The Affordable Care Act (ACA) is under threat of repeal, and while lawmakers argue over what will replace it if anything, the health care policy landscape has already shifted. Entire sectors of the US population—undocumented immigrants and the working poor—were excluded or had limited access to the Affordable Care Act marketplace to begin with, and they continue to struggle to afford primary health care services and to find treatment for chronic illnesses.
As a medical anthropologist, my research in Chicago focuses on how Latinx families navigate well-being and engage in agentive strategies to find affordable healthcare options with the implementation (and possible repeal) of the ACA. According to recent Census data, 18.5 percent of Chicago residents remain uninsured.
One day, I accompanied Ingrid (pseudonym), an undocumented Mexican mother of three, to an informal dental care visit. We got lost trying to locate the facility. There were no signs or advertisements. The office looked like an abandoned clothing store. We hesitantly looked around the dark room filled with clothing displays and caught a glimpse of light peeking through the side hallway which led us to rows of plastic chairs, one occupied by a man cradling a swollen cheek.
The receptionist at the make-shift intake desk stared at his phone while waiting for walked-ins. Ingrid explained that she had a toothache and needed to see a dentist. The attendant nodded and said that she would need to wait a couple of hours. Ingrid went back that afternoon. The dentist removed the teeth that were bothering her. She seemed satisfied with the treatment and the price, but she had limited choices.
Although Ingrid and her husband are undocumented and uninsured, their three US-born children have health insurance through the Illinois All Kids medical card, which includes dental care. Citizenship or legal presence in the US structures Latinx experiences with the health care marketplace—both formal and informal. Because many families live in mixed-status households, coverage is uneven for individual family members.
While the ACA requires companies to extend health care packages (for purchase) to those who do not have full benefits, these plans are unaffordable for most low-wage and part-time workers. Analis, who works as a home care assistant, recently moved to Chicago from Puerto Rico as a result of the economic crisis. Her salary barely covers living expenses for herself and her daughter, which makes health insurance unattainable. Reflecting on her situation, Analis said, “Sal y limón. Porque si tu coges un seguro con esto de homemaker que yo trabajo, se te quedan con el cheque. ¿Cómo voy a mantener la hija mía?” (Salt and lime. If I were to get insurance from my employer, they would keep most of my paycheck. How am I supposed to care for my daughter?) As a single mother navigating a new city, Analis has to choose between coverage and caring for her family. Many low-income families find themselves in similar dilemmas.
Due to Congress’s inability to improve or replace the ACA, the current federal administration shortened the open enrollment period and cut funding for advertising and outreach to communities who could benefit from the program. Agencies are overburdened with caseloads and do not have the adequate resources for enrollment and recruitment. Each year, more families fall between the cracks and do not enroll in a health care plan, which carries significant penalties. In fact, undocumented residents who do not qualify for the ACA, are still subject to annual fines.
Bloated premium costs, high deductibles, and limited insurance plan options are clear examples of where the ACA needs improvement if it continues. Even though the ACA expanded coverage for many people, marginalized communities—immigrants and the working poor—continue to encounter many obstacles. The ACA’s uncertain future compounds these problems and the lack of maintenance and attention to these issues may lead the ACA to collapse while many families are without access to safe and affordable care.
The tax bill enacted just before the close of 2017 eliminated the tax penalty for not obtaining health coverage beginning in 2019, which may alleviate sanctions. But this measure does not expand or improve access to health care for vulnerable communities. Additionally, the Trump administration continues to undercut the ACA, by shortening open enrollment periods and slashing budgets. His stated intention is to let the program unravel.
As public anthropologists, we must continue to engage with communities and advocate for policies that attend to the nuances of the barriers they face. Lack of access to health care is a social injustice. It not only structures and compounds racial, class, and gender inequalities but limits our capacity to fully contribute to society as caregivers and as workers.
Lilian Milanés is a PhD candidate at the University of Kentucky in the department of anthropology. Her research in medical anthropology focuses on access to health care, health inequities, and US Latinx communities.
Cite as: Milanés, Lilian. 2018. “Navigating Healthcare Dilemmas in Chicago.” Anthropology News website, May 9, 2018. DOI: 10.1111/AN.853