How nonprofits are filling in southern Arizona's health care gaps

Volunteer Andrew Kim helps a patient at Clinica Amistad in Tucson on Nov. 3, 2022.
Volunteer Andrew Kim helps a patient at Clinica Amistad in Tucson on Nov. 3, 2022.

Uninsured patients slowly trickled into the waiting room of Clinica Amistad, a free health clinic in south Tucson, filling up every seat in the room shortly after it opened its doors at 5 p.m. on a weekday in the fall.

Volunteer promotoras, or community health workers, had decorated the room for Día de los Muertos, Day of the Dead, with colorful papel picado and pictures of skeletons, giving the clinical setting a welcoming feel.

Clinica Amistad is one of Tucson’s only free primary care clinics, in addition to a clinic run by University of Arizona College of Medicine medical students.

Run by a host of volunteer health care providers and others, the clinic aims to fill the gap of providing health care to people without access to health insurance, including many people without documentation.

In 2020, the clinic had 2,400 patient visits and provided 1,772 volunteer hours by doctors and nurses, according to the organization’s most recent annual report. In addition, about 88% of patients that year identified as “Hispanic or Latinx” with 58% of patients currently uninsured with previous insurance, while 30% have never had health insurance and 12% declined to answer.

Low-income residents in southern Arizona rely primarily on federally qualified health centers that provide health care at decreased costs, county public health departments for a wide range of preventative care services, and free primary health care clinics like Clinica Amistad.

However, there is still a large gap in treatment services for uninsured people who have serious issues. It ends up costing patients thousands or tens of thousands of dollars to treat, said Lisa Kiser, a nurse practitioner and an assistant professor at the University of Arizona.

Kiser is one of the many volunteer health care providers who work at the clinic.

Although Kiser has seen innumerable patients throughout her career, she has an impeccable memory of her patients, their stories and the inequalities they face trying to access care.

She recalled one woman who came to see her whose intrauterine device, or IUD, had perforated her uterus and migrated into her bladder. The woman had frightening symptoms such as painful urination, blood with urination and severe abdominal pain.

However, after going to three different emergency departments in Tucson, no one would take it out.

“No one would call an IUD in her bladder an emergency," Kiser said. “If you walked in and had an IUD stuck in your bladder and you have your insurance, they would immediately take you back and operate on you.”

Kiser said she had to work with a gynecology specialist to have the IUD removed, five months after it had gotten stuck in the woman’s bladder.

While emergency care is offered to those who are uninsured – thanks to the Emergency Medical Treatment and Labor Act of 1986 — not every issue is considered an emergency and treated.

According to an article in the The Western Journal of Emergency Medicine, board-certified emergency physicians are trained in emergency and not primary care. Thus, they do not typically specialize in disease prevention or chronic diseases such as high blood pressure, diabetes, asthma, heart disease or cancer, among others.

Kiser recalled another uninsured patient with uterine cancer who had an impossible decision to make: to stay with her family in the U.S. and die from her disease or return to Mexico for care and risk never seeing her family again.

“She couldn’t get treatment here, so she would have to go back to Mexico, but she would not have a legal or easy way to cross back in the United States,” Kiser said.

Not wanting to be away from her family, the woman chose to stay with her family and died shortly after.

“It’s just appalling in 2022 that I have five people on my schedule that most of them have bleeding issues,” Kiser said. “It is really hard night after night to look at somebody and say, 'Can you go back to your country of origin (to access care).'”

She noted how many of her patients cannot return to Mexico. Some were brought to the U.S. as children, while others crossed the border in ways where they cannot return, or they do not know anyone in their home country anymore.

Kiser also highlighted one particularly vulnerable population that Clinica Amistad serves: people applying for permanent residency. Many immigrants on temporary visas waiting to become permanent residents are scared to apply for federal programs because they do not want it to affect their admission into the country.

Lisa Kiser (right) is a volunteer nurse practitioner while Ivana Burruel is a volunteer nurse at Clinica Amistad in Tucson.
Lisa Kiser (right) is a volunteer nurse practitioner while Ivana Burruel is a volunteer nurse at Clinica Amistad in Tucson.

