid. Now, in terms of cost, thats the next column here or the next table. You might be thinking, gee, how do we know cost. Do we ask people, gee, how much did you cost the medicaid system last year . No, theres a separate Provider Survey within this data set where they actually ask the doctors and hospitals how much was billed. So its generally more accurate estimate than you might expect from first glance. And unsurprisingly you see that immigrant families do cost more than native families. This is for everyone. This is like a per capita or per family estimate so it includes people not on medicaid, in which case, obviously their costs are zero. And you can see again, lower skilled groups like people without a College Degree tend to cost more. Now, when i give this kind of presentation, i sometimes get the reaction, or sometimes people accuse me of stating that immigrants are lazy, immigrants are moochers, immigrants come here to live off the u. S. Taxpayer. No, no, thats not the case. I dont see that in the data. I dont see any special appetite for welfare among immigrants. What i do see is that immigrants have certain demographic characteristics that when found among natives also leave natives more likely to go on medicaid. Im speaking specifically of two things, lower levels of education and larger families. Whether youre born in honduras or washington d. C. , if you live in the United States and you have a low level of education, and you have a lot of mouths to feed, you are likely to be on medicaid. Its not a special problem with immigrants, its just the fact, these are the characteristics that they have. In fact, i have a little numerical example of that. A basic regression analysis. If you look at the cost difference column here, thats the difference in cost between the average immigrant family on medicaid and the average medicaid cost for native families and the first role is no control so that 813 cost difference is the same one we saw in the previous table. Now if we start to control for family size, for example, the number of adults in the family, you see the cost difference go down. The 639. And add in control for children, 423. And finally most importantly you control for the education of the head of the family. And that then, once you do that, the difference is a very negligible 25. So you can see that we can account for virtually all of the cost difference simply by looking at the educational level. Immigrants and the family size. The lesson here in terms of immigration policy should be fairly clear. Its that if we want to reduce immigrant dependency on medicaid, including their childrens dependency on it, then we want to change the selection criteria such that we have more skilled immigrants, such that immigrants come in with the kinds of earning power that we know theyre going to be able to support not only themselves, but also any children or other dependents they might have when theyre in the United States. I think that certainly the proclamation i mentioned earlier, requiring Health Insurance for certain immigrants is a step in the right direction. How meaningful it will be remains to be seen in terms of the exact details of the plan, but as i said, a step in the right direction. A step in the wrong direction would be to expand the eligibility pool among immigrants especially if youre expanding to include Illegal Immigrants and that would be a very costly program and to give us the cost of that, we have dr. Camerota. Before you start, steve, just remind people who are here that we have printouts of both papers in the back and for those watching, both of these reports are online at cis. Org. Thanks. Thank you for that introduction. My name is Steve Camerota for Immigration Studies, the injurys director of research here. I should mention that the report im going to discuss today has two coauthors, one is jason, and the other is karen ziegler. Now, as mark pointed out, at the june 27th democratic president ial debate all the candidates endorsed giving Health Benefits of some kind, governmentprovided benefits to Illegal Immigrants, but there was no exact discussion what form this would take. So, this research is in response to those proposals. It is the case that after the debate, the atlantic magazine surveyed the participants and found that Bernie Sanders, kamala harris, elizabeth warren, cory booker and julio castro all would provide benefits to the undocumented in their words. Joe biden was less clear, but seemed to say that he would allow the Illegal Immigrants to buy insurance on the exchange presumably unsubsidized, so it looks like they would just be allowed to buy insurance on the health care exchanges, and ill go over exactly what that means. Now, under current law, Illegal Immigrants are not allowed to participate in the Health Insurance exchange established by the Affordable Care act, also called obamacare. Thats like the core part of obamacare. So they cannot receive whats called the advanced premium tax credits which are the subsidies paid to Insurance Companies to help low income people afford coverage. Illegal immigrants are also generally barred from participating in medicaid, the Health Insurance program for the poor with some notable exceptions, minors in some states and pregnant women and a few other categories. In general theyre not supposed to be able to get medicaid. Now they said the Democratic Candidates seemed to envision some significant change from this system. Now, as a reminder, here is very briefly how the obamacare or the aca works. Those with incomes under 400 of poverty, about 83,000 for a family of three in 2018, are eligible for the subsidies that reduce the amount that they pay for Health Insurance when they buy it on one of these exchanges. Now, the aca subsidies are paid for by the government, that is by taxpayers