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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,

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Presentation on theme: "Deserving to a Point: Undocumented Immigrants in San Francisco’s Universal Access Model Helen B. Marrow, PhD Robert Wood Johnson Scholar in Health Policy,"— Presentation transcript:

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 “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 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!”, Representative Joe 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


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