When they’re ill, they borrow medicine from relatives or get discounted prescriptions from a community health center.

If they’re hurting from an ear infection, back sprain or other painful injury, they may go to an emergency room.

If they’re depressed and can’t sleep or function well, they may wait for months to see a Spanish-speaking counselor.

Undocumented immigrants in Oklahoma subsist on the edge, not only in terms of finding jobs and places to live, but also in gaining access to basic, continuing medical care. Their access to care is as limited as it is for uninsured legal residents. They also may have little chance of gaining health-care coverage in the coming decade.

Under a proposed immigration reform bill in Congress, illegal immigrants would get provisional legal status and could legally hold jobs. But for at least a decade, they would remain ineligible for Medicaid and could not use tax credits to buy insurance on new health exchanges created under the Affordable Care Act.

Their best shot at insurance would be through an employer. But many immigrants work for small employers who don’t offer health-care coverage.

In Oklahoma, where Gov. Mary Fallin has rejected federal money to expand Medicaid, a recently-released summary of draft recommendations for a state plan to cover the uninsured using private insurers makes no mention of undocumented immigrants.

In the end, the still-growing population of undocumented immigrants in Oklahoma — estimated by the Pew Research Center at 75,000, most of them from Mexico — will likely continue to seek treatment in emergency rooms and free clinics or go without treatment until a health problem becomes too severe to ignore.

Struggle to Survive

People like Rodrigo Ponce of Oklahoma City adapt any way they can.

Ponce’s kidneys are failing so he must seek dialysis twice a week to clean the blood in his system. His daughter, Deisy Escalera, goes with him to doctor’s appointments and helps him manage payments as Ponce’s care racks up debt.

Both Ponce, 52, and Escalera, 23, are undocumented immigrants from Mexico. Ponce came to the United States when he was 16, seeking better economic opportunities. Escalera was brought to America when she was 6 after her mother came to visit her aunt. Her mother realized Escalera would have a better future in the U.S., so she stayed past her six-month visitation period.

Ponce, who declined an interview, doesn’t have health insurance because his status bars him from federal aid. Escalera said private health insurance plans they have viewed require Social Security numbers. He relies on help from his son, who is running Ponce’s landscaping business now, as well as loans from family members and friends to pay for his visits to the dialysis center.

His treatments are subsidized by private funding from the dialysis center. But the monthly bills still total between $1,500 and $2,000 a month, Escalera said. The family has been able to cover the payments because Ponce’s landscaping business is profitable and because friends have offered loans. But their ability to keep doing so is in jeopardy because Ponce lacks the strength to work as often as he did.

“It has definitely taken a toll on him emotionally, not just physically,” Escalera said. Ponce “is seeing everyone around him passing away because of dialysis and how hard that is on your body.”

Escalera said her father’s current options, besides taking the dialysis treatments until his kidneys give out, are limited to finding a way to afford a kidney transplant in America or returning to Mexico and getting the transplant done there at a cheaper rate. In 2011, the average billed price for a kidney transplant in the U.S. was $262,900, according to a research report by Milliman, a consulting firm.

Even if the congressional reform bill is enacted, it might come too late to help Ponce. Escalera said the dialysis treatments are helping, and his kidneys aren’t deteriorating yet, but a transplant is the only solution for long-term survival.

When asked about Ponce’s prognosis, his doctor hasn’t offered any time frames yet. Escalalera she said her family is afraid to press the doctor for more specific information.

If undocumented immigrants had better access to health care, Ponce would be able to afford the costs of getting on the transplant list and having the surgery.

“It’s a person. It could be your mom, your dad,” Escalera said. “Imagine going to the hospital and feeling they are treating you differently once the moment you say you don’t have insurance or you don’t have a Social Security number.”

The Search for Care

The federal government has long denied undocumented immigrants access to federal health-care and other benefits.

Under a previous pathway to citizenship, the Immigration Reform and Control Act of 1986, about 3 million undocumented applicants were denied immediate health-care access. The law withheld federal benefits, including Medicaid, for five years to those given temporary legal status and five additional years to those given legal permanent residency. It provided no health care access to those who remained undocumented.

