A year after Fresno County agreed to defer repaying state road funds to cover the costs of specialty medical care for undocumented immigrants, the pot of money remains largely unused.
Supervisors voted in April 2015 to tap $5.6 million from the deferred payment, but as of May 20, only $260,000 has been billed for health care for undocumented immigrants.
The county program, known as Non-Resident Specialty Care Services, is designed to pay for medical services for adults who have no insurance, can’t pay for care and are not eligible for Medi-Cal, the state-federal health insurance program.
Undocumented immigrants are the lion’s share of those without insurance or means to pay for care. They can get primary care at federally qualified health centers at little or no cost, but the centers don’t provide specialty care, such as gallstone surgery, heart procedures and cancer treatment.
Last week, Senate Bill 10, which would let undocumented adults buy private insurance through Covered California, the state’s health insurance exchange established under the Affordable Care Act, passed the Legislature and headed to the governor’s desk. Undocumented immigrants, however, would not be eligible for federal subsidies to help reduce the cost of health premiums. The law also would need federal approval.
Advocates for the uninsured say Non-Resident Specialty Care Services is a needed safety net program for low-income undocumented workers, but it has not been promoted and has barriers that have kept people from applying for medical help.
Fresno County officials say some of the undocumented workers are eligible for Medi-Cal under a special provision of the law, and that has reduced the need for the specialty services program. And others who assist undocumented immigrants say many have been unwilling to apply because they falsely believe doing so could affect their immigration status.
By all accounts, usage has been far less than was estimated a year ago, when county officials said the specialty services fund could be emptied within three years.
The supervisors set aside the $5.6 million for specialty care based on reports that Community Regional Medical Center had been spending $250,000 a month to serve uninsured and undocumented immigrants after supervisors ended a 20-year health contract with the hospital at the end of November 2014. The county had estimated that 4,000 to 5,000 undocumented workers a year could seek specialty services, but so far only 157 people have been referred and 146 have been approved.
Sandra Celedon-Castro, manager of Fresno Building Healthy Communities, said Fresno County officials feared there would be thousands of applicants for specialty care, so they created a complex application process that has discouraged people from applying. “We basically created this web that folks have to navigate, as if health care access isn’t complicated already,” she said.
For example, the county decided that undocumented workers have to be disqualified for full-scope, comprehensive Medi-Cal before they can be eligible for the county program, she said.
Most undocumented workers are not eligible for full Medi-Cal and receive only restricted services for emergency care. But a specific subset of undocumented immigrants, such as those who are waiting for legal residency documents, are eligible for comprehensive Medi-Cal coverage, Celedon-Castro said. The immigration category is “permanent residency under color of law,” or PRUCOL. Those undocumented immigrants are acknowledging that they are in the country without documentation and that immigration officials know they are here but have said they will not seek their deportation, she said.
It’s unknown how many undocumented immigrants fall into the category of permanent residency under color of law, but Celedon-Castro is concerned that the county health department has encouraged people to declare they are.
“The department was promoting this as if it was a new program, a blanket program that people all of a sudden were eligible for,” she said. “That program is not a new program; it’s been in existence since the ’90s.”
Celedon-Castro said there are likely thousands of undocumented workers in Fresno County who are not able to declare PRUCOL and need the county program for specialty care.
But David Pomaville, the county’s director of public health, said many people who applied for the county program did qualify for full Medi-Cal benefits, which covered their specialty care needs.
But other undocumented immigrants are not willing to apply for services, he said.
Concerns about future immigration status prevents many undocumented workers who need medical care from applying for help, said Eleazar Valdez, outreach specialist at the Central Valley Immigration Integration Collaborative, a nonprofit that assists immigrants in the central San Joaquin Valley.
Immigration raids are frightening, Valdez said. People are afraid to put their name on any document, from a bank account to a utility application, he said. They’re not comfortable filling out a form to get specialty care, even if they need it. “They’d rather have the pain or they’d rather stay at home than to seek medical help,” Valdez said.
Ruben Chavez, chief administrative officer at Clinica Sierra Vista, which operates federally qualified health centers in Fresno and Bakersfield, said the county’s application process has been confusing for his staff who are trying to help people get specialty care.
“I just don’t think (the program) was rolled out well,” Chavez said. “It was never really meant to be a county program. It was meant to just be a pot of money available, and no one was really in charge of it.”
Health centers, however, have become referral agencies for the program.
Pomaville said the county wants people in need of services first to be seen by primary care providers at federally qualified health centers. If they need treatment beyond the ability of those providers, they can then apply for Non-Resident Specialty Care Services. The county has a five-year contract with an outside agency to review claims submitted for payment.
Specialty services are provided through Community Regional Medical Center, and there have been some bumps in getting service, said Brandon Hauk, office manager at Clinica Sierra Vista. Patients can wait six to eight months to be seen by a specialist, he said. “By that time, the authorization has expired and we have to start the approval process all over again.”
A shortage of health care specialists affects everyone in Fresno County, Pomaville said, but the county is looking at the issue of long wait times for patients in the nonresident program.
The county also is working with community groups and health providers to expand outreach and education about the program, Pomaville said.
Valdez said it’s the county’s job to promote the program. He hopes county staff addresses concerns of undocumented workers. “Make sure the people know when they apply for this they’re not going to be apprehended or the information is not going to Immigration,” he said.
Celedon-Castro said the small number of applicants “leaves me to believe we have thousands of Fresnans going without lifesaving care that they need.”