Manjeet Kaur arrived in the U.S. in 1996, elated at the prospect of greeting her first grandchild at birth. The recently-widowed woman, who had never before travelled outside India, nevertheless took the long flight alone to San Francisco, and arrived on schedule, where she was greeted by her son and very-pregnant daughter-in-law, who was expected to deliver three days later.
The baby was not so punctual. “None of the babies in our family have come on time,” joked the tiny, spry woman, now 73, over tea in her Union City, Calif., home.
Two weeks later, baby Jasleen was born; Kaur said she was immediately entranced by the chubby, rosy-cheeked infant. “After so long, I was holding a baby again,” she told India-West, smiling as she recalled the memory.
In the manner traditional to many Indian American families, Kaur immediately took charge, teaching her daughter-in-law the intricacies of caring for baby Jasleen. When her daughter-in-law went back to work as a dental assistant, Kaur was the sole caregiver during the day for the little infant.
Kaur entered the U.S. on a tourist visa, which allowed her to stay in the U.S. for six months. In March of 1997, Kaur’s tourist visa was set to expire; but she was not ready to go home yet. The family applied for an extension to the former Immigration and Naturalization Service – now U.S. Citizenship and Immigration Services – and Kaur was granted an additional six-months stay. She vowed to return to Chandigarh after Jasleen’s first birthday.
And then, the unexpected happened: Manjeet’s son abruptly left the household, and did not return. Attempts to find him through relatives and friends were unsuccessful.
Kaur again applied for an extension of her tourist visa, but this time was denied.
“My head said I must follow the rules and go home,” Kaur told India-West. “But my heart told me, ‘I must obey the rules of a higher order and stay to care for my grandchild.’”
The new grandmother had no immediate relatives in the U.S. to support a possible change of immigration status. So she simply stayed, joining the roster of an estimated 33,000 undocumented Indian seniors who live in the U.S.
Jasleen is now grown and will start university this fall. Kaur, however, has remained.
During her nearly two-decade long stint in the U.S., the Chandigarh native has been unable to get health insurance for a lack of funds; her daughter-in-law has been the sole breadwinner for the three-generation household with a meager salary from her dental assistant job.
Kaur’s undocumented status makes her ineligible for federal or state-subsidized health care. She has relied on free medical clinics, basic check-ups at free health fairs and word-of-mouth remedies — handed down through successive generations of Indians — to keep healthy. She has suffered no major illnesses thus far, but fears the day when she will have to go to the hospital.
Using data derived from the 2010 national census, the Department of Homeland Security estimated that 11.5 million U.S. residents are undocumented. DHS estimates there are 240,000 Indian undocumented people, up 100 percent from the year 2000, when they numbered 120,000.
Indians Fastest-Growing Population of Undocumented Residents
Undocumented Indians represent two percent of the overall population of U.S. residents without adequate immigration papers, but they are the fastest-growing population, noted a 2010 DHS report.
About 575,000 people in the overall undocumented U.S. population of about 11 million are seniors 55 years and over. Summating DHS statistics on Asians, this reporter estimates there are more than 33,000 elderly undocumented Indians living in the U.S.
Undocumented Indian seniors are ineligible for health insurance coverage under the new Affordable Care Act, which rolled out this January; they are also ineligible for Medi-Cal and Medicare.
“This is a huge step backwards for the undocumented population,” Daniel Zingale, senior vice president of the Healthy California Team at The California Endowment, told India-West, noting that 25 percent of the country’s undocumented residents live in this state.
“We can’t avoid the undocumented,” said Zingale. “All Californians – regardless of status – need to have access to basic health care.”
“California needs to move ahead of the nation,” he stated, noting that the undocumented were left out of the ACA plan during its slow limp through Congress, in order to garner bi-partisan support.
Indian American physician Anmol Mahal, who in 1997 launched the India Community Center’s free medical clinic in Milpitas, Calif., told India-West that this very vulnerable population has no access to health care when it most needs it. “They are not getting basic or ongoing preventive health care,” he stated.
