The Supreme Court’s deadlocked decision last week on United States v. Texas leaves millions of immigrants at potential risk for deportation and leaves many of them shut out of health coverage.

For the New York State Health Foundation (NYSHealth), it also represents a blow to our efforts to connect undocumented New Yorkers to coverage. While many of our activities in this area can continue despite the ruling, it closes off options to expand health insurance coverage to tens of thousands more New Yorkers who would have been eligible for insurance coverage if the Supreme Court had sided with the Obama Administration.

In New York, it is still a challenge to get everyone in the state insured. We have a large undocumented immigrant population, and many of these immigrants can only get coverage if they qualify for legal immigration status. In New York City alone, about 345,000 undocumented individuals were uninsured in 2013. Without coverage, many will continue to turn to emergency departments and public hospitals, or defer care and experience adverse health outcomes. It is important—for both the uninsured and for a well-functioning health care system—to devise insurance options for the immigrants left behind.

President Obama issued an executive action in 2012 that provided a policy opening for greater coverage. This action offered Deferred Action for Childhood Arrivals (DACA) status to undocumented immigrants residing in the United States who were brought to this country before the age of sixteen and who have been living here for five or more years. Deferred action can provide immigrants with temporary protections from deportation, with employment authorization, and with a Social Security number so they can work legally and pay taxes.

Readers should note that this past week’s Supreme Court decision in United States v. Texas does not affect the 2012 DACA executive action, which remains intact. That Supreme Court ruling dealt with the later 2014 executive action that would have expanded protections and benefits to a wider swath of undocumented immigrants.

In New York, DACA can also provide a path to health insurance, in part as a result of a pioneering lawsuit. Although federal policy does not offer Medicaid for DACA recipients who would have been eligible based on their income for that public insurance program, a few jurisdictions—New York, California, Massachusetts, and the District of Columbia—use their own funds to provide state-funded Medicaid to income-eligible DACA recipients and others who qualify for Permanent Residence Under Color of Law (PRUCOL) status. The disconnect between federal and state rules regarding these benefits has created massive confusion among the potential beneficiaries of this coverage option.

In summer 2014, when a new intern at NYSHealth, Cesar Andrade, shared with me that he was a DACA recipient, one of my first questions was whether he had health insurance. He didn’t. He was uninsured. I promised him we’d connect him to a health insurance enroller and get him covered. The story has a happy ending: Cesar got Medicaid. And I got an education. I learned that even the most engaged DACA activists, like Cesar, could be unaware that they may qualify for a Medicaid program funded by New York State.

Under the 2012 DACA executive action, New York City estimated that 85,000 people are DACA-eligible—among the largest such concentrations in the United States. The city also estimated that 40–45 percent of this population is likely income-eligible for Medicaid, which could result in 40,000 city residents (and more statewide) potentially gaining health coverage. Yet many potential beneficiaries, activists, and even immigrant-focused community-based organizations and attorneys working with immigrants did not know about this Medicaid option. And those who did know learned only through word of mouth.

In general, DACA uptake had been disproportionately low in New York as compared with other states that have a high share of potential DACA recipients. Experts believe that uptake has been relatively low—in part because the major DACA benefits (protection from deportation, employment authorization, and eligibility for a driver’s license) have not been persuasive enough in New York City, where a sense of sanctuary, cash employment, and public transportation have minimized the attractiveness of those incentives.

When the Mayor’s Office of Immigrant Affairs (MOIA) in New York City sponsored a subway advertising and public education campaign about the benefits of DACA in 2014, it didn’t mention the potential health insurance opportunity. New York State did not offer any explicit guidance confirming that this Medicaid-eligibility benefit extended to DACA recipients. National DACA campaigns also overlook this option. Having a policy on the books is not enough to make a difference if potential beneficiaries don’t know it exists.

So we worked to raise awareness. Cesar created a DACA and Medicaid flyer and got it approved by the state for use by state-funded enrollment navigators. We did media outreach to spread the word, and Cesar’s story was featured on Politico New York.

We also reached out to MOIA about the misunderstanding and confusion we kept hearing about regarding DACA recipients’ potential eligibility for state-funded Medicaid coverage. MOIA Commissioner Nisha Agarwal then proposed a brilliant idea: putting the Medicaid benefit front and center in a new city advertising and public education campaign to encourage more undocumented New Yorkers to apply for DACA.

