آثار مهاجرت بر وضعیت بیمه سلامت بومی

The objective of the paper is to estimate the effects of immigration on natives’ probability of having private coverage and being uninsured. To examine whether immigrants affected employers’ decisions to offer health benefits the study estimates immigration effects on natives’ probability of being offered, eligible for, and a policy-holder of health insurance. Although in many cases the effects are statistically significant, most effects are very small. The increase in immigrant labor supply from 1995 to 2005 increases natives’ uninsurance rates by about 0.7 percentage points and reduces the natives’ probability of being offered and a holder of coverage by 0.8 and 1.9 percentage points, respectively. Immigrants’ weaker preferences for coverage relative to natives’ may be the key factor in this result.

In the last decade, the U.S. economy witnessed a large change in the composition of its labor force. In 1994, foreign-born workers accounted for about 10 percent of the U.S. labor force. By 2006, this number had grown to 15 percent and immigrants had accounted for about 50 percent of the growth in the total U.S. labor force since 1994. The large increase in the immigrant labor force has been a major contributor to changes in the insurance status of the U.S. population. The portion of non-elderly Americans who were uninsured grew from 16 percent in 1994 to almost 18 percent in 2003, with immigrants accounting for 86 percent of the growth between 1998 and 2003.1 Not surprisingly, immigrants are more than twice as likely to be uninsured than natives (32 percent vs. 13 percent) and immigrant non-citizens are three times more likely to have a job that does not offer health coverage than natives (43 percent vs. 14 percent).2 Indeed, the literature finds that the absence of jobs that offers health coverage is the main reason for high uninsurance rates among immigrants (Buchmuller et al., 2006). A growing body of anecdotal evidence suggests that some employers consciously use a strategy of not offering health benefits and engaging in contractual arrangements that enable firms to limit health and disability benefits to the work forces that are predominantly foreign born (Greenhouse, 2006 and Lee, 1999). Clearly, the employers’ decision to not offer health benefits could affect native workers competing for jobs with foreign born population. Understanding the effects of immigration on natives’ insurance benefits is important for policy makers, natives, and immigrant workers. Private coverage remains the key source of financing for health care, accounting for about 30 percent of total health expenditures in the U.S. (Hartman et al., 2009). A significant effect of immigrants on natives’ insurance status, therefore, would affect native's access to care, health status, and productivity. In this study we expand the existing literature by examining the effects of immigration on natives’ likelihood of having private health coverage and being uninsured. We then investigate one of the mechanisms through which immigration could affect native's insurance status. Natives’ employment status, firms’ decision to offer insurance, and firms’ decisions regarding the generosity of health benefits may all be affected by a change in immigrant labor supply. Until now, the literature has entirely focused on documenting the effects of immigration on employment and wages but has not addressed issues related to insurance or other fringe benefits.3 To fill this gap, the study thoroughly examines the relationship between the immigrant labor supply and natives’ likelihood of being offered, eligible for, and a policy-holder of private health insurance. An offer of health insurance is a measure of firm behavior and is a prerequisite for having employer-based insurance. In firms that offer insurance, the eligibility of individual workers for the offered insurance may depend upon a variety of factors such as length of employment, full time vs. part time, etc. Finally, to become a policy-holder of health insurance, an eligible employee must accept the offer of coverage. Studies have consistently documented that offer rates have remained the same or even increased while take up rates have declined (Cutler, 2002 and Cooper and Schone, 1997). One explanation for this finding is that the employer's cost of providing health coverage increased and as a result employers offered less generous coverage. Alternatively, employers may strategically offer parsimonious health benefits in order to reduce take up and, subsequently, to reduce cost of providing insurance to employees. Dranove et al. (2000) found evidence of such strategic behavior in the context of firms encouraging employees to take coverage from their spouses. Employers may also use this strategy if a large percentage of their employees has weak preferences for coverage. (As will be shown later, immigrants have weaker preference for coverage than natives.) This study uses methods developed in Borjas's (2003) to identify the effects of immigration on the insurance status of natives in the years 1995–2005. We also examine the effects of immigration on natives’ wages and employment over the same period. This allows us to rigorously compare the sensitivity of wage results to the time period studied (e.g., our narrower recent period vs. the broader period, 1960–2000 studied by Borjas (2003)). It also provides context for our insurance results by allowing us to compare the relative effects of immigrants on natives’ wages and on natives health benefits. Next, we examine potential theoretical pathways through which immigrants could have affected natives’ insurance status. We compare preferences for coverage between immigrants and natives and provide descriptive evidence on competition between natives and immigrants by examining occupations’ propensities to offer health insurance. We use data from the February and March Supplements of the Current Population Survey (CPS), for the years 1995, 1997, 1999, 2001, and 2005 and for selected years of Medical Expenditures Panel Survey (MEPS).4 The results indicate that immigrants reduced males’ private insurance rates and increased their uninsurance rates. The magnitude of these offsetting effects was almost identical in absolute value. The study finds evidence that natives’ probability of being offered and, especially, holding health insurance has also declined as result of the increase in immigrant labor supply. The rest of the paper is organized as follows. In the next section we describe the relevant literature and provide more details on the contributions of this study. Section 3 describes the data while Section 4 describes empirical specifications. Section 5 provides results while Section 6 discusses channels through which immigrants may affect natives’ insurance status. The last section concludes the paper.