“We have been seeing a number of visiting parents. They are here for an extended period of time – full-time babysitters to their grandkids – who invariably don’t have health insurance and are not eligible to sign up for Obamacare,” said Mahal, adding that the seniors who turn up at ICC’s clinic are often on multiple medications.
Visiting seniors may have traveler’s insurance, but most physicians are unlikely to accept it, he said; attempting to insure an elderly person in the U.S. will cost at least $800 per month in premiums, he added.
Sowmya Rao, associate professor in the Department of Quantitative Health Sciences at the University of Massachusetts Medical School, found out first-hand when he attempted to get health coverage for his 71-year-old mother who was visiting from Bangalore.
In a paper published this September in the Annals of Family Medicine, Rao wrote that his fit and active mother started to feel momentary tightness in her chest during her daily walks around the neighborhood, but did not complain of pain or shortness of breath.
Rao decided to play it safe and took his mother to the hospital. A CT scan revealed severe blockage in the arteries; an angiography was recommended at an estimated cost of $47,000, not including surgeons’ fees or hospital stays. The Indian American professor next found out that his mother’s traveler’s insurance declined to cover the procedure.
Rao took his mother back to Bangalore for the angiography; the procedure, including a 7-day hospital stay and all professional fees, was $4,300, one-tenth of the estimated costs in the U.S.
Undocumented seniors can “self-deport” and return to India for major medical procedures, but are then barred from returning to the U.S. for five to 20 years. Seniors may be required to stay in a detention center during the “self-deportation” process.
The federal Emergency Medical Treatment and Active Labor Act requires any hospital that receives Medicare or MediCal funds to see and stabilize anyone who shows up in their emergency room, regardless of the patient’s insurance or immigration status, or their ability to pay.
“Presently, if you’re undocumented, you seek a doctor who will accept cash payments or go to the ER for basic stabilization. But there’s no basic or ongoing preventive treatment,” explained Mahal, formerly the president of the California Medical Association.
Mahal used the example of a person suffering from pneumonia. “He comes into the ER, would be hospitalized, x-rayed, given breathing treatments, then sent home. And you’re back to square one,” he said, adding that recidivist patients scroll up the cost of health care delivery to the at-large population.
At the ICC free clinic, open twice a week on Wednesday evenings and Saturday mornings, volunteer physicians often see patients whose illnesses go well beyond treatment the clinic can offer, said Mahal.
Anand Gundu, who organized a free “mega health fair” held at the Livermore, Calif., Shiva-Vishnu temple Sept. 6, told India-West that many of the 350 people who turned out for the event were seniors visiting their children and grandchildren, and on an extended stay in the U.S.
“Our programs are the only resource they use,” said Gundu, the former president of the Shiva-Vishnu temple and a retired member of the board.
The mega fair featured specialists in internal medicine, cardiologists, dentists, chiropractors, physical therapists, homeopaths and nephrologists. All were volunteer doctors, who could not prescribe medicine at the fair. “But if the doctor thinks the patient is really poor, they often offer to see them at their own clinics,” said Gundu.
A number of clinics in Northern California serve the uninsured, but Gundu said little information is distributed to those who need their services.
Newly-Arrived Immigrants Also Lack Access to Health Care
Legal permanent resident seniors who have lived in the U.S. for less than five years are also barred from receiving Medi-Cal or Medicare benefits, with some exceptions.
In California, however, LPRs – as they are known – may purchase subsidized health care from the California Covered federally-backed health insurance exchange, until they have lived in the U.S. for five years to qualify for federal benefits, a representative for Covered California told India-West.
However, the subsidy is based on the annual income of the household; many elders living with their children will exceed the income requirements for subsidized premiums.
Using the Covered California online calculator, which determines eligibility, India-West used the mean California household income of $82,000 per year for a family of three to determine costs for insuring a parent, without subsidies. Family plans ranged from a $1,333 per month family premium for the lowest level of coverage through Kaiser, to $1,837 for coverage through Anthem Blue Cross.
Adding a parent to a family plan via Covered California raised premiums by about $900 a month, on average.
