Part 5 (1/2)
Immigration and Health As mentioned earlier, one of the most p.r.o.nounced changes in immigration is its unintended affects on global health care. While we'll explore the risks of cross-border pandemics in the next chapter, immigration linked to demographic trends and globalization are reshaping the nature of medicine in both industrialized and developing countries.
With increased health spending, medical workers are becoming globally mobile. Doctors and nurses from nearly every emerging market-Africa, Southeast Asia, Eastern Europe, Central and Latin America-are being recruited to work in countries with aging populations. For example, in 2005, one third of practicing doctors in the United Kingdom were from overseas.75 The reasons for the health sector migration, according to the WHO, vary. On one hand, troubles in home countries encourage highly skilled workers to leave and take care of Europe's aging populations. A lack of promotion prospects, poor management, unmanageable workloads, inadequate living conditions, and high levels of violence and crime are some of the reasons a health care professional chooses to leave. These motivations are compounded by the opportunities available in other countries. Immigrating doctors and nurses can find better remuneration, upgrade their qualifications, work in a safer environment, and provide a better environment for their own families. The reasons for the health sector migration, according to the WHO, vary. On one hand, troubles in home countries encourage highly skilled workers to leave and take care of Europe's aging populations. A lack of promotion prospects, poor management, unmanageable workloads, inadequate living conditions, and high levels of violence and crime are some of the reasons a health care professional chooses to leave. These motivations are compounded by the opportunities available in other countries. Immigrating doctors and nurses can find better remuneration, upgrade their qualifications, work in a safer environment, and provide a better environment for their own families.76 While the immigration of health care professionals benefits the countries to which they move (as well as their own livelihoods), their emigration is often detrimental to the regions they leave behind. With 11 percent of the world's population and 24 percent of the global burden of disease, Africa is home to only 3 percent of the world's health workers.77 According to the WHO, approximately 25 percent of doctors and 5 percent of the nurses trained in Africa are working in wealthy OECD countries. This has startling implications for those African countries losing health care workers. As health care professionals head to other countries, South Africa surfaces as the only country in the sub-Saharan region that will meet WHO guidelines for the number of health care professional per sector of the population. According to the WHO, approximately 25 percent of doctors and 5 percent of the nurses trained in Africa are working in wealthy OECD countries. This has startling implications for those African countries losing health care workers. As health care professionals head to other countries, South Africa surfaces as the only country in the sub-Saharan region that will meet WHO guidelines for the number of health care professional per sector of the population.78 As the global economy accelerates, health care, too, is being pulled quickly into a market-based system.While doctors and nurses can move across borders these days to satisfy cross-border demand, so can patients. Medical tourism-where patients go abroad for better or cheaper treatments and surgeries-is becoming common. But increasingly, older Americans are simply moving for good. New innovative medical technologies and treatments allow aging Americans to live healthier and more productive lives, but at a cost: U.S. Federal Reserve Chairman Ben Bernanke recently noted, ”per capita health care spending in the United States has increased at a faster rate than per capita income for a number of decades,” with Americans now spending more on health care than for housing or food. Government estimates show that by 2020, health spending will exceed 22 percent of the nation's gross domestic output, largely as Americans age. 79 79 Indeed, growing old in the United States is becoming more expensive. Average monthly costs living in a U.S. nursing home is now more than $5,000, according to MetLife. Indeed, growing old in the United States is becoming more expensive. Average monthly costs living in a U.S. nursing home is now more than $5,000, according to MetLife.80 For many, this sum of money puts an a.s.sisted living facility out of reach. As a result, many American retirees have found a solution: go global, with a growing number moving south of the border to various destinations in Latin America. For many, this sum of money puts an a.s.sisted living facility out of reach. As a result, many American retirees have found a solution: go global, with a growing number moving south of the border to various destinations in Latin America.
