Fair Questions - Paradoxical Replies, Right Answers

For more another excellent collection of questions and answers visit the Physicians for a National Health Program (PNHP ) website.

1. Why should legitimate tax payers buy health care for those who don’t contribute?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Why should we pay for parasites to live off our tax money, the welfare queens and couch potatoes… Shouldn’t they take personal responsibility for their own health and well-being?

Answer: The question assumes that health care is a commodity to be bought and sold, rather than a right. In this country, we assume that everyone has the right to a basic education. We provide police and fire protection without demanding payment. Even legal protection is provided for everyone without asking their religion or citizenship papers. Is Health Care any less important to individuals and our society? The question also assumes that many would benefit who do not deserve. In fact, nearly everyone living in this country pays their share of taxes (except, perhaps, the very wealthy). The number of non-payers in the system is minuscule compared to the overwhelming vast majority of those who would benefit. Should we sacrifice the life-saving benefits for the many because of a barely discernible minority?

I would emphasize that paying for other people’s health care with single payer can reduce everyone’s costs, improve access, and preserve quality of care. We might say “Universal health care is not simply a goal in itself; it is absolutely required to reduce our health care costs.”

2. Wouldn't a payroll tax be unfair to small businesses?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Won’t a payroll tax be a job destroyer?

Answer: For most small (and larger) businesses already providing coverage, the payroll tax will mean substantial savings. However, the payroll tax would mean a cost increase for businesses that are not currently insuring their workers. But it is much less than they would pay for adequate coverage for themselves and their workers. The fairest, most equitable source of funding for health care is a tax on all sources of income including investments so that the burden of support is not just on employees.

We should not attempt to design a perfect health care system. We should focus on the crushing burden of health care all businesses and families face right now. Single payer health care would relieve most, but not all, of that burden. If pressed, we can state that single payer allows us to design any revenue collection we want, including one that protects small businesses. No business enjoys any protection right now.

3. Wouldn't Socialized Medicine destroy the “free enterprise System?”

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Isn’t the first step toward totalitarian socialism often through government-run healthcare?

Answer: The free enterprise system is alive and well in Switzerland, Germany, France, Japan and other nations providing Universal Health Care for its people. All modern countries, including our own, employ a mix of free enterprise and government institutions. Our national highway system, Medicare and postal service have not threatened free enterprise.

We should mention that single payer replaces the dysfunctional competition currently exhibited by private insurance companies but preserves competition among health care providers. We can state that competition among American health insurance companies does not increase access, reduce prices, or improve benefits. It produces the opposite:

Insurance companies compete by restricting policy sales to the healthy and wealthy. They take pains to avoid sick patients and populations that might include sick patients.

They shift costs to patients with deductibles, co-pays, excluded conditions, and restricted networks that avoid providers that provide care for expensive conditions.

They delay or deny costs to providers, making the cost of doing business in health care much more expensive. These expenses are, in turn, ultimately paid in higher premium costs and higher direct charges.

4. Wouldn't Universal Health Care result in excessive wait time for services?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): If we let all those other people into the system won’t we be crowded out of our doctors’ offices?

Answer: In all other national systems, waiting times for essential services are either comparable to ours, or, in most cases, much shorter. There is little or no difference in waiting time for treatment of emergency or life threatening conditions, It is true that in England and Canada, waiting times for elective or non-essential services might be longer than in the USA, but have improved dramatically in recent years. In the USA, for the non and under-insured, waiting time is a moot issue if you get no care at all.

America has the longest waiting times in the world – about 45,000 patients die of treatable conditions each year before they can accumulate enough money to get a physician to treat them. No other industrialized country allows patients to die because they can’t afford care. And regardless of what differences there may be in waiting times for elective procedures, all these other countries provide better care to more people for less money.

5. Why should we entrust health care to costly and inefficient government bureaucracies?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Everything the government touches turns to stool. What will happen if the government becomes responsible for our health?”

