Deserving to a Point:Undocumented Immigrants in San Francisco’s Universal Access Model

Helen B. Marrow, PhD

Robert Wood Johnson Scholar in Health Policy, UCB/UCSF

2008-10

First Annual Research Training Workshop

UC Center of Expertise on Migration and Health (COEMH)

University of California at San Diego, La Jolla, CA

May 13-14, 2010

Restrictive Federal/State Context

11.9-million undocumented in 2008

“Decidedly hostile” (Newton and Adams 2009)

Direct eligibility restrictions since 1970s (Fox 2009)Federal: Emergency Medicaid for select low-income groups Federal: Certain public health measuresSome states: (Limited) nonemergency care for select low-income groups

Indirect eligibility restrictionsProof of state/local residency and low income de facto barrier (HIS)

Other indirect deterrents (e.g., fear, language)

Severe disparities in access & utilization

San Francisco: More Welcoming and Less Stigmatizing Environment

Well-financed & highly-integrated public safety netSF identity: progressive social changePublic providers: local DPH salaries

Protective environment for ~40,000 undocumentedActive sanctuary policy in Administrative Code in 1989

Prohibits asking about status except in felonies or required by federal/state program requirements

Municipal ID ordinance in 2009Conception of local “inhabitance” or “residence” (jus domicili) over citizenship (de Graauw 2009; Ridgley 2008)

Ostensible universal HC “access”San Francisco Healthy Kids (SFHK) initiative in 2002Healthy San Francisco (HSF) ordinance in April 2007

Offers many primary care medical servicesHSF-participating institutions (mostly in safety net)

Question and Main Findings

How does this inclusive local policy context safety-net healthcare providers’ attitudes and behaviors toward undocumented immigrants, and potentially by extension, access to & utilization of care?

In some ways reinforces providers’ aspirational views of the undocumented as morally “deserving” patients

But in other ways constrains them

Highlights the potential of, but also the limitations and internal dilemmas constituting, local “right to care” strategies

N=54 Interviews, 2009

“Hospital Outpatient Clinic” (HOC)

N=38 (70%)

5 Physicians7 Residents8 Registered Nurses3 Nurse Practitioners7 Medical Exam. Assistants4 Clerical staff1 Social worker1 Health worker

Some external contextualization

N=16 (30%)

Other internal hospital clinics / departments

incl. 2 eligibility workers

Nearby Latino-oriented FQHC

Nearby Latino-oriented day-laborer free clinic

1) Constructing Deservingness: Self-Selecting into the Safety Net

Highly-committed, self-selected providersPrimary care, the safety net, and San FranciscoA variety of “health ethics” frameworks shape strong commitment to undocumented immigrants

HumanitarianismHuman rightsSocial justicePublic health“Deserving worker”“Local community resident”“Preventive fiscal”

Concerns identified unilaterally as fiscalColleagues, patients, family and friends reinforce viewsInclusive institutional culture imposes sanctions

2) Reinforcing Deservingness: Facilitating Primary Care

SF policy climate helps put attitudes into practiceReinforces identity as deserving residents (humans, workers)Reinforces view of protected “right” to access careInsulates providers from costs of care (“kicks in money”)Allows providers to not think about legal status in “better than 90 percent” of servicesAllows providers to marshal resources effectively

Can use city contracts to get services elsewhereCan buffer and advocate for individual patients

3) Constraining Deservingness: Gatekeeping Entry to Primary Care

“Inherent selection bias” only see “least fearful”, “most savvy”, and “most persistent”

Hospital’s initial eligibility registration process Clinic’s overburdened phone lines Long clinic appointment waiting lines

HSF still a de facto barrier to entryProof of SF residency, low income, denial from Medi-CalEven affidavits of support from landlords & signed statements from employers hard to amassSofia (non-HOC physician): Stratified immigrant community

4) Constraining Deservingness: Drawing Lines Beyond Primary CareHSF: universal access to primary care services

Not high-tech specialty careNot dental / visionNot most ancillary (“social support”) services

E.g., public housing, GA, SSI, food stamps, disability, hospice

Changes providers’ behaviors (not attitudes)Directly limits the range of resources they can provideForces providers to ask directly about legal statusCurtails providers’ ability to buffer and advocate

Cost of high-tech services rise (specialty care)Rules are strict and strongly enforced (ancillary care)

See clear patterns of “blocked access” emergeSuccess become “voluntary” & “discretionary”

“You Lie!”, RepresentativeJoe Wilson (R-SC) to President Obama

Health Care & Education Reconciliation Act of 2010No public subsidies to undocumented immigrantsCannot even use own money to purchase insurance through new state health exchangesEstimated to become 1/3 of the remaining uninsured population by 2019 (Pear and Herzenshorn 2010)

Raises importance of creative alternatives

SF Shows Promise and Dilemmas of Subnational “Right to Care” StrategiesPromise

Providers: Greater ability to to help reduce disparitiesPatients: More systemic access & utilization of care

Limitations and thorny dilemmasImplementation: Existing institutional structures that gatekeep largely based on market priorities, and/or fail to accommodate special difficulties to meet “standard” bureaucratic requirementsHuman rights vs. humanitarianism: HSF an explicit choice to privilege a minimum level of primary (but not ancillary) services to all low-income city residents, not high-tech specialty services to patients most seriously ill