Updated February 27, 2017
Health care access is local; creating, financing, expanding, or restricting health care access for a low-income population involves local, state, and federal policies. During the Obama administration, health insurance for the estimated 11 million undocumented immigrants in the United States remained severely restricted by this population’s broad exclusion from federally financed public benefits such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and Affordable Care Act (ACA) insurance subsidies. This same period saw moves by some states and major cities to expand health care access for the nation’s remaining uninsured, including many undocumented immigrants. These state and local initiatives have included the creation of programs offering low-cost primary care through public and nonprofit facilities, plus care coordination, in San Francisco (Healthy San Francisco), Los Angeles (My Health LA), and New York City (ActionHealthNYC), and legislative efforts in California and New York to expand public insurance coverage, using state funds, for some undocumented immigrants.
The Obama Administration’s 2012 executive action establishing Deferred Action for Childhood Arrivals (DACA) to allow young undocumented immigrants to work legally sparked the creation of further state, local, and institutional efforts to support this group. Some of these reforms mirrored ACA initiatives targeting millennials and aimed for equity for undocumented immigrants excluded from the ACA. California enacted legislation to allow income-eligible DACA recipients to enroll in Medi-Cal using state funds; DACA recipients in New York State became eligible, under 2001 case law relevant to certain undocumented immigrants, to enroll in state-funded Medicaid. California also expanded Medi-Cal to include undocumented children. New York City’s popular community ID program, IDNYC , launched in 2014 to provide local residents with a recognized form of identification for access to city facilities and services, is being used to connect undocumented immigrants with the city’s public health and hospital system, with benefits such as pharmacy discounts, and as a membership card for the ActionHealthNYC direct-access pilot program now underway.
What will be the fate of these state and local efforts under the new administration? Three sets of issues in health care financing for low-income people in the U.S. are important to watch during a period of uncertainty and apprehension for immigrants, and in the context of the continuing challenge of providing medically appropriate health care to low-income populations lacking access to public insurance. These issues overlap with health care access for specific undocumented populations, such as immigrants in detention centers and victims of trafficking and with access to types of health care, such as prenatal care, that are likely to be used by the undocumented population due to its demographics. They also overlap with efforts to protect the basic civil rights of undocumented immigrants, other immigrants, and members of minority groups as persons entitled to equal protection under the law.
Cities as sanctuary and safety-net: Public policy at federal, state, and local levels, even if not directly related to health, can affect local health care access for immigrants if it reinforces civil rights, or, by contrast, reinforces undocumented immigrants’ avoidance of situations in which they fear being asked for identifying information or confronted by authorities. One question following the February 21, 2017 release of new Department of Homeland Security rules expanding criteria for deportation is whether this policy will affect health care access. Two public health studies from Arizona suggest that crackdowns change health-seeking behavior.
During and following the 2010 enactment of Arizona SB 1070, a highly controversial law reflecting state lawmakers’ goal of “attrition through enforcement,” public health researchers conducting an unrelated study of childhood obesity among residents of a Latino neighborhood in Flagstaff noticed that the new law was creating “a generalized climate of fear . . . In a neighborhood with no major grocery store and several fast food and gas station markets, fear of travel in public could severely skew food purchasing and consumption behaviors . . . Residents also reported reluctance to allow their children to engage in physical exercise outside the home.” Community health professionals interviewed “noted dramatic changes in clinic intake and service use, suggesting rapid behavioral change” among neighborhood residents. A later study that focused on the impact of SB 1070 on health-seeking behavior among families of Mexican origin found that parents were less likely to take babies to the doctor, and adolescents were less likely to seek routine health care. These effects were not limited to immigrants; U.S.-born citizens were also reluctant to use public assistance. The study’s authors concluded that “this law is likely associated with heightened perceptions of fear and lack of community safety, even among . . . US citizens.”
In 2012, the U.S. Supreme Court struck down certain provisions of Arizona’s law, and decisions by lower courts weakened similar laws in other states.
The passage in October 2015 of North Carolina HB 318 (“Protect North Carolina Workers Act”) suggested the continuing appeal of state-level immigration policymaking. In addition to prioritizing cooperation with federal immigration authorities, HB 318 prohibited local “sanctuary city” policies and the issuance of “community IDs” to help city residents without other identification to gain access to public facilities, including hospitals and clinics. In the immediate aftermath of the 2016 presidential election, the mayors of many major cities affirmed “sanctuary city” policies limiting cooperation with federal authorities in efforts to enforce federal immigration law. The consequences of these actions remain to be seen, and could include cutoffs of federal aid. New York City’s mayor has further affirmed that he will delete the IDNYC database if ordered to disclose these records to federal authorities. Sanctuary cities (also states and institutions such as campuses and hospitals) may serve as important sources of civic identity, values, and action; the need for cities to make this declaration underscores the gravity of the national problem.
DACA, immigration policy, and the states: Immigrants and their advocates are bracing for the possibility that DACA, as a process of the Department of Homeland Security, could be eliminated. This action would imperil the immigration status of the 740,000 individuals who have qualified for this program (and who, along with their parents, are now on record as undocumented), and also call into question whether state-level Medicaid access, financial aid, eligibility for licensures, and other programs tied to DACA status will survive. Advocates are reporting an increased demand for health services among the DACA population that reflects the high stress over their uncertain status and future prospects.
Obamacare and Medicaid: Even though undocumented immigrants were formally excluded from the insurance provisions of the ACA – namely, Medicaid expansion in 31 states, and federally subsidized insurance policies – this population benefits indirectly from Medicaid block grants to states that finance safety-net health care programs, such as primary care clinics. This population may also have benefited indirectly from expanded Medicaid criteria, which reduce hospitals’ unreimbursed expenses and in theory free up funds for services to the remaining uninsured. Medicaid spending is a likely early target of the Republican-led Congress, despite the crucial role of Congress in the financing of hospitals, nursing homes, and clinics. If the current federal Medicaid program, which matches eligible state expenditures, is replaced by block grants to states, waivers of state-level requirements for participation, or a mix of both, the result will certainly be reduced safety-net services coupled with more demand for existing services. As people who are currently covered by Medicaid become ineligible, or underinsured relative to their health care needs, they will turn to the same safety-net services – namely, emergency departments and community health centers – that the undocumented and other uninsured populations already rely on.