Paula Medrano shifts uncomfortably on the doctor's examination table, holding out a wrist inflamed and swollen by arthritis. The 78-year-old has no health insurance, lives below the federal poverty level, and can't pay for the medication she needs.
Just days before her appointment, President Barack Obama signed, with much fanfare, a historic bill to extend health care access to 32 million currently uninsured people. But Medrano and her daughter, Juana Aguirre, barely paid attention.
"It's a great thing, but it's not for us," said Aguirre.
Medrano is an undocumented immigrant — one of the 7 million uninsured people living in the United States who were explicitly excluded from the legislation, according to estimates by the Congressional Budget Office.
The question of whether to extend coverage to illegal immigrants was so politically contentious that, under the approved legislation, they will not even be able to buy health insurance in the newly created purchasing pools called exchanges if they pay entirely out of their own pocket.
Proponents of reducing immigration believe that allowing illegal immigrants access to health care is an incentive for them to come, and an unfair tax burden on Americans.
Although the approved legislation explicitly excludes undocumented immigrants from participating in the exchanges, there is no foolproof way of verifying their documentation to keep them out, said Yeh Ling-Ling, executive director of Alliance for a Sustainable USA.
They will also continue to have access to emergency medical assistance.
"It is not fair on struggling Americans," said Yeh.
What is clear is that as the ranks of the uninsured diminish, immigrants like Medrano will continue to patch together health care as they can — at health centers such as Fresno's Clinica Sierra Vista, at hospital emergency rooms, or through programs like Healthy San Francisco, which offers universal health care to all who live in the city.
"We have to be very creative — not asking for labs unless it's really essential, working with generics, working with drug companies, giving them samples," said Juan Carlos Ruvalcaba, the doctor seeing Medrano at Clinica, which charges on a sliding scale of $40 to $70, depending on the patient's ability to pay.
Once an undocumented immigrant himself, Ruvalcaba was able to become a citizen and attend medical school because of an amnesty program in 1986. He remains committed to serving all patients, no matter their insurance or immigration status, but there is only so much he can do, he said.
He was able to give Medrano the drugs she needed, but he asked, "What happens when they need a specialist? What if they end up in the emergency room, and end up with a big bill?"
Some who work with this population are afraid that with the focus shifting onto providing care for the newly insured, those shut out of the system will be forgotten, left to fend for themselves with even fewer resources.
"It may make things worse — if you say 32 million are covered, there may be less done for these large groups who are here, who are working, who are such a large part of our agriculture industry," said Norma Forbes, executive director of Fresno Healthy Communities Access Partners, a nonprofit network of eleven health care organizations in California's rural Central Valley.
Illegal immigrant won't be the only uninsured left: about 16 million Americans are estimated to remain outside the health care system even after access is expanded over the next few years, according to the Congressional Budget Office.
This includes those who opt out, who don't know how to enroll, or who are exempted from the health insurance requirement because they can't afford the premiums, even with a subsidy.
For these patients, there will indeed be fewer options as doctors, hospitals and other providers increase their caseload to take in new patients bearing insurance, said Dan Hawkins, who is charged with policy and research at the National Association of Community Health Centers.
"There will be greater concentration of care for the uninsured in fewer places," Hawkins said.
Community health centers, the lynchpin of the safety net system now caring for the medically underserved, whether they are immigrants or citizens, will remain one of the places where people like Medrano will be able to see a doctor at an affordable cost.
Federally qualified clinics got a substantial funding boost through the health reform package.
They will get $11 billion in new funding over the next five years, which will allow them to double the number of patients they see, from 20 million a year now to 40 million people a year by 2015.
Most of these new patients will come bearing new insurance cards, or be part of the larger pool qualifying for Medicaid. But among them will be illegal immigrants, said Hawkins.
"Health centers will continue to be open to everyone regardless of their ability to pay, undocumented immigrants and everyone else," he said. "We don't know how many of the uninsured we serve right now are undocumented. But we do know a health center is a better, and less expensive, place for them to get that care."
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