Tag Archives: Immigrants

Immigrants and Health – Two Studies

The following two articles come from Dr. Don McCanne’s Quote of the Day blog.

International Journal of Health Services
August 8, 2018
Medical Expenditures on and by Immigrant Populations in the United States: A Systematic Review
By Lila Flavin, Leah Zallman, Danny McCormick, and J. Wesley Boyd

Abstract

In health care policy debates, discussion centers around the often-misperceived costs of providing medical care to immigrants. This review seeks to compare health care expenditures of U.S. immigrants to those of U.S.-born individuals and evaluate the role which immigrants play in the rising cost of health care. We systematically examined all post-2000, peer-reviewed studies in PubMed related to health care expenditures by immigrants written in English in the United States. The reviewers extracted data independently using a standardized approach. Immigrants’ overall expenditures were one-half to two-thirds those of U.S.-born individuals, across all assessed age groups, regardless of immigration status. Per capita expenditures from private and public insurance sources were lower for immigrants, particularly expenditures for undocumented immigrants. Immigrant individuals made larger out-of-pocket health care payments compared to U.S.-born individuals. Overall, immigrants almost certainly paid more toward medical expenses than they withdrew, providing a low-risk pool that subsidized the public and private health insurance markets. We conclude that insurance and medical
care should be made more available to immigrants rather than less so.

From the Discussion

Many Americans, including some in the health care sector, mistakenly believe that immigrants are a financial drain on the U.S. health care system, costing society disproportionately more than the U.S.-born population, i.e., themselves. Our review of the literature overwhelmingly showed that immigrants spend less on health care, including publicly funded health care, compared to their U.S.-born counterparts. Moreover, immigrants contributed more towards Medicare than they withdrew; they are net contributors to Medicare’s trust fund.

Our research categorized immigrants into different groups, but in all categories, these studies found that immigrants accrued fewer health care expenditures than U.S.-born individuals. Among the different payment sources – public, private, or out-of-pocket – public and private expenditures were lower for immigrants, with immigrants spending more out-of-pocket. Differences decreased the longer immigrants resided in the United States.

While annual U.S. medical spending in 2016 was a staggering $3.3 trillion, immigrants accounted for less than 10% of the overall spending – and recent immigrants were responsible for only 1% of total spending. Given these figures, it is unlikely that restrictions on immigration into the United States would result in a meaningful decrease in health care spending. To the contrary, restricting immigration would financially destabilize some parts of the health care economy, as suggested by Zallman and colleagues, who found that immigrants contributed $14 billion more to the Medicare trust fund than they withdrew.

Fiscal responsibility is an important reason for the United States to provide insurance for newly arrived immigrants, as they could continue to enlarge the low-risk pool of healthy individuals that helps offset the cost of insuring high-risk individuals. Currently, under the ACA, undocumented immigrants cannot enroll in the state health care exchanges. If we are seeking to minimize costs, which would seem a major factor in the reasoning of policymakers who would deny immigrants care, then it makes financial sense to enroll individuals who will (on average) contribute more to the health care system than they withdraw. Healthy, young immigrants are precisely whom we should target for Medicaid enrollment, state exchanges, or private health insurance.

http://journals.sagepub.com/doi/full/10.1177/0020731418791963

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The New England Journal of Medicine
August 1, 2018
A New Threat to Immigrants’ Health — The Public-Charge Rule
By Krista M. Perreira, Ph.D., Hirokazu Yoshikawa, Ph.D., and Jonathan Oberlander, Ph.D.

The United States is making major changes to its immigration policies that are spilling over into health policy. In one such change, the Trump administration is drafting a rule on “public charges” that could have important consequences for access to medical care and the health of millions of immigrants and their families. The concept of a public charge dates back to 19th-century immigration law. Under current guidelines, persons labeled as potential public charges can be denied legal entry to the United States. They can also be prevented from adjusting their status from a nonimmigrant visa category (e.g., a student or work visa) to legal permanent resident status. In addition, if they become public charges within the first 5 years after their admission to the United States, for reasons that existed before they came to the country, in rare cases they can be arrested and deported. Immigrants and their families consequently have strong incentives to avoid being deemed public charges.

