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When Victoria Elizondo first went to see a doctor about her symptoms at Legacy Community Clinic, a low-cost clinic in Houston, she didn’t know what was wrong with her but she knew something wasn’t right. Her hands would shake uncontrollably, her heart would beat fast even while resting and she suffered from insomnia.

After the appointment, she was told her immune system was attacking an overactive thyroid, a disorder called Graves’ disease, and that an endocrinologist was the only doctor who could help her. But without health insurance, the cost to see one was exorbitant — as much as $800 for a visit.

“I thought it was a joke,” said Elizondo, a 33-year-old restaurant owner.

Elizondo, who has been paying thousands of dollars a year for treatment, may soon find relief. She is now one of nearly 90,000 DACA recipients in Texas — more than 500,000 across the nation — who finally get a chance at signing up for health insurance through the Affordable Care Act. Through Jan. 15, DACA recipients — those who under the Deferred Action for Childhood Arrivals program are temporarily protected to live and work in the U.S. after being brought to the country unauthorized as children — can enroll in the federal health insurance marketplace for the first time since launching 10 years ago.

Advocacy groups say access to the marketplace will help alleviate the health disparities DACA recipients face, such as high uninsured rates and unmet medical needs after years of putting off care. However, a lawsuit threatens to take this eligibility away as Texas, along with 18 other states, argues the policy would financially harm them. Looming even larger is the uncertainty around the existence of DACA as President-elect Donald Trump has promised mass deportations and ending birthright citizenship for people born to undocumented immigrants. In 2017, he attempted to rescind DACA, arguing that it was unconstitutional. Three years later, the Supreme Court ruled that his attempt was unlawful.

With premium tax credits that help lower health insurance costs set to expire at the end of 2025, Trump also has the ability to not renew them.

These subsidies, as well as cost-sharing reductions, are also now available to DACA recipients, lowering the amount they have to pay for premiums, deductibles and co-payments. DACA recipients cannot qualify for Medicaid, the public health insurance program for low-income individuals, under federal law. It’s also unclear how many DACA recipients in Texas receive health insurance coverage through an employer or as a dependent.

“More than one-third of DACA recipients currently do not have health insurance, so making them eligible to enroll in coverage will improve their health and wellbeing, and help the overall economy,” said U.S. Department of Health and Human Services Secretary Xavier Becerra in a news release.

Cost of health care

Elizondo pays about $200 for each endocrinologist visit and $100 every month for blood work. To cure Graves' disease, she would need to undergo a thyroid gland removal surgery which can cost up to $30,000.

Having health insurance would mean she could spend less time worrying about her personal costs and physical limitations and put more focus on her growing business.

“It’s a big deal for me,” Elizondo said.

According to the Center for Medicare & Medicaid Services, DACA recipients are currently three times more likely to be uninsured than the general U.S. population, resulting in many delaying care because of high out-of-pocket costs. A 2023 survey by the National Immigration Law Center found that more than a third of DACA recipients skipped recommended medical treatments and tests, which can lead to worsening health outcomes and heftier medical costs in the future.

"Right now, people are getting sicker because of (not receiving) preventative care. More folks will have to go to the emergency room," said Cesar Espinosa, executive director of FIEL Houston, Inc., an immigration advocacy group.

Espinosa would know. When he was an uninsured DACA recipient 16 years ago, he collapsed in front of his mother’s door and was rushed by ambulance to the emergency room. He found out there that he had Type 2 diabetes.

Without health insurance, he had to rely on the Harris Health Financial Assistance Program to cover those hospital costs. After losing access to that help, he now needs to find a way to pay for medication, which can cost about $970 without insurance.

“I’m looking forward to also being able to afford a better quality of health care,” he said.

Espinosa, now a permanent resident who also plans to enroll in federal marketplace insurance, hopes others take advantage of the new eligibility, particularly for their mental health needs. The law center report listed mental health as a top medical concern for DACA recipients, but 36% of them said costs were too high to access treatment. The uncertainty associated with the future of DACA is considered “a source of trauma, leading to increased fear, sadness, and distrust,” according to the report.

“You can never be at peace,” Espinosa said.

This distrust of public programs has motivated navigators, nonprofits that receive federal funding to help first-time enrollees sign up for Affordable Care Act coverage, to develop strategies to better help DACA recipients.

Navigators at health organization MHP Salud in Weslaco have printed flyers, brochures, and DACA-related one-pagers and messaging on their website. They cover six regions in Texas, including El Paso, Eagle Pass, San Antonio, and the Rio Grande Valley, working with community health partners and individuals they work with to spread the word.

Eight days into open enrollment, Martinez said MHP Salud had received five inquiries from DACA recipients through their online information form about coverage.

Jennifer Martinez, a program manager at MHP Salud, said the biggest challenge is trying to find where DACA recipients are located. They can be students or business owners, just graduating college or starting their own family.

