California counties are building a patchwork of health plans to cover the last big group of uninsured residents: immigrants living here without legal documentation.
With Californians enthusiastically taking advantage of the Affordable Care Act, the number of uninsured residents is plummeting.
The U.S. Census Bureau reported this fall that from 2013 to 2014, California saw a 4.7 percent drop in the number of people lacking insurance, one of the fastest improvements in the country.
But one group can’t get coverage through the ACA, even if they wanted to pay for it themselves: undocumented immigrants.
In response, California has undergone an abrupt policy reversal. At the beginning of last year, just seven California counties paid for such care. Today, all but 11 do or plan to institute at least limited local coverage as soon as next year.
“At the end of the day, we would rather that there be a statewide solution, both for uniformity and for equity. It is odd that somebody’s access to health care is dependent on where they live in the same state, that living in Riverside County versus San Bernardino County, say, there’s a difference,” said Anthony Wright, executive director of the consumer advocacy group Health Access.
“Without a state solution, the counties are forced to address it. We do believe that as more and more counties move to see the value in providing a smarter safety net, that becomes a bridge to a statewide solution.”
Wright said his organization sees that solution in SB 10, sponsored by state Sen. Ricardo Lara, D-Bell Gardens. The legislation proposes to seek a federal waiver allowing immigrants to purchase unsubsidized health insurance through Covered California, the state’s ACA insurance exchange.
In October, Gov. Jerry Brown signed another Lara bill, SB 4, that commits state funding to include children under 19 in Medi-Cal, California’s health care program for the poor, regardless of their immigration status. Officials predict the new law, which goes into effect in May, will cover an estimated 170,000 undocumented children. The expansion is projected to cost $40 million in the next fiscal year and about $132 million annually after that.
Depending on the availability of funding, SB 10 would offer either full or capped Medi-Cal coverage to undocumented adults. The state legislative analyst has not yet prepared a report on what that might cost. But last week, (Nov. 10) the Public Policy Institute of California released a report predicting that half the state’s undocumented immigrants – or about 1.4 million people – have incomes low enough to be eligible for Medi-Cal.
Meanwhile, for the poorest of the undocumented, access to insurance currently lies in state Welfare and Institutions Code section 17000, a Depression-era requirement that counties “relieve and support all incompetent, poor, indigent persons.” Since the section specifically refers to lawful residents, until recently most counties have interpreted the coverage requirement as not including people who entered the country illegally.
A shift started in April with a 3-2 vote by Fresno County supervisors to accept a deal with state legislators that lets them commit $5.6 million to health care for the indigent, including the undocumented, instead of using the money to repay state road funds. The county program went into effect the same month.
In mid-June, Sacramento County supervisors voted unanimously to restore health care funding that they had cut in 2009 as part of recession-induced budget reductions. A pilot program for 4,000 to 6,000 adults ages 19 to 64 will cost the county more than $5 million this year and will rely on more than $1 million in in-kind contributions from local hospitals, a county report states.
Later that same month, trustees of the state’s County Medical Services Program, which pools the resources of 35 rural counties to provide health services to the poor, voted to provide basic health care to the undocumented. The board also agreed to raise the income eligibility limit for both legal and illegal residents to three times the federal poverty level, about $12,000 for an individual.
In September, Monterey County instituted a pilot insurance service that sets aside $500,000 to pay for lab tests, radiology and pharmacy services. A staff report points out that frequently, the poor can’t afford such services. ”This often leads to people become increasingly ill and they then require more costly hospital and/or emergency room care,” the report states.
A week later, Contra Costa County supervisors, who had responded to recession-related budget shortfalls by cutting services that included the undocumented, approved a renewed program. It is not full scope insurance, but will provide preventive care, assigning up to 3,000 people a “medical home” at a community health center. Other benefits will include regular physician checkups, immunizations, basic laboratory and radiology services and some access to subsidies on medications. Specialty care is not covered.
Los Angeles resident Maria Hernandez knows she’s lucky to live where she does.
Hernandez, 48, found out recently that she has diabetes.
“Since I’m undocumented, I knew that I wouldn’t be able to qualify for any of the insurance programs that people were talking about under Obamacare, and I didn’t know what I was going to do. An illness like this can be really expensive,” she said.
