Dur­ing his State of the Union address on Tues­day, Pres­i­dent Trump put Medicare for All in the crosshairs. Sin­gle-pay­er health­care will ​“bank­rupt our nation by pro­vid­ing free tax­pay­er-fund­ed health­care to mil­lions of ille­gal aliens,” he seethed, ​“forc­ing tax­pay­ers to sub­si­dize free care for any­one in the world who unlaw­ful­ly cross­es our bor­ders.” Like so many of the oth­er claims in Trump’s speech, this one was demon­stra­bly false. If any­thing, the evi­dence sug­gests that immi­grants actu­al­ly sub­si­dize health­care sys­tems — and it is time for advo­cates to push back.

Including immigrants in an insurance system, in other words, makes it more actuarially sound.

For pro­po­nents, the case for sin­gle-pay­er is fun­da­men­tal­ly a moral one: Health­care should be a right, and every­body should be cov­ered. This argu­ment, how­ev­er, is up against the ran­corous rhetoric of the dem­a­gog­ic Right, which is not only advanc­ing dehu­man­iz­ing nar­ra­tives of exclu­sion, but also bol­ster­ing those nar­ra­tives with fac­tu­al inac­cu­ra­cies. Accord­ing to one CNN poll, some 59% of the Amer­i­can pub­lic is opposed to pro­vid­ing pub­lic cov­er­age to the undoc­u­ment­ed. Chang­ing this opin­ion means over­turn­ing the right-wing nar­ra­tive. To do so, we have to make the case that Trump’s claim — that includ­ing all U.S. res­i­dents in a sin­gle-pay­er sys­tem will bank­rupt it — is wrong.

A fun­da­men­tal fact about financ­ing health­care for immi­grants is that they are, com­pared to the native-born pop­u­la­tion, rel­a­tive­ly young, and there­fore healthy. As a result, immi­grants tend to use com­par­a­tive­ly less health­care (indeed, too lit­tle) rel­a­tive to those born in the Unit­ed States. At the same time, they still pay into the sys­tem — even undoc­u­ment­ed immi­grants. Pre­cise num­bers are hard to come by, but as Paul Van De Water of the Cen­ter on Bud­get and Pol­i­cy Pri­or­i­ties has not­ed, undoc­u­ment­ed immi­grants were esti­mat­ed to have con­tributed a net $12 bil­lion into the Social Secu­ri­ty sys­tem via pay­roll tax­es back in 2007. Some­thing sim­i­lar plays out in health­care. As two impor­tant stud­ies led by my col­league Dr. Leah Zall­man at Cam­bridge Health Alliance and Har­vard Med­ical School make clear, in health­care, immi­grants sub­si­dize the U.S.-born.

In a 2013 study pub­lished in Health Affairs, Zall­man and col­leagues exam­ined how much immi­grants pay into the Medicare trust fund, rel­a­tive to how much Medicare spends on their health­care. They found that while immi­grants paid some $33 bil­lion in Medicare tax­es in 2009, they only used $19 bil­lion in health ser­vices — in oth­er words, they sub­si­dized the trust fund to the tune of near­ly $14 bil­lion. In a sec­ond study, also pub­lished in Health Affairs, researchers turned to pri­vate insur­ance, and a sim­i­lar pic­ture emerged. Pre­mi­um con­tri­bu­tions from immi­grants (includ­ing the undoc­u­ment­ed) exceed­ed plans’ out­lays on immi­grants’ health­care. In con­trast, U.S.-born enrollees con­tributed less than what they used in care — a deficit of about $163 per native-born person.

Includ­ing immi­grants in an insur­ance sys­tem, in oth­er words, makes it more actu­ar­i­al­ly sound. ​“Immi­grants sub­si­dize US natives in the pri­vate health insur­ance mar­ket,” the researchers con­clud­ed, ​“just as they are prop­ping up the Medicare Trust Funds.”

Evi­dence from abroad — in par­tic­u­lar, Spain — sim­i­lar­ly strength­ens the eco­nom­ic case for cov­er­ing every­one. Spain’s uni­ver­sal sys­tem dates back to the 1980s, but as health researcher Hele­na Legi­do-Quigley of the Lon­don School of Hygiene and Trop­i­cal Med­i­cine described with col­leagues in Lancet Pub­lic Health, the nation passed a law in 2011 that ​“gave an explic­it right to free health care for all peo­ple liv­ing in Spain, both Span­ish and migrant, irre­spec­tive of their legal sta­tus, mak­ing Spain one of the most migrant-friend­ly health sys­tems in Europe.” Still, it hasn’t been a straight­for­ward path. In 2012, a new­ly elect­ed con­ser­v­a­tive gov­ern­ment reversed this expan­sion. They were met, how­ev­er, with a wave of resis­tance, includ­ing civ­il dis­obe­di­ence. Some 1,300 doc­tors and nurs­es pledged to defy the law and treat immi­grants regard­less of doc­u­men­ta­tion sta­tus, as the British Med­ical Jour­nal report­ed. After elec­tions in 2018, the new left-wing gov­ern­ment of Pedro Sanchez restored cov­er­age to all.

In 2018 (the lat­est year of data avail­able from the OECD), Spain spent some $3,323 per capi­ta on health­care — com­pared to more than $10,000 in the Unit­ed States. It seems unlike­ly that the 2019 fig­ures will change that over­all pic­ture much. As such, the pol­i­cy of extend­ing uni­ver­sal health­care to immi­grants has not bank­rupt­ed Spain’s system.

Legi­do-Quigley and col­leagues, writ­ing in the British Med­ical Jour­nal last year, cite oth­er evi­dence of cost-sav­ings from Euro­pean nations, includ­ing a study in Ger­man that found that a pol­i­cy of lim­it­ing health­care access for asy­lum seek­ers and refugees actu­al­ly led to larg­er health­care costs down the road.

Europe, need­less to say, faces the same sorts of right-wing pop­ulist forces that we con­tend with in the Unit­ed States. Recent con­ser­v­a­tive gov­ern­ments in the Unit­ed King­dom, for instance, have tak­en steps to restrict access to the Nation­al Health Ser­vice to migrants. Achiev­ing true uni­ver­sal cov­er­age will be no eas­i­er here than abroad. But we should see the imped­i­ments as polit­i­cal — not economic.

For advo­cates of Medicare for All, the moral case for uni­ver­sal health­care will always be para­mount. Even if the above real­i­ties were not true, we should still include immi­grants in uni­ver­sal cov­er­age, on the basis that health­care is a human right and no one should be left to die because they can’t afford to go to the doc­tor, regard­less of nation­al ori­gin. How­ev­er, the claim that immi­grants would bank­rupt the sys­tem is an empir­i­cal one that can be dis­proven, and fac­tu­al inac­cu­ra­cies should not be allowed to stand, espe­cial­ly when they are used to ampli­fy xeno­pho­bic bom­bast from Pres­i­dent Trump and his right-wing back­ers. The fact that a Medicare for All sys­tem that includes immi­grants would be eco­nom­i­cal­ly sound is one of the many data points we can use to make the case to mil­lions of peo­ple that it is our moral imper­a­tive to build a Medicare for All sys­tem that includes everyone.