Providing healthcare for non-US citizens a 'moral obligation,' professors say

February 24, 2017 by Molly Callahan, Northeastern University
Credit: Northeastern University

At a time when the country is steeped in nationalist sentiment, and the Trump administration is focused on rolling back the Affordable Care Act, Northeastern University professors Patricia Illingworth and Wendy E. Parmet are making the case for expanding healthcare to non-citizens in the U.S.

Calling it a "moral obligation" and a "global public good," Illingworth and Parmet suggest that is a issue, and that extending coverage in the U.S. to non-citizens could actually alleviate both the cost and care burdens on everyone. In fact, the researchers co-authored a book on the subject, The Health of Newcomers: Immigration, Health Policy, and the Case for Global Solidarity, that ties together their expertise—Illingworth, professor of philosophy and fellow at the Carr Center for Human Rights at Harvard University; and Parmet, the Matthews Distinguished University Professor of Law.

We asked them to explain what role the U.S. should play in providing healthcare for non-citizens and what consequences—good or bad—might be associated with that. Here are their joint answers.

What sort of obligation does the U.S. have to extend healthcare to non-citizen immigrants?

The U.S. is a party to several international agreements that recognize a right to and condemn discrimination in the recognition of that right. The U.S., however, has not ratified the U.N. covenant that speaks most precisely to the issue. Moreover, any internationally-recognized right is likely unenforceable within U.S. courts.

Nor does the U.S. Constitution establish any broad right of non-citizens to government-supported healthcare. Nevertheless, non-citizens within the country do have constitutional rights, and there are circumstances (for example, in prisons) in which the government is obligated to provide non-citizens with access to healthcare. Federal and state statutes also provide many classes of non-citizens with rights to healthcare.

There is, moreover, a moral obligation to provide newcomers with healthcare. Ethics focuses on universal norms and requires that we treat people the same unless there are morally relevant differences among them. With respect to health, there do not appear to be such differences.

Healthcare and the social determinants that impact health ought to be distributed on the basis of health needs. In addition, the right to health applies to all people as a moral right. Because health is a global public good, there are utilitarian reasons to promote the health of all. Everyone benefits when we support health.

In addition, when a global perspective is taken on health, rather than a national one, a case can be made that the health of people in poor countries has been impacted adversely by the activities of rich countries—such as the environmental harms caused by the manufacturing activities of multinationals. Many of these conditions drive migration. Put differently, the activities of people in affluent countries are, in part, responsible for the health of the global poor, the very people who migrate. Affluent nations may have corresponding duties of justice to newcomers that can be fulfilled through healthcare.

To what extent would covering non-citizen immigrants put a financial strain on our healthcare system? How do you balance the financial cost with the human rights obligation?

Providing equal coverage for non-citizens should not put a significant financial strain on our healthcare system. Immigrants as a whole are younger and healthier than non-citizens. They also tend to use fewer healthcare resources.

However, because so many immigrants are uninsured, they have less access to primary care. That means that preventable illnesses are more likely to end up requiring expensive treatment in hospitals. As a result, we all end up paying for the care of uninsured immigrants, just in ways that are extremely inefficient and bad for their health. Since the costs to affluent nations may be higher if we do not provide immigrants with equal care, financial considerations should not be decisive. However, even if the costs were greater by extending equal care to non-citizen immigrants, including undocumented immigrants, the to provide equal access persists.

Are there developed nations that do cover non-citizen immigrants? If so, how are their healthcare systems similar to or different from ours and do they succeed or fail in providing coverage to non-citizen immigrants?

All developed nations, including the U.S., provide some non-citizens access to healthcare coverage. Some nations, such as Canada and Switzerland, offer coverage to a higher percentage of non-citizens than does the U.S. But other nations, including many we think of as having "universal healthcare," exclude from their healthcare programs. Interestingly, there seems to be no correlation between the type of healthcare system that a nation has and its treatment of non-citizens. Non-citizens can be covered or excluded regardless of how the nation organizes its healthcare system.

What are the benefits to expanding healthcare coverage?

First, non-citizens themselves will have better access to healthcare, especially primary care and prevention, which they now often are unable to obtain. As a result, they should experience fewer preventable illnesses and achieve better management of their chronic conditions.

Second, the hospitals and safety net providers that treat non-citizens will face fewer uncompensated costs and financial strains.

Third, the doctors and nurses who treat non-citizens will be able to treat their patients without having to worry about who will pay for needed care.

Finally, citizens will be healthier, as infectious diseases will be diagnosed and treated more quickly and communities will be freed from the emotional and economic burden (not to mention the productivity losses) of having to care for untreated members of their community and family. As we show in the book, health is a public good; the health of one affects the health of all.

Do you think it's possible that the U.S. healthcare system will eventually expand to fully include non-citizens?

Solidarity is often defined as a willingness to carry costs for others—to incur some costs on their behalf. Some studies have suggested that diversity is an obstacle to social trust, cohesion, and the willingness to help "strangers." There is evidence, however, that people living in affluent countries are able to trust others with their health—medical tourism, transplant tourism, and, of course, the medical brain drain, are good examples of the ability of people to trust strangers when they are most vulnerable—that is, when they are sick. It may turn out that because health reflects our shared humanity, it is a sphere in which trust, social connection, and solidarity are possible. We are encouraged by the solidarity with newcomers that took place during the recent protest, "A Day Without Immigrants." In a show of solidarity, many businesses closed to underscore the value of immigrants in our communities. Apparently, some people in the U.S. are willing to carry costs for newcomers.

Explore further: Undocumented immigrants in O.C. use fewer health services than rest of population

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