Buy a bag of lettuce, and I guarantee you that the hands of at least one undocumented worker helped get it to your table. Unfortunately, rigorous identification requirements and changes to federal Disproportionate Share funding for safety-net providers will make access to medical care for that undocumented worker more difficult after implementation of the Patient Protection and Affordable Care Act (PPACA) than it is today.

Every public-sector physician I know supports the PPACA—at least as an improvement over what we have now. It will provide insurance coverage and access to care for approximately 30 million of the current 56 million Americans who currently do not have the “ticket of admission” to health care services.{{1}} We know that the PPACA is not a free lunch, however. The 26 million who continue not to have insurance will find access even more difficult; undocumented patients may find it almost impossible.

Currently, undocumented persons and other indigent, uninsured people are able to access health care services via safety-net providers such as Federally Qualified Health Centers and public hospitals that are largely funded by federal block grants supporting sliding-scale payment programs. After implementation of the PPACA, however, a significant portion of these grant monies will be redirected to finance an expanded Medicaid program and the new health insurance exchanges. Safety-net providers will receive the same level of federal funding only if they see a high volume of newly-covered individuals whose insurance plans will pay for their visits. These clinics and hospitals will simply not be able to afford to provide the same amount of care to those who do not have insurance coverage. Undocumented persons are not eligible for coverage via the PPACA. Even if we wanted to care for everyone—insured and uninsured, documented and undocumented alike—we are not going to be able to. There will simply not be enough primary care clinicians available to do so.

Workforce issues in both public and private sectors are real. We’re busy and stressed now: our schedules are full and our ability to document everything on new electronic medical record systems and provide case management within the “medical home” model has already pushed us to capacity. Plus, most public clinics are not exactly flush with support staff and other resources, and our patients have an array of education, transportation, language and cultural barriers to compliance. While it is true that the PPACA includes some money for FQHC overhead expansion, operations are another matter. Safety-net clinics will undoubtedly be expected to provide care to the “Medicaid half” of the 30 million patients with new coverage (the other half will be covered through the health insurance exchanges), and we are going to be overwhelmed. Further, in addition to the fiscal argument made by public clinic administrators to see as many of these newly-covered patients as possible—and therefore fewer block grant/sliding–scale patients—there is the legal and ethical argument of using a scarce resource (primary care clinicians) in support of the new legislation. If the intent of the PPACA is to provide care for those now entitled to it, are we not, as a nation, obligated to deliver that care to the newly-covered first? And if physician resources are scarce, shouldn’t they go to uninsured citizens and legal residents second? Illegal, undocumented persons will be a very, very distant third.

On the other hand, we all want to eat those healthy bags of lettuce—and we want our patients to eat them too. We need those undocumented workers to get that lettuce to our tables; and the truth is that there are not enough of them now.{{2}} Undocumented workers and their families come to the U.S. to escape poverty and to accept jobs that Americans do not want. They contribute directly to the economy, they pay taxes, and they raise their children here. The healthcare community’s obligation to them may not be straightforward, but it is real.

In California, counties’ and healthcare organizations’ early response to this dilemma has been mixed. We see the problem, but we don’t know what to do about it. Local solutions will most likely be slow and incomplete. The Salinas Valley—self-proclaimed Salad Bowl of the World, home of John Steinbeck, and more recently home to several thousand undocumented indigenous Mexican immigrants from the state of Oaxaca who speak little, if any, Spanish—is struggling to meet medical care demands and remain fiscally solvent. Monterey County’s attempt to develop an early demonstration project in advance of the PPACA has ground almost to a halt over fear of the unanticipated financial consequences of such a project in a small region.

Meanwhile, the number of undocumented workers and their families, like the bags of lettuce they produce, is slowly growing. We could, of course, stop eating lettuce and take all undocumented persons back to the border. Short of that, however, we are going to have to make some kind of conscious decision about what to do for them when they need care. It’s up to us.

[[1]]Congressional Budget Office. Updated estimates for the insurance coverage provisions of the Affordable Care Act. http://www.cbo.gov/publication/43076.  Published March 2012. Accessed November 30, 2012.[[1]]

[[2]]Chebium R, Kelly E. Gannett Washington Bureau, Gannett News Service. Salinas Valley hit by farm worker shortage plaguing rest of U.S. http://www.agweb.com/article/salinas_valley_california_hit_by_farm_worker_shortage_plaguing_rest_of_u.s._LN. Published December 7, 2012. Accessed December 17, 2012.[[2]]