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Citizenship of Convenience

Lifting restrictions on travel visas is supposed to spur tourism. Yet a few citizens do quick cost-benefit checks of other nations’ laws, then hop on planes, relocating for benefits: With the 14th Amendment to the US Constitution providing citizenship to those born in the United States, thousands of pregnant women travel to give birth, thus ensuring those children access to US public education. US citizens with passports in countries with affordable national health care, like Taiwan, travel overseas for treatment; to be reinstated in Taiwan’s National Health Insurance system, citizens returning from overseas need only pay six months of premiums. Such tourism hikes costs for taxpayers in the countries that provide generous health care and education benefits. “Lifting of travel visas requirements for Taiwanese will undoubtedly ease the challenges to birth tourism and add to US immigration problem,” writes Tyler Grant, a 2012-2013 Fulbright Fellow in Taiwan. Countries must tighten loopholes and improve economic conditions – or taxpayers could demand new restrictions on travel for all. – YaleGlobal

Citizenship of Convenience

With passports, dual citizenship, citizens hop between countries for health care, education
Tyler Grant
YaleGlobal, 5 March 2013
Born in the USA: Social-economic advantages of American citizenship draw Taiwanese women to give birth on US soil (top); some US citizens are not happy

TAIPEI: “America is the greatest country in the world with one of the worst health insurance schemes in the world.” This sentiment is echoed by many Taiwanese nationals and articulated by Andrew Lin, a Taiwanese-American who currently resides in Taiwan. Conversations with Taiwanese like Lin show a growing frustration with the economic status of Taiwan, as they look to countries as diverse as the United States and Mainland China for greater opportunity. Many, as Lin’s parents did, make the journey to the United States or Canada to secure opportunity in the form of a foreign passport. 

A few citizens are taking advantage of eased travel regulations to procure health care – and this could lead to new citizenship and economic problems for countries like the United States and Taiwan.  

Families by the thousands secure travel visas and head to the United States, Canada and other nations with the hope of giving birth abroad. This phenomenon, common among Turkish, Chinese and Taiwanese nationals, has grown in recent years and become a business. Private companies transport, house and provide the necessary arrangements for so-called birth tourists to enter the country and stay until they give birth. Taiwan is of particular significance because of its affordable healthcare for citizens and positive relationship with the United States and Canada.

In November 2012,
the US adopted a visa-waiver program with Taiwan that could create financial challenges.

The United States on November 1, 2012, adopted a visa-waiver program with Taiwan, which could create significant financial problems for the Taiwanese and complications for the United States and its ongoing immigration debate. Increasing birth tourism and a larger number of individuals returning to Taiwan to take advantage of affordable medical insurance and low medical costs will raise insurance premiums for all Taiwanese, increase the number of citizens who return to Taiwan to claim cheaper health insurance and put a heavier burden on US taxpayers for public schools.

The number of individuals seeking reinstatement in Taiwan will continue to increase. According to the Taiwan Bureau of Health, the number of citizens who return to Taiwan for medical procedures is estimated at 50,000 returnees per year and expected to increase as health care costs globally go up. Meanwhile, birth tourism may be on the rise, with the US-based Center for Immigration Studies estimating that of the more than 300,000 children born to undocumented residents in the United States every year, 40,000 are to tourists. The National Center for Health Statistics tallied 7,670 births to mothers who used a foreign address. However, this number is likely a low estimate due to birth tourist mothers often using a hotel or current US address for the child’s birth certificate. This rise of birth tourism could increase the number of dual-citizen Taiwanese and the number of individuals returning to Taiwan for health-care reinstatement.

Conversation after conversation with Taiwanese in Yilan County reveals deep frustration with the fairness of the National Health Insurance program. A payroll tax for the Taiwanese workforce pays for these low-cost health-care premiums. Under current regulations, as of January 2013, returning Taiwanese  need only pay six months of insurance premiums to be reinstated. The National Health Insurance has run a deficit for the past several years; premiums are in the hands of the legislature predicted to continue to rise.

Some families don’t pay lifelong taxes, instead relocating back and forth to pick up quick benefits.

Lifting travel-visa requirements for Taiwanese will undoubtedly ease the challenges to birth tourism and add to the US immigration problem. While most Americans are familiar with "anchor babies" – immigration by parents using the US citizenship of their babies as a means towards their own citizenship – birth tourists generally do not seek US citizenship for themselves. Instead, their children, born in the US and raised in Taiwan, often return as high school or college students to take advantage of less expensive, even free, and better education not to mention other services available to American citizens. Neither the children or their parents have paid into the system, instead relocating back and forth to pick up quick benefits.

So, both sides of the Pacific are saddled with significant and risings costs. According to reports by the Taiwan Ministry of Health, in 2011, reinstatement costs were US$ 567 million while medical costs incurred were over US $700 million. The gap is increasing, in 2010, medical costs minus reinstatement costs were less than US $100 million. While the recent policy adoption of a six-month premium reinstatement aims at closing this gap somewhat, it’s not enough. Meanwhile, if the current trend continues, the United States will certainly face a larger number of Taiwanese-American citizens hoping to return to the country as students in US public high schools.