Answer: In fact, the current administrative costs in American private insurance companies are at least twice a high as any of the universal systems in the rest of the world. In Switzerland, for example, with cradle to grave coverage for all citizens, administrative costs are just over 8%. In the USA, private insurance administrative costs are over 19% with some estimates running as high as 30%. These high costs are passed on to the American consumer by higher premiums, co-pays and deductibles. Medicare, serving the most elderly and needy of the population has an administrative overhead of less than 3%.

Good answer. A condensed version might be: Whatever might be its performance in other areas, when it comes to reducing the administrative costs of providing health care, US government programs are five to 20 times more efficient than those of private health insurance companies. Government programs use 2% of health care dollars for administration; no private insurance company can match that; the average is 20% and can be as high as 35% for some companies in some markets.

6. Without the profit motive, who pays for medical research and development?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Won’t he American pharmaceutical companies go broke or stop developing useful drugs?

Answer: In fact, the pharmaceutical industry spends much more on marketing than on R&D. It should also be noted that funding for most R&D is in the form of government grants to research institutions. There is no evidence of decline in R&D in countries that have adopted universal health care.

Although the PNHP and Gerald Friedman proposals demand that drug prices be negotiated by a single payer entity, that is not an intrinsic part of single payer. We should retreat and say that single payer leaves profit-seeking competition among drug companies intact. If they want to sell drugs, they must set competitive prices – it’s the free market in action.

7. Why can’t the Emergency clinics take care of the uninsured?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Since you can’t be turned away from an emergency room, doesn’t everybody get health care?

Answer: In fact, Emergency clinics are for emergencies. Chronic or slowly developing conditions are not well cared for in emergency treatment. Also, waiting for a crisis rather than providing preventative care and early treatment results in increased suffering and fatalities, and much higher cost to the taxpayers and rate payers who support the clinics. In 2011, an estimated 47,000 individuals died from lack of ability to pay for treatable conditions. That is more avoidable deaths monthly than resulted from the infamous attack of 9/11, for which we have spent untold billions to prevent a recurrence.

Emergency rooms do not provide free care to anyone. Patients who come to the administration desk of a hospital must show they can pay or they are not treated. Patients who come to the ER are treated first, and then must pay. Health care, whether via hospital admission or in the ER, can be bankrupting with or without expensive insurance. And no ER provides any care unless the condition is emergent. If your condition is not life-threatening, you are turned away until it turns life-threatening.

8. Why should the majority of people who are employed and covered by health insurance be in favor of a universal system?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Why should anyone who has healthcare through their employer give that up for an unknown and theoretical government-run system?

Short Answer: In all but super expensive premium plans, Private insurance plans are woefully inadequate to serve family needs. Also, typical plans now have huge deductibles.

Long Answer: Most personal bankruptcies are triggered by medical crises in underinsured families. Loss of job means loss of coverage. Excessive co-pays and deductibles. Loss of insurance at retirement. Loss of family coverage at retirement. Little or no control over benefits, change in benefits, exclusions, fees, administrative costs, etc. No portability.

Most of the medical bankruptcies in the US were in families with health insurance. Many of the 45,000 who die each year because they can’t afford treatment for a treatable disease had insurance at the time the condition began. Additionally, a result of the ACA is that 3-5 million fewer Americans will get insurance through their employer. Single payer universal care means access is guaranteed to you and your family no matter what your employer decides, no matter who your employer is, whether you are self-employed, and no matter if you have any employer at all.

In every population which uses single payer, no matter how healthy or sick, single payer provides better care to more people for less money than private health insurance.

9. Who determines benefits and coverage in a universal system?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): You don’t want government bureaucrats and death panels determining what care you get.

Answer: Systems that are called “single payer” provide services that reflect what the people need and are willing to pay for through their taxes, not what the insurance companies want to earn through your premiums. There is the security of knowing that health care management is no longer determined by legislators or insurance executives, but by an appointed panel of patients and providers whose only goal is to provide the best care to the most people at the least cost.