In evaluating whether a person is likely to become a public charge, immigration officials take account of factors such as age, health, financial status, education, and skills. The use of cash assistance for income maintenance (e.g., Supplemental Security Income or Temporary Assistance for Needy Families) and government-funded long-term care are considered in making these determinations. Other noncash benefits such as health and nutrition programs are specifically excluded from consideration, and use of cash-assistance benefits by the immigrant’s dependents is not currently factored in.

The Trump administration is proposing sweeping changes to these guidelines. A draft rule from the Department of Homeland Security (DHS) would substantially expand the definition of a public charge to include any immigrant who “uses or receives one or more public benefits.” Not just cash assistance but nearly all public benefits from federal, state, or local governments would be considered in public-charge determinations, including nonemergency Medicaid, the Children’s Health Insurance Program (CHIP), and subsidized health insurance through the marketplaces created by the Affordable Care Act (ACA); Medicare would be excluded. The DHS draft notes that in making these determinations, “having subsidized insurance will generally be considered a heavily weighted negative factor.” The broadened definition of public charge would also encompass food assistance (the Supplemental Nutrition Assistance Program [SNAP] and the Women, Infants, and Children Program [WIC]), programs designed to assist low-income workers (e.g., the Earned Income Tax Credit [EITC]), housing assistance (Section 8 vouchers), and the Low Income Home Energy Assistance Program. Moreover, not only immigrants’ use of public assistance but use of these programs by any dependents, including U.S.-born citizen spouses and children, would also be considered.

The potential impact of these changes is enormous. In 2016, about 43.7 million immigrants lived in the United States. If enacted, the new regulations would affect people seeking to move to the United States to be reunified with family members and to work, as well as lawfully present immigrants who hope to become legal permanent residents (green-card holders). One estimate suggests that nearly one third of U.S.-born persons could have their use of public benefits considered in the public-charge determination of a family member. This includes “10.4 million citizen children with at least one noncitizen parent.” Notably, unauthorized immigrants are not the primary target of the draft rule, since they are already ineligible for most federally funded public assistance. Instead, lawfully present immigrants would bear the brunt, as well as persons living in “mixed-status” families (those in which some members are citizens and others are not) and persons living abroad who wish to immigrate to the United States.

We believe that the draft public-charge regulation represents a substantial threat to lawfully present immigrants’ access to public programs and health care services. What modifications may be made is uncertain — after the rule is formally proposed, there will be a public comment period, and revisions could be made before it is finalized. But if this rule takes effect, it will most likely harm the health of millions of people and undo decades of work by providers nationwide to increase access to medical care for immigrants and their families.

https://www.nejm.org/doi/full/10.1056/NEJMp1808020?query=featured_secondary

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Immigrants in construction — key facts « Working Immigrants

Peter Rousmaniere posted the following fact sheet about immigrants working in construction. While this has no bearing on health care at present, it does have some bearing on workers’ comp, especially in light of the current regime’s draconian policy towards immigrants from Central America.

As this “crisis” progresses, it may be harder for construction companies to find workers to employ on construction sites.

This, in turn would mean that they may be less construction work, and for the insurance industry, less risk and less profit to be made from insuring these projects.

In workers’ comp, that would translate into less frequency of losses, but it would also cut off revenue from carriers covering such risks.

And he promised to create jobs? Hardly.

Source: Immigrants in construction — key facts « Working Immigrants

Health Care, Immigration, and the Supreme Court

This week America underwent a shock of such magnitude that many believe that this is the end of the experiment begun in 1776, and the United States lost its standing as the “Shining City on a Hill.”

We have witnessed the cruelty of the Trump regime towards innocent children snatched from the arms of their parents, simply because their parents want to escape the violence and oppression of the drug gangs rampant in their home countries.

These parents want not only to secure for their children a life free from being recruited into these gangs, they also want to provide their children with a better life.

And most of them did so according to US immigration law. They presented themselves at legitimate border crossings, and were summarily arrested, had their children separated from them, the children, some as young as a few months old, put in cages, or transferred across the country, and placed in facilities where no press or Congressional observers are allowed to see for themselves, except on special guided tours where they cannot speak to the children.
Recently, a judge in California ordered the regime to re-unite the children with their parents and effectively ended the zero-tolerance policy.

