An exception to universal health insurance: The undocumented

Under the Affordable Care Act signed by President Barack Obama, more than 8 million nationwide have enrolled in the health care insurance system, including more than 3 million Californians either registered with the state’s online health exchange, Covered California, to buy private insurance plans or covered by expanded Medi-Cal (commonly known in Chinese American community as “the white card”).

Peter Lee, executive director of Covered California, has vowed that the goal of the exchange is to expand health insurance to every resident and to make sure that health care is a basic human right, not a privilege. However, in this wave of universal health insurance expansion, there’s an exception: undocumented immigrants.

As of 2013, California had as many as 2.6 million undocumented immigrants, one quarter of the national total, according to the USC Center for the Study of Immigrant Integration. For those undocumented immigrants who grow up, live and work here, a visit to a doctor’s office is a luxury due to their lack of health insurance. 

Many undocumented immigrants came to the United States with the hope of realizing their American dream, which is to have a more stable income, a good education and a secure safety net. They thought all those are possible in the country of democracy and freedom. But in reality, undocumented immigrants cannot afford a simple life choice of buying insurance to see a doctor for medical treatment.

Can’t afford ER visit

Twenty five-year-old Wei Li came to the United State along with his parents and elder brother in 2005 on a tourist visa, thus beginning his life as an undocumented immigrant. Before they came to the United States, Li’s family lived in Brazil, running a restaurant and living a peaceful life, until one day they encountered a group of looters. According to Li, a local criminal gang targeted their small Chinese restaurant and robbed them at gunpoint twice in a month.

Fearing for their lives, the Li family decided to immigrate to the United States through the sponsorship of Li’s uncle, who has lived in the states for many years and is a U.S. citizen. But in order to go through this legal pathway of immigration, they would have had to wait for a long period, which they decided against. So they embarked on the road as undocumented immigrants. They didn’t foresee that the path to  citizenship for the undocumented is extremely difficult.

As undocumented immigrants, the Li family members were unable to obtain work legally in the United States.  Li’s father worked on and off for cash, and the family barely survived. Struggling to just buy food, health insurance is an absolute luxury. They are not eligible for Medi-Cal or private insurance through Covered California, so the words  "illness" and "doctor" are not allowed in the dictionary of their lives.

As long as the physical pain is endurable, they won’t consider going to a doctor.  Li said that when a family member fell ill, they went directly to Walgreens pharmacy. “We just endure the pain. Hopefully, it would pass in a couple of days." If the pain was too much, they would go to a private doctor and pay out of pocket for each visit. Li said the onetime cost usually is between $100 and $200,  not cheap by any means, but still more affordable than a monthly premium for a private health plan.

Li Wei's older brother was diagnosed with brain cancer in 2010, a heavy blow to a family that was barely making ends meet. Li said the family was desperate, as they couldn’t have afforded the expensive treatment for brain cancer even if they  exhausted their life savings.

Fortunately, a volunteer  referred them to a state program, Emergency Medi-Cal, which  helps terminally ill patients and their families. Li said it was a blessing that his brother was admitted to the program and underwent necessary surgery. Yet the side effects of surgery left his brother with limited language and physical ability and memory loss, and he became dependent on his family for everyday basic needs.

Li recounted another incident when he was robbed on his way home by several suspects who knocked him to the ground and kicked him hard. Li called for help, and luckily, a woman walking nearby came to his rescue as the suspects fled. Li suffered head and elbow injuries. The good Samaritan suggested  calling an ambulance, but Li quickly rejected the idea.  “I know an emergency room visit is very expensive and unaffordable as I do not have health insurance," he said.  But the good Samaritan insisted, as Li’s head kept bleeding.

In the emergency room, a nurse suggested Li apply for Healthy San Francisco, a universal health plan offered by the city of San Francisco. It offers basic coverage of physical check ups and doctor visits. Li and his parents joined. At the same time, Li is fully aware that Healthy San Francisco is not  full health insurance, as it is not recognized outside San Francisco. But this is the only plan they can afford.

