Sacramento still denies undocumented immigrants health care

Nearly all major metropolitan areas in California offer medical-care options even though Affordable Care Act leaves most without coverage

Antonio owns a janitorial business and has lived in Sacramento for years, yet he's afraid to get sick because the county offers no safety-net medical care for immigrants without legal documentation.

Antonio owns a janitorial business and has lived in Sacramento for years, yet he's afraid to get sick because the county offers no safety-net medical care for immigrants without legal documentation.

photo by lisa baetz

Martha looks like any one of thousands of young California women, her life spreading out ahead of her, her dreams about to take off. Unlike most, however, the 20-year-old North Highlands resident is undocumented. And because of this, she and her family, most of whom do farmwork out in the fields surrounding town, have virtually no access to medical care.

It's been this way since 2009, when Sacramento County nixed health care for its undocumented population to save just $2.8 million during an extreme budget crunch. This positioned Sacramento alongside many rural and conservative counties in California, rather than with other large metropolitan areas such as San Francisco and Los Angeles—most of which provide at least some health-care access to undocumented residents.

When Martha and her relatives get sick, they self-medicate with Tylenol and herbal teas. When the Tylenol and tea don't work, they simply suck up the pain.

Originally from Jalisco, Mexico, Martha (not her real name) is one of six siblings. Four years ago, her younger brother injured his back while jumping on a trampoline. The wound didn’t heal properly, the family had no ready access to doctors, and to this day, he has a large ball-like protrusion on his lower back.

“Every time he moved or ran, it would bleed, and it would hurt him more,” Martha says. “To this point, we haven’t been able to take him to get checked.”

Meanwhile, her father, now in his 40s, injured his back recently while picking tomatoes, and the pain has gotten so intense that he has had to temporarily stop working. He too cannot afford to get medical care. And the longer he is off of work, the more precarious the family’s finances become.

When Martha was younger, she remembers having some access to medical care. Then it stopped; she doesn’t know why. It’s a fair bet, however, that what she recalls is 2009, when the area’s roughly 100,000 undocumented residents lost access to county-funded medical services.

Five years later, that lack of health care for the undocumented remains a festering wound for Sacramento.

And now, in a particularly cruel twist, elected officials, from Gov. Jerry Brown on down, trumpet the fact that the state has embraced “Obamacare” more than any other. California has successfully enrolled millions of residents in Medi-Cal and the new health-care exchanges. But millions more Californians remain excluded from these programs.

Lacking proper health insurance, undocumented immigrants often rely on charity medical care or on the few local federally qualified indigent care clinics. These clinics use federal funds, so by law they have to see everyone. But they charge a sliding scale for services, which scares off many poor residents. Oftentimes, people wait until they get so sick that they cannot avoid going to the hospital. By then, the costs—both in terms of long-term damage to individuals’ health and in terms of dollars—have massively escalated.

“It costs a lot more to treat someone with full-blown diabetes than to diagnose it [early] and tell them what foods to avoid and give them the medications,” argues Xavier Morales, executive director of the Latino Coalition for a Healthy California. More than 42 percent of Latinos hospitalized in California suffer from diabetes, according to data recently generated by the California Center for Public Health Advocacy and UCLA researchers, many of them undocumented residents. The costs associated with treating those diabetic patients amount to more than $1.6 billion annually.

“And it’s not just diabetes,” Morales continues. “There’s heart disease, stroke. All illnesses that cost a lot more to treat than to prevent.

“It doesn’t make economic sense.”

To save a few million dollars in the short term, Sacramento has locked in place a policy almost guaranteed to cost taxpayers far more in the long run. Like so much else in the roiling debates over immigration, it’s a policy that would be comical in its absurdity if it didn’t come with such an awful human cost.