Again, be careful about designing a perfect system. Start with, “Who determines your benefits now? It’s insurance administrators who are legally obligated to put the financial interests of the investors ahead of the patients’ interests. Many politicians are beholden to health insurance companies which fund their election/re-election campaigns rather than to you, their constituents.
With a single payer system, we have the option of having our benefits determined by a panel of patients, employers, and providers, all of whom must put our medical interest first. It’s not perfect, but it’s a heck of lot better than what you have now.”

“In countries where there is a single health care system--and thus a single pool of money to pay for it--it is somewhat easier to control costs. Britain's NHS often decides, for example, that it won't pay for kidney dialysis for a 90-year-old. That means somebody's grandmother will die, but at least Grandma and her relatives know that the money saved is going to be used to help some sick baby or some accident victim. Limits like that are harder to impose in the U.S. because the money saved here doesn't necessarily help another sick person. If Aetna or United Health declines to pay for somebody's dialysis, the money saved is likely used for dividends to the stockholders or bonuses for the executives. That's a little harder to swallow for the relatives of the sick patient.” T. R. Reid

10. Wouldn't a universal system limit my choice of physician or other providers?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): You don’t want a bureaucrat telling you what Dr. you can go to.

Answer: There is no reason to believe that a universal system will limit choice in any

Way. In fact, it will enhance individual control of options. Currently no American has freedom of choice of provider unless they pay entirely out of pocket. Every current health system restricts who their clients can choose.

Back to “Who determines your physicians right now? Your employer, if you have one, picks your insurance company; your insurance company picks your physicians; and you do what you’re told [that pithy phrase comes from Paul Gorman]. If you have no money, you don’t get to pick any physician at all. In a single payer system, you are free to pick any provider, and a provider can care for any patient...every patient's care will be covered for the same amount of payment.”

11. With no financial impediment, won’t there be a lot of “free loaders” abusing the system?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Why should we pay for parasites to live of our tax money, the welfare queens and couch potatoes… Shouldn’t they take personal responsibility for their own health and well-being?

Answer: The “moral hazard” concern is that patients with no financial impediment will seek and consume more health care. There will be increased utilization of services. In single payer systems in the US and around the world industrialized countries with universal care, patients see their physicians two to four times as frequently as we do. They spend more days in the hospital than we do. They are clearly consuming more care. Yet in these same systems, health care costs are half of ours and citizens are healthier than ours.

The conclusion is that encouraging patients to consume more primary and preventative care reduces costs and improves health.

12. How can a universal system possibly be affordable for the country?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): The country’s already going broke and you’re suggesting that we provide free healthcare for everyone?

Answer: Financing is a challenge, but not because we don’t have the money. We already spend more money than we need for universal comprehensive health care. The challenge is channeling the money we are already spending into taxes. Our current system of financing health care with employer-based private health insurance costs us $350 billion in unnecessary administrative costs that could otherwise be used to provide health care. It is responsible for 45,000 deaths due to treatable conditions that would not occur in other industrialized countries. That system devastates families. It erodes business. It demonizes labor-management relations. It inflates the costs of our goods to uncompetitive levels. It destroys the initiative of entrepreneurs who dare not risk a start up for fear of losing their family’s health care.

This apprehension is partially correct. If we insist on financing additional health care with additional private policies, there is no way we can provide more care to more people without spending more on insurance premiums and/or out of pocket payments. The experience with single payer systems everywhere is that by replacing our private insurance model with a single financing agency we recover enough in unnecessary administrative costs to pay for comprehensive care to everyone.

In every place it is used, and in every study of health care financing in the US, single payer provides better care to more people for less money than American private insurance companies.

13. What is meant by “Health Care is a Human Right?”

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): How can you call anything a right? What about food, water, housing?

