chapter  5
The power of local autonomy: expanding health care to unauthorized immigrants in San Francisco
ByHelen B. Marrow
Pages 15

The federal and state health care policy context toward the estimated 11.1 million unauthorized immigrants living in the USA today has been described as so decidedly hostile that it leaves little leeway for government officials, health care providers, and immigrant advocates to make the situation more inclusive, even when they want to (Newton and Adams 2009). With few exceptions, restrictive government policies have rendered unauthorized immigrants ineligible for most federally funded public health insurance such as Medicare, regular Medicaid, and State Children’s Health Insurance Program (SCHIP) since the

early 1970s (Schwartz and Artiga 2007; Fox 2009). All unauthorized immigrants qualify for select public health and nutrition measures including immunizations, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and testing and treatment for communicable diseases but they can only qualify for a limited form of Emergency Medicaid (which covers labour and delivery and other designated emergencies) if they fall into certain categories like low-income children or pregnant women, and they can only qualify for non-emergency care in a handful of states that use their own state funds to offer it. In addition, unauthorized immigrants face a range of indirect

eligibility restrictions. Many are effectively barred or deterred from seeking care even in federally funded institutions that do not in theory restrict care based on legal status. This is because they are employed in informal jobs, move constantly between jobs, and live in overcrowded housing, so they often have difficulty producing income tax forms or utility bills that can serve as proof of local residency and low income two bureaucratic criteria that are required for admission into such institutions (Portes, Light, and Ferna´ndez-Kelly 2009; Portes, Ferna´ndez-Kelly, and Light 2011). Together with other barriers like fear, direct and indirect eligibility

restrictions lead to some of the most severe disparities in access to and utilization of care among comparable populations in national, state, and local studies (Goldman, Smith and Sood 2005; Ortega et al. 2007). Moreover, under the Health Care and Education Reconciliation Act of 2010, unauthorized immigrants will not be eligible to receive federal subsidies to purchase their own private insurance, nor will they be allowed to purchase health insurance through new state-based health insurance exchanges, even if they pay with their own money. In fact, unauthorized immigrants are projected to become a full one-third of the remaining 23 million uninsured Americans by 2019 (Pear and Herszenhorn 2010). If government officials, health care providers, immigrant advocates,

and other actors want to reduce disparities by legal status whether to help prevent the spread of infectious diseases, reduce the cost of preventable emergency care, or help institutions comply with ethical stances that support the provision of care to all humans, all residents of their communities, or all workers they must look to other creative alternatives. One viable alternative is the national network of federally qualified health centres (FQHCs), which offer a variety of primary, mental, and dental services to unauthorized immigrants across the country and which, like public hospitals, do not in theory restrict care based on legal status. The Health Care and Education Reconciliation Act of 2010 did increase federal funding to FQHCs, and this will

certainly help to reduce some, but not most, disparities in access to and utilization of care for unauthorized immigrants. Other creative alternatives are bi-national, although these too may

be problematic since unauthorized immigrants face increasing restrictions on moving back and forth across international borders. A third set of creative alternatives consists of inclusive sub-national

policies that may be enacted at the state and local levels in receiving communities especially since new patterns of geographic dispersion have brought unauthorized immigrants into an unprecedented array of states and localities, all of which are now struggling to determine how best to respond to their presence. In this article, I ask: what are the mechanisms through which inclusive local policy environments can operate to improve unauthorized immigrants’ access to and utilization of health care, specifically via the actions of providers and staff working in public health care safety nets that they govern?