Caught Between the Cracks of Health Care for the Undocumented

Before businesses open their doors and morning commuters flood the streets, Fresno County’s farm workers have already harvested hundreds of pounds of tomatoes, peaches and grapes on the nearly 1.9 million acres of the county’s farmland.

The produce is loaded onto trucks to be shipped throughout the country, but bringing that produce to the nation’s table tops is not an easy task. The undocumented workers who make up the vast majority of the state’s agricultural labor force suffer both minor and major injuries in the field, a surprisingly harsh work environment. Then they struggle to find the health care they need.

For more than 30 years, undocumented farm workers relied on the county’s health care safety net, the Medically Indigent Services Program (MISP), which provided specialty care coverage for illnesses that require the care of a medical specialist to low-income uninsured adults with no other source of care. In 2013, a court ruling allowed the county to remove the undocumented workers from the program, but the county agreed to provide temporary funding to continue the coverage.

MISP is currently still available in several other counties throughout the state, including Riverside and Los Angeles Counties. However, some of these counties face similar pressures to exclude undocumented immigrants from receiving services and are working hard to not go down Fresno’s path.

Nearly one year into the temporary Non-resident Specialty Care Fund - a temporary program that provides specialty care coverage to the undocumented - health care providers and advocates said that most of the potentially eligible are unaware of the program and those that do apply are faced with a difficult and time consuming application process.

“At one point it was projected that more than 5,000 individuals would utilize the Non-resident Specialty Care Fund per year, we are not even close to 1 percent of that,” said Sandra Celedon with Fresno Building Healthy Communities.

The county has an estimated 45,000 undocumented immigrants and 14,000 were seeking coverage from the MISP program before they were cut off.

“We know those people didn't get well all of a sudden. Their cancer wasn’t cured over night. So, people are going without care,” Celedon said.

In 2014, Clinica Sierra Vista, a Central Valley nonprofit primary health care provider, filed a lawsuit against the county, arguing to keep the MISP after the county tried to lift an injunction that required them to provide indigent care since the 80s. The judge ruled that the county would have to continue to fund the MISP, but the county was no longer obligated to cover the undocumented.

Months after the ruling, the county’s Board of Supervisors approved $5.5 million for the Non-resident Specialty Care Fund through a bill that was introduced by former Assemblyman, Fresno County supervisor Henry Perea. The deal gives the county extra time to pay off  the $5.5 million it owed to the state’s road fund in exchange for providing specialty care for the undocumented.

Advocates blame the public’s lack of awareness of the program on the county who they believe has abdicated its responsibility to make sure the program runs successfully to avoid reimbursing providers for the services they provide. The bill requires the county to contract with federally-backed clinics to provide care, then the county will get reimbursed by the state.

“We have seen a huge level of confusion in our community and the county was really responsible for that,” Celedon said.

Advocates describe the application process for the Non-resident Specialty Care Fund as difficult and involving a lot of red tape, preventing many patients from getting the care they need. Applicants must first be approved for restricted scope Medi-Cal -that allows undocumented immigrants access to emergency and pregnancy related services-- before establishing care with a primary care provider who would then provide a referral that must get approved by a benefit administrator. Once the referral is approved, it is sent to a community regional medical center which would then schedule an appointment with a specialist.

As a primary care provider, Clinica Sierra Vista refers patients to specialists for the treatment of illnesses like diabetes or cancer. And although the number of undocumented patients they receive has remained steady, they have seen a drop off in the number of undocumented patients that are following up with referrals to see specialty care providers, said Stephen Schilling, CEO of Clinica Sierra Vista.

“It is a hard system to navigate and it turns a lot of undocumented people off. These are people that are afraid of being deported. They are living in the shadows and when they see too many obstacles they back down,” Schilling said. “People are falling through the cracks.”

Agriculture remains one of the most dangerous industries in the United States. According to the National Center for Farmworker Health (NCFH), farmworkers face hard physical labor and a range of occupational hazards including pesticide exposure, respiratory problems, infectious diseases and operating hazardous machinery.

Data from the National Center for Farmworker Health shows that every day more than 243 farmworkers suffer injuries that make them unable to work and about 5 percent of those  injuries result in permanent impairment. Many of the illnesses that could be incurred by farmworkers on the job - like neurological problems and blood disorders, both long term effects of pesticide exposure - would need to be treated by specialty care providers.

“The farmworkers are the most marginalized and that’s why these programs are needed to help them get some sort of health care. It’s unfortunate the farmworkers put food on our table, yet they are left out,” said Noe Paramo, legislative analyst with the California Rural Legal Assistance Foundation.

Advocates say the economy and public health are compromised because of the lack of access to health care. It can lead to the spread of communicable diseases and a depleted workforce, one that powers a county agricultural industry valued at $5.6 billion. A lack of coverage also leads to an increase in emergency room visits that leave taxpayers footing the bill.

“I think it’s not only to the benefit of those who need it, because for them it’s a matter of their health and livelihood, but there’s a lot of interests that are served when coverage is provided,” said Mona Tawatao, senior litigator with the Western Center on Law and Poverty.

Following the expansion of coverage under the Affordable Care Act, successful enrollments in Medi-Cal and Covered California have not diminished the need for county indigent care programs.

According to a 2015 report published by Health Access California, a health consumer advocacy coalition, counties with broad eligibility requirements on income and immigration status, including San Francisco and Alameda county, report thousands continue to receive care through their indigent care programs.  Counties that do not serve the undocumented, including Merced and San Bernardino county, have seen enrollment in their indigent care programs drop to a few hundred, sometimes even zero, patients.

The Non-resident Specialty Care Fund is expected to last until April 2016 or until it runs out, but Celedon acknowledged that given the lack of applicants, funding will not run out for the foreseeable future.

The nonprofit, Fresno Healthy Community Access Partners, a coalition of health care and community organizations, is holding monthly meetings to bring together health care providers, advocates and county representatives. The aim of these meetings are to identify some of the possible barriers and issues the program is facing, said Norma Forbes, executive director at Fresno Healthy Community Access Partners.

Once the program ends, there are no plans at the county level to ensure that specialty care coverage for undocumented Fresnans will continue to be funded.

“For ongoing support of specialty care, we are looking to Sacramento for a long-term funding solution,” said Supervisor Perea.

But a state solution could materialize in the not-too-distant future.

Sen. Ricardo Lara, D-Long Beach, has been pushing to extend health care coverage to undocumented Californians. Lara sponsored Senate Bill 4 that was signed by Governor Jerry Brown last year. The legislation will give undocumented children in California access to full Medi-Cal benefits starting in May.

Another bill he introduced in 2014, Senate Bill 10, is currently working its way through the Senate. The legislation would extend eligibility for full-scope Medi-Cal benefits to undocumented individuals 19 years of age and older.

Only time will tell if the Non-resident Specialty Care Fund will last until Senate Bill 10 can give undocumented adults access to care. Until then, it continues to serve a limited few.

Top image: Photo by ALFREDO ESTRELLA/AFP/Getty Images