Pretty much all I could think about during that interminable wait was what might be wrong with me, whether it was fatal, and how much longer I could survive before being seen. I did notice that I wasn’t the only person in visible distress and that from time to time someone who had arrived at the emergency room after me was summoned by a nurse. I remember telling my wife that they must be in even more dire straits than I was, and wondered vaguely what ailed them.
In the end, a CT scan showed that I was suffering from a kidney stone too large to pass through my system. But while I was waiting, I only knew that the pain was relentless and frightening.
Certainly it never crossed my mind to speculate on the immigration status of those other patients. I didn’t wonder how many were foreign-born, or whether they spoke English. And I assuredly never entertained the thought that if only more foreigners without green cards were rounded up and deported, my own wait for medical care would have been shorter.
But while I may not have entertained such thoughts, Vice President JD Vance appears to dwell on little else. At a White House press briefing last week, Vance declared that America’s emergency rooms are plagued with long waits because of undocumented foreigners:
“If you’re an American citizen, and you’ve been to a hospital in the last few years, you probably noticed that wait times are especially large and very often somebody who’s there in the emergency room waiting is an illegal alien — very often, a person who can’t even speak English,” the vice president fumed. “Why do those people get health care benefits at hospitals paid for by American citizens?”
He went on to suggest that Democrats are to blame for turning on “the money spigot” during the Biden administration to supply health care to people in the United States unlawfully.
Vance’s claim is both poisonous and false. His argument, such as it is, rests on two prongs: first, that ER delays are caused by unauthorized immigrants who crowd emergency rooms; and second, that Democrats are deliberately subsidizing their care with taxpayers’ money. This is not just the vice president’s idiosyncratic obsession. It has become a MAGA refrain. Stephen Miller, President Trump’s closest political strategist, has also promoted the idea that Americans are forced to endure long ER waits because Democrats lavish free medical care on undocumented migrants.
This is not a serious public policy analysis. It is crude scapegoating — a way to use public frustration with America’s strained health care system to whip up even more resentment against immigrants. And like so much of the Trumpian narrative on immigration, it is both factually baseless and morally contemptible.
Vance’s accusation may resonate with his party’s political base, but it collapses on contact with the facts. There are at least four reasons why his claim is wrong.
1. The law of the land has been clear since 1986. Emergency rooms treat all patients in crisis because Congress required them to do so nearly 40 years ago. In 1986, President Ronald Reagan — a staunch conservative who championed immigration — signed into law the Emergency Medical Treatment and Labor Act. That statute, known as EMTALA, obliges any hospital receiving Medicare funds to provide emergency care to anyone who shows up with a serious medical condition, regardless of their insurance status, ability to pay, or immigration status.
This was not a Democratic plot to “turn on the spigot” for immigrants. It was a bipartisan response to an ugly practice: hospitals “dumping” patients in crisis because they lacked coverage. EMTALA grew out of horror stories of car accident victims or heart attack patients being transferred mid-crisis because no hospital wanted to be stuck with an unpaid bill. Republicans and Democrats alike recognized that such behavior was unconscionable in a civilized nation. Decent societies don’t demand passports and green cards before allowing doctors to stop someone’s hemorrhaging or deliver a baby.
2. No “spigot of benefits” exists. The picture Vance paints of undocumented immigrants luxuriating in taxpayer-financed health care is simply false. Federal law bars foreigners without immigration visas from virtually all federal welfare or insurance programs. They cannot walk into a doctor’s office, flash an ID, and have Uncle Sam pick up the tab. They can’t acquire subsidized health insurance under the Affordable Care Act, or enroll in Medicare when they turn 65, or collect Social Security benefits when they retire.
The main exception to that ban is “Emergency Medicaid,” which reimburses hospitals for the costs of stabilizing patients in acute crisis who lack coverage. That may include immigrants in the country illegally but isn’t designed for them. Nor is it an entitlement program for patients. It’s a support program for hospitals and it is the institutions that receive the benefits.
3. The dollars involved are minimal. The sums spent by Washington to reimburse hospitals for providing emergency care to noncitizens — a category that includes many legal immigrants — are minuscule compared with other government health care spending. According to KFF, a health policy think tank, just 0.4 percent of Medicaid’s budget pays for emergency care for noncitizens. Of every $100 Medicaid spends, in other words, only 40 cents funds care for noncitizens in life-threatening emergencies.
That is hardly more than a rounding error in a system whose total expenditures exceed $850 billion annually. America’s emergency rooms are under pressure, but not because a trickle of funding is allocated to stabilize undocumented people in crisis. If every immigrant who crossed the border without authorization vanished tomorrow, the average wait time Americans experience in emergency rooms would barely budge. All the more so since noncitizen immigrants are significantly less likely to use emergency room services than naturalized immigrants and US-born residents.
4. Vance’s imagery is xenophobic sleight of hand. Patients in an ER waiting room don’t wear labels advertising their immigration or citizenship status. As I waited for my turn to be examined that night, I had no way of knowing which if any of my fellow patients were citizens, legal immigrants, or migrants who were in the country unlawfully. What Vance is really singling out when he tells audiences they’ve “probably noticed … someone who can’t speak English” is not immigration status at all. It is difference. His point is not to identify a genuine cause of hospital crowding; it is to breed resentment toward people who look or sound foreign.
Long ER waits are maddening and can be frightening. But the culprit isn’t the mother with halting English or the patient with a foreign appearance. To insinuate otherwise is shameful. All it does is further degrade our civic life without solving a single problem.
Emergency rooms are crowded, but not for the reasons Vance and Miller would like voters to believe. The causes of long waits have been studied and debated for years, and are well understood.
Hospitals struggling with staffing shortages have too few nurses and doctors to handle demand. Closures of facilities, especially in rural areas, leave whole communities with fewer options, concentrating patients in those that remain. State regulators are frequently unwilling to give permission for hospitals to expand facilities. Discharge bottlenecks keep patients stuck in hospitals because nursing homes, rehab centers, or psychiatric wards have no beds available. And since scores of millions of Americans don’t have a primary care doctor, they are more likely to end up in emergency rooms with conditions that could have been treated earlier and more effectively elsewhere. Each of these constraints converts clinical demand into idle time in waiting rooms.
The stress and irritation Americans feel when they wait in agony for emergency care are real, as I learned from experience. But blaming immigrants for that misery is contemptible. It is easy to stir up bile against strangers in the waiting room; it is a lot harder to grapple with the fact that our healthcare system is overburdened and understaffed, and that the more government tries to make things better, the worse they tend to become.
Societies are judged in part by how they respond to the vulnerable in their midst — to people in pain or sickness or fear. Even Americans who favor tougher immigration restrictions ought to be able to agree that the time to crack down on unlawful border crossers is not when they are in the throes of a medical emergency. Providing health care to a patient in extremis is not an immigration loophole, no matter how much the vice president insists otherwise.
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Jeff Jacoby can be reached at jeff.jacoby@globe.com. Follow him on X @jeff_jacoby.