The continuously increasing supply of immigrant labor in the United States stimulated economists to investigate whether natives’ wages and employment opportunities have been affected by immigration shocks. This study complements the existing literature by examining the effects of immigration on the insurance measures of natives. We employ Borjas’ (2003) approach to estimate the net effect of immigration on natives’ probability of having private coverage and being uninsured. We find that a 10 percent increase in immigrant labor supply reduces native rates of private coverage by about 0.6 percentage points which translates to an elasticity of 0.2. The effect is insignificant but after accounting for outliers the effect is significant at the 0.10 level.26 Natives’ uninsurance rates increased by almost the same amount (0.7 percentage points) suggesting the failure of public coverage to cover native workers who lost private coverage due to the increase in foreign-born workers. The estimated elasticity is 0.10 which implies that a 10 percent increase in immigrant share increases natives’ uninsurance rates by about one percent. The lost of private insurance could be due to several factors including the loss of a job or a change in employers’ decision whether to offer health benefits. Borjas (2003) finds that a 10 percent increase in immigrant labor reduces natives’ employment time by about 1.5–3.6 percentage points. Borjas's (2003) result is certainly consistent with our immigration effects on natives’ coverage. Prior to our study, however, the extent to which firms change health benefits in response to changes in the share of the labor force that are foreign born was unknown. To investigate this issue, we estimated the effects of immigration on natives’ probability of being offered, eligible for, and a holder of health insurance. Our results are generally consistent with Borjas's (2003) results for immigration effects on natives’ wages. We find that immigrants significantly reduced natives’ offer rate (with an elasticity of 0.03) and, especially, holder rate (with an elasticity 0.06). Our results, combined with Borjas (2003), suggest that natives’ reduction in private coverage occurred both because of the reduction in employment and because of employers’ decisions regarding whether to offer insurance, and if offered, the generosity of health benefits. We find that our results are somewhat sensitive to specifications such as inclusion of total health expenditures in the model or control for outliers. Because they have different preferences for coverage, immigrants may influence employers to alter their health benefits (Goldstein and Pualy, 1976). Our findings indicate that both citizen and non-citizen immigrants have significantly weaker preferences for health insurance than natives implying that immigration may have negatively affected insurance status of the native born workers employed in the same firm. Finally, we evaluated the degree of substitutability among natives, immigrant citizens, and immigrant non-citizens by occupations’ propensities to offer coverage. We found that natives and immigrant citizens are evenly distributed across occupation categories, suggesting moderate competition between the two groups. Non-citizen immigrants are in the most direct competition among themselves while the lowest competition is observed among natives and non-citizen immigrants. The study has several limitations. Although the loss of employment and the reduction of health benefits are the main factors associated with losing coverage, the study does not quantify the contribution of these effects to the natives’ loss of private coverage. Second, it would be useful to know the threshold of the immigration-native labor ratio at which employers are likely to change insurance benefits. Examination of this issue perhaps requires a detailed employer level data set. Finally, due to data limitations, the study was unable to identify immigration effects over longer time periods. Our paper makes several important contributions. The study complements the immigration literature by identifying immigration effects on the health insurance status of natives. The study underscores the importance of disaggregating immigration into citizen and non-citizens categories; an issue that has been ignored in most of the literature that evaluates the impact of immigration on natives’ wages and employment. The results of the study demonstrate a clear need for reform in the health insurance and immigration sectors. Immigrants’ weaker preferences for coverage illustrate that the nation's uninsurance rates are affected by the changing preferences of its population and that the current insurance structure can have significant spillovers on workers who actually want to be insured. The other question that should be asked is why do immigrants care less about health insurance than natives? Immigrants’ initial beliefs about health and better health status than that of natives can certainly be important factors. However, immigrants’ temporary and uncertain status in the country could very well be another important factor that discourages foreign-born workers from investing in health or protecting against unexpected health care costs.