Answer: The United States approved the United Nations Declaration of Human Rights in December 1948. In Article 25, access to medical care was included as a basic human right. Simply put, it means that if you are human, you have basic rights that are essential to well being. In this country we have included police protection, fire protection, education and universal suffrage as basic human rights. Access to health care is no less important.

There is no bullet-proof moral argument for human rights. People don’t change their morals when evidence contradicts them. They do, however, change what they advocate when it is in their financial interest.

14. How can we have Universal Health Care without raising taxes?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Our taxes are already unbearable and you’re suggesting we increase taxes?

Answer: Universal Health Care would be publicly funded, and those funds would come from a new tax program. However, the question should be: “What would be the cost of universal health care to the tax payer?” For the vast majority of taxpayers, individuals as well as businesses, the cost of universal health care would be considerably less than we are all paying now. A good single-payer plan based on Vermont's five principles of Health Care Is a Human Right would prevent the great cost of human suffering and death that we experience under our current health care system, and would provide considerable savings that would more than compensate for any new tax.

A single payer system would relabel what we already spend in premiums and out of pocket payments as “taxes.” The benefit of this relabeling is we receive better care to more people for less money, and that means an increase in discretionary income. Whether we pay for health care with taxes, premiums, or out of pocket, it’s all our money. When we reduce overall health care spending (even if a greater proportion is labeled “taxes”), we save money.

15. Wouldn't providers make much less money in a system of universal health care?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Physicians are already refusing to accept patients on Medicare and Medicaid because of low payment from government-run systems. And now we are asking them to take on more low pay patients?

Answer: Most physicians would gross less money, but the same net amount. Billing, claim documentation and other administrative costs would be nearly eliminated, and payment to physicians would be guaranteed. Fifty-one percent of the nation’s physicians are on record in favor of universal health care. In Saskatchewan, physician income increased by 35% in the first year following passage of their National Health Insurance Act (1963).

The best model we have for statewide health care is the Vermont plan: overall provider payments would not decrease compared to existing payments; comprehensive health care would be provided to everyone in the state, and health care spending be stable or decrease. Single payer does not try to save money by excluding sick people, or by reducing benefits, or by paying providers less like our current system does. Single payer says money by excluding private health insurance administrative costs.

16. Doesn't America have the best health care system in the world?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Don’t we have the best doctors, nurses, and hospitals in the world? We shouldn’t we be more patriotic about this?

Answer: Only if you don’t compare it with anything else. The US ranks 19 out of 19 nations in being able to prevent avoidable deaths from illness. Americans also live fewer years than people in other industrialized countries, and have higher infant mortality rates (more babies under the age of one die per year). According to the Institute of Medicine, 18,000 (babies) die each year from having a lack of health insurance. We have 45 million people without health insurance and the most expensive system on Earth.

It is true that the US probably has the best and most abundant medical technology, but it is over-utilized because it produces profit, and is largely unavailable to the under and non-insured.

The US health care system is number one in two respects: it is the largest single industry in the world – it is three times larger than entire oil industry of Saudi Arabia, for example. It is also the world’s most expensive health care system, substantially ahead of Norway and Switzerland who are competing for second place.

We are not number one in any substantial measure of public health. We rank at or near the bottom of the industrialized nations in maternal mortality, diabetic outcomes, and lives lost to treatable diseases. Our cancer care is not number one in the world except, curiously, for Americans over the age of 65. Maybe Medicare works.

“I don't think the systems used in other countries are inherently un-American. The British system-The Beveridge model--is the same system used by the U.S. Veterans Administration. If this is un-American, why do we use it for America's military heroes? And the Canadian system—the National Health Insurance model--is the model for Medicare. If it were un-American, would we use it for 36 million elderly Americans?” T. R. Reid

17. How would a universal health care system work?

Paradoxical reply: N/A

Answer: No one knows all of the features of an eventual plan, but we know what we want it to do, and we have many successful models to guide our process. No two systems are alike. Germany is different from France, is different from Canada, is different from Taiwan. They are the same in that they all provide health care to everyone in their country, and each was designed to suit their own situation. Ours will be crafted in collaboration with providers, legislators and concerned civic organizations. The proposed criteria are based on the principles of Universality, Transparency, Equity, Accountability, and Participation. The specifics will be unique to our country.

