Access Not Denied? The Role Localities Can Play – Helen B. Marrow
Helen B. Marrow
Universities of California at Berkeley and San Francisco
Mounting evidence shows that rather than overusing healthcare services, as both the American public and its elected officials frequently allege, unauthorized immigrants actually suffer from serious healthcare disparities.[i] A few localities around the United States have implemented noteworthy measures to improve unauthorized immigrants’ healthcare access and reduce these disparities. My research from San Francisco demonstrates how, and why, such measures work.
Unauthorized immigrants have long been deemed “undeserving” of most forms of health care in the United States, especially since the mid-1970s, when the first legal status restrictions on a variety of government programs, including Medicare and Medicaid, were enacted (Fox 2009). In fact, political scientists Lina Newton and Brian Adams (2009) characterize the contemporary American federal policy context toward unauthorized immigrants in health care as so “decidedly hostile” that it leaves states and localities with “little leeway” to improve the situation – even when their government officials, healthcare providers, and immigrant advocates want to do so.
Yet there are notable exceptions, including San Francisco, where local government officials have worked hard to create a more inclusive and less stigmatizing environment for unauthorized immigrants than exists nationwide. Not only have they historically allocated generous funds to the city’s public safety-net infrastructure, but they have also enacted two measures that divorce lack of legal status from the provision and receipt of local public services and benefits. The first is a Sanctuary Ordinance, which prohibits the city’s public employees from either requesting or collecting any information on legal status that is not required by federal or state law, and from cooperating with federal immigration officials regarding any persons not under investigation or convicted of felonies (Tramonte 2009). The second measure is a new Municipal ID Ordinance, which makes it easier for unauthorized immigrants (as well as other city residents) to access the local services and benefits to which they are entitled. Both measures acknowledge unauthorized immigrants’ de facto legitimacy to live in and be part of San Francisco’s civic community on the basis of what geographer Jennifer Ridgley (2008) and political scientist Els de Grauuw (2009) term local “inhabitance” or “residence” (jus domicili) as opposed to birthright, ancestry, or legal citizenship.
Moreover, local government officials have enacted and committed substantial local public funds to two notable health programs – San Francisco Healthy Kids (SFHK) and Healthy San Francisco (HSF) – that increase access to health care for all low-income resident children and adults, respectively, who do not qualify for other forms of federal or state public insurance coverage, regardless of their legal status.[ii]
Although the HSF “universal access” program is limited to primary care services provided by participating institutions or otherwise funded by local HSF monies, it has a tangible effect on providers’ abilities to care for unauthorized immigrants. Within this inclusive local policy environment, the public safety-net primary care providers whom I interviewed in 2009[iii] reported being able to provide care to unauthorized immigrants without worrying about direct costs. And in conjunction with the city’s Sanctuary Ordinance, they reported being able to more effectively buffer against unauthorized patients’ fears of utilizing their services, as well as to marshal resources and advocate for individual unauthorized patients.
For instance, primary care providers reported that San Francisco’s public-salaried payment structure insulates them from having to “eat” the direct costs of treating uninsured patients, which makes them less reluctant to treat unauthorized patients than many providers working either in private practice or in other, less well-funded public healthcare systems. Similarly, they reported that generous funding from city government officials allows them to offer “access to better than 90 per cent” of primary care services without ever thinking or asking about patients’ legal status, which helps them to comply with their dominant professional norm to “suspend judgment” and “not disenfranchise” patients according to personal characteristics. Finally, they reported that San Francisco’s inclusive local policy environment helps them more effectively marshal resources for their unauthorized patients in a variety of ways, not just within their own clinic and hospital, but also outside of it.
At the same time, San Francisco’s inclusive local policy climate has clear limits, and outside its bounds, safety-net providers’ abilities to care for unauthorized immigrants are profoundly constricted. In arenas not governed by HSF – for instance, dental and vision services; high-tech specialty services (like organ transplants) either not offered on-site or not included in the city-funded contract system; and ancillary “social support” services (like public housing, disability, and SSI) – providers reported that their advocacy efforts and autonomy quickly break down. In these realms, they described their efforts to care for unauthorized immigrants as “discretionary” and “voluntary”, as opposed to more systemically supported by inclusive local policy.
Would it be difficult to replicate San Francisco’s model – which even its own safety-net providers called “imperfect” because of its limited focus on primary care services – in other American localities? Absolutely it would. San Francisco is a wealthy and politically liberal city whose public has proven willing to support and contribute taxes to progressive local policies and whose politicians have committed what one physician described to me as “amazing” and “generous” resources to its safety-net healthcare infrastructure. Even still, it’s been no cakewalk here.
But the stakes are growing higher every day, especially now that the Health Care and Education Reconciliation Act of 2010 has stipulated that unauthorized immigrants will not be allowed to receive federal subsidies to purchase their own private insurance, nor to purchase health insurance through new state-based health insurance exchanges, even if they pay completely with their own money (Jackson and Nolan 2010; NILC 2010). As a result, 23 million people will remain uninsured under this Act, and the percentage of unauthorized immigrants among them is projected to rise to one third by 2019 (Pear and Herszenhorn 2010). Unauthorized immigrants’ emergency room costs, currently attributable in large part to their inability to access lower-cost primary and preventive services instead (Dubard and Massing 2007; McConville and Lee 2008), will almost certainly rise as well.
The onus of tempering unauthorized immigrants’ severe disadvantages in access to and utilization of health care are thus left to actors on three levels: (1) federally qualified health centers (national level); (2) states and localities (subnational level); and (3) creative bi- or multi-national initiatives (supranational level). All three sets of actors will be needed. At the subnational level, public safety-net providers in San Francisco unanimously agreed that when a locality chooses to provide all of its low-income residents, regardless of their legal status, with access to a minimum level of primary care services, the entire community – and not just unauthorized immigrants – benefits from improved health and greater social cohesion. And for that, it is a promising local model to follow.
[i] See, for examples, Berk et al. (2000); Capps, Rosenblum, and Fix (2009); Goldman, Smith, and Sood (2005; 2006); Heyman, Núñez, and Talavera (2009); Marcelli et al. (2009); Marshall et al. (2005); Nandi et al. (2008); Ortega et al. (2007); Passel and Cohn (2009); Portes, Light, and Fernández-Kelly (2009); Schur et al. (1999); and Stimpson, Wilson, and Eschbach (2010).
[ii] See Bitler and Shi (2006); Dow, Dube, and Colla (2009); Frates, Diringer, and Hogan (2003); and Katz (2008).
[iii] This research is currently under review at two academic journals.
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Helen B. Marrow, PhD is a 2008-10 Robert Wood Johnson Scholar in Health Policy at the Universities of California at Berkeley and San Francisco, and Assistant Professor of Sociology at Tufts University beginning in September 2010. She is author of New Destination Dreaming: Immigration, Race, and Legal Status in the Rural American South (Stanford University Press, forthcoming 2011), co-editor of The New Americans: A Guide to Immigration since 1965 (Harvard University Press, 2007), and recipient of the 2008 Best Dissertation Award from the American Sociological Association.
Marrow, Helen B. 2010. Access Not Denied? The Role Localities Can Play. AccessDenied: A Conversation on Un/authorized Im/migration and Health. Accessed (date) at