Healthcare Accessibility and Equity in Colorado

When I was little, my father used to say the United States was Superman. This country was a hero, and it could do nothing wrong. He instilled in us gratefulness for this country that, for so long, did not allow us to feel entitled to more. Growing up, I did not understand the nuances of our situation, nor what even being “undocumented” meant. What I did understand was that, as the eldest daughter, I had to bear the responsibility of assisting my parents to navigate a system in a language foreign to our own. When I was younger, a doctor was for emergencies only. In some states, our access to primary care was only through community events. In Colorado, it grew to include some community health networks such as STRIDE, that focus on expanding care to those with limited access due to payment or location. 

Facing these experiences as a child and growing up within this culture inspired me to research what accessibility meant in the wake of new policy actions by the State of Colorado. Colorado passed House Bill 22-1289 in June of 2022 and Senate Bill 20-215 in June of 2020. These bills aimed to support the undocumented community in the state and meant that people like me and my family would soon have increased access to healthcare. HB22-1289 allows access to state Medicaid for pregnant persons and the Children's Health Insurance Program (CHIP) for all children regardless of documentation. SB20-215 allows access to the state health insurance market, including a separate rate for an undocumented care plan (OmniSalud) available for 10,000 residents.  

While these bills opened the doors, I wondered if anyone was able to walk through them. I remembered the undue burden placed on me as a young child to understand complicated healthcare terms and then translate them for my parents in the best way a child could. The first step is creating inclusive policy measures for these community members. However, that does not necessarily mean they will have access to resources to understand insurance plans and the healthcare system. My parents still request my assistance to interpret for their doctors because many healthcare providers do not offer interpretation services, despite legal obligations to do so. Experiences like mine are not new, and they are a reason it is difficult for people like my parents to find the necessary support to continue to attend appointments.  

Additionally, undocumented community members largely work within areas that do not offer paid time off, such as in-field jobs, construction, housekeeping, and babysitting. My father has worked in construction all his life, and partly due to his inability to leave work for health concerns, he now has pulmonary cystic fibrosis, functioning with only 20% lung capacity. He could not take advantage of SB20-215 because the lower-cost program, OmniSalud, was only available for 10,000 Colorado residents. The prices on the insurance market are too high to be able to afford care. Seeing these issues in my own reality influenced and fueled the questions within my research. The findings of the memo are summarized below.  

Question Considered in Analysis  

1. How can legislators effectively implement healthcare policy focused on impacted populations? 
   • 1a. What are the current implementation and success metrics for healthcare policy focused on the undocumented immigrant community? 
   • 1b. Why does implementation matter when considering access and equity for the most impacted populations? 

Summary of Analysis 

Social 

Community members, healthcare providers, and policy action groups note that social, economic, and legal obstacles can cause detrimental health outcomes. This is further supported by state and national legislative history. “These citizen-making processes are embedded within health institutions to which immigrants have unequal access” (Melo & Fleuriet, 2016:160). The citizen-making processes mentioned by Melo & Fleuriet focus on the social and political constructions of personhood and citizenship. The negative and hostile political environment and negative civic opinions limit the political citizenship of undocumented immigrants. According to Melo & Fleuriet (2016:160), “Anthropologists have also considered how public health and other health-care institutions engage in different practices of citizen-making that can reinforce public opinion and stereotypes about immigrants.” Colorado’s undocumented communities have faced several insecurities that limit their access to care even when policies attempt to include them.  

Economic 

It is estimated that 5.5 million undocumented immigrants work within “essential critical infrastructure,” as defined by Department of Homeland Security (DHS), with 74% of undocumented workers being essential infrastructure workers (Kerwin et al., 2020). Despite this, undocumented workers make less than citizens (Telemundo, 2022). Undocumented immigrants not only have to face being paid less due to their status, but also the dilemma of being underpaid or not being paid at all. Many undocumented immigrants work as day laborers throughout the United States, and Colorado is no different. Day laborers, especially those who are undocumented, are vulnerable to the problems of wage theft and unsafe working conditions (Galemba, 2023). Many also need to choose between addressing their health concerns and the need for work. Dr. Michelle Haas has noted this. For my research, I interviewed Dr. Haas because of her frequent interactions with the undocumented community through her work as a physician at Denver Health. She considered the notion of “competing priorities,” meaning that undocumented individuals have different responsibilities in life, such as work obligations, that disengage them from the healthcare system. She often uses this phrase to explain patients' difficulties in choosing to work or prioritizing their health.  