Untreated and left behind

Martha wears a white dress, heeled sandals with orange-painted toenails, and a pink cardigan that hangs loosely off of her shoulders. She explains how she’s long been plagued both by hacking coughs and extreme menstrual cramps. They’re so severe that she would have to take time off from school during her period. She went to the doctor a couple times many years ago, and he prescribed her medicine. She doesn’t remember what this was. And, anyway, her family can’t afford to fill prescriptions.

She’s not alone. The Pew Research Center’s Hispanic Trends Project estimates there are 11.7 million undocumented Americans, of whom slightly more than 2.5 million live in California. That’s close to 7 percent of the state’s population.

The Hispanic Trends Project calculated that, because those who are undocumented tend to be younger than the population as a whole, nearly one in 10 workers in the state is undocumented. Millions of California families are mixed status, meaning that some members—oftentimes the children—are U.S. citizens, while others live in the shadows. In fact, latest estimates are that an astounding one in six California kids live in such mixed-status families.

Assuming Sacramento County, with a population of roughly 1.4 million, follows statewide trends, that means somewhere in the region of 100,000 residents are undocumented, many thousands of whom have at best only minimal, and episodic, access to health care.

This means that many thousands of kids like Martha in the region live in households where a single sickness, even after implementation of the Affordable Care Act, can plunge adults and kids alike into destitution, hunger and homelessness.

“I’m undocumented,” says 49-year-old Antonio, who has been living in Sacramento since he left Aguascalientes, Mexico, in 1995. Early on in his new life in the United States, he says he worked for the National Guard. Later, he ended up employed as a janitor in the IRS building in Sacramento.

While there 
is talk of 
shuttering Sacramento County's 
largest clinic for the indigent, some argue that it should be converted into a care facility for immigrants excluded by the Affordable 
Care Act.

photo by lisa baetz

For the past 17 years, he and his wife have owned their own small janitorial-services company. During that time, when a member of the family has gotten really sick—such as the time he came down with pneumonia and coughed so much that he passed out—they have visited doctors and paid cash to be seen. Most of the time, however, they just tough it out.

When they have a toothache, they go to a dentist and pay to have the tooth pulled rather than filled; it’s cheaper, after all, to remove a tooth than to fix it.

“I try to be healthy,” Antonio —a short man in black jeans, old sneakers, a black T-shirt, and with receding hair and a trim mustache—says matter-of-factly. “The real problem is with one of my daughters.”

He explains that she has a malformation on her back that they never had money to fix. He starts to cry. “When she was little, they found it. I couldn’t afford to go to a specialist. She doesn’t have pain; she’s just a little malformed. Hunchbacked.” She also has teeth problems, which without access to dental coverage, have long gone untreated.

Her younger sister, by contrast, who was born in the United States, and thus is a citizen, has medical coverage and now wears braces.

The arbitrariness of the situation is striking. “A lot of people thought when Obamacare passed they’d be able to get health insurance,” says a young undocumented worker at a health-insurance company. This person holds community-health-education workshops and encourages low-income residents to get screened for common diseases. “They were shocked when they didn’t qualify.

“A lot of people [instead] get medications from Tijuana. But they get no monitoring, no follow-up. Nothing.”

The Affordable Care Act was crafted to leave out America’s undocumented residents—much as Social Security and unemployment insurance in their original New Deal incarnations excluded agricultural and domestic workers, great numbers of whom were black. In the 1930s, FDR swallowed this ugly compromise with the segregationist South, the price to be paid for creating broad social-insurance umbrellas.

In 2010, bowing to anti-immigrant sentiments was a price that pro-health-care-reform politicians were willing to pay to cobble together a bare majority in Congress for legislation expanding health-care access. And so today, millions of America’s poorest, and oftentimes sickest residents lack entry points into the country’s vast and complex health-care-delivery systems.

Researchers at the UCLA Labor Center’s Dream Resource Center reported earlier this year that half of all uninsured undocumented immigrant youth in California had delayed seeking necessary medical treatment at some point during the past 12 months.