through the Insurance Companies for the most part thats how it works. Now, in general, those purchasing insurance through the exchange are either selfemployed or not offered insurance through an employer. The other aspect of the aca, it was originally designed for the lowest income people those were under 138 of poverty, about 29,000 roughly in 2018 for a family of three. People below that level would be able to get medicaid, thats the free Health Insurance you can get as opposed to the subsidized Health Insurance from the exchange, however, many states have chosen not to expand medicaid. Now, the size of the aca subsidy, thats the cost to taxpayers, primarily reflects the persons age and income relative to the poverty threshold. The size goes up, the lower the income. In other words, the poor gets the most help, which of course makes sense. Factors such as a persons Overall Health or preexisting condition dont matter in terms of the subsidy. Now, we basically look at then two scenarios when we try to figure out what it would cost to provide Illegal Immigrants with Health Insurance. The first scenario is basically, what if we just made them all eligible for aca subsidies . It seems to be what the candidates have in mind and so thats one possibility. The second scenario is a mix in which the higher income Illegal Immigrants, those basically between 138 and 400 of poverty would get the aca subsidies and the ones with the lowest income would get medicare. Now, consistent with other research, we estimate that there are about five million uninsured Illegal Immigrants with income low enough to get aca subsidies. Now, there are by most estimates more than twice that number of Illegal Immigrants in the country, but many either have higher incomes so they couldnt get the subsidies or for the most part they are insured by employers. Now, you might say thats surprising, but i think theres a pretty high degree of concensus that very roughly half of Illegal Immigrants have Health Insurance. Now, given their age, we estimate that the average cost of providing an aca subsidy for Illegal Immigrants would be about 4600 a year. While the average cost would be large, that subsidy is actually for the Illegal Immigrants, is still less than what the average person now gets on the subsidies from the aca, thats people who are native born or legal immigrants. This is primarily because Illegal Immigrants are relatively young population so theyd be somewhat less costly to insure with the subsidies. What would the total cost for that roughly five billion be. If they all signed up . 1 100 enrollment, 22 million. If the five billion nearly 23. And this is significantly more than the roughly 17 billion spent each year paying cash benefits to poor people under the temporary assistance for Needy Families Program referred to as tanf. So the welfare, the cash welfare, 17 billion. Potential cost for this is about 23 billion. Now, another way to think about that is, for every one million uninsured Illegal Immigrants who signs up for aca insurance and gets the subsidy, the cost to taxpayers is about 4. 6 billion so you can do your own calculation, each million so you think only 2 million, 4. 6 times 2, 3 billion, 4. 6 times 3. Do your own estimate. Of course, many Illegal Immigrants eligible for the aca subsidies would probably not sign up, in fact, we estimate that less than half would actually sign up based on our research. So we think the actual cost would not be the nearly 23 billion, but actually more like 10. 4 billion. Now, what i think is interesting about this number, although we think that Illegal Immigrants are on average cheaper to insure and we think less than half of them would actually sign up, its still the case that in the first year, the costs would be over 10 billion. And it might run to over 100 billion in the first ten years, which is in the normal budget horizon used by the Congressional Budget Office when estimating costs of new legislation. Now, although we consider this aca only approach the most likely policy, at least politically, that would be adopted to insure illegals, we estimate what it would cost if we had a hybrid approach. Aca for the highest income. Medicaid for the lowest. Now, compared to the aca only approach, the total cost of the aca medicaid hybrid approach would be about 19. 6 billion. Again, if everybody enrolled. This is somewhat lower than our aca only approach, again, assuming 100 enrollment. The lower cost of a mixed aca approach partly reflects our assumption that Illegal Immigrants on medicaid consumed somewhat less than health care than the average person on that program. By contrast, aca subsidies as i mentioned before are paid to companies and mostly reflect the persons age and income, not their actual consumption of health care, but with medicaid, the government would be insuring people directly and the tendency of immigrants, including Illegal Immigrants and hurricane irispanic immigran medicare we think that would slightly lower the cost. It may be less burdensome to provide medicaid to the lowest income immigrants medicaid itself is slightly cheaper, not just slightly cheaper than aca. Medicaid because the government can negotiate down prices and demand lower fees from doctors and health care providers, is actually less costly, people on medicaid, the typical person than the typical person now getting aca and that would be true if we gave it to Illegal Immigrants. It seems counter intuitive. The Free Health Care insurance from the government is actually somewhat cheaper. If we gave Illegal Immigrants, at least the lowest income ones access to medicaid, it would be somewhat cheaper than the subsidies under the obamacare. Like our aca only analysis, we do not think that many immigrants would take advantage of an aca medicaid system, again based on other he will rolement rates, a mixed acamedicaid approach 10. 