Tomorrow, at 11 am, I, and many others around the nation will take part in a march to protest this cruel and un-American action. The march I will be attending will be held in West Palm Beach and will cross the Intracoastal Waterway by way of a bridge connecting the mainland with Palm Beach island. The march will terminate at Mar-a-Lago, the former home of Marjorie Merriweather Post, heiress to the Post cereal fortune, and that is now owned by the Orangutan.

Why am I writing this, and what does it have to do with health care? And what does the Supreme Court have to do with these other issues?

That is what this post will attempt to address.

To begin with, the immigration issue will have a profound effect on the health care system, as the older Americans get, the more home health and nurses’ aides they are going to need.

Preventing these unfortunate men, women and children, fleeing violence and drug gangs, and civil war and corruption at home, will mean that in the future there will be fewer workers to take these and many other jobs in health care and other industries.

In addition, the so-called “travel ban”, is really a cynical attempt to impose a Muslim ban without calling it one. The Supreme Court weighed in on this move this week, ignoring the racist comments made by the Orangutan, and gave him wide latitude to ban anyone he does not like.

This will have the chilling effect of preventing both medical students and physicians from coming to the US, not only from the countries on the list, but all other Muslim nations. The medical travel industry, also may feel some effect, as providers and facilitators from Gulf states, and other nations in the region, may be prevented from attending conferences and speaking engagements, and Americans who go to the UAE may be given greater scrutiny upon return to the US.

As a grandson of immigrants, this un-constitutional, un-American, and inhumane action by this regime is very disturbing and sickened me when I heard the cries of those children. But, according to recent polling on the issue, 58% of Republicans approved of the separation of children from their parents, while 92% of Democrats disapproved. The CNN poll results are here:

On top of the immigration debacle, and the “travel ban”, there was a third and more devastating blow to American democracy and to the Republic this week. The retirement of Justice Anthony Kennedy, a swing vote on many issues brought before the Court, portends that the Court will be radically altered once a replacement is chosen and confirmed by the Senate.

But unlike the Merritt Garland nomination, Mitch McConnell is vowing to confirm whatever nominee the Orangutan appoints, and the regime promises to appoint a strict Conservative justice. Several commentators have indicated that abortion, LGBTQ rights, and maybe even health care, could be overturned if one more current justice, most probably Ruth Bader Ginsberg, retires or like Scalia, dies in the next two years. She is 85.

Overturning Roe v. Wade and making abortion illegal once again, will force women to seek back alley abortions, and will severely impact their health and lives. Also, it is possible that birth control and access to it, may be denied to women, and that will have serious impacts on health care in the future. Some believe that Roe is settled law, but don’t count on them being right. The Religious Right is waiting for the day that women are forced to carry to term pregnancies they don’t want, and then have any neo-natal or post-natal care taken away, so that they and their babies suffer needlessly.

A strict Conservative on the bench also threatens gay marriage and LGBTQ rights, as it was Justice Kennedy who broke with the Conservatives and said that gay people had a constitutional right to marry. It may mean that more cases like the recent Colorado case may be decided in the plaintiff’s favor, albeit without the bias the state Commission showed to religion.

Lastly, health care could face enormous challenges ahead if the makeup of the Court swings radically to the right. The current Court ruled that the ACA was Constitutional, but since the coup of 2016, the GOP has steadily destroyed the law and a radical Supreme Court just might put the last nail in the coffin and deny millions of Americans health care. There is also a health care bill in Congress that will remove many diseases and pre-existing conditions from coverage.

This is especially disturbing to yours truly, as I have one of those pre-existing conditions: ESRD. Right now, I have Medicare only, but who knows what a radical Court may do to that and the other health care programs such as Medicaid, CHIP, etc.

In college, I was taught that the Court generally swings from liberal to conservative, but in my lifetime, it has gone from liberal to conservative, to radically conservative, so that now we may be headed for a judicial, corporate dictatorship where the people have little or no rights, and Corporate and religious interests have all the rights.

The following quote sums up our predicament:

“When fascism comes to America it will be wrapped in the flag and carrying a cross.”
Sinclair Lewis

So, what do we do?

Well, the march tomorrow morning is a start. I have been critical of those groups opposed to this regime sitting on their kiesters and doing nothing except marching once a year in January for two straight years in the Women’s Marches. This crisis is bigger than just one demographic group. This fight is for the soul of the nation and for the Republic as a democratic republic. A journalist heard this morning on MSNBC said she went to Minnesota recently when the Orangutan was there, and she said that the cab driver told her that he is a Republican, is against the Orangutan, and cannot speak to friends about him because they believe him 100% and think he is a god.

