US Immigration: the Curiosity of Numbers that Don’t Add Up

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The chart below shows data for population growth pulled from the Census Wonder data system. A positive number in the “Missing” column means that the population grew by more than the net of births, naturalizations and deaths. A negative number means it grew by less than the combination of births, naturalizations and deaths.

Here’s the problem. Say you want to assume that there are 1 million illegal immigrants entering the US in 2015. To make the numbers work, you have to have more than 800,000 people living in the US leaving.

  • Possible explanation 1: That’s the American Diaspora, and it appears to be quite real.
  • Possible explanation 2: There’s less illegal immigration than most people think.

In 2011 and 2012, we appear to have had more people leaving the US than entering.

In fact, if Explanation 1 is true, then were we to stop illegal immigration, we would have a steady population drain and slower economic growth. Without major changes in productivity, economic growth is directly linked to the size of the workforce. 

This is just a preliminary analysis. I’m looking for additional data.

You may also notice from the table that the death rate is edging upward. That’s probably just the natural result of the aging US population.

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ACA Repeal: The Latest

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The Senate proposal is out. The proposed law is 142 pages of (perhaps unnecessary) complexity, and, given the rushed nature, probable errors. But it’s out.

It’s not out in time to prevent damage for 2018.

  • Withdrawal of insurers: Aetna notified agents that it will be withdrawing from individual markets in 18 states. Notices to policy holders will be sent on or about July 1st. Other firms have announced withdrawals from a few states, most particularly Iowa and Indiana.
  • Heavy rate increases: Insurers in the individual market in Virgina have asked for a 30% rate increase for 2018, based on uncertainty about whether the Federal government will continue subsidies for health insurance. Insurers in NY State have asked for a 16.6% increase. Most other states will be in that range.

The proposal represents a mixed signal for consumers.

  • Pre-existing conditions: The Senate version conforms with the House version in requiring insurers to cover people with pre-existing conditions. HOWEVER . . .
  • Coverage: States can apply for waivers allowing insurers to reduce the coverage they provide. Services required by people with pre-existing conditions may not be covered.
  • Medicaid: The bill supports a contraction of Federal Medicaid funding, but delays the start of cutbacks until 2021. The House version started cuts in 2020, an election year. The Senate version of the cuts are later and deeper.
    • The Medicaid expansion was an increase of the income limit for eligibility from 100% of poverty level to 138%.
    • Under the Senate version people making more than 100% of poverty level would be prevented from enrolling in Medicaid starting in 2020.
    • All Federal funding for the expansion would be limited in 2023.
    • The impact on the Medicaid program for children, CHIP, is unclear at this time.
    • Inflation adjustments for Medicaid funding would be changed from an index based on medical costs to the overall Consumer Price Index (CPI), which would reduce annual increases in funding in all future years. (See graph.) (4) The focus of this change is strictly on reducing Federal spending, not helping consumers. Federal payments would lag behind increases in medical costs — who pays the difference?fredgraph
  • Tax credits to help pay for insurance: The House version based subsidies on age; the Senate version reverts to income as the basis, consistent with the existing ACA rules. However,
    • The Senate version reduces the maximum income eligible for these subsidies, making some people now receiving subsidies ineligible for them in the future. On low low end, the Senate version makes subsidies available for people earning below below poverty level who might not be eligible for Medicaid in their state. The Senate version maintains cost-sharing subsidies for insurers through 2019.
    • The Senate version reduces the amount of subsidy people receive, increasing out of pocket costs for everyone, and especially for those between age 50 and 64.
  • Planned Parenthood: Both House and Senate versions remove funding for Planned Parenthood.
  • Tax reductions for affluent households: The Senate and House versions are in agreement on this; the reductions remain intact.
  • Individual mandate: Penalties for not having insurance are eliminated.

