There is a remarkably simple principle that Washington has spent years trying to make complicated: if you are in the United States illegally, American taxpayers should not be obligated to provide you with benefits intended for Americans and people legally admitted to this country. That should not be controversial. It should not be considered cruel. It should not require a graduate seminar in immigration policy to understand. A country either has borders, citizenship, immigration laws and eligibility requirements, or it doesn't. And somewhere along the way, we began pretending that enforcing those distinctions was morally suspect.

First, Let's Get the Language Straight

I am going to use the term illegal alien. Not because I am trying to insult anyone, but because American immigration law has long used alien as a legal term for a person who is not a citizen or national of the United States, and federal statutes and government agencies have used terms including illegal alien and alien unlawfully present. The modern insistence that everyone must say "undocumented immigrant" is a political preference, not some binding rule of English or law. People are free to use whatever terminology they prefer. So am I.

And the issue here isn't anybody's ethnicity, birthplace or humanity. It is legal status. Legal immigrants followed the rules. Citizens are members of the political community. Illegal aliens are present in violation of immigration law or without lawful immigration status. Those categories mean something. At least they are supposed to.

"But Illegal Aliens Can't Get Medicaid"

This is where the conversation gets interesting. You frequently hear some variation of: illegal aliens aren't eligible for Medicaid, so taxpayers aren't paying for their healthcare. That statement contains enough truth to be misleading.

Federal Medicaid generally requires recipients to be citizens or qualifying noncitizens. Illegal aliens generally are not eligible for ordinary full-scope federally funded Medicaid. Fine. Case closed? Not remotely.

Federal law nevertheless requires Medicaid coverage for certain emergency medical services provided to otherwise eligible people regardless of lawful immigration status. Medicaid's own guidance specifically recognizes emergency coverage for non-qualified noncitizens. Then there are states that decided federal restrictions weren't generous enough. Some states created their own Medicaid-like programs, using state taxpayer money, to provide broader healthcare coverage regardless of immigration status.

So when somebody says, "Illegal aliens don't get Medicaid," the proper response is: which Medicaid? Which benefits? Which state? And whose money are we talking about? Because the actual answer is considerably more complicated than the slogan.

And Yes, We Are Talking About Billions

This is the part taxpayers deserve to hear without political spin. CBO examined the immigration surge that began in 2021 and found that it imposed measurable costs on state and local governments. In 2023 alone, immigrants associated with that surge generated approximately $10.1 billion in state and local tax revenues while governments spent approximately $19.3 billion providing goods and services associated with the surge.

Net direct cost: $9.2 billion in one year. Using a broader measure, CBO estimated a potential net cost of $9.8 billion.

That does not mean every person in CBO's "surge" category was an illegal alien. CBO explicitly says the group included different immigration circumstances, including some people who had permission to remain temporarily and some who did not. That distinction matters. But CBO also reported that most of the surge consisted of what it calls "other foreign nationals," people who were not lawful permanent residents, were not admitted on the usual temporary basis under the Immigration and Nationality Act, and generally did not have a pathway to permanent residence based on their existing status.

The expenses were real: education, shelter, healthcare, border security, legal and translation services, public infrastructure and government administration. And somebody paid them. You did.

California Shows How Far This Can Go

California provides perhaps the clearest example of what happens when a state decides immigration status should no longer matter for healthcare eligibility. The state expanded Medi-Cal coverage to income-eligible residents regardless of immigration status. By 2025, California officials were confronting costs running into the billions of dollars annually for that coverage. A congressional Budget Committee release, citing California Department of Finance figures, reported an estimated $8.4 billion in fiscal-year spending associated with health coverage for illegal aliens.

We can argue about whether California should do that. California voters and legislators can decide how they want to spend California money. But let's stop pretending the money doesn't exist. It exists, and every dollar spent somewhere represents a dollar that cannot simultaneously be spent somewhere else. That is called an opportunity cost, and apparently it disappears from political discussion whenever immigration enters the room.

What Could $9 Billion Buy?

Forget the national argument for a moment and think about what several billion dollars represents. It could finance thousands of additional police officers, repair aging bridges, expand veterans' mental-health services and help homeless American veterans get off the streets. It could fund addiction treatment, improve rural hospitals, expand services for disabled Americans and help municipalities build water infrastructure. It could improve schools, reduce property-tax burdens, fund wildfire mitigation in Western states, help American foster children or go toward the national debt.

Or, and I know this sounds revolutionary, government could simply leave some of it in the pockets of the taxpayers who earned it.

Every government program involves choices. The question isn't whether an illegal alien needing medical treatment is a human being worthy of compassion. Of course he is. The question is whether compassion creates an unlimited financial claim against American taxpayers. It cannot. No government on Earth operates that way.

Emergency Care Is the Hard Case

There is one distinction worth making because otherwise this argument becomes too easy to caricature. If somebody is bleeding to death outside an emergency room, I do not want the hospital receptionist checking immigration papers before a doctor stops the bleeding. Most Americans don't. Civilized societies provide emergency care, and federal policy recognizes exactly that, which is why emergency Medicaid exists for people who otherwise satisfy financial requirements but are ineligible for regular Medicaid because of immigration status.

