Cecilia Ramirez is worried about her weight and troubling symptoms that hint of diabetes, but won't seek medical help because she can't afford it.
"I don't go to the doctor when I'm sick _ it's too expensive," she said.
Though she is a sales worker at an insurance agency in Highlandtown, an East Baltimore neighborhood where many Hispanic immigrants have settled in recent years, Ramirez, 23, has no health insurance.
Her predicament is shared by thousands of other immigrants in East Baltimore, and millions nationally, who cannot afford regular medical services and are uninsured because they do not have legal U.S. residency or citizenship.
Ramirez's parents came illegally to the U.S. from Mexico when she was 10. Her immigration status now _ "lawfully present" _ allows her to work and study here without fear of deportation, but she has no path to citizenship. She is ineligible for health coverage under the Affordable Care Act or any other public insurance program.
Her $23,000 annual income would easily qualify her for Medicaid, but only her two young children can get it. Ramirez's employer can't afford to offer her private health insurance either, and even if it did, she doubts she could afford it. So, how can Ramirez deal with the hacking from her lungs?
"Vicks VapoRub," said her boss, David Rosario, drawing cynical laughter from Ramirez and others in the office.
Many Latinos, uninsured or not, have trouble finding medical care. Some have trouble speaking and understanding English, are poor and undereducated, or lack transportation. Others come from cultures where health care is a luxury they don't regularly seek out.
But the inability of noncitizens to join affordable health plans remains the primary impediment for people from Mexico, Central America and South America.
"What we're seeing across the country is that the undocumented are one of the most vulnerable groups out there when it comes to insurability," said Steven Lopez, manager of the health policy project at the National Council of La Raza, the largest Latino advocacy group in the U.S. "The opportunity to get regular health care is the key to finding greater opportunity. If you don't have your health, you're not going to progress in life."
Nationwide, more than 5 million people living in the U.S. illegally do not have medical coverage, with indications that most are Hispanic, according to an Urban Institute report released in March.
"This is the tricky part for us," said Leana Wen, Baltimore's health commissioner. "The Affordable Care Act excludes these individuals. ... "They fall through the cracks."
"People can start businesses and buy homes, but they can't get medical insurance," said Rosario, who is board president of the Latino Providers Network, an organization that links Hispanics to services.
As a result, health care providers say that when they see people come into their offices or clinics, they are often in advanced stages of illness.
"Typically, we see a lot of diabetes and obesity-related diseases, like high blood pressure," said Kathleen Page, an infectious disease specialist at Johns Hopkins Hospital and a co-founder of Centro SOL, a clinic and outreach program that treats Hispanic clients at reduced prices. Baltimore Latinos suffer higher rates of those disorders despite being younger as a group than the rest of the city's population. Chronic infections and mental health problems such as anxiety and depression run rampant, Page added.
About 95 percent of the Hispanic patients she sees at her HIV clinic live here illegally and lack health insurance.
Latinos' ability to find treatment is tied directly to their immigration status.
Some people in the U.S. without documentation can receive payments for baby deliveries through Emergency Medicaid. Federally qualified health clinics offer basic medical care to thousands of the uninsured at reduced rates, with no questions asked about status, but the federal government offers no insurance options for those living in the U.S. without permission.
Insurability can vary even within households, reflecting mixed immigration status among family members. Cecilia Ramirez's mother, who does not have permission to live in the U.S., long remained uninsured, putting off treatment for uterine fibroids for years because she was worried about the cost of care.
Meanwhile, Ramirez's children, 7-year-old Jenny and Kimberly, 3, receive insurance through Medicaid. Because they were born in the U.S., giving them citizenship, and they meet Medicaid's eligibility standards, they are able to see primary care physicians and get other care if needed. Much of it is paid for, unlike their mother's.
As a foreign-born child of immigrants who entered the U.S. without permission, Ramirez's access to health care is problematic. She applied for and received "lawfully present" status under a 2012 Obama administration policy that allowed people who arrived in the U.S. before age 16 and are now under age 35 to work and study in the U.S. without fearing deportation. About 665,000 others have also received such status nationwide, according to figures from the Department of Homeland Security. But they were also excluded from gaining health insurance under the Affordable Care Act by a related policy of the Department of Health and Human Services. Some states, including California and New York, have softened their standards and enrolled some people here illegally in Medicaid. But nationally, most remain without coverage.
To help people low-income people in the U.S. illegally, several institutions in East Baltimore have cobbled together medical services beyond hospitals. Baltimore City, Johns Hopkins Bayview, two federally subsidized clinics and one charity-run clinic offer bilingual interpreters, health providers who speak Spanish and, perhaps most importantly, low fees and sliding scales for care.
The Access Partnership, or TAP, a Johns Hopkins charitable program, offers diagnostic tests and visits to specialists for very low fees, usually no more than $20. The program serves people who lack insurance, make 200 percent or less of the federal poverty level and have been local residents for six months. More than 90 percent are Hispanic, and none are asked if they are living in the U.S. illegally, said Barbara Cook, the group's medical director.
Cecilia Ramirez's mother got diagnostic tests and subsequent surgery a little over a year ago to remove her uterus with help from TAP. Nonetheless, Ramirez wonders if the outcome would have been better if she had gotten help earlier.
"If she had had insurance, she might have sought out care, instead of having to wait so long that they had to remove part of her body," she said.
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(Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.)
