Last in Line for Health Care: Bridging the Gap in Care for Undocumented People Across California
Written by Lisa Shue, BS and Sonali Saluja, MD, MPH
Governor Gavin Newsom recently unveiled plans to expand health insurance to young undocumented people—a proposal that would continue to pave California’s path towards universal health insurance within the state(1). While the Affordable Care Act has considerably decreased the number of uninsured people, undocumented immigrants have been excluded from this historic insurance expansion. In California, where nearly a quarter of the country’s undocumented immigrants live (2), poor undocumented children became eligible for Medicaid in 2016 (3). Yet for undocumented adults, who now comprise the single biggest group of Californians without insurance, access to health care remains a significant challenge (4).
For uninsured and undocumented people in California, health care is highly fragmented. Health services for indigent (poor and uninsured) Californians are still determined by an 80-year-old law that explicitly states counties are only responsible for providing care for “lawfully” residing persons (5). The law is vague and does not delineate income eligibility, out-of-pocket costs, or even minimum standards of care that should be provided. Each county has interpreted the ambiguous law in different ways, including whether or not to cover undocumented immigrants in their indigent care programs. The result has been a highly variable health care landscape within California where program eligibility and benefits for undocumented residents change from one county to another.
Only a handful of California’s 58 counties have programs in place that provide poor undocumented adults with primary care services (6). Primary care is the hallmark of a functioning health care system and the gateway to maintaining a healthy population with preventive care such as vaccines and cancer screening. Not surprisingly, studies show that people without primary care tend to have worse health outcomes and ultimately present to doctors and other health care providers with much more advanced diseases (7).
Among the few counties that do offer primary care programs for low-income undocumented people there is considerable variability. Counties like Los Angeles and San Francisco offer relatively robust programs. MyHealthLA and Healthy San Francisco follow a medical home model in which participants receive care at a primary care clinic and can also receive specialty and hospital services from county hospitals. These two programs cover laboratory tests, prescription medications, and even some alcohol and drug abuse treatment services (8,9). In contrast, other county programs, such as Santa Cruz’ MediCruz, have stricter eligibility requirements and limited benefits. The MediCruz program does not cover a variety of treatments for common conditions such as mental health care for anxiety and depression, problems that disproportionately affect lower-income residents (10,11).
Another group of 35 mostly rural counties are served by the County Medical Services Program (CMSP), which set up a pilot program in 2016 that gave some undocumented immigrants access to primary care; however, the poorest immigrants were excluded from the program (12). This year CMSP is starting a new pilot program known as Path2Health, which will expand their primary care coverage to a limited number of poor undocumented people (13).
In the remaining 11 counties, indigent care programs exclude all undocumented residents (14). For the uninsured and undocumented residents of these counties, options for primary care are limited to paying out-of-pocket for care, or seeking out community clinics that provide charity care, usually on a sliding scale.
Without any changes to California’s current system, health care for many undocumented people will continue to be inadequate. Residents of some counties will still rely on costly care in the emergency room and will be less likely to get preventive care or have a primary care doctor. Support for a single-payer, universal health insurance system is currently strong in the state—but without federal backing, California is at least several years away from launching such a comprehensive program. The Governor’s proposal would cover poor undocumented young adults, up to age 26, with state-sponsored health insurance (Medi-Cal). While this is most certainly a step in the right direction, millions of undocumented adults in the state will continue to remain uninsured. For older undocumented adults, who are much more likely to have chronic health conditions that require consistent medical care than their younger counterparts, getting primary care will remain challenging.
Yet Californians can still work towards expanding primary care services for poor undocumented people. County indigent care programs should follow in the footsteps of successful programs like MyHealthLA and Healthy San Francisco to include undocumented residents who continue to fall through the cracks of a fragmented health care system. California has undoubtedly made improvements to health care access in the last few years, and the momentum for change remains strong. By taking steps to improve county indigent care programs, California can continue to bridge the gap towards universal coverage and set a high standard in health care for the rest of the country.