Health Reform and Access for Undocumented Patients: Pressure on the Safety-Net

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.