ACA Leaves Undocumented Immigrants Out in the Cold: Community Health Clinics to the Rescue

By Patricia Guadalupe, NewsTaco

Marta Jiménez counts herself as one of the lucky ones. Marta, who asked not to use her real name because she is undocumented, first came to Washington, D.C., from Central America nearly 30 years ago on a tourist visa and overstayed, eventually getting married to a fellow undocumented immigrant and raising three daughters born in the United States who are now adults and on their own. Marta gets by with money from babysitting and cleaning houses after a divorce ten years ago left her with little, which is hampered by her very limited English skills that leave her with few options.

Marta has some health issues, including a bad back and bad knees aggravated by a fall down a flight of stairs several years ago, but she says she’s lucky because even though she’s undocumented she has health insurance. Lucky indeed, because many Latinos – whether they be citizens, legal residents or undocumented immigrants – have no insurance at all. In fact, Hispanics comprise the largest share of the uninsured among all groups in the United States – more than 12 million Latino adults and close to three million Latino children have no medical coverage.

The undocumented don’t qualify for Obamacare.

More than 50 million Latinos live in the United States, making them the fastest-growing population group in the country. The Urban Institute and the Pew Hispanic Center calculate that 36 percent of Latinos in the United States are immigrants, and of those 24% are undocumented.

Because Jiménez is undocumented, she doesn’t qualify to participate in the federal Affordable Care Act, more commonly known as Obamacare. Negotiators of that landmark piece of legislation have said they felt they needed to make that concession – exclusion of undocumented immigrants – in order for it to pass and benefit a far greater number of people than it was going to leave out. But that means millions – approximately 12 million undocumented immigrants live in the United States — all across the country have to fend for themselves when it comes to healthcare. For low-income Latinos – of which there are many, especially among the undocumented population – that means not being able even to participate in Medicaid, the government’s healthcare program for the poor.

While Obamacare mandates that Medicaid coverage be expanded to cover families up to 133 percent of poverty guidelines and health subsidies be provided to help families with incomes up to 400% of poverty guidelines, undocumented immigrants can’t avail themselves of that coverage.

Nothing changed for the undocumented.

“For undocumented immigrants, nothing has changed under Obamacare,” said Barrie Lynn Tapia, an attorney and former social worker in Washington, D.C., who works with underserved communities.

Additionally, not only are undocumented immigrants prohibited from receiving tax subsidies under Obamacare, they can’t purchase any coverage in ACA even if they paid full price out of their pockets.

Just a handful of states and the city of Washington, D.C., offer healthcare coverage to undocumented immigrants. In the nation’s capital, the program is called D.C. Healthcare Alliance, which is run by the city and has become the de facto healthcare provider for undocumented residents. Marta Jiménez joined the Alliance nearly ten years ago and visits participating community clinics throughout the city for a variety of health needs.

“They (Alliance) pay for everything, and there is no deductible. I honestly don’t think I would’ve gotten a better deal under Obamacare even if I could qualify,” she says. “I am very grateful that I live in a city that cares about its people, even those without papers, and that they help me in Spanish.”

Community clinics matter.

If an undocumented immigrant lives elsewhere, what are they to do? For many undocumented immigrants, the hospital emergency room has been the only option, but for routine medical care, this is where community healthcare clinics are stepping in to help undocumented immigrants get the medical attention they need.

CDP-36And that’s where community healthcare clinics are stepping in to help undocumented immigrants get the medical attention they need. There are also what are called Federally Qualified Health Centers, community health centers that receive some federal funding under ACA. They provide a wide variety of services, from primary care to dental to mental health.

“Today, uninsured individuals, including many uninsured immigrants, often rely on community health centers and clinics for their care. Safety-net providers are seen as a trusted source for care, and are able to offer culturally and linguistically appropriate services that meet the needs of diverse populations,” says a report from the Kaiser Family Foundation. “Under the ACA, these providers will likely remain a primary source of care for millions (including) non-citizens who remain uninsured after 2014.”

California and Texas affected the most.

In the country’s most populous states, such as California, the impact of excluding undocumented immigrants from ACA is particularly acute. In the Golden State alone, nearly three million residents are undocumented immigrants, with an estimated one million living in Los Angeles County. The Public Policy Institute of California estimates that by 2019, 60 percent of uninsured residents in the entire state will be living in just the Los Angeles area.  In Texas, it is estimated that 800,000 of the uninsured are undocumented immigrants, and the state has the dubious honor of having the nation’s highest percentage of uninsured among all populations: 24.6 percent. Community health centers in both those states and across the country are really the only choice for many.

There are approximately 1,200 FQHCs across the nation (a total of more than 9,000 when adding satellite offices and multiple branches from the same center). Not coincidentally, a majority of the clinics across the country happen to be in areas with large Latino populations, including California, Texas and New York, and in states with a rapidly growing number of Latino residents, such as Pennsylvania, Ohio and North Carolina, and many have seen an uptick in numbers since ACA’s implementation. This is particularly true for centers near areas that do not have programs like DC Alliance, where the number of people requesting service has jumped.

