LOS ANGELES, Calif — Ruben Acosta, a 53-year-old security guard and legal immigrant from Mexico, shoved his fears aside and made a visit to a school administration building in Compton on a Wednesday last week because he wanted health insurance.
“A lot of Latino people don’t come because they’re afraid,” said Acosta, who brought his wife and 6-year-old granddaughter, a U.S. citizen, to the Covered California enrollment event at the Compton Unified School District. There, people working for the California health care exchange established by the Affordable Care Act sought to enroll members of the demographic group with the lowest rate of insurance coverage in America into the program the president they helped elect said would benefit them.
It’s been a bit of a challenge. The enrollment of Latinos under Obamacare is turning out to be much harder than anyone expected. The president’s oversight of a massive ramp up in the deportation of undocumented immigrants — nearly 2 million of whom have been expelled during his five years in office — has led critics to dub him the “deporter in chief.” It has also created an environment of fear and suspicion in Latino communities that’s undermining willingness to enroll in Obamacare. Traumatized by watching families ripped apart and disappointed that promised immigration reforms have remained stubbornly out of reach, families of mixed legal standing now worry that seeking insurance could lead to the arrest and deportation of loved ones or loss of U.S.-citizen children, rather than increased economic security and better health.
“Obama promised that [applicants’ immigration status] information won’t be shared, but he also promised he’d pass immigration reform,” Acosta said, raising his eyebrows as he relayed reasons to be wary of government promises.
Acosta overcame his own doubts because his health care plan from work does not cover his wife, 46-year-old Ana Acosta, who is still paying back a $5,000 emergency room bill from the last time she got sick. It also helps that most of his immediate family members are either in the U.S. legally or are citizens.
Undocumented immigrants — and even many legal immigrants — are excluded entirely from the Affordable Care Act, which passed four years ago in part because Democrats were emphatic that no unauthorized immigrant would benefit from the law. Requiring the vast majority of Americans to purchase health insurance or face a fine on their taxes was controversial enough without bringing in the hot-button issue of illegal immigration. Even young undocumented immigrants who are eligible for work permits — the so-called “dreamers” brought to America as children — will be barred from insurance under Obamacare, the administration clarified in 2012.
This exclusion, and Obama’s reputation for deporting unauthorized immigrants at a faster rate than any other president, has created enormous challenges for those working to enroll Latinos in Obamacare by the March 31 open enrollment deadline.
“The threat of deportation is real, and … that risk is too great for many people,” said Marisol Franco, director of policy at California Latinas for Reproductive Justice, which is part of the Latino Obamacare recruitment effort. “It really is a disincentive for people to apply for coverage and for people to just decide, you know what, maybe we’ll just pay the penalty.”
Latinos, who are younger on average than the population as a whole and who make up more than 60 percent of the uninsured in California, will need to sign up for insurance in the state in droves in order to offset the costs of sicker, older people. The same holds true around the country: A third of all nonelderly, uninsured Americans are Latino, nearly 16 million in total.
But California has more undocumented immigrants than any state — 2 million of them — and is the only one of the three big states with large Latino populations and high numbers of uninsured to accept the expansion of Medicaid for those who are legal (Texas and Florida turned the Medicaid expansion down). That makes the enrollment effort in the Golden State especially important, and complicated.
On the one hand, California is arguably the state that’s been most generous to immigrants in its Obamacare implementation. Its Democratic leaders have arranged to use state funds to enroll undocumented young people with “deferred action” status in Medi-Cal, California’s low-income health care program. And several counties, including Los Angeles, have provided their own funds to help undocumented people receive primary care through community health centers that treat all comers regardless of nationality or immigration status.
In February, State Sen. Ricardo Lara, a Democrat, introduced legislation to go even further. Lara proposed setting up a “mirror” health care exchange where undocumented immigrants can purchase health insurance with subsidies provided by the state. Lara’s bill would also let older undocumented immigrants, and not just the dreamers, qualify for state-funded Medi-Cal.
Meanwhile, the state's existing programs have not all gone as planned.The state’s Spanish-language advertising campaign targeting Latinos has been criticized for being too literal and clumsy. And only 22 percent of Covered California’s customers are Latino so far — a figure that's 100,000 people short of the state's March 31 enrollment goal for the demographic.
Many California leaders were taken aback that a state that signed up more people for its health care exchange than any other is doing so poorly with Latinos, a group that is generally seen as a Democratic stronghold. It’s also surprising given that Latinos have been more supportive, in general, of Obamacare than other groups. A recent Pew Research Center poll found that 47 percent said they approved of the law, compared with just 33 percent of whites surveyed.
The existing patchwork of plans and programs also can add a painful emotional charge to the already challenging enrollment process, as parents discover that some of their children are eligible and not others, based on their immigration status. “I was just talking with a family the other day saying, ‘You’re telling me I can sign up one kid for coverage and not the other kid?’” said Anthony Wright, executive director of Health Access California, a consumer advocacy group in the state. “The idea that you would give health care coverage to one kid and not the other can be a real barrier.”
Obama stressed in a Spanish-language town hall earlier this month that no health care information would be shared with immigration officials or used in any way to punish people for immigration violations. Homeland Security Secretary Jeh Johnson also wrote an op-ed in La Opinion emphasizing that immigrant families have nothing to fear when applying. “We have partnered with community organizations and trusted sources like Spanish language media to spread the word that no one in America who is eligible should be afraid to apply for health coverage because they have an undocumented family member,“ said Katherine Vargas, a White House spokeswoman.
