Early on a recent morning, men huddle in the Home Depot parking lot, ground zero for day laborers on the hunt for work. Cars pull into the lot, and the men swarm.
Among them is Marcos, at 65, wiry and bronzed with a silvery smile. He's been in the country illegally for 20 years. When he's sick, he just rests, because - like most undocumented workers - he doesn't have insurance.
"I don't know if I have high blood pressure," he said. "Because I don't check. Doctors, you know, are expensive."
For decades, the United States has struggled to deal with the health care needs of its undocumented immigrants - now an estimated 11 million - mainly through emergency room care and community health centers. But that struggle will evolve. As with the rest of America, the undocumented population is aging and developing the same health problems that plague other senior citizens.
Many undocumented adults lack health insurance, and even though they're guaranteed emergency care, they often can't get treated for chronic issues such as high blood pressure. What's more, experts predict that many forgo preventive care, making chronic conditions worse - and more expensive to treat.
"They're hosed. If you're an undocumented immigrant, you're paying into Social Security and Medicare, but can't claim it," said Steven Wallace of the UCLA Center for Health Policy Research.
When uninsured people end up in the hospital, that pushes up rates for those who have insurance. Or public programs like Emergency Medicaid pick up the tab. This contributes to a game of shifting costs, Wallace said.
"It'll place a strain on the entire health care system," Wallace said.
Approximately 10% of the undocumented population is over 55 now, according to the Migration Policy Institute, but researchers agree that their numbers will rise.
"The unauthorized immigrant population has become more settled, and as a result is aging," said Mark Hugo Lopez of the Pew Research Center.
Estimates vary on how many undocumented immigrants lack insurance. The Kaiser Foundation estimates 39 percent are uninsured, while the Migration Policy Institute, which analyzes U.S. Census data, estimates as many as 71 percent of undocumented adults do not have insurance.
Like Marcos, older undocumented people tend to be poor. The Affordable Care Act doesn't cover them, and they don't qualify for Medicaid, Medicare or Social Security, even though many pay taxes. Few can afford private insurance.
That means most must turn to emergency rooms or community health centers, which provide primary care to poor people, regardless of immigration status. But community health centers can't provide extensive care, Wallace said. And because Congress has yet to fund them, their future is precarious.
Leighton Ku, professor and director of the Center for Health Policy Research at George Washington University, said immigrants, both authorized and unauthorized, are much less likely to use health care than are U.S. citizens. Until, that is, they're quite ill.
"Their numbers are going to grow and we're going to have an epidemic on our hands," said Maryland state Del. Joseline Pe-a-Melnyk, a Democrat. "Who's going to pay for it?"
A 2014 report published by the journal of the Texas Medical Association found that undocumented immigrants with kidney disease face considerable barriers to care. By the time they do get help, they need dialysis, costing Texas taxpayers as much as $10 million a year.
Stepping in to help
Many cities have tried to step in. A 2016 Wall Street Journal story noted that 25 counties with large undocumented populations provide some non-emergency health care to these immigrants, at a combined cost of what the paper estimated is more than $1 billion each year.
Washington, D.C., Los Angeles and San Francisco are among the places where undocumented immigrants can usually get routine care, thanks to locally funded programs.
In Los Angeles, Dr. Christina Hillson, a family practice doctor at the Eisner Health Clinic, said she's seeing a growing number of elderly undocumented patients, whom she's treated for everything from ovarian cancer to amputations resulting from untreated diabetes.
Patients who are critically ill are considered emergencies and can get treated at hospitals, she said. Sometimes Hillson will send patients who aren't as ill to the ER, because it's the only way they can see a specialist.
Snapshot of a population
Most undocumented people immigrated here when they were young and tended to be healthier than native-born citizens, Wallace said. But as they age, they lose that advantage.
Undocumented women are more likely to have family in the U.S., who can help care for them as they age, said Randy Capps of the Migration Policy Institute. But men are more likely to be single. Because they often work as manual laborers, they're more likely to get hurt on the job, Capps said.
"They're going to age faster and become disabled at higher rates," Capps said. "It's going to make for a much tougher old age."
There's no one easy solution to helping older residents who live in the United States illegally, health and immigration experts say.
"The policy solution for illegals is to enforce the law and encourage them to return home, thereby avoiding the problem," said Steven Camarota of the Center for Immigration Studies, which favors limiting immigration.
Joe Caldwell of the National Council on Aging, an advocacy group, said federal immigration legislation providing a pathway to citizenship would allow seniors to access care.
Such legislation is unlikely any time soon.
Outside the Home Depot, Marcos and his friends gather in the cold sunshine. He's been paying taxes for years, Marcos said, and he's got pages of documents to prove it. He'd love to become documented, "but that's practically impossible," he said.
A year ago, Marcos said, he had tightness in his chest. He had no choice but to go to the ER, but he hasn't followed up. He'd rather stalk the parking lot here, looking for work.
"No work," Marcos said, "no money."
The Pew Charitable Trusts funds both the Pew Research Center and Stateline.
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