Sticking points:

  • For conservatives: Treating healthcare as a human right. They would rather see the ACA eliminated without replacement.
  • For moderates and those in competitive districts

Collateral damage:

  • Insurance coverage: There’s a debate as to how many people will not have insurance coverage with this law.  Estimates vary between 13 and 23 million.  The reasons for the variance in estimates include:
    • Time frame — loss of coverage will build over time as insurance costs increase and subsidies don’t.
    • Medicaid — how many people will lose coverage under Medicaid. That impacts more people than you would expect. Most people don’t have Long Term Care insurance, and Medicaid has become the prime vehicle for paying for home health aides and nursing home costs. Since nursing home costs average nationally more than $9,000 per month and Medicare pays for only the first 100 days, there are a lot of middle income families that will be in trouble. Even some moderately affluent families will be affected, and the poor . . . forget about it.
  • Tax increases: Healthcare for the uninsured will fall back on emergency rooms, largely of public hospitals. That will drive costs and budget increases and increases in local taxes. Tax savings for the rich will mean tax increases for everyone else.
  • Economic stagnation: The US is a consumer economy. I’ve argued previously that money siphoned from consumers for education, housing and healthcare is money they can’t spend for anything else. One analyst sees 1.1 million jobs disappearing by 2020 with passage of the AHCA. (3)

 


Sources:

  1. M. J. Lee, Tami Luhby, Lauren Fox, Phil Mattingley, “Senate GOP finally unveils secret health care bill; currently lacks votes to pass,” CNN, 22 June 2017. http://www.cnn.com/2017/06/22/politics/senate-health-care-bill/index.html
  2. Stephanie Armour, Kristina Peterson and Louise Radnofsky, “Battle Lines Drawn on Health Care,” The Wall Street Journal, 23 June 2017, P. A1.
  3. Josh Bivens, “Millions of people have a lot to lose under the AHCA,” Economic Policy Institute, 21 June 2017. http://www.epi.org/publication/millions-of-people-have-a-lot-to-lose-under-the-ahca/?utm_source=Economic+Policy+Institute&utm_campaign=50e819bfcb-EMAIL_CAMPAIGN_2017_06_23&utm_medium=email&utm_term=0_e7c5826c50-50e819bfcb-58834721&mc_cid=50e819bfcb&mc_eid=0541ad0f29
  4. Federal Reserve Bank of St. Louis, Economic Research. Chart downloaded 25 June 2017. https://fred.stlouisfed.org/graph/?id=CPIMEDSL,
  5. Bob Bryan, “Unveiled: The Secret Senate Healthcare bill,” Business Insider, 22 June 2017. http://www.businessinsider.com/senate-healthcare-bill-trumpcare-ahca-details-2017-6

A Different Perspective on Mexico

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The monologue on Mexico focuses on those crossing the border into the US. In fact, that’smexico a very narrow view of the relationship between the two countries.

According to the State Department, there are one million US citizens living in Mexico. However,

  • That figure was first reported in 2014. The number has been increasing since. The US government doesn’t  track residents living out of the country as long as they pay their taxes.
    • One US expat realtor reports a 40% increase in home sales in one US expat enclave just in the last year.
    • A commentator in The Guardian estimates the number of Americans living in Mexico as closer  to two million.
  • A number of the US citizens living in Mexico aren’t there legally (estimates vary from 50 to 90 percent). The Mexican government isn’t particularly good about tracking them, and doesn’t deport them. In fact, Mexico abolished a mandatory prison sentence for undocumented immigrants in 2008. Those who have not committed a crime are simply allowed to stay.

CNN reports that there are four reasons that Americans give for moving to Mexico:

  • Climate
  • Culture
  • Cost of living
  • Escaping the US political climate

One American comments that doctors in Mexico are more helpful and enjoyable to visit than are doctors in the US.

It’s cheap. It’s very patient-oriented. It’s like my father practiced in Illinois about 50 years ago, without all the paperwork.

Many Americans, including some in Congress, view Mexico through the prism of an out-dated stereotype. Of course, if that changes, more Americans might move there.


Sources:

  1. Instituto Nacional de Estadística y Geografíca. http://www.inegi.org.mx/\
  2. Adam Taylor, “Mexico has its own immigration problem: American retirees,” The Washington Post, 21 November 2014. https://www.washingtonpost.com/news/worldviews/wp/2014/11/21/mexico-has-its-own-immigration-problem-american-retirees/?utm_term=.dc11626a341f
  3. Leyla Santiago and Traci Tamura, “South of the border, US expats have a different take on Mexico,” CNN 24 June 2017.  http://www.cnn.com/2017/06/24/americas/mexico-american-expats/index.html
  4. “News Report: 91.2% of All Americans Who Live in Mexico Are Living There Illegally,” Latino Rebels, 5 March 2017. http://www.latinorebels.com/2017/03/05/news-report-91-2-of-all-americans-who-live-in-mexico-are-living-there-illegally/
  5. Millions of Americans live in Mexico. Can we continue to coexist?” The Guardian, 23 January 2017. https://www.theguardian.com/commentisfree/2017/jan/23/trump-futures-mexico-us-interlocked-wall-border

Immigration and the New American Reality

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“I don’t want my child to grow up in the US.”

