Deserving to a point: Unauthorized immigrants in San Francisco’s universal access healthcare model

In the “decidedly hostile” federal context toward unauthorized immigrants in American healthcare (Newton & Adams, 2009, p. 422), a few subnational governments have implemented strategies seeking to expand their access to and utilization of care. In this article, I draw on interviews conducted with 36 primary care providers working in San Francisco’s public safety net between May and September 2009 to examine how such inclusive local policies work. On one hand, San Francisco’s inclusive local policy climate both encourages and reinforces public safety-net providers’ views of unauthorized immigrants as patients morally deserving of equal care, and helps them to translate their inclusive views into actual behaviors by providing them with increased financial resources. On the other hand, both hidden and formal barriers to care remain in place, which limits public safety-net providers’ abilities to extend equal care to unauthorized immigrants even within this purportedly inclusive local policy context. I discuss the implications of the San Francisco case for policymakers, providers, and immigrants elsewhere.

► San Francisco’s inclusive local policy environment lowers the barriers to access to healthcare for unauthorized immigrants.
► Symbolically, it encourages providers to view unauthorized immigrants as morally deserving clients.
► Instrumentally, it provides material resources that allow providers to extend care in a more systematic way.
► Yet formal barriers to specialty medical and ancillary care, and bureaucratic barriers to primary medical care, remain.
► This case study highlights institutional contradictions underlying inclusive subnational strategies to reduce unauthorized immigrants’ health vulnerability.