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Providing Health Care to Unauthorized Immigrants - Lessons from San Francisco

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About eleven million unauthorized immigrants live and work in the United States today. Like everyone else, these workers and families need health care. But they often cannot get it, and the challenges are sure to persist. The Affordable Care Act of 2010 promises to extend health insurance coverage to more than thirty million Americans who currently lack it. But unauthorized immigrants are barred from the planned expansions of Medicaid, and they will not even be able to use their own money to buy private insurance on the new state exchanges.

Despite the legal barriers, many advocates, providers, and officials want to provide health care to unauthorized immigrants. Human decency aside, people without access to basic care can spread infectious diseases; and the costs of health care rise for everyone when unauthorized immigrants have no place to go but hospital emergency rooms.

Alternatives for Reaching Unauthorized Immigrants

What can be done? In some border areas, U.S. and Mexican providers work together to provide health care services, but unauthorized immigrants may not benefit because they have the hardest time moving back and forth across the border. Beyond cross-border partnerships, federally subsidized community health centers offer a variety of primary, mental health, and dental services that reach unauthorized immigrants as well as others. But a recent study by Princeton University researchers shows that such community centers are not to be found everywhere. They also require proof of residence and proof of low income from the patients they serve. Such requirements leave out many of the neediest people and may deter unauthorized immigrants.

Local initiatives are the final alternative. Unauthorized immigrants have spread out and now live and work in cities and towns in most of the U.S. states. Local officials end up on the front lines of immigration issues. Some try to crack down and drive people away, but others look for ways to extend basic community services to unauthorized residents. For health care, San Francisco is the most instructive case.

A Close Look at Health Care in San Francisco

Local government officials in San Francisco have worked hard to create a more inclusive and less stigmatizing environment for unauthorized immigrants. San Francisco offers a municipal ID card to all city residents, and it has a history of generously funding public services open to all. In the health arena, San Francisco has enacted and offered funds to two key programs that reach residents regardless of legal status. The San Francisco Healthy Kids initiative subsidizes health coverage for all local children from birth to age 18 who do not qualify for other forms of federal or state coverage. Likewise, the Healthy San Francisco initiative provides access to primary medical care for all local residents ages 18 to 65, though it is not equivalent to full health insurance coverage. Various specialty and primary care services are not covered, including dental and vision care, organ transplants, and long-term care.

To find out more about how these inclusive local policies work on the ground, I recently interviewed 54 health care providers and staff members in San Francisco. Most of my interviewees worked in a large outpatient facility which, like its parent public hospital, serves many low income patients, including people who are uninsured and members of racial, ethnic, or linguistic minority groups. Others worked in hospital-affiliated clinics and departments or nearby community clinics serving Latinos and laborers. My results reveal the strengths and limitations of San Francisco’s pioneering efforts to be inclusive in health care provision.

In several ways, San Francisco’s programs breach the barriers that have kept many unauthorized residents elsewhere from getting needed care. Funding and resources allow health care providers to act on their preference to care for all comers in a systematic way, not just sporadically or at individual discretion. There is also an important symbolic benefit, because officially sanctioned programs send the message that unauthorized patients are worthy of equal care – not morally unworthy people to be pushed aside.

But purely local programs cannot get around all the legal barriers. San Francisco physicians, nurses, and other providers still have to deal with bureaucratic rules, even ones built into the Healthy San Francisco initiative, that keep them from doing many medically appropriate things to treat unauthorized patients. And legal barriers remain decisive when it comes to advanced services and other benefits – such as treatment from specialists or access to mental health and nursing home care, and help with rehabilitation or disability. Legal status continues to be, in the words of one San Francisco physician, “determinant of the care one receives” beyond basics.

Key Lessons

My results highlight the potential for city and state governments to extend much-needed services to unauthorized immigrants who otherwise suffer in the current legal environment. Inclusive local programs may be politically difficult to enact and challenging to fund in a sustained way. But local authorities have room to maneuver. Unless willing to let unauthorized people literally die unassisted, local communities already pay to provide them with health care services in some way. Last-minute emergency care is much more expensive and less efficient than the sorts of un-stigmatized and regularly accessible care offered by San Francisco. This is a cost-benefit calculation that local officials in many places make – and health care providers will often urge them to find sustained, inclusive alternatives to sporadic emergency measures.

Yet my results also show that even providers who have good intentions and work in the most welcoming of places cannot get around all of the obstacles thrown up by national laws and widespread American public beliefs that unauthorized immigrants do not “deserve” equal health care or other vital social services. Ultimately, the United States will have to find better solutions at the national level, so that millions of unauthorized people who live and work in our midst can become equal members of the civic community. Until then, local communities like San Francisco can make a difference, even though they cannot do it all.

Read more in Helen B. Marrow, “Deserving to a Point: Unauthorized Immigrants in San Francisco’s Universal Access Healthcare Model,” Social Science & Medicine 74, no. 6 (2012): 846-54; and “The Power of Local Autonomy: Expanding Health Care to Unauthorized Immigrants in San Francisco,” Ethnic & Racial Studies 35, no. 1 (2012): 72-87.