In Mexico, for example, a patient can receive a studio apartment, three meals a day, laundry and cleaning service, and 24-hour care from English-speaking staff for only $1,300 a month-a quarter of what an average nursing home costs in some parts of the United States.81 While many U.S. insurance companies and government providers such as Veterans Affairs, Medicare, and Medicaid will not cover foreign medical bills, some overseas governments will even cover foreigners living in their country. For example, the Mexican Social Security Inst.i.tute (IMSS) allows foreigners to benefit from their services. An American with diabetes living in Mexico, who needs regular amounts of insulin and other medications, can pay $140 a year and have all of his medical bills covered. While many U.S. insurance companies and government providers such as Veterans Affairs, Medicare, and Medicaid will not cover foreign medical bills, some overseas governments will even cover foreigners living in their country. For example, the Mexican Social Security Inst.i.tute (IMSS) allows foreigners to benefit from their services. An American with diabetes living in Mexico, who needs regular amounts of insulin and other medications, can pay $140 a year and have all of his medical bills covered.82 Interestingly, the U.S. Emba.s.sy in Mexico has no reports of Americans filing complaints against Mexican nursing homes. Interestingly, the U.S. Emba.s.sy in Mexico has no reports of Americans filing complaints against Mexican nursing homes.83 Furthermore, as the industry expands, the Mexican government has begun projects with U.S. university hospitals and health care companies to begin standardizing the care available for Americans living in retirement homes. Furthermore, as the industry expands, the Mexican government has begun projects with U.S. university hospitals and health care companies to begin standardizing the care available for Americans living in retirement homes.
It's not only the price of the services that make living in places like Mexico or Panama comfortable for Americans. Many U.S. retirees live alongside other expats in enclaves such as Lake Chapala, an American-style retirement community about 50 minutes from Guadalajara and 600 miles from Texas (voted second best climate worldwide by National Geographic!). The communities here are being designed with cushy resort amenities such as restaurants, satellite television, and newspapers, libraries, social clubs and even movie theaters-all in English. There are dozens of restaurants, and the community has more than 50 English-speaking social organizations.84 In contrast to the United States' restrictive visa regulations, which have only become stiffer since 9/11, foreign governments have adopted legislation to facilitate this kind of immigration.85 These foreign government incentives are not philanthropic gestures toward ex-pats, but rather shrewd commercial ac.u.men; they are luring a potent form of foreign direct investment. U.S. (and European) retirees-like multinational corporations-are good for local business. These foreign government incentives are not philanthropic gestures toward ex-pats, but rather shrewd commercial ac.u.men; they are luring a potent form of foreign direct investment. U.S. (and European) retirees-like multinational corporations-are good for local business.86 They create demand for services (such as construction of medical facilities and homes and ongoing medical treatment) and for day-to-day household items. According to a survey of U.S. retirees living in Mexico and Panama, retirees spend considerable amounts of money in their newly adopted homes and on local spending-often more than $250,000 in the first 18 months of such a move. They create demand for services (such as construction of medical facilities and homes and ongoing medical treatment) and for day-to-day household items. According to a survey of U.S. retirees living in Mexico and Panama, retirees spend considerable amounts of money in their newly adopted homes and on local spending-often more than $250,000 in the first 18 months of such a move.87 This is happening elsewhere in the world, where foreign governments have been making the most of the fact that American retirees are good for their countries. American baby boomer retirees who can no longer afford to live in Florida or Arizona on a pension have figured out they can enjoy a higher standard of living elsewhere.
Toward an Immigration Policy To address immigration challenges earnestly, the United States must accept global labor compet.i.tion and integration.The United States, like other wealthy countries, is undergoing a ma.s.sive demographic s.h.i.+ft. Its citizens are better educated and less fertile than ever before, yet the need for low or unskilled workers only continues to grow and there are plenty of countries willing to supply the talent. Moreover, the flow of workers is not within U.S. policymakers' powers to stop; as long as there are jobs, workers will come, whether or not the law condones migration. However, with some foresight-and acknowledgment of the useful tool immigration can be-a combination of looser restrictions on educational visas, amnesty for workers who are already in the United States illegally, and guest worker measures may help achieve the balance of skilled and unskilled workers the country so direly needs to fix the ailing immigration system.