After the ACA roll-out, insurance companies have been banned from using pre-existing conditions to determine premium costs.
All applicants must have a social security number, said the Covered California representative. Therefore, documented immigrants cannot purchase health insurance for undocumented family members.
Even more troubling, the federal Department of Health and Human Services announced in September that more than 115,000 people who bought coverage through federal and state-supported health care exchanges would be losing their coverage – often without warning – for failing to provide proof of U.S. citizenship or legal residency. In California, more than 50,000 families stand to lose their coverage because of unresolved residency issues, reported The Washington Post.
Rishi Manchanda, president and founder of HealthBegins, which aims to improve health care access in vulnerable communities, told India-West he dove into the boggy morass of the pre-ACA health insurance environment as his parents contemplated permanently emigrating from Botswana to spend more time with their grandchildren.
Manchanda had to buy health insurance for his parents before they met the five-year residency requirement that might have qualified them for MediCal or Medicare. He said he was shocked by the cost of health insurance and the lack of benefits.
His parents stocked up on all their medications in Botswana and got their check-ups there as well.
“My family’s experience is not uncommon. It is a demographic phenomenon that is happening in our community. A lot of Indians are trying to bring their parents over,” said Manchanda, formerly the director of Social Medicine and Health Equity at St. John’s Well Child and Family Centers, a community health center network in South Central Los Angeles.
ACA Has Benefited the Community
South Asian American community organizers, however, contend that Indian American seniors have largely benefited from the Affordable Care Act.
“Formerly, premiums were very high,” Manju Kulkarni, executive director of the South Asian Network, told India-West. One couple she works with were formerly paying $1,500 per month for health insurance premiums, and having to cut down on groceries and other essentials as a result.
With their new, ACA-backed plan, the couple now pays under $500 per month, she said.
Indian American seniors have increased health care needs as they age, but would in the past often put off seeing a doctor or getting treatments because they cannot afford them. “Now they are getting treated,” said Kulkarni, adding that over the past year, SAN has been doing outreach and education in the South Asian American community to inform people of their benefits under the ACA. The organization has also enrolled a number of people in Covered California.
“Seniors don’t understand insurance,” asserted Kulkarni, recalling an instance when SAN was being interviewed by the Los Angeles Times. The reporter interviewed a gentleman from Bangladesh, who said he didn’t have insurance. “But he opened up his wallet and there was a Medi-Cal card,” she said.
Federally Qualified Health Care Centers have also received a “bump up” as part of health care reform, said Kulkarni. “It was understood that they would be serving more clients.” FQHCs are a safety net for the undocumented, providing a lot of free, individual care to those who lack health insurance.
The ACA mandates that $11 billion of additional funding would be allocated to FQHCs from 2011 to 2015 to serve 15 to 20 million more people by the year 2015.
In 2011, California Governor Jerry Brown proposed a $100 million cut in state funding to the 36 California community clinics that receive federal funds. The proposal was blocked by the state Legislature.
“Many of the draconian cuts the governor had proposed have not gone through, but there’s just basically enough funding to maintain the status quo,” said Zingale of The California Endowment.
Moina Shaiq, founder of the Muslim Support Network in Fremont, Calif., also said seniors are unaware of the services they can avail of. While there are few resources for people who lack health insurance, the Tri City Health Center in Fremont – home to one of the largest concentrations of Indian Americans in the nation – offers sliding scale health care services.
The MSN holds a monthly meeting with local seniors to inform them about health care resources they can access, Shaiq told India-West.
But Zingale and Mahal both contended that undocumented residents are loathe to accessing health care at community clinics for fear of somehow getting “under the radar” of immigration agencies.
“The basic (ethos) of the undocumented is that you don’t want to become visible to the system,” said Mahal.
“The spirit of the ACA was to provide health care access to all. We must now see how we can address the undocumented population,” said Manchanda.
Mahal thinks otherwise: “The desire to cover the undocumented – I don’t see that changing.”
Sunita Sohrabji wrote this article for India-West with support from the MetLife Journalists in Aging Fellows program, a project of New America Media and the Gerontological Society of America.