NYSHealth awarded a grant of almost $344,000 to support this campaign, the largest effort in the United States to highlight DACA recipients’ potential for state Medicaid eligibility.

The campaign, which launched in May, includes advertisements on most of the city’s subway lines, as well as on bus shelters and phone kiosks; ads in ethnic and community media; social media ads; video testimonials from those who have received DACA and Medicaid (including Cesar); distribution of more than 125,000 info cards to laundromats, nail salons, check-cashing businesses, and independent pharmacies; training of immigrant-serving attorneys, community-based organizations, and insurance navigators; a Web page at nyc.gov/DACA; and training of 311 operators to refer all calls asking about DACA and health insurance to the correct resources. The campaign ads run in English, Spanish, Chinese, Korean, Haitian-Creole, Russian, Polish, Urdu, Bangla, French, and Arabic. All of the ads mention both the 311 hotline and the city’s dedicated DACA website.

We are heartened that this campaign’s metrics have already exceeded those from the city’s previous DACA campaign. The city’s 311 helpline has experienced an increase in DACA inquiries. Within a few weeks following the campaign’s launch in early May 2016, the campaign recorded 13,500 website visits, whereas the 2014 campaign averaged 1,000 visits per month.

Recognizing the focus on a young adult population, the campaign used social media as a core component. By using multiple languages, social media engagement for the period of May 5–June 17, 2016, resulted in more than 49,000 clicks on campaign postings across Facebook, Instagram, and Twitter.

We will never know the campaign’s true impact on Medicaid enrollments because the state does not have the means to filter out DACA recipients in its system. Instead, funders often have to measure success with the data they do have available.

When the campaign ends in late July 2016, it will have a legacy beyond the subway ads. We have engaged those organizations with the deepest reach to those enrolled in DACA (known as the “DACA-mented”) and DACA-eligible persons. These organizations will sustain the message going forward, and awareness will no longer rely on word of mouth. In this political environment, in which the undocumented feel hesitant to come forward, the state has put out the welcome mat and has shined a light on the benefits that New York offers.

As funders, we accept risk when we make big bets. Immigrants remain the largest population of the uninsured and the final frontier in coverage. Through the MOIA campaign, we took advantage of what we could do to expand health care coverage for immigrants in New York while the challenge to the 2014 executive action advanced through the courts. Looking ahead, we also laid the groundwork for future options to cover undocumented immigrants.

To that end, with cofunding from the United Hospital Fund, New York Community Trust, and the Altman Foundation, we sponsored a rigorous fiscal analysis of three possible options to cover the undocumented in New York State. Released in January 2016 by the Community Service Society of New York, the report is a model for how funders can spur a conversation in their states about how to cover the immigrant populations left behind. Already, there is a campaign in the state legislature in Albany to tackle the report’s first proposal—to extend the state’s newly implemented Basic Health Plan, which offers low- or no-cost coverage to those with incomes up to 200 percent of the federal poverty level, to DACA recipients.

We had hoped to reach greater numbers of undocumented immigrants who would have been eligible for health insurance coverage under the 2014 executive action. However, the Supreme Court decision has put an end, for now, to a planned project to support education and outreach efforts for immigrant-serving organizations and attorneys.

Grant making in the policy arena often requires the ability to see what issues are emerging around the corner, the creativity to scale tall obstacles, and the flexibility to adjust when the ground shifts. As funders of policy change, we are patient. Post-United States v. Texas, opportunities do remain for funders and advocates in New York and elsewhere to seek out change at the state level. Cesar, the intern who inspired the campaign, is headed to medical school later this summer—and he is prepared to stay in this fight.

Related resources:

Video about Cesar Andrade, the NYSHealth intern mentioned above.

Empire Justice Center, “Health Coverage Crosswalk: Eligibility by Immigration Status,” August 2015.  This information focuses on New York State.

“Supreme Court Decision Deals Blow to Health Coverage Efforts in California,” by Soumya Karlamangla, June 23, 2016, Los Angeles Times.

Editor’s note:

Related reading:

“Supreme Court Deadlock Keeps Immigrants’ Health at Risk,” California Wellness Foundation website, based upon an essay by Cal Wellness President and CEO, Judy Belk, published on June 24 by the Huffington Post.