Great! Now we have a Caucasian version of Kim Jong Un.

We have to work together, because in the words of Pastor Niemoeller:

First, they came for the Socialists, and I did not speak out—
Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out—
Because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out—
Because I was not a Jew.
Then they came for me—and there was no one left to speak for me.

The Founding Fathers knew something like this would happen, but never thought that the Electoral College, created to prevent this, would actually make it a reality. We are living in scary times.

Have a good weekend everyone, and if I don’t write before Wednesday, have a safe and happy Fourth…it may be our last.

The Cry of the Children

Taking a break from writing about health care, workers’ comp, and medical travel, I want to talk about something I saw, or rather heard yesterday afternoon on MSNBC.

It was an audio (furnished by ProPublica) of children crying at a detention center (more like Concentration Camp) that broke my heart. I was in tears, and very seldom do so. But those cries went right to me.

If they did to you, then you are a good human being. If not, then you have no soul. And please, don’t quote me that that’s the law, or it is in the Bible, or they are illegal and have no rights.

EVERY HUMAN BEING HAS RIGHTS.

And as for whether or not they are “illegal”, I guess you forgot that when your ancestors arrived on the Mayflower or whatever ship they sailed on, the landlords here for thousands of years knew you were “illegal” too.

The ancestors of all of these people now streaming to our border came to this hemisphere some 20,000 years ago, so by those standards, you, me, and all the rest of us are undocumented aliens. But no one tells us to leave. Or yanks our kids from our arms.

That we do this and many other things to minorities is a symptom of our greed, ignorance, and stupidity that never seems to die out. Take for example, our Confederate-era Attorney General, Jeff “Foghorn Leghorn” Sessions. That refugee from the set of “Gone With the Wind” is not only a religious zealot, but a full-out bigot and racist from a region of the nation that still has not given up its racism and hatred of non-whites, and non-Christians. In this case, non-Protestants from Catholic Latin America.

Too many of our fellow Americans have been poisoned by talk radio, Fox News, and local politicians to see that we are all immigrants and that at times in the long history of the human species, we were migrants too. Our prehistoric ancestors migrated, as did many more recent peoples. But none ever subjected to such cruelty, except during the 1930’s and 1940’s.

We were all taught in school to believe in the ideals of America as a shining city on a hill (incidentally, an idea the Puritans created), and was more about a religious view than a secular one. We were all taught about why we fought a revolution, why we have a Declaration of Independence, and why we have a Constitution that secures our rights and liberties.

And now we are throwing all that away because of a clique of neo-fascist, racist bullies and bigots, headed by a pathological liar and con man, who has conned a large segment of the American people (by which I mean White people) that he can make America great again, all the while cozying up to dictators and dissing our friends.

Folks, this is how Hitler and the Nazis began. And it ended with 6 million dead (my maternal great-uncle, aunt and their six children among them), so don’t tell me it is legal or biblical. You know where you can put that.

And those of you who say they have stolen our jobs or they are criminals and rapists, I have news for you…next time you are in a restaurant, or a family member is in a hospital, bus your own table, and clean up your family member’s dirty linen. Because if Herr Miller (Stephen) gets his way, there won’t be any bus boys, nurses’ aides, home health aides, janitors, and other occupations Americans won’t be filling begging for workers. Oh, and you can come to Florida and pick your own fruits and vegetables, because there won’t be anyone to do it for you.

AMERICA IS A NATION OF IMMIGRANTS, SO WE NEED THESE PEOPLE.

 

Typical Family of Four Now Paying Over $28,000 for Health Care

A report issued Monday by Milliman indicated that the cost of health care for a typical American family covered by the average employer-sponsored preferred provider organization (PPO) plan in 2018 is $28,166, as per the Milliman Medical Index (MMI).

Broken down into component parts, this represents the following costs:

2018 MMI Components of Spending
31% ($8,631) – Inpatient
19% ($5,395) – Outpatient
29% ($8,275) – Professional services
17% ($4,888) – Pharmacy
4% ($995) – Other (Home health, ambulance, DME, prosthetics)

The key takeaway from the report is that employers are paying more; but employees are paying a lot more.

