Published on: December 27, 2012

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.

Ref­er­ences    (↵ returns to text)
  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.
  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.

Suggested citation

Marc Tunzi, MD, "Health Reform and Access for Undocumented Patients: Pressure on the Safety-Net," Undocumented Patients web site (Garrison, NY: The Hastings Center), originally published on: December 27, 2012. Available at http://undocumentedpatients.org/commentary/health-reform-access-pressure-safety-net/