But that message is not getting through.
“They say, ‘they’re going to deport us.’ There is a lot of fear,” said Ivan Escalante, a retired legal immigrant from El Salvador who has been pushing for his fellow parishioners at St. Agatha’s Catholic Church in Los Angeles to enroll. “The people are confused right now.” One undocumented parishioner told Escalante she wasn’t going to sign up her U.S. citizen child for insurance, because she thinks the authorities will take her child away from her.
Indeed, the oft-repeated rumor among undocumented Latinos is that if you bring your U.S. citizen children to sign up, “se los llevan ”— they will take them. Other rumors enrollers are battling: that children who purchase insurance on the exchange will later be denied admission to state colleges and that a future president could use the information about family members to hunt down undocumented people and deport them, even if Obama does not.
One of the ways Covered California enrollers are trying to combat the widespread fear is by setting up events at what they call “trust channels” — institutions in which undocumented people already have relationships and have learned to not fear deportation, like public schools, churches and libraries.
Last week, Covered California held an event at such a “trust channel” — the Compton Unified School District, home to 25,000 mostly Latino and low-income students. With just two weeks until the deadline to sign up for insurance or face a fine, enrollers were working hard to sign up the handful of people who showed up, using the now-functioning state exchange website.
The trust-channel strategy succeeded in convincing a 23-year-old undocumented immigrant named Daniel, who declined to give his last name, to find out if he qualified for any coverage.
Daniel handed his Salvadoran ID card to the enroller, who quickly became confused.
“This is not a green card, is it?” she asked. “What is it?”
The enroller pulled up on her laptop a long list of documents that allow people to sign up for health coverage. “Do you see any that fits?” she asked. Daniel said he did not, so the enroller brought over a Covered California specialist who spoke Spanish. The specialist asked what the ID was, and Daniel’s cousin Mayra, a legal immigrant who attended the event with him, responded, “This is the ID that they give us in our country.”
“In your country, but not here,” the enroller replied. “For Covered California, you won’t be eligible for any plan.” She turned Daniel away and told him to reapply when he received legal immigration status.
“I’m a little bit worried. I have to be insured,” said Daniel, who came to the U.S. in 2007 when he was 16 years old, after he was denied. Daniel had heard that young dreamers like him qualified for Medi-Cal in California. He was correct, but he lacked the deferred action status from the federal government that the state requires.
Some activists are splitting their time between getting the word out about Obamacare and trying to convince the state to expand coverage for people like Daniel, through the Lara bill and at the federal level.
“We were thrown under the bus,” says Mayra Joana, a 26-year-old undocumented immigrant and activist at the UCLA Labor Center who received deferred action status last year. She signed up for Medi-Cal last month, under the state’s expansion of health care covered for dreamers, but her parents, both undocumented, are not eligible. Mayra, who asked only to be identified by her first and middle names, felt “very nervous” enrolling.
“I knew that I qualified and I knew that I would be able to enroll, but I think a lot of my hesitation and fear came from just living as an undocumented person for a long time,” Mayra said.
If, as seems likely, state coverage is not expanded to undocumented immigrants, the group will have to rely on care from community health clinics, the only thing funded by Obamacare that was designed to provide for them. The Affordable Care Act sets aside millions of dollars each year for the clinics, which are not allowed to turn away people who are uninsured or who lack legal immigration status. Last year, community health care clinics in California received $30 million dollars through the law.
Several clinics’ leaders in Los Angeles said they saw increased patient visits from undocumented immigrants last year, and that continuing to serve this population will be tough, even with the federal funding, because of uncertainty regarding the state’s contributions. Nine counties in California cover some medical care for undocumented immigrants who live below 133 percent of the federal poverty line. But it’s unclear which counties will continue to provide this money in the future, because the program was meant to be a stop-gap measure for all low-income uninsured people until the state’s Medicaid expansion went through. Now that the counties have been able to transfer almost everyone except undocumented people to state-funded Medicaid, they are reconsidering whether they should continue to bankroll the programs.
Ingrid Estrada, community relations director at Clinica Romero, a network of community health centers in Los Angeles, said more than half of the clinic’s 15,000 patients are undocumented, and that it would be “catastrophic” if they lost any of the $200,000 they get each year from the county to care for undocumented people. “I don’t know where that money would come from,” she said. Los Angeles has agreed to extend the funds for another year, but it’s unclear whether they will continue to do so after 2015.
As the uninsured population of U.S. citizens shrinks, undocumented people are expected to begin to make up a larger and larger share of the uninsured. A third of all uninsured people in California in five years will be undocumented, according to an analysis from UCLA researchers, up from 20 percent now.
Health professionals are worried they’ll need to start turning people away from the community health centers, sending undocumented patients to emergency rooms and re-establishing the inefficient and expensive health care delivery pattern Obamacare was intended to fix. They say the federal and state governments have shirked their responsibilities by failing to provide for the undocumented and continue to offload an enormous public health problem onto them.
“It’s easy as a person high up … to say, ‘We aren’t going to have undocumented immigrants access these funds.’ But when they’re in your clinic, crying, it’s hard,” Estrada said.