7 billion annually or again, over 100 billion over ten years. So this means, however, if you notice, once we take into account likely enrollment, the cost of a medicaid aca approach rather than just an aca approach would be slightly higher, even though the average cost of medicaid is less than the average cost of aca. Now, this seems strange. The range for this is that the likely enrollment rates for medicaid are so much higher than the likely enrollment rates for the aca. So, in sum, it costs less that insure each person on medicaid than with aca subsidies, but more Illegal Immigrants would certainly take advantage of medicaid. Remember, medicaid is free. And if you get aca subsidies, you still have to pay something and that makes Medicaid Enrollment rates generally much, much higher. In conclusion, i would say this, look, providing Illegal Immigrants with public Health Benefits may soon become reality depending how the political situation evolves. Of course the cost of providing Health Insurance to Illegal Immigrants would depend heavily on what we choose, but if you look at the current system, the two primary ways we deliver free or reduced Health Care Insurance to low income residents are medicaid and aca subsidies. Our Analysis Shows that allowing Illegal Immigrants access to the programs would likely cost taxpayers 10 or 11 billion dollars assuming likely enrollment rates, but its possible the costs could be up to 23 billion. Now, one important caveat about the estimates we make no assumption how giving free or Subsidized Health care to Illegal Immigrants might significantly increase the flow of new Illegal Immigrants into the country. If low income people in other countries can come here free and get health care, it seems very likely that that could spur at least some additional illegal immigration, creating new costs because as you can see from these numbers, the value of that free insurance or the value of the subsidized insurance runs into the many thousands of dollars and that is certainly an attractive option or certainly an attractive incentive. Now, specific costs aside. I think this may be the most figure fact. If president ial candidates are advocating spending billions of dollars on people who are in the country illegally, in my view, this is significant in its own right, because it suggests that allowing in large numbers of less educated workers, inevitably generates political pressure for access to social programs. If theres significant political pressure to provide people who arent supposed to be in the country with benefits that cost thousands of dollars, it seems almost certain that over time pressure will grow to provide Health Insurance to low income guest workers or others, quote, temporary immigrants as well. Right now, most legal immigrants cannot access medicaid, for example. At least for the first five years, as jason said. But if we give medicaid to Illegal Immigrants, surely that would have to change and wed have to give them access and the legal immigrants would have to get it and thats many million as well. The high cost of providing health care to less educated workers who earn modest wages and employers who do not provide coverage is a reminder that tolerating illegal immigration or allowing them in legally is likely to create a significant burden for taxpayers. Thats not just theyre lazy, thats not because theyre not here to work, rather, affects the changing and low income and types of jobs they do which means they dont pay a lot in taxes and they will tend to use a lot in services, including potentially, this one. Now, this, of course, is a big difference from immigration historically and had nothing to do, really, with some sort of difference between the immigrants coming today and now, it has to do with us, our society. We have a well developed welfare state in which were very likely to offer coverage to people once here. Thank you. Thank you, steve. Chris pope from the Manhattan Institute will respond to the papers and maybe more broadly discuss this issue of health care for immigrants. Chris. Thanks. I think this is an interesting discussion to have. I think in washington what we tend to have, we have everyone sort of spends their whole career in the policy silos. I spent all of my life in Health Care Policy talking with Health Care Policy people having the same discussions about Health Care Policy and nothing much about immigration and you guys are all presumably somewhat somewhat similar and think that much of the details of health care and yet, the first thing i think, suddenly i notice and everyone in my world notices is the health care is enormously complicated sector policy, the rules, the entitlement rules, the regulations associated with Health Insurance are very, very difficult and these guys have done a great job in terms of like trying to understand it, trying to penetrate really whats going on and trying to interpret and really approach it from an outsiders perspective. As someone who spends their life working on Health Care Policy im kind of impressed how well youve done really trying to make sense of it all. The things i think, just as sort of in the policy world we have these independent silos in terms of how policy analysts were able to think about different policy sections. Its true of candidates and people making Public Policy when they develop immigration policy they dont think that much about Health Care Policy and when you think about Health Care Policy you dont think that much about immigration policy and obviously, this is not entirely possible. Like we have these overlap between the policy areas and this is a pretty good example of one that the public charge rule, which is sort of long established and obviously has an intuitive support for