A PATCH­WORK OF CARE BY COUN­TIES

For those in the U.S. il­le­gally and unin­sured, where they live de­ter­mines ac­cess to health ser­vices

Los Angeles Times - - FRONT PAGE - By Soumya Kar­la­mangla

Mar­garita Vasquez lacked health in­sur­ance and couldn’t af­ford an eye op­er­a­tion to ward off blind­ness.

But un­der a Los An­ge­les County pro­gram that extends health­care ser­vices to poor res­i­dents who are in the coun­try il­le­gally, the 64-year-old un­der­went surgery ear­lier this year and can now see clearly. “It saved me,” she said. An hour’s drive to the east, in the f lat­lands of the In­land Em­pire, Su­jey Be­cerra wasn’t as for­tu­nate.

The 39-year-old didn’t have the means to pay for a surgery to re­move ovar­ian cysts and put off the pro­ce­dure for months, un­til she be­gan hem­or­rhag­ing and was rushed to a hos­pi­tal emer­gency room. Scar­ring from the last-minute op­er­a­tion left her hurt­ing, and with­out ac­cess to fol­low-up treat­ment.

“I’m in pain con­stantly — all night, all day,” she said.

For unin­sured Cal­i­for­nia im­mi­grants such as Vasquez and Be­cerra, which side of a county line they live on can sig­nif­i­cantly af­fect the care avail­able when they’re sick.

Coun­ties are re­quired un­der a 1933 state law to “re­lieve and sup­port all in­com­pe­tent poor, in­di­gent per­sons.” That re­quire­ment has been open to in­ter­pre­ta­tion when it comes to health­care for those in the coun­try il­le­gally. Among the 11 coun­ties that pro­vide low-cost med­i­cal care to such im­mi­grants, some limit treat­ment to se­ri­ously ill pa­tients or chil­dren.

The re­main­ing 47 coun­ties do not con­sider th­ese im­mi­grants to be cov­ered by the state man­date.

County-to-county dif­fer­ences in such care have ex­isted for decades. But Pres­i­dent Obama’s over-

haul of the health­care sys­tem is fo­cus­ing new at­ten­tion on the dis­par­i­ties and com­pli­cat­ing choices for lo­cal of­fi­cials as they con­sider what, if any, health­care they should pro­vide to Cal­i­for­ni­ans who re­main unin­sured.

“Ev­ery­thing is get­ting shaken up,” said Catherine Teare, se­nior pro­gram of­fi­cer for health re­form at the Cal­i­for­nia Health-Care Foun­da­tion, not­ing that the Af­ford­able Care Act al­tered how the state’s health­care sys­tem is funded and op­er­ates.

With health in­sur­ance cov­er­age ex­panded to mil­lions more Cal­i­for­ni­ans, peo­ple living here il­le­gally — who are barred from sign­ing up for Oba­macare — now make up the sin­gle big­gest group of unin­sured state res­i­dents. A quar­ter of that pop­u­la­tion has pri­vate in­sur­ance cov­er­age through their job or that of a fam­ily mem­ber, re­searchers say. But that leaves close to 1.5 mil­lion unin­sured.

Now, ad­vo­cates for the poor are urg­ing state and county of­fi­cials to wade back into dis­cus­sions about po­lit­i­cally sen­si­tive and po­ten­tially costly op­tions for im­prov­ing health­care for those living here il­le­gally.

Last week, the state Se­nate passed a bill, with most Repub­li­cans op­posed, that would pro­vide health­care to hun­dreds of thou­sands of chil­dren younger than 19 who are here il­le­gally.

Some have sharply crit­i­cized ef­forts to ex­pand such cov­er­age. “They seem to stay up late in Sacra­mento think­ing up new benefits and ser­vices to pro­vide to il­le­gal aliens, even as they’re cut­ting back ser­vices to every­body else,” said Ira Mehlman, a spokesman for the Fed­er­a­tion for Amer­i­can Im­mi­gra­tion Re­form.

How­ever, re­duc­tions made in county health pro­gram fund­ing to help fi­nance Oba­macare have made it more dif­fi­cult for some lo­cal of­fi­cials to add — and in some cases main­tain — med­i­cal care for the poor and res­i­dents living here il­le­gally. The state with­drew some $900 mil­lion from lo­cal pro­grams to help pay for ex­panded in­sur­ance cov­er­age for those el­i­gi­ble to re­ceive Medi-Cal, the gov­ern­ment med­i­cal pro­gram for the poor.

Poor im­mi­grants who aren’t el­i­gi­ble for free or sub­si­dized in­sur­ance plans of­fered by the state can go to emer­gency rooms and com­mu­nity free clin­ics, but gen­er­ally don’t have ac­cess to spe­cial­ists or surgery. For just a por­tion of emer­gency room vis­its and preg­nancy care in­volv­ing those living here il­le­gally, the state pays an es­ti­mated $1.4 bil­lion an­nu­ally.

Some ex­perts ar­gue that leav­ing large num­bers of res­i­dents unin­sured and re­ly­ing on emer­gency rooms as a last-re­sort form of health­care will un­der­cut sav­ings an­tic­i­pated un­der Obama- care. UCLA health pol­icy pro­fes­sor Steven Wal­lace noted the fed­eral health sys­tem over­haul is based on an ex­pec­ta­tion that easy ac­cess to regular, pre­ven­tive care will keep pa­tients healthy and re­duce over­all med­i­cal costs.

