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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)

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deserving to a point undocumented immigrants in san francisco s universal access model

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

restrictive federal state context
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
san francisco more welcoming and less stigmatizing environment
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)
question and main findings
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
n 54 interviews 2009
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
1 constructing deservingness self selecting into the safety net
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
2 reinforcing deservingness facilitating primary care
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
3 constraining deservingness gatekeeping entry to primary care
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
4 constraining deservingness drawing lines beyond primary care
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”
you lie representative joe wilson r sc to president obama
“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
sf shows promise and dilemmas of subnational right to care strategies
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