The United States is not the only country facing immigration challenges:There are more people migrating to Asia, Latin America, and Europe than ever before. As a result, one can argue that international organizations, destination countries, and origin countries all need to work together to create a comprehensive, functioning pro-immigration environment. The line between destination and source country is beginning to blur, as previous net sending countries are becoming net destinations. Still, sending countries have understandably different interests from destination countries. Destination countries are concerned about attracting the right kind of labor, protecting domestic jobs, and integrating immigrants. Source countries are focused on losing skilled workers, dependence on remittances, and the role that diaspora communities play in domestic politics. These interests would be best coordinated through a multilateral forum versus the haphazard approach of the past.
Today, the UN High Committee on Refugees (UNHCR) and the International Organization for Migration (IOM) are the two major intergovernmental bodies that work with immigration policy. The UNHCR focuses of refugees-a decreasing percentage of immigrants. The IOM, founded in 1951 to deal with displaced WWII refugees, tackles the whole spectrum of immigration policy and has 121 members. Ninety-five percent of the IOM's funding comes through voluntary contributions for projects, leaving the organization spa.r.s.e funds to do more than advise on policy; it doesn't have the teeth to enforce immigration policies. To create a more effective multilateral forum, the IOM could be folded into the UN system, therefore gaining access to a wider members.h.i.+p and steadier funding. In addition to keeping better tabs on migration trends, this newly reincarnated UN IOM could be charged with developing a global registry of immigration and coordinating efforts between Interpol and individual countries to identify international criminals and terrorists who are trying to cross borders illegally. It could additionally work on measures to rapidly identify medical outbreaks like avian flu. More important, the UN IOM should create international guidelines and develop best practices in immigration policy for host countries to ensure that quality standards for the working conditions of migrant populations are met. It could also work to garner better financial support for refugees who are forced to immigrate during times of civil wars and natural disasters.
Facing the ticking demographic time bomb, efforts to block immigration may mean a slow, yet certain, economic strangulation. The United States and other rich nations will continually need professors, doctors and nurses, apple pickers and nannies; the countries risk depopulation and economic stagnation if they do not learn to better embrace immigrant communities. Places like the United States that are primarily destination countries need to focus on creating realistic realistic policies and immigration reform. Not addressing illegal immigration or simply building a wall between countries (like the unfortunate one being built between the United States and Mexico) does not insure that immigrants are going to disappear. Destination countries should view the potential of this labor as added productivity, a tool to be used in the economy by government like monetary or fiscal policy with important links to Social Security and other retirement systems. Hopefully, such a mind-set would help lessen the xenophobic stigma attached to immigrants. After all, in the United States, virtually every citizen descended from an immigrant within the last three to four generations.The United States has always been a magnet for the world's best and brightest, but there is compet.i.tion in the Macro Quantum world. In the next generation it is likely that some emerging market economies will become choice destination countries for immigrants. Mexico already receives large numbers of immigrants from Central America. Don't be surprised to find that Americans may even begin to leave for better opportunities abroad in the not-so-distant future. policies and immigration reform. Not addressing illegal immigration or simply building a wall between countries (like the unfortunate one being built between the United States and Mexico) does not insure that immigrants are going to disappear. Destination countries should view the potential of this labor as added productivity, a tool to be used in the economy by government like monetary or fiscal policy with important links to Social Security and other retirement systems. Hopefully, such a mind-set would help lessen the xenophobic stigma attached to immigrants. After all, in the United States, virtually every citizen descended from an immigrant within the last three to four generations.The United States has always been a magnet for the world's best and brightest, but there is compet.i.tion in the Macro Quantum world. In the next generation it is likely that some emerging market economies will become choice destination countries for immigrants. Mexico already receives large numbers of immigrants from Central America. Don't be surprised to find that Americans may even begin to leave for better opportunities abroad in the not-so-distant future.
Finally, there is great need for origin countries to control exit out of their own borders. Historically, the United States has served as an employment outlet for Mexican labor. This reliance was risky, because the outlet valve could be abruptly curtailed by more effective border control. While a freer flow of people across borders needs to be cultivated, there should be a structured, organized system, not a hodgepodge of country-specific policies. Moreover, origin countries should no longer free ride by relying upon wealthier destination countries to do all of the policing. After all, the line between origin and destination is increasingly blurred. Many of the states sending extra workers abroad are also playing host to inflows of workers from elsewhere. Because their interests are no longer so distinct, sending and receiving countries, working through a multilateral UN IOM, could coordinate domestic policies to maintain, and hopefully accelerate, the capitalist peace in the twenty-first century.
