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CONCORD, Calif. — After suffering for three years from peeling hands and bleeding fingers, the house cleaner from Mexico finally sought help from a doctor.

Maria Bajonero described her condition to Dr. Scott Loeliger in a recent visit to his clinic here.

“When is it worse?” he asked her in Spanish.


“Always,” she replied.

Bajonero, who’s 43, said she doesn’t wear gloves because she’s allergic to latex. She had been using over-the-counter soap and cream, but nothing seemed to help.


“You don’t have health insurance?” he asked.

“No,” she said.

Bajonero is one of the estimated 1 million to 1.5 million undocumented immigrants in California living without health insurance, and many are struggling to stay healthy while juggling low-wage jobs.

California has gone further than most states to help these people, who are not eligible for federally subsidized health insurance through the Affordable Care Act. In May, the state expanded Medicaid to some 185,000 undocumented children from low-income households using state dollars, becoming the fifth state to do so. And it’s now seeking to become the first state to allow undocumented adults to buy insurance on the state’s health exchange.

But a visit to one of California’s safety net clinics that deals most intensively with undocumented immigrants shows that expanded access to insurance wouldn’t remove many barriers preventing this group from staying healthy.

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Bajonero describes her condition to Loeliger during a recent visit. She has suffered for three years with peeling hands and bleeding fingers. Elizabeth D. Herman for STAT

Bajonero, who earns about $150 per day, said the main reason she doesn’t visit the doctor is that she works five days a week and doesn’t want to miss a day’s pay. One day last month, she seized the chance on her day off to seek relief for her hands.

She called in the morning and lucked out on a same-day urgent visit to La Clínica Monument in Concord, a city of 125,000 about 30 miles northeast of San Francisco. Part of a network of 30 clinics in the Bay Area, La Clínica Monument is known around town as the “no-papers clinic,” because it’s one of the only places undocumented immigrants can rely on for primary care. It’s named after the heavily Latino corridor that runs through the city.

Four in 10 patients who walk in the door are undocumented immigrants, mostly Latinos from Mexico. Most of them, like Bajonero, work in low-wage jobs in restaurant kitchens, on construction sites, or in private homes as cleaners and caretakers.

Like many federally qualified community health clinics, La Clínica Monument has been swamped with patients insured through the Affordable Care Act. It is also a safety net for the uninsured, who, depending on income, can pay discounted rates. The clinic’s 12,000 patients often wait months for regular appointments. Each full-time doctor churns through 24 patients per day, many of whom avoid the clinic as long as possible.

Bajonero got a brief visit with Loeliger, a family practice doctor. He asked her about her general health. She revealed she hadn’t been to a doctor in four years, meaning she was overdue for a Pap smear.

Loeliger wrote her a prescription for hand cream — and urged her to come back for a women’s health exam. But Bajonero wasn’t eager, after hearing that the day’s visit would cost her $140.

Undocumented immigrants are more likely to work in low-wage jobs without health benefits, compared to citizens and lawfully present immigrants, said Samantha Artiga, an analyst at the Kaiser Family Foundation, a nonprofit health policy organization. “Because they’re low-income, even when health insurance is offered, it’s not affordable,” she said.

Contra Costa County, which includes Concord, recently launched a pilot program providing basic health coverage to some undocumented adults, after eliminating services in 2009. The new program aims to cover preventive care visits for 3,000 immigrants.

One goal is to reduce the strain on emergency rooms — and therefore cut overall costs — by encouraging patients to get help before medical problems become urgent, said Alvaro Fuentes, executive director of the Community Clinic Consortium, which is implementing the program.

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The nurse’s station in La Clínica Monument, which is currently 40 percent understaffed. Elizabeth D. Herman for STAT
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The clinic staff often assists patients who do not speak English with tasks such as reading mail and setting up appointments with specialists who speak Spanish.

But data from previous Medicaid expansions suggest the opposite, he acknowledged: “The newly insured are visiting ERs at a higher rate. … Once they get insurance, the emergency room is like a one-stop shop.”

