A Local Solution

Part 3 continued: Undocumented and Uninsured – A Health Care Challenge

[Editor’s Note: Click this link for an overview of the series and an interview with the author.]

Tammy Worth — Special correspondent to The Hale Center for Journalism

The cleaning crew at the Farmland Foods plant in rural Milan, Mo., clocks in at 10 p.m. every weeknight. They perform light cleanup until the last of the production shift leaves at midnight, and the real work begins.

For the remainder of the evening, the air conditioning and heat are turned off, even during the stifling Missouri summers and frigid winters. The high-pressure water hoses used to blast leftover meat and various pig remnants from the equipment, walls and ceilings can reach temperatures greater than 200 degrees. The crew cleans with chemicals like formaldehyde and ammonia. The heating and air aren’t turned back on until 4 a.m. when the next cutting crew begins their shift.

This intense, physical work environment leaves the employees prone to issues like burns, headaches, nose bleeds, insomnia and dizziness. The go-to treatment for these conditions is often some sort of herbal tea or a cocktail of Tylenol and Red Bull.

Such low-tech medicine is used because most of the people cleaning the plant are workers living in the states illegally. They are from places like Guatemala and Honduras. They do not have health insurance and rarely visit a doctor’s office. Their situation won’t improve in the foreseeable future because they are undocumented immigrants: one of the largest groups excluded from the Affordable Care Act.

Social Welfare Board

Maria is an undocumented immigrant and mother of four whose husband works at the Farmland plant. Before her family moved to Milan, they lived in St. Joseph, Mo., a town she talks about wistfully. In St. Joe, she received WIC support with a person who spoke Spanish. She didn’t have health insurance there, either, but birth control and services like a Pap smear were affordable.

This health care was available through the Social Welfare Board, a clinic started in 1913 by a physician wanting to provide health care to anyone in need. The organization is governed by a Missouri state statute and overseen by a board of directors. Money from the city and county accounts for about 40 percent of its operating budget; the remainder is a patchwork of funds from foundations, grants and patient payments, which range from $2 to $10 per visit.

Linda Judah, director of the organization, said they consistently mold to the needs of the community. She made a major alteration in 2006 when the Triumph Foods Plant opened.

When immigrants began working at the plant, Judah decided to provide care regardless of a patient’s immigration status. The local hospital system wouldn’t extend financial aid to immigrants, and she said they work on a policy of “stabilize and release” for those without health insurance.

She began hearing stories of unsafe working conditions at the plant; of unhealthy immigrants brought to St. Joe that couldn’t work and were then left to fend for themselves. She set up meetings with the plant’s ownership to see what could be done about the situation.

They created a plan whereby her clinic performs pre-employment physicals and treats uninsured workers with a $67 reimbursement from the plant.

“I do believe that when an employer comes to town and is actively recruiting people from other countries, they need to do health screenings and make sure they are healthy enough to do what they are required to do,” she said.

Judah’s group goes out into the community with an interpreter to provide free mammograms and breast exams. They work with organizations to provide family planning services and offer inexpensive birth control. She works with a lab that takes cash payments for services at dramatically reduced rates. She uses pharmaceutical assistance programs to help patients pay for necessary medication.

“It is important to make sure their (immigrants’) health is taken care of,” Judah said. “Regardless of who is here, regardless of their residency status, if they are going to be here for any length of time, they are going to use our resources. The health of the community is reflected by the health of the poor.”

In the near future, it is likely that the impetus for finding ways to care for undocumented immigrants will remain in the hands of state and local entities.

Joe Connor, director of the Public Health Department for the Unified Government of Wyandotte County/Kansas City, Kan., spends about $60,000 a year on interpreting services for the department. They work at the county level to provide safety net preventive services for the entire community. They focus on things like immunizations, tracking sexually transmitted diseases, women’s health, family planning and prenatal services.

“We primarily focus on services we are good at and that meet the mission of improving the overall health of the community,” he said. “We have a high STD and teen pregnancy rate and low immunization rate.”

