Immigrants are crucial to U.S. Health System Resilience

Introduction

Health systems in the United States and across the world are increasingly challenged by a polycrisis of converging shocks and stresses, both climate- and non-climate related.¹ These shocks and stresses include (a) the COVID-19 pandemic, which continues to burden health agencies; (b) an uptick in disasters induced by a changing climate, adding to health needs and compromising health infrastructure; and (c) demographic shifts characterized by an aging population coupled with a steady decline in fertility that shape expenditures and labor availability.^2–5 It is difficult and relatively unproductive to attempt to disentangle the effects of climate change on these crises.⁶ Instead, these and other crises should be examined together; understood as placing incredible stress on an already stressed health system. In this context, as a recognized mechanism for managing health system risk, health system resilience, or the capacity of health systems to prepare for, respond to, recover from and transform in response to shocks and stresses,⁷ is critical for maintaining mental health and more general well-being.

We argue that, in contrast to the often-negative rhetoric surrounding immigrants and immigration,⁸ in the United States immigrants’ contributions are crucial to ensuring a resilient health system that is responsive to mental health needs amidst polycrisis. Far from being a drain on health systems and resources, immigrants are an asset: they contribute to the economy, to the labor force pool, and to responses to acute and chronic disasters. Yet, immigrants’ contributions have been traditionally overlooked as a health system strength.

To substantiate this argument, we illustrate how immigrants play a fundamental role in addressing three shocks and stresses impacting the US health systems: economic volatility, a changing workforce, and accelerating disaster threats. We conclude with a discussion of how, despite their contributions to American society, immigrants face challenges related to invisibility, stigma, and multiple obstacles workforce entry, which exacerbates challenges to U.S. public health preparedness.

Immigrants Contribute to the Economy in Ways that Alleviate Health System Fiscal Shocks

Two fiscal shocks are impacting US health systems: growing healthcare expenditures and large-scale reductions in the tax base attributable to population shifts. Baby Boomers are exiting the workforce, representing a significant decline in payroll taxes and an increase in health care expenditures. Americans are living longer than ever, and as a result, they spend greater amounts of time drawing Medicare health benefits, including more expensive benefits typically used at older ages. Given expenses associated with Medicare, this reduction in the workforce and increase in the retired population could translate to about a 30% increase in the health care costs for older adults.⁹

The US fertility rate has reached a record low, mirroring long-term reductions in the workforce and consequent declines in revenue collection required to subsidize health programs.¹⁰ In turn, the doubly-amplified demographic shift of an aging population coupled with decreasing fertility is likely to affect several major revenue streams (e.g., tax revenues) in the coming decades.¹¹ Simultaneously, unemployment spikes associated with the COVID-19 pandemic and associated mitigation strategies created additional short-term fiscal stress as job losses led to an additional drop in payroll taxes.

Immigrants impact the economy in ways that help alleviate public health fiscal shocks and stresses. In contrast to people born in the United States, who, between 2006 and 2018, consumed $98 billion more in Medicare than they contributed through taxes (making them net consumers of Medicare services), immigrants are net contributors to Medicare, contributing nearly $75 billion more in taxes than they spent in that same period.¹² This is partly due to the demographic profile of immigrants, who, compared to people born in the United States, are more likely to be working-age taxpayers, thus contributing taxes and using fewer health system resources.¹³

Immigrants Contribute to the Health Labor Pool to Reduce Labor Stresses

Providing health services is labor intensive, to the extent that the health care industry constitutes the largest source of employment in the United States.¹⁴ This industry is also projected to grow rapidly over the coming decades, with demands outstripping supply, partly due to increases in health needs as Americans age out of the workforce and into retirement at rates that outpace new workers coming into the labor pool,¹⁵ but also partly due to factors such as staff burnout and turnover associated with the COVID-19 pandemic.¹⁶ Together, the changing ratio of workers to retirees, the shrinking labor force pool, and labor shortages in health care associated with public health emergencies could represent a potentially significant strain affecting the tax base available to maintain health systems.

Before the COVID-19 pandemic, predictions forecast a US shortfall of up to 139,160 physicians by 2030.¹⁷ Shortfalls may be particularly acute in rural America, where nearly one-third of practicing doctors are over 60 and nearing retirement age.¹⁸ When the pandemic hit, shortfalls increased further as healthcare workers resigned due to safety and burnout while needs expanded.¹⁹

Immigration can help counteract some of these demographic shifts. Almost 30% of America’s physicians are foreign-born,²⁰ and compared to their US-born counterparts, immigrants are twice as likely to be physicians, and more frequently fill positions in medically underserved areas. For instance, immigrants are twice as likely to work as home health aides, clinical technicians, and other front-line occupations critical to a functional health system.²¹

Immigrants Support Health System Disaster Preparedness, Response, and Recovery

Accelerating disaster threats, including climate- and non-climate related natural hazards as well as public health crises, require large amounts of resources and effectively take these resources away from other priorities. These disaster threats therefore pose a challenge to the health system by constraining the provision of health services and reducing the pool of available essential workers.

Immigrants are instrumental to public health readiness and play a crucial role in delivering essential health services during public health emergencies. During the COVID-19 pandemic, for instance, 74% of undocumented immigrants were employed as essential workers.²² Response and recovery to natural hazards is similar. A sizeable workforce is needed to rebuild and recover following many disasters. For example, prompt rebuilding and repair of critical infrastructure impacted by hurricanes and wildfires, including hospitals, roads, and energy and water supply plants, are critical for providing continuity in care provision to prevent further loss of health and lives. Furthermore, 25% of immigrants work in construction,²³ where they play a valuable role in rebuilding infrastructure post-disaster.

Exposure to disasters is also associated with increases in mental and behavioral health challenges, where again immigrants provide valuable mental health services. For instance, there is a critical shortage of psychiatrists in the United States – a deficit of 3400 as of 2016 – and this shortage is expected only to grow given the age of the current workforce (60% of psychiatrists are 55 or older).²⁴ Foreign-licensed physicians constitute almost a third of practicing psychiatrists,²⁵ and outside of psychiatry, immigrants working as clinical psychologists, therapists, counselors, and psychiatric aides are also participating in the US mental health workforce in growing numbers.

Conclusions

A polycrisis of converging shocks and stresses have underscored the challenges facing health systems in the United States, including those related to providing essential mental health services. Immigrants can enhance health system resilience by leveraging the availability of global talent to support health systems before, during, and after crises. Nonetheless, the invisibility of immigrants’ crucial role in health system resilience is three-fold, including for immigrants who are skilled and highly trained in medical professions critical to US health systems. First, immigrants’ contributions have been traditionally overlooked as an asset to health systems. Second, immigrants often face deeply entrenched social prejudice that frames them as fiscal burdens and social threats.²⁶ Third, working in the United States as a foreigner requires navigating an ever-changing series of legal restrictions and policies. Navigating these laws and policies can be time consuming and costly, and successfully securing a pathway to permanently and legally work in the country is by no means guaranteed.

As a result, a first step towards leveraging immigrants for a resilient health system involves making the relative invisibility of immigrants’ contributions to American society – including in the area of health – visible. Immigrants’ contributions represent a critical component for a functioning health system in general and a health system resilient to crisis. For the United States to capture and value the resources that immigrants provide and bolster public health system resilience, the country needs to shift from old paradigms that portray immigrants as a burden to society to a new approach that focuses on immigrants’ contributions as an asset to health systems and to broader societal well-being.