many voters that care about it hasnt always been thought of as a Health Care Policy issue. But were in a pretty different world now. 50, 60 years ago, health care was not was not dominating the welfare state the way it is today. Health care, Health Insurance premiums were less than a thousand dollars not that long ago, only a decade or two ago, that was like a fairly standard amount that people would pay and now were talking about tens of thousands of dollars for a family coverage. It looms large in terms of family budgets, especially for people who are lower down the income scale. If youre earning around the minimum wage and then also have the Health Care Benefit, that sort of works, potentially, 20,000 for family coverage. That Health Care Benefit is an enormous is sort of an enormous feature relative to your compensation and its also true, with respect to the public the public sort of spending side of things. If you look at cbo data even in 2008, health care was means tested federal programs. By 2028 its going to be 71 . So health care, if youre talking about a public charge, if youre talking about public entitlements, youre kind of really talking about Health Care Just in crude numbers. Its not possible to talk about this issue without talking about health care. A hundred years ago, absolutely, it was possible to talk about this issue without talking about health care. Health care was not really that important of a thing. But really, these days when youre talking about burdens on taxpayers, its really all about health care that were talking about. So, the other thing that i think really has changed recently and again, this is really from a health care perspective, is what happened with the Affordable Care act. Prior to the Affordable Care act, we obviously had the medicare program, which is for elderly and qualifying disabled individuals. People who paid into the program over large periods of time. We had Medicaid Program which prior to the Affordable Care act had been for various sections of categorical beneficiaries. For the most part, like ablebodied working age adults what medicare. The Affordable Care act really change that. It ensured the Medicaid Program was expanded to ablebodied working age adult under, earning less than 138 of the federal Poverty Level which is probably about 15,000 for individual and then for a family it increases, depending on the amount of people in the household, 20, 30, 40,000 thousand depending on the household size. This means you get the coverage if you you are less than that t you dont get come not entitled to the coverage if you earn more than that. Thats straight away creates a whole host of complications that were never really involved in healthcare policy before the Affordable Care act. Great work incentive issues, creates questions of people coming in and claim access to benefits in a way that really was never really an issue that policymakers had to grapple with. Nonetheless, i think its sort of like a caveat i would suggest is the Affordable Care act, the entitlement expansion of the Affordable Care act is only about 10 of healthcare spending. For some of the reasons that were touched on earlier, ablebodied working age adults that are low incomes can be fairly young which means they can be fairly healthy. They are not considered as many Healthcare Services as people on medicare. Thats why its sort of like the strange phenomena of Public Policy that i so they feel like a healthcare guy, that is when you throw out the big number it sounds really huge and almost every context and then in healthcare context its like that stuff that big of a number. Compared to cannot of money to the public is spending on welfare benefits, even on food stamps, these are infamous enormous numbers. But in terms like when you talk about it was an estimate in the public charge role of 30 billion per year, thats a big, big number but its 3 of healthcare spending. There is a sense in which like what does this mean . In terms of sorted is never potentially because the net . There are some reasons to think it might be. Firstly, theres this issue of employersponsored insurance. A big reason why not that much is spent in terms of Exchange Subsidies is because like 90 of americans who get Health Insurance to private entrance get it to their employers and they are not entitled to Exchange Subsidies or medicaid if employers are providing it. If employersponsored insurance the noncitizens is greater than it is to citizens, you might see a larger proportion claiming aca subsidies or claiming medicaid then you just might assume from the general population. Secondarily, there was sort of the issue with medicaid that was touched on. A lot of medicaid looking relatively cheap relative to other payers is because the cost is a a little hidden. If youre a hospital, if you accept medicaid you get a lot of Tax Advantages on the backend. You get a lot of discounts from Drug Companies on the backend. So the extent to which the actual dollar figure medicaid actually represents your true cost of enrolling an individual medicaid, thats a little bit uncertain. There is the issue with which i think is really came out of the debate, which is hard to imagine this is a serious proposal, which is to provide a universal coverage to anyone who essentially shows up. Thats not a policy that any country in the world does and theres no way it would actually happen. The reason is simply this, li, we have a lot of medical therapists in the United States that are not available around the rest of the world. A lot of cutting edge drug therapies the cost 100,000, 200,000 and its almost severed from immigration policy. Like theres no way we would set up an entitlement that would provide, where taxpayers would pay for drugs that are not available for europeans with cancer to come over, claim