In this nation of immigrants, everything old is new again.
Many of the options explored at the beginning of the century to treat the swell of immigrants from Europe are now being applied to aid more recent arrivals from Asia and Latin America. Among them: preventive-care programs delivered through churches and schools, and low-cost insurance.
Meanwhile, such efforts play against a backdrop as old and familiar as a chapter from an American history text : xenophobia-tinged politics aimed at cutting aid.
Yet the need for immigrant healthcare will continue to grow rather than diminish. According to a recent article on the subject in the Journal of the American Medical Association, the number of Latino immigrants will swell to 12% from 9% of the total U.S. population in the next decade. And while studies indicate both immigrant and U.S.-born Latinos are steadily moving up the socioeconomic ladder, they still constitute 18% of the entire U.S. population living below the poverty level and 22% of all impoverished children-among groups most at risk for health problems.
The proportion of Asian children living below the poverty level is far lower, at about 3.3%. However, Asians as individuals tend to seek out medical help at a far lower rate than other ethnic groups, making an average of 4.5 doctor visits per year, compared with 5.5 for Latinos and 6.5 for Caucasians, according to the Asian-American Health Forum.
Because immigrants have lower incomes than those of the native population, they also tend to be more dependent on government-sponsored healthcare programs. According to a recent study published jointly by the conservative Cato Institute and the National Immigration Forum, a politically moderate group supporting legal immigration and opposing benefit cutoffs to legal and illegal immigrants, annual per-capita Medicaid expenditures for immigrants total $752, compared with $627 for natives.
Add to that federal welfare reform that gives states block grants to handle welfare costs, recent cuts in Social Security disability benefits, and a push in Congress to restrict Medicaid benefits to both legal and illegal immigrants, and the question of who will be holding the check at the end looms large.
California cauldron. While the immigrant healthcare issue is one of national significance, nowhere has the situation crystallized as it has in California. The state has long been the nation's trendsetter for healthcare, but it also has been its lightning rod for the recent anti-immigrant backlash.
The state's demographics tell a stark story. For example, 46% of all Latinos in Los Angeles County-the most populous county in the nation-are without health insurance. That's 50% higher than the countywide average of 31% and more than double the rate among Caucasians.
"The recent developments on the federal level are a real curse on California," observes Jim Lott, senior vice president of the Healthcare Association of Southern California. He notes that 60% of the nation's legal immigrants reside in the state, with 24% in Los Angeles County alone. Federal welfare reform could add $495 million a year to the cost Southern California healthcare providers would have to shoulder to care for them, he estimates. That includes $345 million in uncompensated care at regional hospitals, 60% of which already operate in the red. And those are just the numbers for immigrants with legal residence.
Among the solutions? Low-cost insurance was a staple of the old European immigrant households, and it has begun a rebirth. Last month, Woodland Hills-based Blue Cross of California rolled out a new policy called Medifam, which will provide coverage for the working poor of Boyle Heights, a predominantly Latino community east of downtown Los Angeles. Medifam provides coverage for households earning between the poverty level and twice the poverty level, or $15,000 to $31,000 a year for a family of four. Premiums are about a quarter of the prevailing rate, or less than $1,000 a year.
The Medifam program is being coordinated through White Memorial Medical Center in Los Angeles, the Family Care Specialists medical group and the Chicano/Latino Medical Association of Los Angeles County.
"There are many hard-working Californians today who do not have access to needed healthcare because they fall into the gap between state and local indigent programs and employment-based coverage," says Keith P. Bishop, commissioner of the California Department of Corporations, which oversees HMOs and recently approved the Medifam product. "I am hopeful that the Medifam pilot will provide needed coverage to fill the gap."
Blue Cross officials couldn't immediately provide enrollment or financial projections for Medifam. Spokeswoman Cynthia Coulter notes that there are plans to expand the program to other parts of the state with a preponderance of low-income households, such as the San Joaquin Valley. Its major cities, Fresno, Modesto and Stockton, have among the nation's highest concentrations of Cambodian and Vietnamese immigrants.