Good Fences Make Good Neighbors?Ninety-six miles of wall through the heart of Berlin became an emblem of the Cold War struggle between good and evil, between freedom and oppression, between democracy and communism. Today, a wall intended to cover the 2,000-mile border between the United States and Mexico is currently under construction. It will cost an estimated $49 billion to build and maintain for 25 years.o Is there some sort of ideological message that the U.S. government is trying to send with building the fence? Is Mexico our enemy? Is there some sort of ideological message that the U.S. government is trying to send with building the fence? Is Mexico our enemy?There are millions of illegal immigrants who enter into the United States by crossing the U.S.-Mexico border each year. The U.S. government traditionally places a lot of the blame on the Mexican government for not keeping its citizens within its own borders. Nonetheless, this is only one side of a very complicated problem.When President Bush met with newly elected Mexican President Felipe Calderon in 2007, Bush repeatedly expressed the necessity for Mexico to do something to stem the tide of illegal immigration. Calderon made a commitment to do so, but under one condition: that President Bush better control the illegal arms entering Mexico from the United States. Ninety-five percent of illegal weapons in Mexico come from America.p Today, drug cartels are often better armed than the police and the military. In 2007, more than 2,500 Mexican citizens were killed in the cross fire with these smuggled weapons. Today, drug cartels are often better armed than the police and the military. In 2007, more than 2,500 Mexican citizens were killed in the cross fire with these smuggled weapons.A second argument used to bolster support for the border fence centers upon national security in the wake of 9/11. In discussions about the fence, for example, Republican Congressman Duncan Hunter, a member of the House Armed Services Committee, said, ”If you look at the list of people who have crossed that piece of the border in the last several years, there are a ton of people that come from terrorist nations and from states that back terrorism.”q But Mexico isn't one of them. The construction of the border fence is an example of Micro Domestic policy made by the U.S. government that is causing unfettered resentment from our southern neighbor, and rightfully so. It has become wrapped in a mixture of ideological terms that run the gamut from illegal immigration to the global war on terrorism. This focus on the flow from south to north, however, is misplaced. If the U.S. really wanted to get political support from Mexico to patrol its border, it would enact tougher gun laws (much to the chagrin of the National Rifle a.s.sociation and arms producers!) and enforce them better. But Mexico isn't one of them. The construction of the border fence is an example of Micro Domestic policy made by the U.S. government that is causing unfettered resentment from our southern neighbor, and rightfully so. It has become wrapped in a mixture of ideological terms that run the gamut from illegal immigration to the global war on terrorism. This focus on the flow from south to north, however, is misplaced. If the U.S. really wanted to get political support from Mexico to patrol its border, it would enact tougher gun laws (much to the chagrin of the National Rifle a.s.sociation and arms producers!) and enforce them better.The fence has likely exacerbated crime and had a large human cost as well. because the fence surrounds strategic U.S. cities, immigrants are forced to cross in rural and inhospitable stretches of desert instead. This has increased the cost-as well as the profits-or human smugglers, but it has also resulted in a larger number of deaths: Between 1996 and 2000, border crossing deaths increased fourfold.rFurthermore, the United States desperately needs the immigrants from Mexico and other countries to maintain a dynamic economy. Strangely, there may be more unintended Freakonomic Freakonomic consequences of such fence building. Did anyone ever think that to build the fence we'd employ illegal, undoc.u.mented immigrants? We've already mentioned that Hispanic construction workers in the United States have drastically increased over the past 15 years. According to the Bureau of Labor and Statistics, foreign-born workers comprise 20 percent of the U.S. construction workforce. consequences of such fence building. Did anyone ever think that to build the fence we'd employ illegal, undoc.u.mented immigrants? We've already mentioned that Hispanic construction workers in the United States have drastically increased over the past 15 years. According to the Bureau of Labor and Statistics, foreign-born workers comprise 20 percent of the U.S. construction workforce.s If 20 percent is the official number, then one can estimate that the actual percentage of undoc.u.mented workers in construction is much higher. So even if the myriad of lawsuits and legislative debate about the fence are completed, the very people that anti-immigration Americans hope to keep out of the United States with the fence may ironically be a large part of its construction. If 20 percent is the official number, then one can estimate that the actual percentage of undoc.u.mented workers in construction is much higher. So even if the myriad of lawsuits and legislative debate about the fence are completed, the very people that anti-immigration Americans hope to keep out of the United States with the fence may ironically be a large part of its construction.