the drug spending, get all the treatment and then go back. Like, aside from all the question of how that interrelates with the third world and serve where were at, sorting the greater flows of immigration, but it does sort of raise the same question. That raises one more point, which is the interaction between the immigration proposals and the singlepayer debate, which is two things have really, really expensive if they interact with existing public law, with existing Affordable Care act, how would they interact with the singlepayer system where there were no premiums, no outofpocket costs, where everything is essentially funded by taxes . That i think was the strange thing of the debate, was you could almost to some degree come up with a number as you guys have done for how immigration interacts with existing healthcare law. I dont know how you even come up with a number for how it would interact with whats your post on singlepayer. With a caveat some of the candidates dont entirely endorse singlepayer, so biden, bidens proposal you could actually say has an actual number attached to it but the Bernie Sanders kind of end of the spectrum i just dont think you could even say a number with that. The final point i would make is really, how does consort thinking again like feedback between the policy areas, to the extent we have an expanding healthcare system. To the extent with a more universal healthcare system, there is a big demand for labor. Healthcare is incredibly labor intensive Healthcare Industry and theres a lot of low Skilled Labor especially think of longterm care issues. If you think about the aging of the baby boom generation in a few years people are going to be going into their 80s. They are going to need roundtheclock nursing care, need home health assistance. In terms of the native workforce, traditionally that is not been with the workers come from for that. Traditionally youve had a very large share of immigrant workers that are responsible for providing these home health services, and the extent spending on healthcare increases and use dispensing au of their countries around the world, with physician fees control, with which is controlled, with kind of real tight budgetary controls, it really does tend quite often you see this in germany and england, it tends to feedback and immigration policy, really just under the pressure of challenges of keeping the trains run on time in terms of the healthcare system. Thank you, chris. The last point was interesting because i guess the increase in healthcare costs will create pressure to bring it immigrant workers who wont be paid very much, who will then create political pressure to provide healthcare to those people, which its almost a vicious cycle. I just wanted to raise a first issue and the guess or anybody, steve come something you brought up but its worth underlining. A lot of the lobbyists for expanded immigration, especially those from the business, corporate side and libertarians say its possible to have a kind of immigration approach. We let in lots and lots and lots of people regardless of their skills and education, and some of thats not going to create any cost to taxpayers. It obviously goes beyond the healthcare issue, but, i mean, we tried this before in creating a kind of wall around public services. It hasnt really worked very well. Just wondering if you could talk more about that experience of welfare reform . Yes. So we do have restrictions on the new legal immigrants and Illegal Immigrants are not supposed to get stuff, but when you look at all the data the government collects in the current populations, the survey Income Program participation, its clear a very large fraction of immigrant families do use these programs and even those who were in the country illegally. The reason is it doesnt cover all programs, a lot of pressure. As electives i think about the women and infants and Children Nutrition program. Just say the name and it answers the question of whether were going to keep anybody off that program. We are not come right . But that always went into the billions of dollars. You just have to accept that. If a person is or it would get it. Of the things that matter it states sometimes take under the own initiative to provide services, as jason mentioned whats very common in immigrant families is for the family to receive the benefit on half of usborn child. Thats very, just generally that program i mentioned of tanf, a very large fraction of whats called child old house with her so the family gets a check but technically the adults in family dont come just the children which of course is kind of a difference without anything meaningful distinction. But nonetheless, that sort of what happens. I think that other things of course is political pressure tends to move the ball back. Look, will be tough, restrict. With that overtime when no one is looking you write regulations and thats with sapro will for reformist vote, the regulations themselves tend to walk back a lot of the restrictions. The recent battle happens is that a very large fraction of immigrant are low income. You could argue they need the services. Once here, its very hard to prevent that from happening. What these proposals for Illegal Immigrants might as is even people who are not supposed to be in the country you can still create about a political pressure to spend money on them because they are here. They do work. It becomes very hard to avoid that political pressure and get its a very different situation than existed during the last great weight of immigration 100 euros ago when we did nothing well Development First eight. Your answer so comprehensive. I was looking for an in and it just didnt have. One point i would add to that is we have, for instance, the requirement, federal requirement that anyone asking