Churches, which have become epicenters in the drive to insure the uninsured, have found much the same thing: an inability to access affordable insurance or safety-net programs, and as a result, pools of immigrants who don’t go to the doctor when they get sick.

When Sacramento Area Congregations Together held a series of 15 enrollment fairs at local places of worship this year, there was so much demand, it “turned away about half the families,” recalls ACT organizer Annie Fox, who has been campaigning to find ways to insure undocumented residents.

For Dan Garza, a pastor at Ebenezer Christian Center who spoke at an event organized by ACT at the Congregation B’Nai Israel synagogue in Land Park in late May, the plight of undocumented people flies in the face of religious teachings. “The Scriptures declare to the prophet Moses ’You shall love your neighbor as yourself,’” he noted. “Everyone, including immigrants, are created in the image of God.”

Sacramento’s cow town policy

As we head toward the November election, health insurance for the undocumented residents has become a hot-button topic. In the run-up to the June primaries, progressive Sacramento-area candidates rushed to explain why they support expanded health-care access.

Patrick Kennedy, who recently won election to the county board of supervisors, calls what happened in 2009 “an abomination.”

“It’s ludicrous. A $30 flu shot can save hundreds-of-thousands of dollars in an influenza epidemic. But it’s not just economic. It’s moral,” he explains.

At the state level, a series of bills have recently been proposed offering various fixes for this problem. Chief among these is the Lara Bill, or Senate Bill 1005, proposed by state Sen. Ricardo Lara. This would create a parallel Medi-Cal and health-care-exchange system in California specifically for those who are undocumented. Many health-care advocates and immigrants-rights groups have endorsed it as a sensible public-policy proposal.

But because of the sticker price, in the hundreds of millions of dollars, it is facing an uphill fight to get out of committee and onto a floor vote anytime soon.

Opponents of coverage in Sacramento argue that there’s nothing abnormal about the region’s situation. They say most counties in California don’t cover the people who are undocumented, and by law they don’t have to: Section 17000 of the Welfare and Institutions code, which deals with health care for the indigent, gives counties the option not to care for those in the country illegally . As a result, 49 of the state’s 58 counties don’t provide such coverage.

Martha says when her family gets sick, they suck up the pain, 
because the government denies them health care. Her father 
had to stop working recently because of excruciating back pain.

photo by lisa baetz

NumbersUSA and other groups opposed to paths to citizenship and other rights for undocumented immigrants argue that people oughtn’t to be “rewarded” for illegally crossing national borders or for overstaying their visas. They cite a 2007 poll, conducted by Arizona State University researchers, showing that a small majority of residents in Southwestern states oppose equal health-care access for the undocumented. Many politicians, especially in rural counties, make similar arguments.

Yet increasingly, in large metropolitan centers, political leaders and public-health advocates argue the exact opposite.

The nine California counties that do cover undocumented immigrants include almost all of the largest metropolitan centers in the state.

Los Angeles and San Francisco have both set in place plans to provide something close to true universal coverage within their boundaries, and Oakland, Riverside, and San Jose aren’t far behind.

In fact, of the state’s biggest cities, only San Diego and Sacramento don’t provide such coverage—though, come June 20, they will also be joined in this rather shameful club by Fresno, which recently convinced a court to overturn a decades-long injunction barring the county from cutting off immigrants from access to health care. Overnight, when the county’s rollback commences, thousands of undocumented immigrants will lose what little health-care security they had in Fresno.

Opponents also argue that providing coverage to those who are here illegally is an unaffordable luxury in austere times. That might be true if we only consider the costs to individual government agencies. But taken as a whole, not providing care is far more expensive to society than intervening in health crises early.

A slew of public-health studies indicates that, in the long-run, providing preventative care to the undocumented saves money. By contrast, waiting until people get so sick that they end up in ERs—which have a legal mandate to treat everyone regardless of whether or not they have insurance or can pay their medical bills—costs a ton of money.

