María had only been in the United States for about a year when the pandemic hit. She had entered the country without documentation and settled in Brooklyn, finding some work under the table preparing tamales and doing food prep at a restaurant. It was a brief period of relative calm. By late April, she was out of a job and experiencing the symptoms she’d seen on the news: loss of smell and taste, dizziness, diarrhea, persistent pain in the lungs, loss of balance. “I didn’t go to a doctor because I don’t have insurance,” she told me. “I didn’t have the money to pay.”
She tried to wait out her symptoms, but her condition eventually deteriorated to the point that she needed to go to the hospital. When she arrived, she was relieved to learn that her Covid-19 testing and initial treatment would be covered by Emergency Medicaid, a federal program that can extend Medicaid coverage to otherwise uninsured individuals if they have an acute medical emergency. While running other tests, medical staff also informed her that she had developed diabetes. It was concerning news. A chronic illness was something she hadn’t planned for, and the medical staff she encountered were concerned about what it would mean for her recovery.
Now, almost four months later, María is one of the many thousands of Covid “long haulers”—patients who have officially recovered from exposure to the virus but are still navigating ongoing health issues. She’s also lost her emergency insurance—which is only designed to cover immediately life-threatening situations—so she’s buying insulin and other medication from a local clinic. Money is tight though, and she’s been worried that she won’t be able to pay for it much longer. She recently paid $80 for medication for acute gastritis and lung inflammation, while the rent bills keep piling up. As an undocumented immigrant, she was not eligible for any federal relief programs, and the food she gets from a local aid organization only goes so far. Last week, María started working again, this time cleaning houses. “I feel so much pain in my lungs as I’m cleaning,” she said. Still, she doesn’t see an alternative.
She’s not alone in that predicament. Many states have clarified that testing and treatment of an active Covid infection must be available to all and can be covered with Emergency Medicaid, but there’s been little discussion about what happens afterward. Under federal law, hospitals and medical providers in general must tend to people facing immediately life-threatening conditions but are under no obligation to keep providing care to an uninsured patient who is not in a state of emergency, even if the lack of treatment will trigger just such a situation. That describes María and other insurance-ineligible immigrants hoping to recover from the long-ranging health catastrophe that is Covid-19. Without long-term aid from the state, though, they are essentially left on their own.
The effort to make health care affordable and accessible for immigrants without status has been active and shifting for decades. Undocumented people were explicitly excluded from the marketplaces created as part of the 2010 Affordable Care Act, and activists were outraged when even recipients of the Deferred Action for Childhood Arrivals program were locked out of coverage. Currently, people without legal status remain ineligible for standard Medicaid, the Children’s Health Insurance Program, and the federally funded health insurance marketplaces. In certain emergency circumstances, they can qualify for Emergency Medicaid, though as cases like María’s make clear, the program is inflexible and largely exists as a temporary bandage.
Over the years, the basic outline of the policy debate has remained more or less static, with immigration activists and health professionals pointing out that uninsured rates remain high among noncitizens generally and the undocumented particularly, which, beyond its express cruelty, ends up being a public health problem and costing state and local governments money anyway as people end up in emergency rooms for preventable issues. The typical conservative response to warn of increasing cost and the supposed encouragement of more irregular immigration.
Nothing much changed in the Covid era. Neither the Cares Act nor its failed would-be successors have really attempted to grant eligibility to anyone who doesn’t already have it. In response, it has been largely individual states grappling with how to head off a continuing health crisis.
In January, California became the first state to allow young people up to age 25 to participate in the state’s Medicaid program, known as Medi-Cal. Local activists have for a couple of years also been pushing for undocumented seniors to be eligible for coverage, an effort made more pressing by the pandemic. The proposal had been included in Governor Gavin Newsom’s budget proposal earlier this year but appears to have fallen by the wayside in the face of expected deficits.
“How an expansion of health care for seniors, especially undocumented seniors who have gone so long without access to anything in the midst of this pandemic that disproportionately impacts older people, how that falls into the ‘can wait for later’ category … is what we are completely at odds with the governor’s administration about,” said Sarah Dar, the director of health and public benefits policy at the California Immigrant Policy Center.
The state has expanded what’s known as presumptive eligibility for Medicaid for those seeking Covid care, which essentially means that people are considered eligible off the bat and might only be disenrolled if, for example, they don’t meet the income requirements. According to Dar, the scope of treatment covered is far-reaching, but it’s still unclear at this stage if undocumented immigrants could have conditions derivative of or exacerbated by SARS-CoV-2 included as well.