for treatment in emergency room be cared for. Thats federal law and, frankly, im not sure how many voters are outside the Cato Institute or reason magazine who would be willing to people even if they are illegal aliens die on the steps of hospital. Its not just what happened, just to reinforce sure. Any questions for any of the panels . Yes, sir. Wait for the microphone. Thank you so much for organizing this panel, very interesting. This is a question for steve and maybe more. What you expect from the steady, do you expect a a democratic country to change the promises regarding this issue are at least give some more details about the plans regarding immigration as well . Thank yous. I just hope it informs the debate and maybe would help them fleshed out come help assemble, we think this proposal based on this research and drawing in other evidence would cost ten 20 billion to the tax base can decide. As chris pointed out something that cost 20 billion, thats thats an enormous sum, but in reality relative what we spent on healthcare and other things, you could argue its not that big. But you shouldnt, i think its always a bad idea to have a policy proposal out there without some sense of what its going to cost. And i hope thats what we get out of the study. As far as what affect you have i have no idea of the part of is up to reporters from the post and the times, et cetera, to ask candidates, theres an estimate this is going to cost ask, what is your response to the . In some sense it really does depend on whether people following the candidates actually confront them about this and try to get some kind of response. Any other questions . Yes, sir. [inaudible] hold long. On. Wait for the microphone. Wasnt any consideration given to the potential economic benefit of having a health or pipe was more productive . How did that factor into your study . We focus just on the cost of providing care. Theres certainly evidence that when you get give people insur, their healthcare outcomes can improve. They consume a lot of health care, if youre sick you only wait and you go to hospital and it costs a lot. The evidence is pretty clear that happens but on bows people put off the care, they do less. If you give people insurance, expenditures go with a special for taxpayers but its possible maybe it would make the public, make them a lot healthier and i would be a positive outcome. Remember, its mostly a population of people between ages 1845. Its a relatively young population, so the art, remember we dont do any cost of usborn children. There are roughly 5,000,000 minor children of Illegal Immigrants in the United States but they are usborn. We didnt do anything with that, those figures because they all technically eligible right now. Its possible that could be one of the benefits is folks could be a little better off and maybe a little healthier, and more productive. There are a lot of moving parts here. As chris pointed out, some of these estimates might be low, and you also observed a good actually draw more people so theres a lot of dynamic elements to it, but those are, its not clear how you quantify or where it would end up being in that plus or in that mind is. Whereas these numbers are more concrete. We just say we dont deal with the secondary cost or possible other things, like increased migration. Wait for the mic. Fred lucas with the daily signal. Aca come current medicaid, did you factor in the whole medicare for all proposal which seems part of what the democrat candidates were talking about . We did not. You could get an idea, if there are 5 Million People come average cost of medicaid, look at the tables and figures and you could come up with a number. That number would probably be something very, very rough like 20 billion in december, which is give everybody medicaid. Its a little cheaper than the aca. Medicare for all, many, it was estimated to be around 30 trillion. Which come back to say 10,000,000,00024,000,000,000, with that just be almost a drop in the bucket to the overall 30 trillion thats not what we spend. You me over how many years . Probably related to the estimated cost for medicare for all. Right, estimated cost medicare for all. 1 billion here, a billion there, it starts to add a. The one thing i i would suit that is the assumption it would not change the amount of people come into the country for medical care, thats when you see like a really big change to that figure. As i mentioned, like the therapies we have in this country, the degree of intensity of care, quality. If you think its like, like erbe shakes the car to the Cleveland Clinic, if its not just, if its a superrich around the world theyre are able to o the Cleveland Clinic if its use taxers append a for everybody, all bets are off in terms of numbers if that would happen, if there were any chance it would. I know you guys abruptly this could cost 33 billion to taxpayers but i was wondering if you factor in how much would cost roughly in average income family in their pockets . Oh, jimmy, so individual. High range estimate, i can assume quit all the secondary cost you could take that number and divided by the number of average household in the United States. Did you could get, im have been great at mental math but if afterwards we can figure it out, divide that out. In the front. Wait for the mic. Lisa with Congressional Budget Office. We are curious to get a sense of what you would think on your likely enrollment adjustment. Would you assume, does that factor in the same type of a rate individual seven programs already . Because we like enrollment rates, say for example, citizen children of parents who are unauthorized. And their involvement rate is lower than just a general average medicaid child. So would you expect the Illegal Immigrants that would get coverage to have in essence the