Single payer applies the principle of simplicity. Everyone is in one risk pool – human beings. Everyone receives the same benefits – treatable conditions are treated. Every provider is in network. Every provider encounter uses one set of paperwork. Every provider is paid from one agency.

The single payer agency, unlike private insurance companies, is accountable to people who use it – us. The workings and actions of the single payer agency are open to inspection by anyone. Taxpayers pay into the system, they run the system, they benefit from the system.

Details vary, but we are free to construct a single payer that answers our needs as patients and taxpayers, not the needs of shareholders and administrators.

18. Won’t most of the current problems be alleviated by Obama’s Affordable Health Care Act of 2011?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Shouldn’t we give Obamacare a chance? How can you tell this early that it won’t solve most of the healthcare problems?

Answer: ACA deals with many issues but does not resolve the central problem of finance. The over-arching issues of unacceptable administrative costs and the demand for profitability resulting in unsustainable inflation of cost remain.

The ACA does everything we are doing wrong (i.e., financing health care through private insurance companies who are not accountable to patients or taxpayers) and does it more intensely. The ACA provides many benefits to many people, but it does not provide better care to more people for less money than we are paying now.

Whether the ACA succeeds, fails, or remains a mystery, we need real health care reform.

19. A single-payer universal system may work in smaller countries with more uniform populations but how can it work in the United States with its much larger and diverse population?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Aren’t we too big and too diverse to succeed at universal health care?

Answer: Our population is indeed bigger than most countries which have a successful universal healthcare system. But Brazil has two thirds our population and does guarantee healthcare for all residents and protects its people from healthcare-induced bankruptcies. Compared to other countries with successful universal healthcare the US has an average level racial diversity but more tolerance for racial diversity.*

20. How can we ever match the power of the health industry and their lobbyists?

Paradoxical reply (“Let me rephrase what I think you’re asking,…”): Does David have a chance against this Goliath?

Answer: It is an issue of national security and self interest that we have a healthy population and unfettered access to health care. The Goliaths who benefitted from slavery, child labor, and suppressed voter and civil rights have been defeated by groups of determined and passionate Americans in the past.

* http://www.washingtonpost.com/blogs/worldviews/wp/2013/05/15/a-fascinating-map-of-the-worlds-most-and-least-racially-tolerant-countries/

21. Are you kidding me, provide Health care for undocumented immigrants?

Paradoxical reply: (“Let me rephrase what I think you’re asking,…”): I sense you can picture masses of Mexicans and Canadians crossing the border for free healthcare. We surely cannot afford the expense of providing more care at greater cost to a population of uninvited outsiders.

Above all, we must protect our already endangered health care system from the ruinous expense of caring for the undocumented as well.

Answer: Or so goes the argument. Is it true?

The answer is not trivial. The future of both immigration reform and our family’s access to health care rests on getting this right. This is where immigration reform efforts run aground. We run grave risks if we base immigration policy on intuition, no matter how appealing that intuition might be.

The argument against including the undocumented in our health care system rests on assumptions: (1) immigrants consume more health care dollars than native born Americans, (2) the cost of their health care exceeds what they pay in taxes; (3) providing free health care only encourages more illegal immigration (and further drains our public resources), and (4) excluding them will reduce health care costs for the rest of us.

None of these assumptions are correct.

Of the 25 million immigrants in the US (8% of the population), 12 million are undocumented. A 2005 study estimated these 25 million immigrants consume $39 billion annually in health care, (less than 2% of the $2.6 trillion spent by all Americans). The Pew Hispanic Center found 40% of the undocumented already own private insurance policies, and thus pay their own way.