But emergency humanitarian treatment is one thing. Turning temporary emergency protection into a gateway toward increasingly comprehensive taxpayer-funded benefits is something entirely different. We ought to be capable of maintaining both propositions simultaneously: don't let human beings die in the street, and illegal presence in America should not create entitlement to the same taxpayer-financed benefits available to citizens and lawful residents. Those ideas are not contradictory. They are what borders mean.

"But They Pay Taxes"

Yes, many do, and any intellectually serious discussion has to acknowledge it. CBO estimates that the recent immigration surge increases government revenues substantially. At the federal level, CBO projected that increased immigration would generate approximately $1.2 trillion in additional federal revenue from 2024 through 2034, exceeding certain additional federal expenditures and reducing projected federal deficits overall. That matters. It would be dishonest to discuss costs while pretending revenues do not exist.

But here's the equally important part. Federal finances are not the same thing as state and local finances. CBO found that while the surge was projected to improve the federal fiscal picture, it created a net fiscal burden on state and local governments, particularly because schools, housing, healthcare and other services are delivered locally. That explains why both sides can throw around apparently contradictory numbers and occasionally both be telling the truth. Washington collects payroll and income taxes. Denver, New York, Chicago, Los Angeles and other communities have to provide classrooms, shelters, hospitals, police services and infrastructure. Different ledger. Different result.

And That Brings Us Back to Medicaid Data

Which makes the recent political fight over Medicaid information almost comical. For years Americans were assured that illegal aliens weren't really receiving Medicaid benefits. Then the federal government began looking at Medicaid-system information for immigration-enforcement purposes, and suddenly politicians were deeply concerned that immigration officials might identify illegal aliens through those records.

That doesn't prove every illegal alien appearing in a Medicaid database was receiving full Medicaid benefits. They weren't. Emergency Medicaid exists. State-funded programs exist. Mixed-status families exist. Eligibility records exist. That is exactly why the original meme oversimplifies the issue. But it does expose something worth discussing: if immigration status is sufficiently relevant to Medicaid administration that government databases record it, then taxpayers are entitled to ask exactly what benefits are being provided, to whom, under what authority and at what cost. That isn't xenophobia. That's accounting.

Citizenship Has to Mean Something

This is ultimately bigger than Medicaid. Citizenship carries obligations. We pay taxes, obey laws, serve on juries, and some Americans serve in the military. We finance the institutions of government. In return, membership in the nation carries benefits and protections. Legal immigrants also enter into a defined relationship with this country under rules established by law. If someone can bypass the immigration system and then progressively receive the same public benefits anyway, the distinction between lawful and unlawful immigration becomes increasingly meaningless, and that isn't fair to Americans, isn't fair to taxpayers, and perhaps most importantly, isn't fair to the millions of immigrants who did things the right way.

This Isn't About Hating Immigrants

That accusation has become tiresome. America can be profoundly pro-immigration while being fiercely opposed to illegal immigration. In fact, those positions fit together perfectly. Bring us ambitious people, engineers, roofers, doctors, carpenters, entrepreneurs, farm workers, scientists, nurses, tradesmen and software developers, people who want to build businesses, raise families and become Americans. Have an immigration system large enough to serve the country's economic needs and flexible enough to attract talented and hardworking people. Then enforce it. Otherwise it isn't an immigration system. It's a suggestion.

Charity Is Virtuous. Compulsory Charity Has Limits.

Americans are extraordinarily charitable. If churches want to feed migrants, wonderful. If charities want to house people, wonderful. If citizens want to contribute their own money, wonderful. Private compassion is one of the strengths of this country. But government spending is different. Government doesn't donate money. It takes money from taxpayers and allocates it. That creates an obligation to prioritize.

When American families cannot afford healthcare, housing and groceries, when veterans sleep beneath bridges, when rural hospitals close, and when cities raise taxes because shelters are overflowing, government should have to explain the priority rather than simply scream "compassion" and declare the discussion finished. Compassion without limits isn't public policy. It's bankruptcy.

There Is Nothing Radical About This

The radical position isn't enforcing immigration law and reserving ordinary public benefits primarily for citizens and lawful residents. That was historically the normal position. The strange position is that a nation may establish immigration requirements, watch millions of people circumvent those requirements, incur billions in resulting costs and then be morally forbidden from asking whether any of this makes sense. It makes no sense.

A generous immigration system needs enforcement precisely because generosity cannot survive unlimited abuse. A welfare state requires eligibility rules precisely because resources are finite. And citizenship requires meaningful distinctions precisely because otherwise citizenship becomes little more than paperwork.

There is plenty of room for compassion. There is plenty of room for legal immigration. There is plenty of room for asylum genuinely authorized under law. There is room for emergency medicine because we remain human beings before we are accountants. But there also has to be room for one sentence that shouldn't require an apology: if you are not legally entitled to live in the United States, you should not expect American taxpayers to finance your life here.

That isn't hatred. It isn't racism. It isn't anti-immigrant. It's the difference between having an immigration system and pretending to have one. And with governments spending billions of dollars while American taxpayers are already carrying a federal debt measured in tens of trillions, perhaps asking "why are we paying for this?" isn't the cruel question. Perhaps refusing to ask it is the irresponsible thing.