That’s partly because people aren’t “accustomed to receiving preventive care in the first place,” said Nancy Gomez, organizing director of Health Access California, a nonprofit advocacy group that is pushing to expand federal health insurance programs to undocumented immigrants. Reasons they stay away from the doctor include fear of deportation and cultural differences around health care.

Another challenge: The clinics that undocumented immigrants rely on are under great strain. La Clínica Monument is currently 40 percent understaffed, said Jane Garcia, CEO of La Clínica de La Raza, the community health center network that runs the clinic. The network is down 14 physicians across its 30 clinics, contributing to long wait times.

“We are hurting,” she said.

The shortage has become so bad that La Clínica Monument dropped the requirement that its doctors and nurse practitioners speak Spanish, Garcia said. When needed, the clinic relies on medical assistants to translate.

The Contra Costa experiment, paid for by the county and three local hospitals, is one of many efforts to tackle the question: Whose responsibility is it to pay for health care for immigrants who broke the law entering the country, but on whose labor the state and country depend?

Almost all of California’s 58 counties are taking on that responsibility, in part, by offering some health insurance coverage to undocumented patients. But depending on which county a person lives in, they could have health insurance, or none. Not-for-profits such as Operation Access in San Francisco and Cirugia sin Fronteras in Bakersfield have also emerged to connect undocumented immigrants with volunteer surgeons who will work for free or for discounted rates.

Legislation to expand Medicaid to undocumented immigrant adults, as well as to kids, has so far failed. But advocates won a smaller victory in June, when Governor Jerry Brown signed a law that would allow undocumented immigrants to purchase insurance plans on the state’s health exchange, the marketplace of private plans created through the ACA. If the Obama administration approves, California would become the first state to pass such a measure.

Opponents, including California Republican Congressman Darrell Issa, are trying to block the move, arguing it would burden taxpayers and would betray Democrats’ earlier promise that the ACA would not cover undocumented immigrants. If it’s approved, it would be a largely symbolic effort, because undocumented immigrants would not qualify for subsidies on the marketplace in the way low-income citizens do.

Meanwhile, gaps in the system create sometimes bizarre incentives for patients to receive less-than-optimal care. For instance, low-income undocumented women can apply for a program called Family PACT, which pays for reproductive health services, including Pap smears. Health clinics can use the Pap smear as a way to pay for general checkups on women’s health.

But when a woman gets her tubes tied, she becomes ineligible for the program. That puts doctors in a strange spot when a woman comes to them for contraceptive options: The best clinical practice would be tubal ligation, but the smart financial move would be to get an intrauterine device.

Legal status may prompt different prescription choices, too. Because they’re uninsured, many undocumented patients at La Clínica use old-school insulin syringes instead of more costly pills for managing diabetes, which are the standard of care, Loeliger said.

Insulin shots are far less convenient. Katie Morales, a family nurse practitioner at La Clínica, said one of her diabetic patients spends 10 hours a day washing dishes and doesn’t have time to inject insulin, so his blood sugar levels get out of control.

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Juan, a house painter who wished to remain unidentified, gets his vital signs checked during an appointment to treat leg numbness. Elizabeth D. Herman for STAT

As she entered her evening shift, Morales sat with Juan, a 42-year-old undocumented immigrant from Mexico. Juan, who declined to give his last name for fear of deportation, paints houses for a living. He doesn’t have health insurance. He went to see Morales about persistent numbness in his legs.

Juan said he and other undocumented immigrants he knows tend to avoid the doctor. When he fell from a ladder and busted his knee, for instance, he took ibuprofen and waited it out.

Morales tried to refer him to a physical therapist. But she told him the first appointment would cost $125 — just $25 shy of Juan’s daily paycheck. He said he couldn’t afford to go.

Even for patients who do have insurance, finding specialists is a problem, especially for mental health, CEO Garcia said.

So Morales and other clinicians take on as much as they can.

“We’re managing a lot of really complicated patients here on our own,” she said. “We’re struggling to keep up.”