And while Medifam isn't targeted directly to immigrants per se, noncitizens with legal residency are eligible. Also, buyers can limit coverage to just their children if desired.
Yet drawbacks remain. Lott was concerned that even with discounted premiums, families already struggling to make ends meet will have trouble affording the premiums. And while Medifam will operate as an HMO product, it's stripped to the bone. For instance, it will not pay for inpatient care. However, enrollees can be admitted to White Memorial under Medi-Cal, the state's Medicaid program.
Illegal aliens. And Medifam doesn't address another chronic problem: paying for undocumented immigrants. Now that federal welfare reform is shifting Medicaid management costs back to local governments, states such as California are entering legal battles to avoid the burden. Meanwhile, the actual cost of healthcare for illegals remains murky. The Cato Institute/National Immigration Forum study notes that most undocumented immigrants tend to avoid public-sector services for fear of being deported. Lott says that when they do receive healthcare, it's usually after admittance to an emergency room. That high-cost form of delivery is customarily absorbed by the admitting hospital.
If illegals receive any preventive care, they tend to get it at the grass-roots community level, mainly through programs set up at churches and schools that are often privately endowed.
Queen of Angels-Hollywood Presbyterian Medical Center in Los Angeles has formed a program called the Greater Hollywood Health Partnership, part of a larger countywide church-based program called the Health and Faith Coalition. With a mixture of volunteerism and grants from such private donors as the Robert Wood Johnson Foundation, the ARCO oil company and the James Irvine Foundation, the partnership has managed to cobble together a network of 30 area churches that provide on-site treatments such as blood screenings. Between January 1995 and May 1996, the partnership made more than 18,000 patient contacts and 2,800 referrals to local physicians and clinics not inclined to ask too many probing questions. In turn, the hospital heads off future uncompensated-care costs.
"We're in an area of Los Angeles where 48% of the residents are foreign-born noncitizens, and 27% live below the poverty line," says the Rev. Steve Ryan, Queen of Angels-Hollywood Presbyterian's head of chaplaincy services. "In their situation, and this type of climate, they are reluctant to approach government agencies for help. But the one place they know they can receive help without questions being asked is the church."
The Los Angeles Unified School District also conducts its own on-site disease screening and immunizations for students of all ages. Five campus-based clinics have sprung up in low-income and minority communities in the past decade, with three others in the planning stages. Like the Greater Hollywood Health Partnership, much of the costs are underwritten by grants and donations.
Yet despite the innovation of these programs, they are under constant strain. L.A. Unified's on-campus clinics allow the district to boast of not having a single student with tuberculosis at a time when it's epidemic among immigrant populations. However, the district must still kick in $125,000 a year of its own money to cover costs.
"Ideally, we'd like to have a clinic in every high school complex. The need is incredible. But we're in times of real flux, and with welfare reform it's going to get worse," says Sally Coughlan, the district's assistant superintendent in charge of health and human services.
Birth of a problem. Indeed, under the auspices of federal welfare reform, Gov. Pete Wilson late last year attempted to issue emergency health regulations that would have barred illegals from receiving prenatal care. Prenatal care for illegals costs the state $70 million annually, and it's among many Medi-Cal programs Wilson's administration is trying to take away from them. The regulations were contested by a variety of healthcare and civil-rights organizations, and the issue is now being fought in court.
According to various county and statewide studies, denying prenatal care would cause premature births and cases of syphilis and AIDS transmitted to infants to balloon.
"It's a penny-wise, pound-foolish policy to pursue," says Lott, of the Healthcare Association of Southern California. His organization estimates that each dollar spent on prenatal care saves seven down the line. And no matter how heated the rhetoric surrounding immigrant care becomes, those premature and infected children would be entitled to the seven upstream dollars because they are born into U.S. citizenship.