Juan Jimenez has kidney disease and his lab results are getting worse. Suzanne Powell, his family physician at La Clinica de la Raza in Concord – about 20 miles east of Oakland – is out of answers. She needs to get Jimenez to a specialist.
“The concern is that he’ll advance, that his kidney disease will advance to the point where he needs dialysis. And because he’s so young and has a family and is obviously working, we don’t want that to happen. So, it’s pretty urgent that he get in,” says Powell.
But the 33-year-old is an undocumented immigrant from Mexico. He supports his partner and their two daughters working construction and doesn’t get health insurance through his job.
Jimenez pays out-of-pocket for doctor visits, prescription drugs and labs. If the community clinic's sliding scale wasn't available to him, he'd have few options for health care.
“Like many people, we just look for home remedies from our mothers or from our grandmothers,” Jimenez says through a translator.
This January, millions of low-income Californians will have new health insurance options under the Affordable Care Act. But a hole in coverage still exists for one group: roughly 1 million undocumented immigrants will be without insurance in 2014, according to the UC Berkeley Labor Center.
With few exceptions, most people without papers will continue to be barred from Medi-Cal, the state's health program for the poor. And they're not allowed to buy plans on the state’s new insurance marketplace – Covered California – even at full cost.
Without insurance, Powell says her very ill patients usually can't afford referrals to outside specialists. Instead, she searches hospitals for volunteer doctors willing to work on a sliding scale.
“There’s a lot of mornings when I wake up thinking about a patient, you know, worried I can’t get them in, I don’t know what I’m going to do, and that’s very hard,” says Powell.
Community clinics and emergency rooms have long provided safety-net care to this group. And that's unlikely to change.
More people enrolled in Medi-Cal under health reform will mean busier community clinics. Carmela Castellano-Garcia of the California Primary Care Association, a group that represents community clinics, says that because undocumented immigrants are excluded, funding their care will continue to be a challenge.
“There will continue to be a financial strain on the community health centers as a result of health care reform not providing any real coverage for this population,” she says.
Providing full coverage to this group would save the state money, says Castellano-Garcia. “Ultimately, we think that the evidence shows that it just makes economic sense to have individuals healthy as opposed to waiting for very costly emergency room visits.”
California provides more health programs to low-income people without legal status than many other states. But these benefits are granted only in some situations like pregnancies and certain emergencies.
Unexpectedly, by expanding healthcare to legal residents, the Affordable Care Act may indirectly help people who are undocumented. More community clinics are being built around the state. And health reform's new Medi-Cal rules could expand emergency coverage to more people who are here without papers.
But Reshma Shamasunder, of the California Immigrant Policy Center says the emergency Medi-Cal program doesn't provide follow-up care until the person becomes seriously ill again.
"So yes, it’s great that a slightly expanded population can access emergency Medi-Cal, that's better than nothing. But it’s a flawed program and it doesn’t substitute for coverage,” she says.
With papers but still without coverage
Three months ago, Pablo Barrios was given a work permit and a social security number under the temporary Deferred Action for Childhood Arrivals program because he was brought here illegally when he was five years old.
California will only be able to use state funds, not federal dollars, to enroll people like Barrios in Medi-Cal. And if childhood arrivals make too much money to qualify for Medi-Cal, they're not allowed to buy plans on the exchange or receive subsidies.
Still, the 25-year-old works doing outreach about the Affordable Care Act for St. John’s Well Child and Family Center, a community clinic in South Los Angeles.
He says the work is bittersweet, but there is an upside: generating funds for the safety-net clinic. “Medi-Cal eligible patients bring in money to the clinic and whatever funds they bring in, whatever amount, a percentage is used to subsidize patients who are uninsured,” he adds.
But providing healthcare to undocumented immigrants is a politically contentious issue. Ira Mehlman from the Federation for American Immigration Reform says people who have arrived here illegally should be discouraged from staying.
“They have to take responsibility for themselves and either come up with some way to provide their own healthcare insurance or that ought to be one of the factors leading people to decide, ‘maybe I shouldn’t be remaining in the United States illegally, maybe I ought to return to my home country,’” says Mehlman.
An immigration reform bill passed by the Senate would do little to change healthcare options in the short term. If it passes in the House of Representatives, immigrants granted a pathway to citizenship would wait 10 years before getting health insurance subsides and 15 years before they're eligible for Medi-Cal.
Castellano-Garcia, of the California Primary Care Association, says that excluding undocumented immigrants harms the state. “These are individuals that are in our workforce, they’re in our homes, they’re taking care of our families, they’re really part of the fabric of California.”
Back at La Clinica, Jimenez is trying to sign up for Medi-Cal. It's a last ditch effort. Undocumented immigrants generally aren't eligible but the clinic thinks he may qualify through his daughter, who was born here.
Jimenez has applied before but it didn't work. He says life for him and his family would change if they had insurance. “It would be different because we’d have more coverage. We wouldn’t be as sick. We’d get our own prescriptions. With this insurance, we’d be relieved,” he says.
Jimenez will wait at least a month to hear back from Medi-Cal.