Part of knowing what services to provide is understanding the makeup of the community, which he said has always been one of “refugees and immigrants.” His challenge is to find ways to provide preventive services and keep people away from costly emergency rooms.

“We don’t have a say about who lives here,” he said. “Folks live in our community, and it is our job to respond. It doesn’t matter to us what their status is …. The instance of disease is everywhere so why would it matter who they are?”

WyJo Care

A major gap in services for undocumented immigrants is specialty treatment. WyJo Care is a program that aims to fill this need by connecting low-income, uninsured patients from Wyandotte and Johnson County to doctors and hospitals that donate services for free.

“I can’t tell you how many patients we see that have been to two to three emergency rooms looking for help,” said Jacque Amspacker, the executive director of the Medical Society for Johnson and Wyandotte County, which runs WyJo Care.

Amspacker said they provide care for everyone and don’t ask about documentation status. About 25 percent of her patient don’t provide a Social Security number, and 30 percent speak languages other than English. A “big chunk” of her budget goes toward interpretation services.

Patients can wait up to six months to see a physician, depending upon how long her list is. They are helping patients, but also the area economy, Amspacker said.

“If you don’t help them, they get into a vicious cycle and are going from place to place and running up bills they won’t be able to pay,” she said. “If you can help get them better, you can stop the cycle.”

Try as they might, Amspaker said they can’t provide care for everyone who needs help. There are never enough specialty physicians who donate time to serve the needs in the community. Since its inception, the clinic has helped 6,200 patients; in 2012, with a $140,000 budget and one staff member, they were able to provide about $6 million in donated care to uninsured, low-income individuals.

The Northeast Missouri Family Health Clinic

A health center opened in Milan a few years after the Farmland plant opened to care for the city’s low-income population. Much like the clinics in the Kansas City area, The Northeast Missouri Family Health Clinic isn’t always able to reach everyone in need.

“When I say I have a clinic in Milan where there are thousands of immigrants, people assume they are swamping us,” said Andy Grimm, the clinic’s CEO. “I would like to see more.”

The couple hundred immigrant patients they treat each years seems “shockingly low,” and while he knows there is more need out there, it isn’t that easy to get to everyone.

“I’m motivated to see them, and I can’t get them in the door,” Grimm said.

This population has a tendency to self-diagnose and self-medicate, he said. They also don’t have a reliance, trust or sense of involvement with the U.S.’s preventive medical system.

“They aren’t like the North American family that, when their kid gets the sniffles, they have insurance, go to the doctor, and pay a $25 co-pay to get tested for strep,” he said. “They have to be pretty darn sick before they go to a doctor.”

Insurance challenges are part of the problem as well. Grimm’s office has been contacted more than once about identity theft from insurance agencies. Once, he received a call from a sheriff’s department in Texas after an 80-year-old woman found insurance with her name had been used at his clinic in Milan.

“Someone had purchased a false ID (with her information) and used it to get insurance through Farmland,” he said. “They were trying to figure out who was fraudulently billing her insurance.”

The clinic offers patients a sliding-fee scale that reduces the cost of services in accordance to a patient’s income. Because the clinic receives federal funding, patients have to fill out paperwork and offer personal information to qualify for the discounted rate. Information about sex, race and ethnicity are required.

At times, even the simplest of information can be difficult to ascertain, Grimm said. In order to qualify for a sliding scale, the clinic has to know the number of people in a patient’s household as well as their income. But immigrants usually aren’t willing to open up because their landlord may think three people are living in the house, but there may be 10, Grimm said.

“A lot don’t want to fill out paperwork, especially if they are undocumented and don’t have insurance,” Grimm said. “The whole system is designed not to get them involved.

“We get audited every year because they want to make sure the money is going to the right people. I understand why the system is in place, but the increased accountability at all levels of government doesn’t make the system easier for illegal immigrants to navigate.”

Worth reported this special series during a year-long Association of Health Care Journalists Reporting Fellowship on Health Care Performance supported by The Commonwealth Fund.

Major Funding for Health coverage on KCPT provided by Assurant Employee Benefits and the Health Care Foundation of Greater Kansas City.