Chapter 6.
Promoting Tomorrow's Health instead of Paying for Yesterday's Ills So many people spend their health gaining wealth, and then have to spend their wealth to regain their health.
-A. J. REB MATERI
Amid today's globalization, goods are moving, people are moving, and their diseases are going with them-as microbes tucked delicately into the corners of their suitcases, as trans.m.u.ted superbugs gone airborne and recycled in airplane ventilation systems, as the threat of anthrax sachets sent via mail, or even as the lead fumes of the Chinese-made toys wrapped for the holiday season. While these cross-border epidemics and bioterrorist threats have dominated the headlines lately, the Macro Quantum concept of health must extend far beyond germs, terrorists, and tainted goods. Health is a vital component of a nation's comparative advantage, and failing to treat it as such significantly handicaps the domestic labor force and impedes businesses from functioning.
Consider that the most probable killer today is mundane chronic illness-largely preventable ailments linked to smoking, inactivity, and obesity, such as heart disease, stroke, cancer, and type II diabetes. As globalization and prosperity have spread, so have sedentary, overconsumptive habits and the maladies that accompany them. Globally, chronic diseases are expected to increase 17 percent between 2005 and 2015.1 While some of this increase is the inevitable product of aging populations, many of these afflictions could be nipped in the bud through cheap and easy preventative behaviors: regular health checks, exercise, proper nutrition, and avoiding cigarettes. While some of this increase is the inevitable product of aging populations, many of these afflictions could be nipped in the bud through cheap and easy preventative behaviors: regular health checks, exercise, proper nutrition, and avoiding cigarettes.
By ignoring easy preventative fixes, not only must we later spend multiples of the cost of prevention on remediation, but we're actually depleting the most valuable resource-human capital. Reliance on remediation results in shortened life spans and less productive people. Chronic conditions cause major limitations in activity for more than one of every 10 Americans, or more than 25 million people, according to the Centers for Disease Control and Prevention (CDC).2 In addition to individual suffering, businesses saddled with huge health and pension costs also are penalized-especially in the United States where employers, not the government, foot most of the bills for employee healthcare. (See In addition to individual suffering, businesses saddled with huge health and pension costs also are penalized-especially in the United States where employers, not the government, foot most of the bills for employee healthcare. (See Table 6.1 Table 6.1.) To ensure a level global playing field for U.S. companies, we must radically s.h.i.+ft how we think about health and health care. Remember our earlier discussion about GDP as a product of population and per capita output. Chronic illness affects both variables: population (better health makes for longer life spans and lower infant mortality) and per capita output (not only is a healthy worker much more effective than an unhealthy one, but a company unburdened by high costs of overspending on employee health care and sick days is also more efficient). (See Figure 6.1 Figure 6.1.) As President Theodore Roosevelt once said, ”No nation can be strong if it is comprised of citizens who are impoverished and sick.” It is only by combining good policies with lifestyle changes that health can be converted from a drag on the U.S. economy into its biggest a.s.set: healthy, productive people.
Table 6.1 Life Expectancy by Country (Average for the 2005-2010 Period) Life Expectancy by Country (Average for the 2005-2010 Period) SOURCE: UN 2006.