There are multiple answers for these two countries that are much simpler than amending the US Constitution or further altering Taiwan’s premium payable schedule. The first response is creating a more positive economic climate in Taiwan. Stephen Chen, a Taiwanese-American who lives in the United States, points to economic disparities as a key reason behind such relocations: “It's easier to find a job [in the United States] than in Taiwan, at least that's the perception [in Taiwan].” While economic growth in Taiwan has remained at a constant, steady increase over the last three years, perceptions of security are not so high, as revealed by the approval rating of President Ma Ying-Jeou and his party’s economic policies, which have fallen below 20 percent, according to The Economist. Creating greater economic security rather than sending jobs to Mainland China, the United States or Canada – at least the perception of security – could reduce birth tourism somewhat and retain workers in Taiwan.

One drastic
measure could be to
end dual citizenship
for health-care or
other benefits.

Secondly, Taiwan and the United States could adjust immigration laws to account for birth and medical tourism. While arriving in the United States as a pregnant “tourist” is not illegal, misrepresentation on visa forms and during interviews with Immigration and Customs agents is a federal offense. Gary Chodorow, a Beijing immigration lawyer, points out that birth tourism companies coach immigrants on what to say to customs officials and how to fill out visa forms, albeit deceptively. The United States could deter birth tourism with harsher penalties or stricter enforcement. Hong Kong recently employed similar strategies, reducing the number of Mainland China mothers immigrating to Hong Kong to give birth to below 35,000 per year, according to Beijing-based Caixin.

In Taiwan, a drastic but reasonable measure could be to end dual citizenship for health care benefits. This would mean that at 18 or 21 years of age, adults would have to choose which citizenship to recognize. If the individual chose the United States, the individual could not return to Taiwan for National Healthcare and instead would use US or traveler’s health insurance.

Thirdly, other Taiwanese pursue foreign passports for their children as necessity, out of fear of regional instability with a hostile North Korea and China. Countless Taiwanese parents remember the 1996 Taiwan Strait crisis and earlier crises, and regard an escape plan for their children as necessity. Chen voices the concern of many Taiwanese:  “the most effective way for us to decrease the rate of birth tourism is to promote peace and stability in regions where birth tourists originate and to strengthen mutually each other’s economic development.”

Few can fault individuals for seeking economic opportunities for their children in tough financial times. The United States and Taiwan must work together to regulate transient citizens who seek benefits and rights without taking on the responsibilities of citizenship – or the consequences could be costly, ruining travel opportunities for all.


Tyler Grant is a graduate of Washington and Lee University. He is currently a 2012-2013 Fulbright Fellow to the Republic of China – Taiwan. The author will field readers' questions for a week after the publication date.

