Trends come in threes

By  |  June 16, 2013 | 

All things come in threes, or so they say.

In my time in practice, I have cared for many undocumented adults. Usually Latino, young, and male, their issues reduce into two categories: injuries related to work (construction and food service) and uncontrolled flares of chronic conditions (diabetes and asthma). Occasionally, I also care for desperate folks in need of dialysis, transplants, or continued mechanical ventilation. Difficulty understates the latter category.

Usually we, “the system,” cobble together a plan at time of discharge. However, the endings to these stories would not be our health care system’s shining moment. These patients have nowhere to turn after they leave the hospital.  They either depart to their country of origin, or more likely, suffer.

However, in the last year I have encountered something unusual. Due to an aging demographic within the undocumented community,  I have admitted three patients, not with the conditions described above, but with cognitive impairment.  Many have been here a generation plus, and now find themselves in frail states without reliable caregivers. No insurance, no savings, minimal command of English, and in need of custodial care. What to do?

For those unfamiliar with what normally occurs, social workers and ancillary hospital staff pursue placement for these individuals.  Because they have no assets or insurance, we seek out assistance from local, state, and religious organizations, and sometimes a local attaché for answers.  The remedy requires imagination and I can tell you first hand, our institutions hit a wall.  A big one.  Patients linger for weeks or months and I won’t dwell on the travail needed to achieve a satisfactory denouement.

We always discuss long term care planning and the difficulties our own citizens encounter when they need 24/7 assitance.  Imagine how immigrants who have lived ambigiously for decades will fare when they can no longer function independently.  The immigration debate in Washington speaks nary a word on how a labor force, aging and undocumented, will need not ERs and primary care, but nurses’ aides and walkers.

I attempted to search for the percentage of undocumented immigrants in the US older than age 65.  I only uncovered the percentage of immigrants here both legally and not ( 13%).  Extrapolate the figure to what we know:

How many unauthorized immigrants are in the United States?
According to the Department of Homeland Security’s Office of Immigration Statistics (OIS), an estimated 11.5 million unauthorized immigrants resided in the United States as of January 2011. The estimates, released in March 2012, suggest that the unauthorized population is virtually unchanged compared to the revised 2010 estimate of 11.6 million. The largest shares of the 11.5 million unauthorized immigrants resided in California (25 percent), Texas (16 percent), and Florida (6 percent). Arizona and Georgia — two states that recently passed immigration enforcement laws — are home to 3 percent and 4 percent of the nation’s unauthorized immigrants, respectively.

If you fudge the percentage downward for only unauthorized immigrants, I would think a few hundred thousand seniors without access to care live within our borders.  Not a huge demographic, but a potentially costly one relative to size when we consider direct and indirect outlays.

Of note, Health Affairs released two papers recently addressing immigrants’ (documented and undocumented) impact on the health system. The first tackled whether they contribute more to US aggregate spending than they take (they do), and the second examined public dollars allocated to pay for their care (appreciably lower than US natives).  Unfortunately, neither speaks to the future “unauthorized” and aged workforce, but only to the dominant youthful cohort of today.  Who will endure here long-term and whether a pathway to citizenship materializes from Capitol Hill remains unknown.

Something also of interest, below you will see a US map (fig. 1) denoting regions with leading languages spoken behind English. While Spanish dominates, you might be surprised to note Italian, German, and Polish dialects, etc., in locales you would never expect. We have a diverse country, and despite the stereotypes, Mexicans and Latinos comprise only half our immigrant inhabitants (fig. 2).


region graph

Are these regions also magnets for non-citizens with needs we cannot foresee?

In closing, what does an aging workforce require in a shadow economy most of us ignore–and will these demands unexpectedly materialize in the decade to come?  Not evidence-based prognostication by any account but I have practiced long enough to read the tealeaves.  My threesome augurs continued difficulties, and my recent run of admissions portends an immigration (? LTC) problem I only see worsening.



  1. […] by Bradley Flansbaum […]

  2. Maggie Mahar June 21, 2013 at 6:17 am - Reply


    As you pointed out in the post, Health Affairs recently documented that illegal
    immigrants give more than they take out of the economy.

    They do many job that Americans don’t want to do– at least not for the wages we
    pay for these jobs

    Washing dishes in our restaurants; cleaning bathrooms in our offices and homes
    back-breaking contruction jobs that are not well-paid; caring for our children at low wages without Social Security or health benefits.

    (A sidenote on child care: in this country, in contrast to other developed countries, we don’t havehigh quality, safe and affordable child care that is subsidized by the gvt As a reults, many , working parents can’t healthcare they can afford. So they wind up paying ilegal immigrants too little for childcare that is not safe.See Jon Cohn’s recent cover story in Fortune)

    Most other developed countires realize that they need immigrant workers and include them in their health care systems.

    By contrast,we pretend that we don’t need or want them, delcare them illegal and then turn our heads when businesses (WAl-Mart- via sub-contractors) , some of our favorit upscale resturants , and upper-middle class families hire them–often paying less than they would have to pay an American worker, almost always without paying social security benefits.

    Both businesses and families profit from their labor.

    When these immigrant wokers grow old, we as a civilized society, have a moral responsibilty to make sure that they rceive health care. (This is what virtually all developed countires do. )

    Undocumented immigrants should be eligible for Medicaid and include in the ACA” ‘xchanges where they should be eliglble for subisidies, based on income. (If their employers had paid into SS they would actually have income)

    How to do we pay for this? First, stiff fines for buisnesses that hire undocumented workers and underpay them. Secondly, fines for famlilies who don’t contribute to their Social Security.

    Would this mean that these new immigrants wouldn’t be able to find jobs?

    I doubt it. In my experience,many are excellent workers. And they are willing to do jobs that young American just won’t do.

    These folks deserve to receive health benefits

    Will Congress ever include them in Medicaid and in the ACA?

    The demographics of this country are rapidly chaning.

    Latinos , African Americans, Asians, and new Immigrarnts elected Barack Obama—Twice
    n each case, he failed to win a majority among non-hispanic whites.,

    Indivuals in these groups are now much, much more likley to come out and vote– they have learned that their vote counts.

    I’m hopeful that, going forward, these “undocumented workers”–who have given so much to the country — will be included in our “ursal health care system.”


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About the Author:

Brad Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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