Ac­cord­ing to pro­jec­tions from UC Berke­ley and UCLA, peo­ple in the coun­try il­le­gally will con­tinue to make up about half the roughly 3 mil­lion Cal­i­for­ni­ans lack­ing in­sur­ance four years from now.

“That’s the next big group to go af­ter,” Wal­lace said.

Pro­po­nents of in­creased cov­er­age point out that in re­cent years Cal­i­for­ni­ans have shown a will­ing­ness to ex­tend priv­i­leges to those living here il­le­gally, in­clud­ing driver’s li­censes and low­er­cost, in-state tu­ition at the state’s public col­leges and uni­ver­si­ties.

One re­cent sur­vey con­ducted for the Public Pol­icy In­sti­tute of Cal­i­for­nia found that 80% of Cal­i­for­ni­ans fa­vored a path to cit­i­zen­ship for those living here il­le­gally, in­clud­ing 66% of Repub­li­cans.

With more elected of­fi­cials voic­ing sup­port for ex­panded med­i­cal cov­er­age for

those res­i­dents, the big ques­tion has be­come: Whose fi­nan­cial re­spon­si­bil­ity is it?

State of­fi­cials are con­sid­er­ing pick­ing up as least some of the cost.

Mar­cos Tor­res, 45, has lived in San Bernardino for a quar­ter of a cen­tury. Tor­res says he can’t af­ford health in­sur­ance for him or his wife on his con­struc­tion worker’s salary. And the county doesn’t pro­vide any free or low-cost health­care for those in the U.S. il­le­gally.

Tor­res — who has two daugh­ters, one a stu­dent at­tend­ing UC Irvine on a schol­ar­ship and the other in high school — said he couldn’t re­call vis­it­ing a doc­tor. His chil­dren are U.S. cit­i­zens who qual­ify for var­i­ous types of cov­er­age. But when Tor­res or his wife get sick, he said, they take over-the­counter medicines and wait un­til they re­cover. “That’s what we do, we go and get the Tylenol,” he said.

He said nei­ther he nor his wife have been se­ri­ously sick, but he wor­ries about what will hap­pen as they age.

San Bernardino County of­fi­cials, cit­ing in­creased costs, say they have no plans to ex­pand cov­er­age to res­i­dents such as Tor­res. But some other coun­ties that haven’t of­fered such ser­vices in the past are re­think­ing the is­sue. One is Sacra­mento.

The county’s elected Board of Su­per­vi­sors is con­sid­er­ing pro­vid­ing pri­mary and spe­cialty care, on a first­come, first-served ba­sis, to roughly 10,000 of the county’s 50,000 im­mi­grants lack­ing proper legal sta­tus.

The one free clinic in the county that serves such pa­tients of­ten has a line around the block hours be­fore it opens at 7 a.m.

An­nie Fox, an ad­vo­cate with the com­mu­nity group Sacra­mento ACT, re­called her ef­fort to get help for a 14- year-old son of a farm­worker who in­jured his tail­bone in a tram­po­line ac­ci­dent. He de­vel­oped a golf-ball-sized bump on his back that re­mains un­com­fort­able and some­times be­comes in­fected.

De­spite re­peated ef­forts to get him the care he needed, Fox said he still hasn’t qual­i­fied for ser­vices, five years later.

In other coun­ties, of­fi­cials are likely to be re­luc­tant to in­crease ser­vices be­cause of the re­cent state fund­ing cuts for health ser­vices, said Gabrielle Les­sard, a health pol­icy at­tor­ney at the Na­tional Im­mi­gra­tion Law Cen­ter.

Alex Briscoe, direc­tor of Alameda County’s Health Care Ser­vices Agency, said the cuts could end up re­duc­ing county ser­vices for the re­main­ing unin­sured — what he calls “one of the un­in­tended con­se­quences of the Af­ford­able Care Act.” He said his county lost 80% of the $51 mil­lion a year the county pre­vi­ously spent on the pro­gram.

Be­cerra in San Bernardino County says she hasn’t been able to work and hopes the state or county will one day pro­vide the health cov­er­age she needs. She said she’s un­sure what to do about her med­i­cal prob­lems, but gen­er­ally has been happy living in Cal­i­for­nia the last six years. Her 10-yearold autis­tic son is get­ting a bet­ter ed­u­ca­tion, she said, and she feels safer than if she stayed in Mex­ico.

“My plan is to live,” she said.

Ir­fan Khan Los An­ge­les Times

SU­JEY BE­CERRA lives in San Bernardino County, which doesn’t of­fer health­care to those in the U.S. il­le­gally. She even­tu­ally got emer­gency treat­ment, but it left her with con­stant pain.

Ir­fan Khan Los An­ge­les Times

SU­JEY BE­CERRA, in Per­ris with sons Gon­zalo Cervantes, left, and Alexan­dre, lives in con­stant pain af­ter putting off re­moval of ovar­ian cysts be­cause she was unin­sured and un­able to pay for it. Emer­gency surgery was even­tu­ally re­quired but no fol­low-up care is avail­able.

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