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

1. 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

2. 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 measures • Some states: (Limited) nonemergency care for select low-income groups • Indirect eligibility restrictions • Proof of state/local residency and low income de facto barrier (HIS) • Other indirect deterrents (e.g., fear, language) • Severe disparities in access & utilization

3. San Francisco: More Welcoming and Less Stigmatizing Environment • Well-financed & highly-integrated public safety net • SF identity: progressive social change • Public providers: local DPH salaries • Protective environment for ~40,000 undocumented • Active 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 2009 • Conception 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 2002 • Healthy San Francisco (HSF) ordinance in April 2007 • Offers many primary care medical services • HSF-participating institutions (mostly in safety net)

4. 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

5. N=54 Interviews, 2009 “Hospital Outpatient Clinic” (HOC) N=38 (70%) • 5 Physicians • 7 Residents • 8 Registered Nurses • 3 Nurse Practitioners • 7 Medical Exam. Assistants • 4 Clerical staff • 1 Social worker • 1 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

6. 1) Constructing Deservingness: Self-Selecting into the Safety Net • Highly-committed, self-selected providers • Primary care, the safety net, and San Francisco • A variety of “health ethics” frameworks shape strong commitment to undocumented immigrants • Humanitarianism • Human rights • Social justice • Public health • “Deserving worker” • “Local community resident” • “Preventive fiscal” • Concerns identified unilaterally as fiscal • Colleagues, patients, family and friends  reinforce views • Inclusive institutional culture imposes sanctions

7. 2) Reinforcing Deservingness: Facilitating Primary Care • SF policy climate helps put attitudes into practice • Reinforces identity as deserving residents (humans, workers) • Reinforces view of protected “right” to access care • Insulates providers from costs of care (“kicks in money”) • Allows providers to not think about legal status in “better than 90 percent” of services • Allows providers to marshal resources effectively • Can use city contracts to get services elsewhere • Can buffer and advocate for individual patients

8. 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 entry • Proof of SF residency, low income, denial from Medi-Cal • Even affidavits of support from landlords & signed statements from employers hard to amass • Sofia (non-HOC physician): Stratified immigrant community

9. 4) Constraining Deservingness: Drawing Lines Beyond Primary Care • HSF: universal access to primary care services • Not high-tech specialty care • Not dental / vision • Not 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 provide • Forces providers to ask directly about legal status • Curtails 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” emerge • Success become “voluntary” & “discretionary”

10. “You Lie!”, RepresentativeJoe Wilson (R-SC) to President Obama • Health Care & Education Reconciliation Act of 2010 • No public subsidies to undocumented immigrants • Cannot even use own money to purchase insurance through new state health exchanges • Estimated to become 1/3 of the remaining uninsured population by 2019 (Pear and Herzenshorn 2010) • Raises importance of creative alternatives

11. SF Shows Promise and Dilemmas of Subnational “Right to Care” Strategies • Promise • Providers: Greater ability to to help reduce disparities • Patients: More systemic access & utilization of care • Limitations and thorny dilemmas • Implementation: Existing institutional structures that gatekeep largely based on market priorities, and/or fail to accommodate special difficulties to meet “standard” bureaucratic requirements • Human 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