According to the National Immigration Law Center, officials can deny immigrants permanent residence into the country if applicants are likely to become a public charge, or dependent on public assistance, which includes Medicaid.

While the Biden administration stopped enforcing much of that policy, unlike the Trump administration, those fears persist, Kiser said. For people in those situations, paying for health care out of pocket or applying to public programs are not viable options.

“That is why Clinica Amistad exists,” Kiser said.

Los Angeles County created its own health care program for residents left out of the Affordable Care Act

While advocates in Pima County vouch for a public health option for the uninsured, other counties across the country are proving that health care for everyone is possible.

In Los Angeles County, residents who are uninsured or underinsured can get help from the county’s health care program called My Health LA.

Through a network of more than 200 community clinics, anyone who lives in the county can get help.

Services range from primary care to specialty care for residents no matter their immigration status, said Anna Gorman, the program’s director.

“We know that primary care is a better way to keep people healthy and help people manage their chronic diseases, rather than having them go without coverage and ending up in the emergency room,” Gorman said.

She reiterated that funding such a program, which comes from the county and the state, faced little to no opposition from county residents when it began almost 10 years ago.

Gorman said there was no specific tax raise for the program.

“L.A. County and California as a whole … have realized that everyone should have access to health care regardless of their immigration,” she said.

In a recent turn of events, My Health LA will soon no longer be necessary as California plans to expand Medi-Cal, the state’s public insurance program. In 2024, Medi-Cal will expand to include every California resident no matter the resident’s age or immigration status, covering an estimated 764,000 immigrants without documentation, according to California’s Office of the Governor.

How southern Arizona counties address public health

In Pima County, while there is no overarching safety-net program, the public health department offers a range of services such as HIV testing and treatment, STD testing, vaccinations, family planning, reproductive health, help accessing insurance options and more.

According to the 2021 Pima County Community Health Needs Assessment, increasing access to health care is a concern among community members.

Although there have been discussions about this issue in the department, no plan is in place to establish a health care program for the uninsured, said Theresa Cullen, Pima County’s public health director.

She reiterated the health department doesn’t create policy, but rather informs it.

Cullen called the current health care system for the uninsured and underinsured a “patchwork quilt” that has some holes, where people can find free care through free clinics like Clinica Amistad and the University of Arizona’s Commitment to Underserved People programs, a clinic helping those who are under-resourced.

In Cochise County, while the county health department offers many free services for the uninsured such as free vaccines, and family support to new mothers and their families, primary health care for low-income families is provided by Chiricahua Community Health Centers, the local federally qualified health center in the county.

“We are all about prevention. We want to prevent illness,” said Alicia Thompson, Cochise County’s director of Health and Social Services, noting that providing primary care is not in the purview of the public health department.

The Chiricahua program, as a federally qualified health center with clinics throughout the county, provides primary care on a sliding fee scale.

Dennis Walto, chief of external affairs for Chiricahua Community Health Centers, said no one is turned away based on their ability to pay, their immigration status, insurance status or medical condition.

“We do have a sliding scale and that sliding scale does slide to zero,” he said. The largest barrier to getting health care is access, he said, noting that the center often brings care out to the patients through a mobile clinic or providing transportation.

He also said the center works with specialists to make sure patients are not priced out of expensive specialty care.

In Santa Cruz County, public health responsibilities have been contracted out to the county’s federally qualified health center, Mariposa Community Health Center.

A model of the body's organs at Clinica Amistad in Tucson.
A model of the body's organs at Clinica Amistad in Tucson.

Back at Tucson’s Clinica Amistad, Kiser sat in a room preparing to see a long list of patients, many of whom had abnormal uterine bleeding, noting that for every person who finds a way to the clinic, many more in the community do not.

“That’s why people walk in the door with glucose levels of 400 … and hypertensive crisis and mental health issues that are not being addressed,” she said.

According to the Centers for Disease Control and Prevention, a glucose level of 126 mg/dL is the minimum to be diagnosed with diabetes.

“If you don’t have access to care, then these (issues) are worse,” she said. 

Coverage of southern Arizona on and in The Arizona Republic is funded by the nonprofit Report for America in association with The Republic.

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This article originally appeared on Arizona Republic: Nonprofits fill gaps in southern Arizona's health care