Li knows  that everyone is subject to illness, but says that undocumented immigrants have to pay a high price once they fall ill. Li is frustrated that basic health care depends on one’s immigration status. “Everybody should have to right to go to a doctor regardless of race, age, gender and religion,” he sai 

Healthy San Francisco: Hope for undocumented immigrants

Among 58 counties in California, 11 offer some kind of public health plan that undocumented immigrants can join. San Francisco, Alameda, San Mateo and Santa Clara are the Bay Area counties that do. Among them, Healthy San Francisco is the best known one.  Kimberly Oka, director of Healthy San Francisco, said that the main purpose of Healthy San Francisco is to offer city residents who cannot afford insurance or do not meet the federal health benefits an option so that they can get regular medical care and won’t wait until their health deteriorates enough to warrant emergency care.

To apply for Healthy San Francisco, one must be a resident of San Francisco, between the ages of 18 and 64, and have no health insurance for at least 90 days.  Undocumented immigrants may apply if they meet these requirements.

Huang Xianglin, senior health program planner for Healthy San Francisco, provided some statistics from a Healthy San Francisco enrollees’ self report card. As of March 31, 41,000 residents enrolled in Healthy San Francisco, among them 16,000 who were not eligible for Medi-Cal or Covered California, including some undocumented immigrants.

Huang said that because Healthy San Francisco is not a health insurance plan, its options are limited, in terms of physicians and hospitals, and no optical or dental care is offered. Health care outside of San Francisco is also not available under Healthy San Francisco. Compared with regular insurance plan, Healthy San Francisco is much more affordable; for example, based on income and family size, the quarterly “participant fee” is from nothing to $450.  Sixty per cent of Healthy San Francisco enrollees do not pay any participant fee.

Among Healthy San Francisco enrollees, many are Asian and young. Asian participants account for 37.8 percent (with 26.2 percent Chinese), followed by 33 percent Hispanics. Forty-six percent of enrollees are 25 to 44 years old, and 22 percent are 45 to 54 years old.

Undocumented have no right to fall ill?

Jirayut Lattivongskorn had a similar experience as Wei Li.  Born in Thailand, he came to the United States on a tourist visa with his parents and brother and sister, hoping to get legal residency sponsored by their aunt, who is a naturalized citizen. He was only nine then. And they have been waiting for more than 10 years.   

As an undocumented immigrant, Lattivongskorn said the status has kept him and his family members from having a physical exam for more than 10 years. At home, they have a broad range of drugs in their cupboard, helping them fight through flu, pain, allergies, fever, dysentery and so on.  This is common for a lot of families like his. In fact, a doctor’s visit never crosses the minds of undocumented immigrants, unless their condition is life threatening.

Lattivongskorn once suffered acute gum inflammation and was in terrible pain.  He tried his best, but couldn’t endure it any more. In desperation, he visited a dentist for treatment and got a bill of $1,800. It was a large sum, Lattivongskorn recalled, equaling all his savings earned from summer jobs.

Lattivongskorn learned later when he interned at a non-profit organization that Alameda County, where he lived, has a program called Healthy Pac, similar to Healthy San Francisco, that provides basic health care for people like him. He was happy to enroll with his parents so they can get a physical examination for the first time in more than a decade. 

Lattivongskorn said he and his family are grateful for a program like Healthy Pac. Though not a comprehensive health insurance plan, it is, nevertheless, vital to low-income residents who cannot afford health insurance. But he also knows that Healthy Pac has its limits and fewer services. He said once his mother had to wait for four months before she could make an appointment with her doctor. 

Both the Affordable Care Act and Covered California intentionally exclude undocumented immigrants, lamented Lattivongskorn. “Immigration reform and health care reform can’t be separated,” he said, “Healthcare is a human right. Everyone is entitled to it, not only those with citizenship.”  Lattivongskorn pointed out that “to think opposite was very dangerous, one can’t expect not getting sick because one is an undocumented immigrant."

New bill proposed

In April, state Sen. Ricardo Lara (D-Bell Gardens) introduced SB 1005, the Health for All Act, which would have expanded Medi-Cal to undocumented immigrants and created a new insurance exchange for the undocumented to obtain subsidized insurance. Many undocumented immigrants applauded the bill, including Li and Lattivongskorn. They hope the bill can pass the legislature and became the law, so they won’t depend on emergency care as their only primary care and live a healthy life style in its true sense.