The remaining seven million immigrants who are both undocumented and uninsured consume miniscule amounts of health care, about $4.3 billion annually. Per capita, they consume less than one tenth of what native born Americans spend. This is not statistical flim-flam: multiple studies corroborate that immigrants consume fewer health care dollars per person than native born Americans. No evidence refutes this.

Even so, does this small amount of health care exceed what undocumented immigrants pay in taxes? No. Immigrants subsidize the rest of us. A recent article in Health Affairs found that Medicare receives $16 billion more in taxes from undocumented immigrants than is spent on their care. The Social Security administration discovered immigrants generated $12 billion in payroll taxes for benefits they will never receive.

In sum, immigrants inject $30 billion in taxes each year without receiving any services in return.

Perhaps excluding immigrants might still reduce overall health care spending. Again, evidence says No.

The absolute amount of health care savings by excluding undocumented immigrants is small, less than 2% of total health spending.

But even this small savings disappears when we include enforcement costs of such a policy. The Government Accounting Office found efforts to exclude undocumented immigrants from Medicaid were expensive – very expensive: states on average spent $100 on administration to save 14 cents in health care.

Worse, these efforts to verify residency resulted in delay or denial of Medicaid to many US citizens unable to produce the required documentation.

States are not the only agencies that lose by excluding immigrants. Smaller communities also pay heavily when they restrict health care access. Studies from the University of Pennsylvania and the Commonwealth Fund showed that as an area’s uninsured population grows, access and quality of care for the insured go down. If a community wants to protect its health care, extending care to all residents (including the undocumented) appears the better choice.

Still, some argue that providing health care to undocumented immigrants encourages more illegal immigration. Unlikely. Immigrants come here for jobs, not health care. Undocumented Latinos, for example, primarily immigrated to states with employment opportunities; family and housing were secondary considerations. In contrast, data from the California Immigrant Policy Center shows readily accessible public health care played no role: instead, those states with the least generous public health care benefit programs showed the fastest rise in immigrant population.

Parenthetically, we should note that 40% of our undocumented immigrants entered the US legally and then overstayed their visas. Erecting physical barriers or withholding free services to prevent illegal entry to the US is of limited value in reducing the overall number of undocumented immigrants.

Regardless of economic arguments, some insist we should punish criminals (i.e., people who enter the US illegally) by denying them health care. This runs contrary to a legal principle: The only people in the US constitutionally entitled to medical care at public expense are those in prison. (Shockingly, we find stories of native born Americans committing crimes solely to get care they could not afford as free citizens but would receive as convicted felons.) Should undocumented immigrants who pay more in taxes than they receive in public benefits be excluded from health care while convicted felons who pay no taxes are included? It’s hard to find an economic justification for this conclusion.

Absent economic and legal reasons, is there a moral reason to deny health care to undocumented immigrants? Many citizens, despite financial reasons to the contrary, cannot tolerate their tax dollars serving undocumented immigrants.

Such an argument cannot be refuted. Moral disputes are about ideals, not facts. However, we must acknowledge the real costs of implementing this argument as public policy. Denying health care to undocumented immigrants costs us money, increases our taxes, and reduces our access to health care.

What is the best solution to immigration reform? No answers are easy, but let’s not make hard answers harder. Immigration reform is simpler, our health care more accessible, and our taxes lower when we extend health care to everyone, including undocumented immigrants.

Sam Metz August 2013

The late Senator Paul Wellstone expressed this well: “We all do better when we all do better.”

In addition to the above Q & A, suggestions to answer tough questions are available within our Speakers’ Portal.

Recommended Reading:

Berk ML et al, Health care use among undocumented Latino immigrants. Health Affairs 2000;19(4):51-64.