Legal 

Undocumented community members have a fear of using services that could potentially result in the deportation of themselves or their family members due to their legal status. “Fear of deportation and avoidance of institutions leads some mixed-status families to limit or delay services for children or withdraw from programs altogether” (Castañeda & Melo, 2014:4). Families with children that are U.S. citizens while others in the family (such as the parents) lack such documentation are defined as mixed-status families. Despite their children being U.S. citizens, many families fear that going to the doctor could still get them into trouble. The Public Charge Rule increased concerns in the immigrant community around seeking out necessary care because they either feared for their own future of obtaining citizenship or feared it would negatively impact their closest family members. Additionally, there are barriers to being able to go to an appointment. Although Colorado permits access to drivers’ licenses for undocumented community members (SB13-251), many faced issues obtaining appointments because only 3-5 DMVs in the state used to offer this ID or their licenses were invalidated due to system malfunction. This issue left 40% eligible community members out of the program and with fear of driving for any reason. It was not until 2023 that all Colorado DMVs began to offer this ID for community members. Expanding this access allows them to have a means to get to their appointments.  

Deservingness 

An important finding from Willen (2012:812) demonstrates “the need for rigorous investigation of how unauthorized im/migrants… conceptualize their relative deservingness of health-related concerns.” One measure that impacts “deservingness” is language. Wei (2019) focuses on language's historical role in creating, transmitting, and perpetuating anti-immigrant prejudice. In the United States, we have recognized the impact of terminology through the evolution of definitions for undocumented community members. Language to refer to undocumented immigrants has changed from “illegal alien” to “illegal immigrant” and currently “undocumented non-citizen” (Rose, 2021). Willen (2012:815) affirms that “such discursive framings nonetheless have resounding consequences, in part by serving as ‘symbolic props’ for patterns of structural inequality and structural violence that produce and exacerbate health-related vulnerability.”  

Colorado Republican Representatives Ken Buck, Lauren Boebert, and Doug Lamborn recently introduced a federal bill (the No Federal Tax Dollars for Illegal Aliens Health Insurance Act). This act intended to fight against SB20-215 for the approval granted by the federal government regarding the use of the Section 1332 waiver to obtain funding for the undocumented community. Statements like the one above by Representative Ken Buck disillusion community members and separate them from feeling deserving of care. It further continues the use of the term “illegal alien” despite the previous impact of the term on feelings regarding the deservingness of healthcare. Policy history in Colorado and nationally has created a distance to accessing care by telling undocumented immigrants they are not worthy or deserving of equitable healthcare access. The anti-immigrant language and rhetoric continuing to be used against community members push them away from centralized care.  

Results 

When considering the connection between healthcare policy and immigration, the most obvious solution can be to grant documentation to those vulnerable due to their legal status in the country. Unfortunately, that and most other blanket solutions for the undocumented population can only occur at the federal level. The state level is currently at a critical nexus where states can provide substantial care for a vulnerable population unsupported by the federal government in life-saving preventative care. However, increasing access to healthcare through state policy is only the first step. The implementation process of enacted legislation is imperative and should be one of the top priorities when drafting legislation impacting vulnerable communities. California is one example where state policy has expanded access to all, but barriers persist to increasing accessibility for the undocumented community. This research focused on the main obstacles for undocumented individuals and found that considerable fear and a lack of resources (language, education, and system navigation) limit their ability to access care.  

Expanding healthcare access policy in Colorado has its success metrics focused on increasing the accessibility of healthcare services. Therefore, healthcare policy implementation success metrics need to include community-focused metrics and analyze the needs and gaps that community members in Colorado face in accessing care. This paper focused on the impact of state and national policy history and used interviews with those involved in the various steps of the policy process to determine some limitations faced by undocumented community members in Colorado.  

Colorado should not only focus on passing inclusive healthcare legislation, but also an assessment focused on accessibility, equity within healthcare institutions, and whether the programs are achieving their intended impact through continued community and policy group conversations. This can be accomplished by collaborating with community leaders, organizers, and organizations to obtain information on how the program operates within the community lens.   

Finally, community distrust and confusion with the system still exist despite increasing access to care. It is hard to understand healthcare overall, but even more so when you do not speak the language and previous policies have alienated you. Additionally, the policy history in both Colorado and nationally has caused overall community distrust. Policies have changed almost every other year. The immigrant community has historically been excluded within the country and especially during the policy process. Policy action groups like the Colorado’s Center for Health Progress have noted that there needs to be community voices within policy conversations. The implementation process of SB20-215 showed that there needs to be community input. The best way to continue developing trust in institutions is to include the voices of impacted community members and their leaders and organizations.