In July, U.S. Rep. Joaquin Castro along with five other Texas officials wrote a letter to the U.S. Department of Health and Human Services urging them to expand their outreach and enrollment assistance efforts for DACA recipients.

“We’re going on a first date with DACA recipients,” said Stacey Thompson, a program director at Civic Heart Community Services, another health navigator organization. “We’re nervous but we’re also excited to serve them.”

Fear of taking subsidies

According to health policy research organization Kaiser Family Foundation, 43% of DACA-eligible individuals have incomes below 200% of the federal poverty level compared with 26% of U.S.-born individuals in the same age group. That’s $30,120 for one person and $62,400 for a family of four.

Since many DACA recipients are low-income and are generally barred from Medicaid, tax credits and cost-sharing reductions for marketplace plans could make the difference between having health insurance or not.

“The tax credits are huge,” said Scott Heard, senior program coordinator for the Prosper Health Coverage Program at Foundation Communities in Austin. “I don’t think some people realize just how essential that is to the program. It’s pretty much not affordable without the tax credits.”

During his previous term, Trump had led an unsuccessful effort to rid the Affordable Care Act, and although he could renew the charge in his upcoming term, a more likely action is that he could whittle away subsidies that help low-income individuals afford a marketplace plan, regardless of their citizenship.

Further complicating the issue, DACA recipients also fear using subsidies could block their paths to citizenship. During the last Trump administration, federal officials broadened rules so that certain immigrants who received Medicaid, housing assistance, child care subsidies, and other benefits for more than 12 months within any 36-month period could be deemed a public charge. Being labeled a public charge or a potential public charge carries high consequences: the inability to become lawful permanent residents.

Espinosa said DACA recipients fear using Affordable Care Act subsidies will carry the same penalty.

“We tell them the truth and that this is not a public charge,” he said. “They are not here illegally. They do have a permit to be here. We are hoping to be able to explain to people what this really means and hoping that they’ll take a chance and do it.”

An uncertain future

DACA recipients were originally excluded from the Affordable Care Act because they were not considered lawfully present. In a 2023 report, Medha Makhlouf, a Pennsylvania State University law professor, suggested that the U.S. Department of Health and Human Services’ decision to exclude DACA recipients was not based on health policy.

“It relied on a desire to not interfere with immigration policymaking,” Makhlouf wrote. “The decision to ‘carve out’ DACA beneficiaries from the category of lawfully present noncitizens was made under pressure from an administration that was concerned about appearing too lenient on immigration issues.”

Those fears that the move would cause political pushback have been validated by a lawsuit, first filed in August, that seeks to reverse DACA recipients’ eligibility for Affordable Care Act coverage. The attorney generals from 19 states, including Texas, argue that by allowing DACA recipients to benefit from subsidized health insurance and making them lawfully present in their health care system, these individuals will want to stay in the United States longer. This will in turn cause states to spend more money on education, health care, law enforcement, and other limited resources, they say. Texas spends more than $250 million each year on social services to DACA recipients, according to the lawsuit.

However, Waco-based economist Ray Perryman told the Dallas Morning News that to his knowledge there is no Texas database or study that tracks what costs the state incurs because of DACA recipients. Texas used Perryman’s estimates in the lawsuit but he said that “none of my analysis regarding immigration or the DACA recipients has identified any cost to the state imposed by DACA recipients.”

DACA advocates say that health insurance coverage helps lower costs because people do not have to wait until their health problems become more serious and more expensive, possibly putting more financial burden on health systems.

Navigators say that federally-funded clinics are the closest thing uninsured DACA recipients have to reliable quality health care.

Nicolas Espiritu, the deputy director of legal at the National Immigration Law Center, said that he does not believe that any states will be harmed if the marketplace is opened up to DACA recipients. If anything, it would be a benefit to states.

“Texas also doesn’t bear any costs for administering the program,” he said. “The health care access and quality and overall health care outcomes will only improve by ensuring that everyone has health care.”

First: Victoria Elizondo, a DACA recipient and chef-owner of Cochinita & Co., in her Houston restaurant on Nov. 8, 2024. Last: Elizondo has a laugh with her employees in the kitchen. Credit: Danielle Villasana for The Texas Tribune

Elizondo has been excited to sign up for Affordable Care Act insurance, listing out all the appointments she would like to make — those for regular health checkups, a gynecologist and mental health therapy. But with the results of Election Day, Elizondo fears she may never get it.

In the meantime, Elizondo, a decorated chef and owner of Houston-based Cochinita & Co., will continue to do what she has always done — push through tired and physically draining days as best she can.

“I have 17 employees, so it’s like I have 17 children,” she said. “The amount of energy it requires is high. Sometimes I feel like I’m not able to meet the demands the business requires.”

This article originally appeared in The Texas Tribune at https://www.texastribune.org/2024/11/12/texas-health-insurance-daca-affordable-care-act/.

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