The health care expenditures are funded by employer contributions to health plans and by employees through their payroll deductions and out-of-pocket expenses incurred when care is received, according to the report.

The report continues that they are seeing over the long-term, and that employees are paying a higher percentage of the total, with employee expenses increasing 5.9%, and employer expenses increasing 3.5% in 2018.

The total cost of health care is shared by both the employer and employee for a family of four, the MMI stated, which breaks down to three categories:

1. Employer subsidy. Employers that sponsor health plans subsidize the cost of healthcare for their employees by allocating compensation dollars to pay a large share of the cost.
2. Employee contribution. Employees who choose to participate in the employer’s health benefit plan typically also pay a substantial portion of costs, usually through payroll deduction.
3. Employee out-of-pocket cost at time of service. When employees receive care, they also often pay for a portion of these services via health plan deductibles and/or point-of-service copays.

The relative proportions of medical costs for 2018 are:

56% ($15,788) – Employer contribution
27% ($7,674) – Employee contribution
17% ($4,704) – Employee out-of-pocket

Looking at this another way, employees are paying a total of 44% as either a contribution or out-of-pocket, which adds up to $12,378, compared to the employers’ 56% and $15,788, respectively.

As health care gets more expensive, it will naturally lead to higher costs for employers, but also higher costs for employees. And as has been happening more commonly, employers are shifting more of the costs onto the employees. With stagnant wages, as reported daily in the news, this is going to be a problem for those families caught in the squeeze between rising costs for medical care and stagnant wages.

This would be resolved by creating a single payer health care system that will save both employers and employees money,

 

Foreign-born Workers on the Rise: What it Means for Work Comp and Medical Travel

Working Immigrants.com posted a report this weekend that indicated that the percentage of foreign-born workers in the US will rise from 16% to 20% of the workforce over the next 26 years.

It will grow for the next 15 years, then the pace will slow considerably. Citing a Census Bureau publication from March 2015, Working Immigrants said that the total population of the US is expected to grow from about 319 million in 2014, to 359 million in 2030, and 380 million in 2040, which is an increase of 19% over the next 26 years.

According to the report, the working age population will grow by 12%.

There is a higher rate of employment among foreign-born, due to the fact that they mainly come here to work, and they are more concentrated in working age brackets ― 80% between 18 and 64, vs 62% among native born.

Modest increases in the foreign-born population will result in higher shares of employment for these workers.

By 2040, foreign-born workers will be one fifth of the workforce.

It is a given that not many of these workers will have a great command of English, and the most likely foreign-born workers will be Hispanics and Asians.

A workforce that does not have a command of English, is mainly from Central and South America and Asia, will no doubt put a strain on an already strained social welfare system, especially workers’ comp, since they are more likely to be injured on the job.

So those of you in the medical travel industry looking for patients and trying to entice well-off Americans down to Latin America for dental work, cosmetic surgery, plastic surgery, and other treatments not available in the US or that are too expensive, should consider expanding your offerings to your fellow Latino immigrants, or change direction and consider doing so by offering to facilitate less expensive surgeries for common injuries found in the workers’ comp space.

And those of you in workers’ comp who have shut your minds to new ideas and refuse to listen to what I am saying, either should learn Spanish or Chinese, or deal with the changing nature of health care globally, and stop worrying about stepping on the toes of the vested interests, and start thinking about the interests of all those new foreign-born workers who will be coming here in the next 26 years (24 now that it is 2016).

They may not feel comfortable going to a hospital for surgery if the staff there does not speak their language, or the food is unfamiliar, and they may even recover faster if they know they are surrounded by friends and family in their home country. That will lead to a more productive and happier employee.

And a happier employee will improve your bottom line.


I am willing to work with any broker, carrier, or employer interested in saving money on expensive surgeries, and to provide the best care for their injured workers or their client’s employees.

Ask me any questions you may have on how to save money on expensive surgeries under workers’ comp.

I am also looking for a partner who shares my vision of global health care for injured workers.

I am also willing to work with any health care provider, medical tourism facilitator or facility to help you take advantage of a market segment treating workers injured on the job. Workers’ compensation is going through dramatic changes, and may one day be folded into general health care. Injured workers needing surgery for compensable injuries will need to seek alternatives that provide quality medical care at lower cost to their employers. Caribbean and Latin America region preferred.

