Crozet Annals of Medicine: Mother of Exiles

I have been watching the immigration debate in Congress with a great deal of interest. I work in the ER of a charity hospital and so I see a lot of immigrants, both documented and undocumented. Many of my patients are refugees from terrible places. We are often the only place they can go for care. It is one of the great professional satisfactions of my life that I get to train young physicians to care for this vulnerable population and watch them bring the natural dignity and empathy of youth to the bedside of these supplicants.

At the same time I see a lot of Medicare and Medicaid patients because, let’s face it, the elderly and the impoverished are high frequency consumers of health care, i.e. they are sicker than the younger, employed population.

These two patient groups, the immigrants and the Medicare/Medicaid recipients are tightly linked in an important way that should greatly inform the immigration policies of the U.S.

The U.S. has two emerging demographic problems. First, our population is living longer. As the baby boomers enter old age, the number of Americans ages 65 and older is projected to more than double from 46 million today to over 98 million by 2060, and the 65-and-older age group’s share of the total population will rise to nearly 24 percent from 15 percent.

In fact, the fastest growing segment of our population is those 90 years old and over. At the extreme end, the number of Americans living to 100 years old or older has increased 44 percent in recent years, from 50,281 centenarians in 2000 to 72,197 in 2014.

The second problem is that far fewer babies are being born. U.S. females are becoming less fertile, as women in all societies do as they get wealthier. Put these two factors together, more older Americans and fewer young Americans, and you have a demographic time bomb.

The reason this is a problem is what’s known as the dependancy ratio. The dependancy ratio is the proportion of the population in the retirement age versus the proportion of the population in the working age range. The World Bank sets this internationally as the age >65 vs the 15-64 age range to standardize comparisons across countries. The graph below shows the problem. In 2011 the dependancy ratio in the U.S. was roughly 80 workers supporting 20 non-workers. By 2030 just 55 workers will be supporting 35 non-workers and by 2050 the trend will have worsened slightly. To put it simply, there are ever more people in the cart and fewer people pulling the cart.

The support I am talking about that the workers give the non -workers is primarily dollars for Medicare, Medicaid and Social Security. The dependency ratio is the key reason why these programs are going bankrupt so soon. Not enough workers are paying in to these programs and more people are taking dollars out of them.

And yet the U.S. is actually much less negatively affected than the other westernized democracies. Take Japan as an extreme example. Japan has the same problem we do but much more intensely. They live a very long time (the longest lifespan in the world by far) and their birthrate is vanishingly small. On top of that, due to strong societal preferences, Japan has had close to zero immigration. By 2050, over 70 percent of the Japanese population will be supported by the less than 30 percent of the population in the 15-64 age range. This is known as population senesence and it is not sustainable for long.

All of this hinges on fertility rates. In order have at least a steady state, with no population loss over time, each woman must have on average 2.1 children (the 0.1 is to offset infant mortality). Currently the U.S. fertility rate stands at 1.82 children per woman. Still not great but compared to Japan at 1.4 kids per mom or South Korea at 1.1 kids per mom, our nation skews younger and our dependency ratio is more sustainable as we continue to feed young people into the workforce.

So the key questions are why is the U.S. doing so much better than all of these other rich countries that look like us, and how can we do even better? The answer is to the first question is immigration and the answer to the second question is more immigration.

Lets look at the facts as gathered by the Pew Research Center.

The increase in U.S. births since 1970 has been driven entirely by births to immigrant mothers. In 1970 the annual number of U.S. births stood at 3.74 million. By 2014, the number had risen 7 percent to 4 million. During that same time, the annual number of births to immigrant women tripled, from 274,000 to 901,000. Meanwhile, births to U.S.-born women declined from 3.46 million to 3.10 million. In other words, were it not for the increase in births to immigrant women, the annual number of U.S. births would have declined since 1970.

Immigrant women have higher fertility rates than U.S.-born women. In 2014, there were 58.3 births per 1,000 U.S.-born women ages 15 to 44; by contrast, there were 84.2 births per 1,000 foreign born women in this age group.

U.S. births outside of marriage have declined since 2008, primarily among immigrant women. Over the long term, non-marital births had been on the rise in the U.S. In 2014, 40 percent of all U.S. births were to unmarried women, up from 21percent of births in 1984. Among foreign-born women, the share of births that occurred outside of marriage hit a high of 37 percent in 2008 and has since fallen steadily. Among U.S.-born women, the share of babies born outside of marriage has held steady over that same period. While foreign-born women have always been less likely to have babies outside of marriage than U.S.-born women, the roughly 10-percentage-point gap in this measure in 2014 (42 percent vs. 33 percent) is the widest since data became available in 1984.

The immigration debate is nuanced and multi-faceted, but one thing is clear. The long-term financial health of Medicare, Medicaid and Social Security for all of us citizens lies in the robust welcoming of immigrants that has always been one of this country’s founding ideals.

The New Colossus

Not like the brazen giant of Greek fame,
With conquering limbs astride from l and to land;
Here at our sea-washed, sunset gates shall stand
A mighty woman with a torch, whose flame
Is the imprisoned lightning, and her name
Mother of Exiles. From her beacon-hand
Glows world-wide welcome; her mild eyes command
The air-bridged harbor that twin cities frame.
“Keep ancient lands, your storied pomp!” cries she
With silent lips. “Give me your tired, your poor,
Your huddled masses yearning to breathe free,
The wretched refuse of your teeming shore.
Send these, the homeless, tempest-tost to me,
I lift my lamp beside the golden door!” 

  -Emma Lazarus

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