Community clinics already see a change.

“We have definitely noticed an increase in demand from folks who are ineligible for Obamacare and who live in (neighboring) Maryland, because they do not have other safety net services like the Alliance,” said Alicia Wilson, executive director of La Clínica del Pueblo, a FQHC community healthcare clinic in the nation’s capital that provides services regardless of immigration status. “Some also report that they have a harder time getting appointments at community health centers in their area because they are uninsured and the waiting lists are long.” Wilson doesn’t expect it to slow down anytime soon, adding, “We anticipate more and more people turning to us for healthcare.  We are working hard to be able to meet that need.  We have been working on making our systems more efficient so that we can handle more patients without adding too much to our overall expenses, but we may be scaling up our services in some areas.”

La Clínica was initially staffed by volunteer doctors and other healthcare providers when it first opened in 1983 and has grown from a once-a-week clinic with a modest budget to a daily healthcare provider with a multi-million dollar budget and modern offices. Other community health care centers across the country have grown and are expecting to serve a greater number of people.

The federal program creating FQHCs goes back to the 1960s, and was expanded in the 1990s under the Health Center Consolidation Act to allow the clinics to accept Medicare and Medicaid patients. Federal funding of these clinics is approximately $3 billion annually and they serve more than 21 million people nationwide.

Federal funds fall short.

Under ACA, federally qualified community healthcare clinics received $150 million in funding to help local clinics that provide primary care services mainly to poor and uninsured patients, but that doesn’t begin to cover the cost of serving the growing population of undocumented immigrants, as the bulk of that money is to help communities enroll in Obamacare and that does not cover the undocumented.

ACA also creates a five-year $11 billion trust fund called the Community Health Center Fund to build new centers, hire more staff and generally assist with the anticipated increased costs of providing services.

The increased demand in services among the undocumented immigrant community, many of whom speak very little or no English, means these community health clinics have to hire more healthcare profesionals.

More doctors, medical professionals needed.

The Association of American Medical Colleges has estimated that by 2020 the nationwide shortage of doctors will grow to more than 90,000. The Obama administration has allocated $250 million to help “train and develop” 16,000 new healthcare professionals over the next five years, but that is not expected to keep up with demand in the Latino community, especially among dominant Spanish speakers.

“In terms of the Latino community nationwide and the number of doctors and healthcare providers who are Latino, there is no parity, and with the Affordable Care Act there will be an increased demand for healthcare,” said Dr. Elena Rios, president of the National Hispanic Medical Association, a non-profit association in Washington, D.C., representing 45,000 Latino physicians.

That also means hiring more interpreters skilled in medical terminology.

“Too many Latino families do this informally, such as bringing along a relative or a child, or they pull in the janitor at the doctor’s office or the hospital to translate, when there’s no need to do that at all and it can even be dangerous. You open yourself up to errors and even issues of privacy,” says La Clínica’s Wilson.

The immigrant health safety net.

Immigration activists call these clinics the community’s “safety net” that provide services otherwise denied under the landmark ACA healthcare law, but excluding undocumented immigrants from ACA places a huge strain on states and localities, and in particular on community health centers.

Three billion dollars in annual federal funding for these community health centers sounds like a lot of money, but it is a drop in the bucket compared to the nearly $3 trillion that is spent annually on healthcare across the nation.

“We do anticipate having to do more with less,” says La Clínica’s Wilson. “We are hopeful that support for community health centers will continue to increase, and other reforms such as in alternate payment methods will help shore up the true costs of providing the holistic care we provide.  In the short term, however, I do not see any additional dollars coming, just for us to provide care to more uninsured patients.”

Funding shortfalls and mistrust.

“And actually, funding to hospitals, for instance, is going down because the federal government figures more people will have insurance so they won’t use that hospital as their healthcare and safety net,” said Harry Greenspun, M.D., Senior Advisor at the Deloitte Center for Health Solutions.

In fact, under ACA, reimbursement to hospitals for Medicaid services are expected to drop by 50 percent starting in 2015, and a new report says those providers are at a loss as to how to pay for incurring those costs while at the same time services to other uninsured populations – undocumented immigrants who can’t qualify for those programs.

Dr. Greenspun also participates in a multicultural healthcare advisory program, the Wellpoint External Advisory Council on Health Inequities and is co-author of the book “Reengineering Health Care: A Manifesto for Radically Rethinking Health Care Delivery.”

In underserved communities such as the undocumented immigrant population, Dr. Greenspun says, there still exists a high level of distrust – be it a fear of deportation or other concerns — and more outreach is needed. “They don’t have good information and many skip care. People who need care don’t have a good way to know where to get good quality care and sometimes they don’t understand what they’re looking at. There needs to be more health literacy, more access to information, and more multicultural outreach programs to reach the diverse populations.”

Patricia Guadalupe is an experienced multimedia journalist who strives to get the stories no one else has and looks for different angles in those stories that are covered by everyone else. She’s a contributing writer for NBCNews, AARP en Español, Latino Magazine, and Capitol Hill Editor for Hispanic Link.

[Photo courtesy of La Clinica del Pueblo]

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