Call me for more information, next steps, or connection strategies at (561) 738-0458 or (561) 603-1685, cell. Email me at: richard_krasner@hotmail.com.

Will accept invitations to speak or attend conferences.

Connect with me on LinkedIn, check out my website, FutureComp Consulting, and follow my blog at: richardkrasner.wordpress.com.

Transforming Workers’ Comp Blog is now viewed all over the world in over 250 countries and political entities. I have published 300 articles and counting, many of them re-published in newsletters and other blogs.

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Immigration Reform Revisted

Tomorrow evening President Obama is to unveil his plan to grant millions of undocumented immigrants a form of legal status by executive action.

As reported in two articles today, one in Health Affairs blog, and the other in The New York Times, access to health care will not be a part of the President’s plan.

In “The Case For Advancing Access to Health Coverage And Care For Immigrant Women and Families”, Kinsey Hasstedt said that a web of policy barriers to public and private insurance options effectively keeps millions of immigrant women and their families from affordable coverage and the basic health care, including sexual and reproductive health services that coverage makes possible.

Of course, this sounds all too familiar to anyone who has read my articles in the past about immigration reform, medical tourism/travel, and its implementation into workers’ comp.

Ms. Hasstedt also said that many lawful immigrants are ineligible for coverage through Medicaid and CHIP (Children’s Health Insurance Program) during their first five years of legal residency. And as reported in today’s New York Times, undocumented immigrants are barred from public coverage, and the ACA prohibits them from purchasing any coverage, subsidized or not, through the exchanges.

In The New York Times article, Obama’s Executive Order on Immigration Is Unlikely to Include Health Benefits, the president will use his executive authority to provide work permits for up to five million people who are in the US illegally, and shield them from deportation. But his order will not allow them to be eligible for subsidized, low-cost plans from the government’s health insurance marketplace.

Ms. Hasstedt noted in her article that past immigration policy reforms, both executive (something the GOP forgot about because it was Saint Ronnie who did it) and congressional have failed to address the health care needs of immigrants.

I know there are many in the immigrant community, and among their supporters in the rest of the country who applaud the President for taking this long-overdue action due to the inaction of a Congress more in tune with the sentiments of those who like wearing white sheets, than a party whose last occupant of the White House preached “Compassionate Conservatism”.

And there are many within the Insurance and Risk Management and Workers’ Comp industry who downplay the impact immigration reform and the granting legal status to undocumented workers will have on the number of claims filed under workers’ comp.

But as I said in many previous posts, there is no way that workers’ comp can handle all of the claims that will be filed not only by legal residents, but by immigrants and those who are granted legal work status, as the President will do tomorrow night.

The medical tourism/travel industry is not perfect. Name me one industry that is. But the reality is that I have found, having attended three different conferences in the span of two years , that there are highly professional and dedicated people out there, physicians, hospitals and clinics who not only are seeking patients for private pay or group health insurance, but would probably consider taking on patients under workers’ comp, especially in the areas of orthopedic surgeries from work-related accidents, repetitive motion injuries such as Carpal Tunnel, and even weight-loss surgery, as I mentioned in my last post.

So while many in the industry are gambling in Las Vegas this week, which as the commercial says is where their money is going to stay, and where many Hispanics once called home before we showed up, it is high time to seriously consider medical tourism/travel as an option.

The influx of immigrants, and the soon-to-be announced legal status of the undocumented will put a terrible strain on an already strained health care system. It’s time to open the safety valve and let injured workers, many of them Latino, receive care in their home countries and in neighboring countries so that there are no language or cultural barriers to contend with.

Opening up a safety valve and immigration is nothing new. It’s how millions of Europeans came to America in the 19th and 20th centuries. I would not be here writing this today if my grandparents could not use the safety valve of immigration to escape what would have been a terrible fate. Thousands of Irish would have starved if they could not immigrate to the US and other countries. And millions of Chinese would have died in labor camps, famines and revolutions in the early 20th century.

But so long as the US workers’ comp system is locked away in a “padded cell”, the increased number of legal and undocumented workers with legal work status will add more demand on an already overburdened health care system.

The choice is yours. You can go with the flow of history, or stay in Las Vegas and party your way to irrelevance.