Camarota SA. Illegal Immigrants and HR 3200: Estimate of Potential Costs to Taxpayers. Center for Immigration Studies. September 2009. http://www.cis.org/IllegalsAndHealthCareHR3200

Goldman DP, et al. Immigrants And The Cost Of Medical Care. Health Affairs. 2006;25(6):1700-11 http://content.healthaffairs.org/content/25/6/1700.abstract

Government Accounting Office, 2007; quoted at http://thegavel.democraticleader.house.gov/?p=618

Ku L. Health Insurance Coverage and Medical Expenditures of Immigrants and Native-Born Citizens in the United States. Am J Public Health. 2009;99(7):1322–8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696660/

Mohanty SA, et al. Health care expenditures of immigrants in the United States: A nationally representative analysis. American Journal of Public Health, 2005;95(8):1431-8. http://ajph.aphapublications.org/cgi/reprint/95/8/1431

Passel J, Zimmerman W., Are immigrants leaving California? Urban Institute, Washington DC, 2001. http://www.immigrationpolicy.org/sites/default/files/docs/healthcare01-07.pdf

Pauly MV, Pagán JA. Spillovers And Vulnerability: The Case Of Community Uninsurance. Health Aff 2007;26:1304-1314. http://content.healthaffairs.org/content/26/5/1304

Radley DC, Schoen C. Geographic Variation in Access to Care -The Relationship with Quality. N Engl J Med 2012; 367:3-6 (July 5, 2012) http://www.nejm.org/doi/full/10.1056/NEJMp1204516?query=TOC

Schoen C, et al. US health system performance: A national scorecard. Health Affairs Web exclusive, November/December 2006; 25(6): w457-w475. http://content.healthaffairs.org/content/25/6/w457.full.pdf+html

Sommers, BD. Stuck between Health and Immigration Reform — Care for Undocumented Immigrants. N Engl J Med, July 24, 2013. DOI: 10.1056/NEJMp1306636. http://www.nejm.org/doi/full/10.1056/NEJMp1306636?query=TOC

Stimpson JP, et al. Trends In Health Care Spending For Immigrants In The United States. Health Affairs. 2010;29(3): 544-50. http://content.healthaffairs.org/content/29/3/544.abstract

Other references in this essay on health care for undocumented immigrants:

ANO (Autonomous Non-Profit Organisation). Old man robs bank to return to jail. RT.Com, February 14, 2013.

FindLaw.com. Rights of Inmates. (no date) http://civilrights.findlaw.com/other-constitutional-rights/rights-of-inmates.html

Friedman, TL. If Churchill Could See Us Now. New York Times, July 16, 2013. http://www.nytimes.com/2013/07/17/opinion/friedman-if-churchill-could-see-us-now.html

Goss S, et al. Effects of unauthorized immigration on the actuarial status of the Social Security Trust Funds. Office of the Chief Actuary, Social Security Administration. April 2013. http://www.socialsecurity.gov/OACT/NOTES/pdf_notes/note151.pdf

Herbeck, D. Ex-convict says he got himself arrested to get prison health care. The Buffalo News. December 8, 2012. http://www.buffalonews.com/apps/pbcs.dll/article?AID=/20121208/CITYANDREGION/121209222/1002

Keehan SP, et al., National Health Spending Projections Through 2020: Economic Recovery and Reform Drive Faster Spending Growth. Health Affairs. 2011;30(8).

Mezerich, J. On purposely getting arrested. The Atlantic Monthly, February 26, 2013. http://www.theatlantic.com/health/archive/2013/02/on-purposely-getting-arrested-to-get-life-saving-surgery/273282/.

Preston J. 11.2 Million Illegal Immigrants in U.S. in 2010, Report Says; No Change From ’09. New York Times. February 1, 2011. http://www.nytimes.com/2011/02/02/us/02immig.html

Zallman L, et al. Immigrants Contributed An Estimated $115.2 Billion More To The Medicare Trust Fund Than They Took Out In 2002 -09. Health Affairs, June 2013. Web First, May 29, 2013. http://content.healthaffairs.org/content/early/2013/05/20/hlthaff.2012.1223