In the long run, providing health-care access is also a good public-health policy: for absent access to doctors, to medical tests, to annual checkups, and to prescription drugs, undocumented residents can serve as incubators for diseases such as tuberculosis, HIV, syphilis, gonorrhea, hepatitis and a laundry list of other serious illnesses that, once in the community, rapidly infect people across demographic boundaries.

“We have public-health expert witnesses from UCLA and other organizations. We have documents from the county of Fresno showing they’re only able to treat and take care of 50 percent of active TB cases in the county,” says Stephen Schilling, CEO of Clinica Sierra Vista, which has led the fight to try to stop Fresno from rolling back its health care for undocumented immigrants. “Allowing that population to go completely underground and not have access to primary and secondary services” means that infectious diseases will spread more rapidly, and epidemics will be harder to contain, he says.

Put simply, expressing frustration at the condition of the country’s porous borders by barring undocumented immigrants from health care is akin to cutting off one’s nose to spite someone else.

Just don’t get sick

Martha says that when her family is at work, there’s a fear. “In the fields, when you get sick or injured, [owners are] scared you’re going to fight for your rights,” she explains. “And so you just lose your job.”

Recently, at an ACT-sponsored board of supervisors candidates’ forum, Martha talked of a co-worker who heard a terrible buzzing in her ear. She ended up having to go to the emergency room to have an earwig removed. The woman was, averred Martha, promptly fired, her employer fearing that having herself been on the wrong side of an expensive health-care emergency, she would otherwise begin to agitate among fellow workers to get the company to provide them with insurance.

Meanwhile, nearly five years after the recession technically ended, Sacramento is in a far better fiscal position than it was in 2009. It has more tax dollars coming in. What’s more, because of the provisions of the Affordable Care Act, the state is taking over responsibility from the counties for covering millions of residents who previously weren’t eligible for Medi-Cal. The Department of Health and Human Services budget is in the luxurious position of having some disposable money to play with. Which is why advocates have launched a full-court effort to fund a system of health-care services for undocumented residents in Sacramento County.

There is talk of shutting down the county’s one remaining large-scale health clinic for the indigent, located on the corner of Broadway and Stockton Boulevard. Far better, argues Fox of ACT, to invest some of those spare dollars and to convert it into a clinic dedicated to providing coverage to undocumented immigrants excluded from the provisions of the ACA.

“Oh, man,” says Antonio, as he ponders what it would be like to have regular access to doctors. “First thing I’d do is get a general checkup. That way, you feel you can just keep going. I have cramps in my hand. I have a little pimple on my chest. A checkup would be, oh, man, wonderful.”

For Martha, who is starting classes at American River College in the fall, the precariousness of her family’s health is serving as something of a motivating force. “I want to go into the medical field,” the young farmworker explains. “I love serving people. I always thought if I went into the medical field, we wouldn’t suffer from being sick. I could help my family. Both my parents, they’re always struggling with their feet hurting, bones hurting. At work, we’re exposed to chemicals and get very bad allergies.”

“Let’s say I have an accident, and I’m not able to work,” says Antonio. “Then nobody’s going to support my family. We are so scared to get sick.”

He laughs softly. But it’s a nervous laugh, a laugh with no joy behind it. “If I had to go to emergency room, I don’t know.” His voice trails off at the thought of the medical bills he would accrue.

“My wife has arthritis. But we can do nothing about it. She takes Motrin or Tylenol.” He stops and smiles a fatalistic smile. A gap-toothed smile, a shrug of the shoulders, a what-are-you-going-to-do-about-it sort of smile.

Sacramento is his home; he’s been here for decades. He pays taxes here. His children have been educated here. But Antonio knows that so long as he’s here, so long as he’s undocumented, and so long as the county tries to save a few dollars here and there on the backs of people such as him and his wife, he still can’t afford to let himself get sick.