same enrollment rate as citizen children or the same enrollment rate of the general medicaid population . Or is there something about this population that you would assume its going to be low . So what we assumed was we could find a circuit population in the American Community survey. We looked at all 50 states plus the district of columbia. Our circuit population were eligible hispanics, hispanic citizens who could enroll. As i recall, for adults it was about 70 70 for medicaid whom to have, fit fitbit income proe and action enrolled but it varied in normalcy by states so we adjusted the number for each state. For children, and would look for children under 2 of poverty, as i recall recall national the enrollment rate was very high, i thank you 2 . But there are not that many illegal immigrant children. Theres lots of children of Illegal Immigrants but they are usborn. Thats what we did to a consumption. They government estimate a little over 80 of Illegal Immigrants are hispanic so you could argue and it looks like for the nonhispanics its only a little different but we just use one circuit population and did 51 calculations by age to come up with what we think is a reasonable estimate. We think the enrollment rates will be pretty relatively high but are much higher than the aca has but lower than they are for some other relevant population, and thats how we did it with the American Community survey. Thank you. Question back there. Macon, Cronkite News at arizona pbs. You mentioned have a public charge will has been more enforced, the top administration. Why dont we see the same push underneath bush . That the great political question. Mark, do you want to handle that one . I have no idea. Some of it was inertia, in other words, under the Clinton Administration they actually decide what welfare programs participation in which welfare programs would constitute becoming a public charge. Essentially they said if you were on Public Housing and on medicaid and food stamps, you were selfsufficient. That didnt count as welfare. My sense is the Bush Administration was really not that different. If anything, for most of its tenure, they were more lax on immigration even than the Clinton Administration was, only towards the end did they tighten up. I have no idea what the internal dynamics were, but i suspect nobody even thought of issue, nobody brought it up under the Bush Administration. Which really suggest, again this is a critical point, but where the political point where the political demand was for the current perspective that trump as a kid was offering, that the republican and democratic establishment basically a very similar perspectives perspectiy didnt get that much on immigration. Any of the questions . Do you guys have any final points you want to make . Chris . No. Okay, good. I appreciate everybodys coming. Again, the hard copies are in the back if you would like them. The reports themselves are on our website at cis. Org, as was all the rest of her work in the video and transcript of this will be online within a few days as well. Appreciate your coming and hope to see you at our next event. Thank you. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] general joseph votel former command of the Central Command speaks today about use Security Operations in the middle east. Hes joining a discussion hosted by the middle east institute in washington, d. C. Live coverage at 12 30 p. M. Eastern here on cspan2. Tonight we continue booktv program showcasing whats available every weekend on cspan2. Tonight the theme this history. Sunday at night eastern on after words in her latest book tough love, former Obama AdministrationNational Security adviser and u. N. Ambassador susan rice talks about her life and career in american diplomacy and foreign policy. Shes interviewed by robin wright, author and columnist for the new yorker. Were you worried about that what he would back in terms of russian innovation . Its important for the American People understand it has to stop. This has been constant. They were very actively involved in 2016 as we saw through stealing, packing and stealing emails from the dnc, from john podesta and others on the clinton campaign. They tried to infiltrate our electoral system. They put out false information and then they were very active on social media trying to pit americans against each other over domestic issues of contention, whether race or immigration or guns are what have you. Their whole thing is to discredit our democracy, to cause people in this country to hate one another and turn against one another. And to try to weaken as from within. Watch after words sunday night at nine eastern on booktv on cspan2. A new cspan poll shows just over half of americans are confident that the 2020 president election will be open and fair. Theres a significant partisan gap on the question 72 of republicans are confident in the system, only 39 of of democrats share that belief. 58 of americans think foreign governments are among the threats to the system. Only 41 of republicans share in that concern. More than threequarters of democrats and over half of independents believe that foreign governments may interfere with u. S. Elections. 31 people believe the federal government has done enough to protect elections from foreign interference. 54 of republicans report having either a great deal or a fair amount of confidence in federal efforts. Only 16 of democrats democrats and just over 25 of independents agree. You can find all of the results including what americans think president ial candidate should be required to release their tax returns and whether citizens should be required to show a government id to vote, at cspan. Org. A look not at what medicare for all entails. The American Enterprise institute hosted a discussion on various health care