In Illinois, another state with a large undocumented population, the governor recently approved including undocumented seniors in a Medicaid-like state program, though it’s harder for a more wide-ranging insurance program to be put in place given the state’s lack of its own marketplace. Luvia Quinones, the health policy director at the Illinois Coalition for Immigrant and Refugee Rights, said that her organization had been largely focused on making sure Covid testing and treatment were widely available and that hospitals were attempting to bill Medicaid before billing patients.
“It has been more than anything highlighting, emphasizing, educating on existing services that are either free or low cost for anyone regardless of status, whether it be free and charitable clinics or federally qualified health centers,” she said. Still, she was hopeful that Governor J.B. Pritzker remains interested in finding a way to provide coverage to all state residents, whatever their immigration status.
Even in areas with robust public health systems, like New York City with its new and universally available NYC Care managed care program, these lack the capacity to deal with the onslaught of need and are a significant expenditure at a time when state and local governments are staring down huge budget holes. “These public hospitals, which have gotten slammed during this process, were underfunded to begin with,” said New York State Senator Gustavo Rivera, a Democrat who represents part of the Bronx.
Rivera and Assemblyman Dick Gottfried have introduced bills in the state Senate and Assembly that would extend eligibility for the state insurance marketplace’s Essential Plan to otherwise ineligible individuals provided that they had “a confirmed or suspected case of novel coronavirus” and a household income below 200 percent of the federal poverty level. There would be no distinctions between these enrollees and other enrollees on the front end; they’d have the same insurance product as other lower-income New Yorkers. On the back end, these enrollments would be funded directly by the state, and the provisions would sunset 60 days after the state terminated its coronavirus-related emergency declaration.
It seems a little odd to extend insurance eligibility to a needy population just to have it depend on diagnosis or exposure to the virus and let it end along with the formal end of the pandemic declaration, particularly given the sustained health impact, but advocates view it as something that can be implemented practically overnight and relatively cheaply for a population in dire straits. It would be a stopgap solution on the way to universal eligibility for insurance and, eventually, a state single-payer system.
“We’re talking about a population that can’t wait that long, because even if the New York Health Act passed tomorrow, it would take several years to actually put in place,” said Max Hadler, director of health policy for the New York Immigration Coalition, referencing the single-payer legislative proposal. “The relative simplicity of it means that these people could get coverage very quickly,” which is exceedingly important as public health experts uneasily contemplate the possibility of a second spike in the fall. While it’s hard to arrive at definitive estimates, the NYIC believes that ultimately fewer than 10,000 would sign up for the program, making the cost manageable even with shrinking revenues.
The pandemic hasn’t fundamentally changed the calculus on our failed health system so much as brought the festering issue into sharp relief and made the downstream consequences far more acute. Addressing the issue will require a clear-eyed understanding of what dealing with this crisis entails. As a state like New York—for months the undisputed epicenter of the country’s outbreak—tentatively reopens and allows itself to imagine a post-Covid future, its leaders must keep in mind that the health effects will far outlast the lifespan of the virus. It can pat itself on the back over its number of recoveries, but as María knows well, that’s a subjective designation.
Yet there is very little appetite across the board for any additional state expenditures: If anything, many advocates are desperately trying just to maintain the current level of services. “All of [the policy conversation] is still happening in the context of ‘How do we prevent cuts?’ and not in the context of ‘What new horizons can we approach?’” said Hadler. New York Governor Andrew Cuomo only recently and very tentatively raised the prospect of increasing taxes on the state’s wealthiest residents, having spent months repeating the dubious right-wing talking point that such a step would trigger an exodus of millionaires.
Rivera acknowledged that his conversations with colleagues in the state Senate on the eligibility expansion have been “difficult, because we are lacking in resources right now.” However, his position has been that this pandemic is far from over, and not moving to protect people now is irresponsible. “You have a shared risk pool, they would be included in that pool. Therefore the cost would be amortized among the entire population,” he said. “We’re still in the first wave. We’re not in the second wave by any stretch of the imagination. I sincerely believe that we’re going to face an uptick in cases at some point in the future. And we need to be ready for it.”
María, for her part, is working three days a week in three different houses, and her nephew has managed to find work two days a week, which she hopes will allow them to start paying some of the debts they incurred while they were unemployed. She’s focused on staying in her apartment with her son and pursuing an asylum process. This tenuous balance depends on managing the pain in her lungs without access to a doctor. She worries about what will happen if she has to stop working again but, for now, takes things one day at a time.