Americans are in worse shape than most believe. It should come as no surprise that as the world's richest country the United States leads the way in terms of lifestyle diseases. Chronic illnesses account for roughly 70 percent of health costs and deaths in the United States,3 well above the 60 percent global average. well above the 60 percent global average.4 The nation has witnessed a quadrupling in the rate of childhood obesity and a doubling in the asthma rate over the past 30 years. The nation has witnessed a quadrupling in the rate of childhood obesity and a doubling in the asthma rate over the past 30 years.5 But what may come as a surprise is that the United States spends more than any other country on health care-a whopping $2.3 trillion in 2007, or $7,600 per person-yet the country still ranked only 38 out of 195 in terms of life expectancy. But what may come as a surprise is that the United States spends more than any other country on health care-a whopping $2.3 trillion in 2007, or $7,600 per person-yet the country still ranked only 38 out of 195 in terms of life expectancy.6 Figure 6.1 Increase in Value of Labor if Global Chronic Illness Is Reduced by 2 Percent Annually until 2015 Increase in Value of Labor if Global Chronic Illness Is Reduced by 2 Percent Annually until 2015 SOURCE:WHO.
While most industrialized countries provide their citizens with at least a basic standard of care-often called ”socialized medicine”-most Americans and their employers are largely responsible for their own health care costs.Yet the U.S. government's annual outlays of $600 billion tops what most foreign universal systems spend on socialized medicine.7 One study comparing Australia, Canada, New Zealand, the United Kingdom, and the United States found that the United States performed poorest in 16 out of 30 measures of care, and ”stands out for income-based disparities in patient experiences-particularly for more negative primary care experiences for adults with below-average incomes.” One study comparing Australia, Canada, New Zealand, the United Kingdom, and the United States found that the United States performed poorest in 16 out of 30 measures of care, and ”stands out for income-based disparities in patient experiences-particularly for more negative primary care experiences for adults with below-average incomes.”8 This underscores our major quandary: We're spending more on health care than any other country, yet by many measures, we aren't getting the care we need. Indeed, as the ultimate expression of the U.S. system's dysfunction, we have seen a growing number of dissatisfied Americans go abroad for health care. (See This underscores our major quandary: We're spending more on health care than any other country, yet by many measures, we aren't getting the care we need. Indeed, as the ultimate expression of the U.S. system's dysfunction, we have seen a growing number of dissatisfied Americans go abroad for health care. (See Figure 6.2 Figure 6.2.) While lifestyle choices are ultimately the responsibility of individuals, the public sector is culpable for failing to spread awareness on health issues, allowing health care costs to rise beyond the reach of many Americans, and incentivizing curative-as opposed to preventative-medicine. National health care systems everywhere vary in the degree of central control, regulation, and cost sharing they impose, as well as in the role of private insurance, but the U.S. health care system is uniquely convoluted and bloated by any standard.9 Its complex incentive structure leads to overconsumption of medical services for some and being priced out of the system for others, as well as misunderstandings between doctors, insurance companies, and patients. And as far as preventative care goes, consider that for fiscal year 2009 the U.S. Centers for Disease Control (CDC) requested $932 million for ”health promotion,” including chronic disease prevention as well as genomic and birth defect research-a decrease of $30 million from the previous year. Its complex incentive structure leads to overconsumption of medical services for some and being priced out of the system for others, as well as misunderstandings between doctors, insurance companies, and patients. And as far as preventative care goes, consider that for fiscal year 2009 the U.S. Centers for Disease Control (CDC) requested $932 million for ”health promotion,” including chronic disease prevention as well as genomic and birth defect research-a decrease of $30 million from the previous year.10 This is only about two-thirds the amount requested for health-related terrorism spending ($1.419 million) and half the amount requested for infectious diseases ($1.870 million). This is only about two-thirds the amount requested for health-related terrorism spending ($1.419 million) and half the amount requested for infectious diseases ($1.870 million).11 Addressing the United States' skewed pricing structure and the poor delivery system could reduce U.S. companies' burden, freeing them from the huge disadvantage they have compared to companies from countries with socialized systems of medicine. Addressing the United States' skewed pricing structure and the poor delivery system could reduce U.S. companies' burden, freeing them from the huge disadvantage they have compared to companies from countries with socialized systems of medicine.
Figure 6.2 Per Capita Health Care Spending and Average Life Expectancy Per Capita Health Care Spending and Average Life Expectancy SOURCE: UC Atlas, University of California Santa Clara. ucatlas.ucsc.edu/health/spend/cost_longlife75.gif.