What do you do if you’re not allowed to buy insurance?

As New York has extended health insurance coverage to a growing share of its population, one group has traditionally been left out: immigrants living in the country illegally.

Now, New York City is taking steps to improve health care for immigrants, particularly for those who are undocumented, through a recently introduced program. But there is still room for improvement, advocates say, most notably by expanding the network of providers. 

In January, Mayor Bill de Blasio unveiled NYC Care, a new program meant to provide access to health care for people who are ineligible for insurance – including undocumented immigrants. Those who enroll in the plan will get an NYC Care card, a primary care doctor and access to a network of information, all through New York City Health + Hospitals, the city’s public hospital system.

NYC Care largely publicizes existing services already available through Health + Hospitals, which is obligated to treat anyone who walks in their door and provides a sliding scale payment option for those without insurance. The program also calls for hiring more doctors and service staff to accommodate more patients, with $25 million allocated in the latest city budget and an expectation that $100 million a year would be needed going forward. Health + Hospitals President and CEO Mitchell Katz has characterized the program as improving customer service in order to get more people to seek preventive care rather than waiting until a problem is bad enough to require a trip to the emergency room.

Max Hadler, director of health policy at the New York Immigration Coalition, said the program, which is set to roll out in the Bronx in August and citywide by the end of 2020, is a step in the right direction. “There’s a number of different ways in which NYC Care can improve access, in some cases by improving the actual coordination of care, and in some cases by doing a more concerted effort to get the word out about services that are already available but that many people may not be aware of or fear using because of all the negative messaging coming from Washington,” Hadler said.

Even before the introduction of NYC Care, the city had mechanisms to serve uninsured communities thanks to the city’s municipal hospital system, which is the largest in the nation. Becca Telzak, director of health programs at Make the Road New York, said she hopes NYC Care’s increased capacity would help remove barriers to care. “I think it’s hard for people to get appointments. It’s hard to then, once they go for primary care, be connected to all the other services they need,” Telzak said. “And then I think at that point, people just kind of give up and stop going.”

NYC Care comes after a short-lived pilot called Action Health NYC in 2015. About 1,300 immigrants enrolled in the health care access program, which was hailed as a success. Hadler said NYC Care seems to be modeled on Action Health, but differs in a significant way. “Action Health NYC was a very, very small one-year pilot that got pretty unceremoniously discontinued from one day to the next,” Hadler said. “NYC Care is being positioned as a full-scale, citywide, permanent program.”

That is not to say the initiative does not have room for improvement. While Telzack said NYC Care reflects many of the positive aspects of Action Health NYC, it falls short in one key aspect: excluding federally qualified health centers, or community health centers, as part of its network.

As it stands, NYC Care is strictly a Health + Hospitals program. Enrollees will only be able to visit hospitals and clinics within the public hospital system. While Health + Hospitals has 11 hospitals and seven health centers across the five boroughs  – along with over 60 other patient-care facilities – many undocumented immigrants use and have relationships with the city’s 41 community health centers that focus on primary care.

New York City Councilman Mark Levine, who chairs the Health Committee, said he is planning to introduce legislation to build on NYC Care by expanding the program to include community health centers. He said now that budget negotiations are over, he wants to focus on improving health care for undocumented immigrants and hopes to plan a hearing in the near future. “(Community health centers) should be, really, the backbone of this program, as they were in the pilot that New York City ran, Action Health, in 2015,” Levine told City & State.

Although New York City has a fairly low rate of uninsured residents, immigrants are disproportionately those without insurance. According to 2017 census data, only 7.3% of residents don’t have insurance, or just over 615,000 people. However, 12.3% of immigrants are uninsured, a number that increases to 21.5% among noncitizens. The census does not currently inquire about a person’s immigration status, meaning that the noncitizen population also includes legal U.S. residents.

Undocumented immigrants are one of the few groups of people who have not benefited from statewide efforts to insure more people. About 38% of the state’s population has public insurance through Medicaid and Medicare, and 49% receive health insurance through work. While New York has helped insure those that don’t fall into those two categories through its health care marketplace and the low-cost, state-run Essential Plan, that does not help undocumented immigrants. They don’t qualify for the Essential Plan or the New York City-run MetroPlus health insurance plan, and can’t buy private insurance on the marketplace. Though they may be able to get some coverage through Medicaid under specific circumstances, it is not a viable option either.

In the absence of state action to institute single-payer health care or directly fund insurance for undocumented immigrants, access to care programs like NYC Care are really the only way for municipalities like New York City to address health care disparities. “There are limited things the city can do and NYC Care is a really good move toward exercising the options available,” Hadler said. “The state is really failing on immigrant health right now. And the state has the option, and I think ultimately, the obligation, to step up as well.”

Clarification: NYC Care does not provide insurance; an earlier version of the headline implied it does. Also, the number of Health + Hospitals facilities in the city has been updated to reflect a number of smaller locations not included in an earlier version of the story.