Some states try to fill the gap by offering at least some health care for illegal immigrants. In Oklahoma, the Soon-to-be-Sooners program provides health care for pregnant women regardless of their legal status. However, the only comprehensive coverage option for undocumented immigrants in many states is purchasing private health insurance, which is too expensive for many families.

Undocumented immigrants tend to work for low wages, and their average incomes are lower than those for legal residents and citizens, according to a 2013 Henry J. Kaiser Family Foundation report. Because of this, these families would benefit from direct government health-care assistance, but their legal status prevents them from getting it. Many turn to hospital emergency rooms or community clinics that accept payments based on income.

Trips to the ER are expensive; uninsured people typically can’t afford to pay the full cost. They become part of about $500 million in uncompensated care costs accrued each year in Oklahoma, according to the Oklahoma Hospital Association.

Some low-income families obtain treatment from community health centers or charities. Variety Care, a nonprofit chain of clinics, serves about 57,000 Oklahomans a year, a third of whom are uninsured. Since Variety Care is a federally qualified health center, it doesn’t ask about citizenship status, much like a hospital emergency room.

Variety Care offers preventive care screenings and handles urgent issues with sliding-scale fees that are based on income, said CEO Lou Carmichael. But when it comes to bigger medical conditions or problems, the poor still struggle, she said.

“Getting primary care at Variety Care, they are going to feel safe and get everything they need,” Carmichael said. “But if they need surgery, that’s a little more threatening, that’s a little further out of the comfort zone.”

Consequences of Limited Access

Dr. Charles Bryant operates a diabetes clinic in Oklahoma City. Among the people he sees is a couple in which the woman is an American citizen and the man is an undocumented immigrant. Both have Type 1 diabetes.

The woman has access to insulin with her insurance coverage; her undocumented partner does not. Instead, he uses her insulin when he doesn’t feel well, which Bryant said is hazardous to his health because he isn’t routinely monitoring his blood sugar and taking insulin daily.

Bryant has been trying to get the undocumented man to visit Variety Care, which has reduced-price prescriptions, but he won’t go. Bryant thinks the man is in denial about his disease. But his undocumented status may also play a role in his reluctance to seek care.

“He’s been out of control so long … the damage is going on,” Bryant said. “At some point, he is going to have significant problems.”

Complications could include kidney failure, loss of vision and foot problems that could lead to amputation, Bryant said.

Health Care, Deferred

The immigration-reform bill before Congress would provide a pathway to citizenship to those who entered the country illegally before Dec. 31, 2011.

Qualifying immigrants would get what is called registered provisional immigrant status. They could legally work and get health coverage through an employer, but they would still be barred from Medicaid, the Children’s Health Insurance Program and other federal safety-net benefits for at least 10 years.

However, so-called “dreamers” — younger immigrants who were given deferred action on their undocumented status — would only have to wait five years.

Immigrants with provisional status would not be eligible for tax credits to help buy insurance on the health insurance exchanges that will go live in October. However, they could buy insurance at full price on the exchanges. Immigrants who have green cards or work or student visas could use the tax credits.

The most likely option for many newly legalized immigrants would be insurance from their employers. The Affordable Care Act will require businesses with more than 50 full-time employees to provide health insurance options or pay fines.

Immigration reform would be an improvement, but it wouldn’t completely solve the health-care problem for newly legalized immigrants, said Jenny Rejeske, National Immigration Law Center health policy analyst.

Most newly-legalized families would still struggle to get health care, since most work in small businesses that won’t be required to offer insurance, Rejeske said. Families that don’t get insurance from employers would be forced to use the health exchange system at full price.

“Since these folks are disproportionately low-income, access to full-price insurance, even through the exchange, will be meaningless,” she said.

Note: Chase Cook is reporting on illegal immigrants and health care as part of an “Immigration in the Heartland” fellowship sponsored by the Institute for Justice and Journalism.

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