But Hernandez did qualify for My Health L.A, Los Angeles County’s $61 million program serving the undocumented at or below 138 percent of the federal poverty level. For a family of four, that means a monthly income no higher than $2,743.
My Health L.A. offers primary care, chronic disease management, prescription medication and specialty care at county facilities.
“For me, it makes all the difference between having a chance of maintaining my health and not,” Hernandez said.
35 miles to the east of Hernandez’ south L.A. home, Ontario resident Jorge Gomez is far less sanguine. He says his chronic asthma seems to be getting worse, leaving him short of breath and sometimes unable to report to the maintenance company where he works, even when it’s not severe enough to send him to the emergency room.
“The doctor told me that if I don’t start taking my preventive medicine, I risk permanent lung damage, but how am I supposed to pay for it?” Gomez said.
Ontario is in San Bernardino County, which numbers among the 11 California counties that don’t currently include or plan to include undocumented adults in health care that extends beyond the episodic. The others are Kern, Merced, Orange, Placer, San Diego, San Joaquin, San Luis Obispo, Santa Barbara, Stanislaus and Ventura counties, according to a California HealthCare Foundation report published last month.
“The truth is, we don’t have anything in San Bernardino County that specifically addresses the undocumented because we don’t know who the undocumented is,” said David Wert, spokesman for the San Bernardino County Board of Supervisors.
“We can’t ask people who show up at our clinics whether or not they’re documented. If they’re sick, we care for them. If they don’t have money, that’s OK, because the state gets money from the state and federal government to pay for indigents, whether they’re documented or undocumented.”
It’s true that federal law bars emergency rooms from seeking information about patients’ immigration status or apportioning care on that basis. The CHCF report notes that San Bernardino County does treat the indigent at clinics operated by its Arrowhead Regional Medical Center.
“It’s difficult to get a really clear description of what different counties are doing with their indigent care programs,” said Catherine Teare, who oversaw the research behind the report.
“Some counties enroll their residents into insurance-like programs. Other counties, particularly those with public hospitals, may just provide episodic care regardless of ability to pay. In both cases, the counties are getting care to their residents, but their structures are very different, and for that reason it’s very difficult to compare apples to apples. On the ground, from the perspective of someone seeking care, it can be extremely difficult to identify and understand what’s available, particularly where there isn’t an insurance program, but rather services available through county facilities. Those not be well publicized in a way that will lead people to understand that they can get that care.”
While she said she lacks the detailed information about San Bernardino County to critique its policies, Teare said she agrees with those who advocate continuity of care.
“Generally, it’s great if people can seek care early in the course of an illness, before problems get bigger and they get sicker,” she said. “That’s typically going to be more available if you have something that’s more like insurance.”
In Santa Barbara County, Supervisor Steve Lavagnino said he’d support expanded healthcare services for the undocumented, if religious institutions and other charities were willing to pay for it.
“There are folks that are here undocumented, and I understand why they came here, but it’s not up to me or any other taxpayer to subsidize their stay,” he said, adding that many of his constituents who are legal residents also lack adequate medical coverage.
“You have to live in the real world. It’s just like if somebody came to my house and knocked on the door and said he was hungry, I’d feed that person. If 10 people showed up, I’d do my best to feed those people. But if 1,000 people showed up, I’d have to say, ‘You know what? I can’t do it all. And that’s what California has to finally realize. You can’t do it all.”
Even when counties don’t fund their own fully developed health plans that include the indigent undocumented, service levels vary widely. For instance, in Kern County, some 30 clinics operated by federally qualified health centers provide primary care on a sliding scale based on income and family size, regardless of a person’s immigration status, said Bill Phelps chief of programs at Bakersfield-based Clinica Sierra Vista.
He said in politically conservative Kern County, where government revenues are largely founded on the petrochemical industry, a steep drop in gas prices makes it unlikely that local officials will expand health care entitlements to include the undocumented.
Anthony Wright, the Health Access director, says the fact that local authorities are faced with such choices reflects a national failure.
“I people actually had the path to legal and citizen status, then you wouldn’t need these workarounds at the state and county level,” he said.
“But in the absence of federal action, then the question is, what do you do about Californians, our neighbors and friends, who are already here and who, like it or not, are already in the health system?”