Rights:Copyright © 2013 Yale Center for the Study of Globalization

Comments on this Article

11 March 2013
I'll go so far as to say that there is no need for the 14th Amendment at all. The main intent of the 14th Amerndment was to provide automatic citizenship for blacks born in the US. This was so they could not be excluded from voting. Since there are no more slaves or indentured servants in the US, there is no need for that article of the amendment nor the article pertaining to legislative apportionment. Neither is there a need to deal with punishing those guilty of insurrection,i.e., fighting on the side of the South in the Civil War, nor any of the other issues pertaining to the Civil War. Abolish the whole amendment, and you'd be back to where we should be, that is, with Congress able to pass effective legislation controlling immigration.
5,000 "illegal" births a year? I'd say that would be a tally for a few months in East LA. A famous mural in that part of LA declares "Somos la Mayoridad!" (We are the Majority). In large tracts of LA, you can live very happily without speaking a word of English. Fake driver's licenses and green cards are easily available.
I worked in Taiwan in the very early 90s, when it was still a haven for teacher-travelers who would work (illegally) during the summer vacation as English teachers. The summer of '91 featured a crackdown on those teachers, with fines and deportation being the usual result if caught. Taiwan's policy on immigration is strict and stringent, as ours should be.
On the other hand, Little Taiwan, as Monterrey Park (east of Los Angeles) is called, has some dynamite Chinese (Taiwanese) restaurants.
-Steve , Thailand
10 March 2013
Thank you all for your comments and thank you Gary for the information you have provided and experienced first hand.
Finding specific numbers for this phenomenon is difficult. As Gary and my conversations with others have suggested, many women that travel to the United States for the purpose of birth tourism are coached to answer questions and fill out forms in specific ways meaning that when they provide addresses for their newborn child often they put a hotel or residence of the company owner who helped them enter the United States. This makes it difficult to count precisely. Estimates vary but the lowest estimate I have seen was in the range of 5,000 to 10,000 babies with the higher estimates ranging in the hundreds of thousands. The United States has other immigration struggles not all of which comes from birth tourism so it is difficult to take estimates for total children born to illegals in the United States and subtract those that are birth tourists. However, companies that run out of Beijing, Taipei, Turkey, and other countries where a U.S. passport is valued significantly suggest a booming business. I will work on finding more precise figures from these companies and reporting on that when I can.
As far as implications for US immigration policy, I think the issue is more complicated. Overlooking politics itself - from a policy standpoint, altering the 14th amendment seems unfeasible.
-Tyler Grant , Yilan, Taiwan
9 March 2013
Well,It's really funny for those"oversea Taiwanese" returning back to Taiwan to get the cheap medical treatment by paying only six months of insurance premiums.Hence,I think the policy that those American-Taiwanese who are in their age of 18 are needed to choose the citizenship between Taiwan and US is really important to be enacted.
-David LIU , Taiwan
8 March 2013
The 14th Amendment was ratified in 1868, when there were no passports, visas, or restrictions on immigration. Its statement of citizen is dramatically simple. "All citizens born ... in the United States, and subject to the jurisdiction thereof, are citizens of the United States...."
For those not familiar with the circumstances of its passage, it was in fact ratified for the benefit of blacks. Because the US had stopped importing slaves in 1808, at least blacks under 60 were granted full citizenship. Other articles in the amendment deal with other unsettled Civil War issues, including the odious (and often referenced) apportionment article which counted slaves as 3/5s of a person.
It was not the intent of those writing the amendment to dictate immigration policy.
This amendment is clearly out of date and needs to be itself amended.
Arguments about "how many babies are born" are disingenuous. A low estimate would be 300,000 a year. But those anchor babies then pave the way for citizenship for parents, then parents and siblings of their parents, and thus wives of those family members, and thus families of the wives, etc.
If we eliminated automatic citizenship by birth (for future births), it would be a relatively simple matter to establish the citizenship of the child based on his birth to natural or naturalized parents. Otherwise, his birth certificate would be marked "non-citizen". He would no longer be a "jackpot" baby, a term often used today.
-Steve , Thailand
8 March 2013
I’m always in awe how governments are so good at playing “victim” when a trivial number of people abuse the government, but are totally dumbfounded when governments create conditions that wind up abusing thousands to millions of citizens.
Example 1: The 1987, 1997 and 2007 global financial crises, that were mainly of US making, were the product of an “Oops, my bad” situational blindness that the US bureaucrats responsible for the conditions, from the President down, played to the hilt but cost millions of citizens around the world their life’s saves. Ne’er a “Sorry about that” has ever been uttered.
Example 2: Today, in the US, if you ship your household goods overseas, shippers can do what they want with your property and bill you what they want. If you report the “plundering” of your property to the government you will be asked to fill out a complaint for which the only action is the acknowledgement that they received your complaint. It appears that as long as the felons pay their taxes our bottom-line focused government is happy to: (1) enjoy the incremental taxes collected from “tax-paying” felons; and, (2) enjoy the savings incurred by NOT investigating, prosecuting, and jailing the felons. Ne’er a “Sorry about that” has ever been uttered about that either.
I would suggest that a movement is needed to build an International Criminal Court – along the lines of the Nuremberg Criminal Court – that would put the felons and the government officials who permitted the plundering and crimes against humanity to be put behind bars, along with really non-trivial fines.
To reduce the debate to concrete numbers - in other words, we can all agree that 5 is more than 4. To achieve that goal, would a qualified Yale econometrician be so kind as to calculate two sets of measures so that gibberish can be reduced to concrete numbers and the order of magnitude difference?
Case 1: (a) the number of foreign mothers and the amount of money of which they “abuse” the US government when they give birth in the US to get citizenship for their kids; (b) the number of Taiwanese and the amount of money of which they “abuse” the Taiwanese government when they travel back to Taiwan for health benefits.
Case 2: (c) the number of people worldwide and the total amount of money of which they were “abused” by the US government playing “Oops, my bad;” (d) the number of Americans and the total amount of money of which they were “plundered” (property and crooked billings) because the US government was playing “Oops.”
To be scientific, the Null Hypothesis is: That the total amount of money in (a) and (b) is NOT greater than the total amount of money in (c) and (d) by a magnitude of 10,000.
-Dr. A-F , Panama
7 March 2013
This is an issue that I didn't know about.
I was wondering, how does this effect the US's overall policy on immigration and how it will effect the current debate on immigration in the US?
-Leon Cross , United States
7 March 2013
Do you have any non-anecdotal evidence of the "thousands" of people coming to the US to have children? Most of the information I've seen suggests that this is a tempest in a teapot spurred on by politicians looking to cash in on xenophobia (
-Jason Currie , Pittsburgh, PA
7 March 2013
Thanks for picking up on my point that the U.S. should dissuade birth tourists through stricter enforcement of existing laws.
Just as you say there's no need to change the 14th amendment, similarly there's no need to take the draconian measure of banning pregnant women from visiting the U.S.
An intended mother or father who lies to a consular officer at a U.S. Embassy or to a customs officer at a U.S. airport about the principal purpose of travel has already committed a number of felonies and may be permanently barred from entering the U.S. in the future. (For ideas how consular officers and customs offers should better enforce existing laws, see
Gary Chodorow
-Gary Chodorow , Beijing