That’s a simple and direct statement from a financial professional who moved to Europe earlier this year. Her child will grow up learning between four and six languages and without the attitude/belligerence she sees in US schools. Plus college and healthcare are free.

Europeans pay high taxes. However, because so many expenses are included in those taxes, they have more money available to spend than most Americans do. That’s driving a faster economic recover in Europe than the US is seeing.

That prompted me to look at the data on migration. What are the trends? You might be surprised.

  1. Both legal and illegal immigration peaked prior to the recession in late 2008. The trends since are downward. The declines started during the Obama administration.
    • The illegal immigrant population peaked at 12.2 million in 2007.(2)
  2. Most illegal immigrants living in the US have been in the US for more than ten years. They are homeowners and taxpayers.
  3. Mexico no longer accounts for a majority of illegal immigrants. The majority now from from a combination of Central America and Asia.
  4. Mexico provides the largest number of LEGAL immigrants to the US. (1) Most Hispanic residents in the US are legal residents. (3)
  5. Recent immigrants from Mexico tend to work in the US for a few years and then return to Mexico. Pew reported in 2012 that net immigration from Mexico was zero, with the number of people leaving the US matching the number entering.
    • This “breakeven” has little to do with US immigration enforcement. People are leaving for a lower cost of living and better social services.

FT_17.04.17_unauthorized_update_2015-1The State Department estimates that 9 million US (non-military) citizens are now residents of other countries. That’s up from 4 million in 1999. However, the government has no formal mechanism for tracking citizens who move overseas. The actual number could be lower or much higher.

  • Seniors are part of the out-migration. Financial advisors recommend considering moves to places like Costa Rica in order to be able to maintain a reasonable standard of living on Medicare. (5)

The US is changing relative to other countries. There are a growing number of valid reasons for not wanting to live here, and that will have an impact on the economy and employment in the future — probably driving more jobs and business investment offshore. Don’t expect driving people and money out of the US to improve job prospects and the economy here. That’s naive in the extreme.


Sources:

  1. Homeland Security, “Yearbook of Immigration Statistics 2015.” https://www.dhs.gov/immigration-statistics/yearbook/2015/
  2. Jeffrey Passel and D’Vera Cohn, “As Mexican share declined, U.S. unauthorized immigrant population fell in 2015 below recession level,” Pew Research Center, 25 April 2017. http://www.pewresearch.org/fact-tank/2017/04/25/as-mexican-share-declined-u-s-unauthorized-immigrant-population-fell-in-2015-below-recession-level/
  3. Jie Zong and Jeanne Batalova, “Frequently Requested Statistics on Immigrants and Immigration in the United States,” Migration Policy Institute, 8 March 2017. http://www.migrationpolicy.org/article/frequently-requested-statistics-immigrants-and-immigration-united-states
  4. US State Department, “CA by the Numbers,” updated June 2016.  https://travel.state.gov/content/dam/travel/CA_By_the_Numbers.pdf
  5. “Retire Overseas . . . and Live Better for Less . . . ” International Living, undated.  https://www.internationalliving-magazine.com/?gclid=COyAv7-tytQCFYWNswodZNkMcw

The [State] Politics of Health Insurance

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In the rush to repeal the Affordable Care Act, the Trump Administration has been repeating the mantra that the individual insurance marketplaces are “failing.” Like most statements made by politicians these days, the facts seem to be a little different.

Clearly, Iowa is in crisis. With the withdrawal of Aetna from the individual marketplace, there is a real risk they may have no insurers offering individual coverage through the marketplace in 2018.

My suspicion is that Aetna’s withdrawal has more to do with its stock price and financial liabilities after a failed merger attempt than with the ACA itself. Aetna has also stopped writing small group insurance in some states.

However, Pennsylvania has six carriers committed to the marketplace for 2018. The only concern is what the Trump administration might do the mess things up.

Further, another insurer, Centene, has announced that it is expanding individual marketplace coverage into three new states — Kansas, Missouri and Nevada.

So what’s the real story with Iowa? If the fault were with ACA, it would be impacting every state and every carrier, and that’s not the case. What have state officials done to mess things up?

If you know the story, please reply. I’d like to know, both about Iowa and about other states where local officials are whining about Obamacare. Let’s get the full story out into the open.

 

Brain Tumor Options

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Brain tumors are pernicious. How do you know when a headache is just due to stress or a sign of something more serious? Right now, 1 in every 161 cancer diagnoses involves a brain tumor, but these tumors can be a natural follow-on to other cancers. Glioblastoma is the most deadly form of brain tumor, killing 83% of the youngest patients it infects within five years.

Medicine is changing rapidly, and that brings both benefits and problems. Obviously, new treatment methods can improve outcomes for patients. However, it is a challenge to keep up with developments and know what’s best. It’s a challenge for doctors, and worse for patients.

The traditional approach has involved surgery, chemotherapy and radiation therapy to remove and kill cancer cells.  These approaches have met with varied success. The five year survival rates for various brain tumors are shown in the chart below:

Five-year survival rates, selected brain tumors (2)

Five-year survival rates Age of patient
Tumor type 20-44 45-54 55-64
Low-grade (diffuse) astrocytoma 65% 43% 21%
Anaplastic astrocytoma 49% 29% 10%
Glioblastoma 17% 6% 4%
Oligodendroglioma 85% 79% 64%
Anaplastic oligodendroglioma 67% 55% 38%

New research is finding that radiation treatment can affect brain function, possibly producing the cognitive impairment seen in many patients after treatment. (3,4)

There are a number of options, but your local doctor may or may not know what they are, or have access to them.

The NIH National Cancer Institute highlights three categories of research under way:

  • Therapeutic vaccines
  • CAR T-cell therapy (taking patient cells, re-engineering them, and reinjecting them in the patient)
  • Checkpoint inhibitors that allow the patient’s immune system to attack tumor cells (5)

These approaches fall under the broad label of immunotherapy.

Where are clinical trials happening?

  • Duke is a leader in brain tumor research and has a number of clinical trials underway testing treatments for brain tumors involving immunotherapy and the manipulation of T and B cells. (6)
  • Other centers with clinical trials include:
    • The University of Florida
    • The University of Texas Southwestern Medical Center, also featuring clinical trials with imunotherapy
    • The Dana Farber Cancer Center, Boston, Massachusetts
    • Cedars-Sinai Medical Center, Los Angeles, California
    • University of California, Irvine, California
    • Mayo Clinic, Rochester, Minnesota
    • University of Alabama
    • MD Anderson Cancer Center, Univ. of Texas, Houston
    • Provident Cancer Center, Portland, Oregon
    • City of Hope Medical Center, Duarte, California
    • NIH Clinical Center, Bethesda, Maryland

The bulk of innovative work is happening on the east and west coast, leaving people in the North Central, Midwest, Plains and much of the South and Southwest without ready access to advanced medical treatment. Even with access, doctors in these areas will have little experience dealing with side effects, and that could be fatal for a patient.

This explains in part why, as discussed in prior blog posts, where you live in the US effects your life expectancy.

How prepared are you to relocate for three or six months for treatment?


Sources:

  1. American Brain Tumor Association. http://www.abta.org
  2. American Cancer Society, “Survival Rates for Selected Adult Brain and Spinal Cord Tumors.” https://www.cancer.org/cancer/brain-spinal-cord-tumors-adults/detection-diagnosis-staging/survival-rates.html
  3. University of California – San Diego. “Radiation therapy vital to treating brain tumors, but it exacts a toll: Researchers say treatment alters neural networks and may cause long-term cognitive impairment.” ScienceDaily. ScienceDaily, 9 June 2017. <www.sciencedaily.com/releases/2017/06/170609133810.htm>.
  4. Carrie R McDonald et al. Altered network topology in patients with primary brain tumors after fractionated radiotherapy. Brain Connectivity, June 2017 DOI: 10.1059/brain.2017.0494
  5. Duke Neurosurgery, “Research Initiatives.” https://neurosurgery.duke.edu/research/basic-research/duke-brain-tumor-immunotherapy-program/research-initiatives.
  6. UT Southwestern Medical Center. “New approach to destroying deadly brain tumors.” ScienceDaily. ScienceDaily, 13 June 2017. <www.sciencedaily.com/releases/2017/06/170613102056.htm>.
  7. Musella Foundation, “Clinical Trials and Noteworthy Treatments for Brain Tumors,” last updated 5 February 2017. https://www.virtualtrials.com/Immunotherapy_treatments.cfm