By Rachel Bluth and Emily Schultheis
Originally published in Politico
LOS ANGELES — One recent morning, not long after the Trump administration launched its extraordinary immigration crackdown in Los Angeles, Alfredo Contreras pulled a large RV into the parking lot of a rehab center south of the city’s skyline.
The RV is part of a small fleet of rolling exam rooms run by St. John’s Community Health that have taken on heightened importance in the city’s health care — and, increasingly, political — landscape since the start of the raids. With teams of masked agents cruising the streets, many of the region’s nearly 1 million undocumented immigrants are keeping close to home, refusing to go far to grocery shop or work, let alone visit the doctor.
Contreras recalled that seven women were waiting to be seen when the staff got word of a raid happening at a nearby church. The agents, they were warned, likely were headed their way next.
Contreras and another worker slipped quietly outside and posted up in front of the parking lot’s gate. Soon after, five unmarked cars with tinted windows pulled up nearby.
One of the cars drove closer and a standoff ensued. Contreras told his colleague they wouldn’t let the agents pass unless they had a warrant. An agent snapped photos of the men, but came no further. The cars left.
A patient at one of St. John’s Community Health mobile clinics called “Health Express”, top, at the edge of McArthur Park, bottom, in Los Angeles.
St. John’s staff speak with a patient during a mobile health clinic stop at MacArthur Park. The mobile clinics are aimed at providing care to people who slip through the cracks of traditional clinics, including undocumented immigrants, homeless people, and schoolchildren.
“The patients are out there, but they’re afraid,” Contreras said later. “That’s one of our biggest downfalls right now … people are not coming out.”
With the immigration enforcement ongoing, the incident highlighted the severe challenges facing groups like St. John’s. As families balance the need for medical care against the risk of deportation, community health centers are scrambling to continue to provide care and to stay afloat amid the financial impact brought on by the crisis.
Meanwhile, the upheaval in health care access is contributing to a shift in politics in the nation’s second-most populous city — turning health care practitioners into donors and lobbyists. Clinic leaders, including St. John’s CEO Jim Mangia, are taking on increasingly political roles, working the halls of government to stave off threats not just from Republicans in Washington, but Democrats in Sacramento as well.
An unhoused man, background unidentified, receives medical treatment for wounds on his legs from the medical staff at one of St. John’s Community Health mobile clinics.
Doctors and nurses provide care to a patient in a St. John’s mobile clinic. The RVs, which set up at different points around the city, are equipped with exam rooms and necessary medical equipment.
Missed appointments
St. John’s has been a presence in Los Angeles for 60 years. And for about half of that time, Mangia has been a presence at St. John’s. The nonprofit is mostly funded by the federal government and has a mandate to serve everyone who walks through its doors regardless of ability to pay.
The clinic operates 28 sites in and around L.A. that serve about 125,000 patients who make 550,000 visits each year. Mangia believes his organization is the largest provider of care for undocumented immigrants in the country, with around 25,000 of its patients living in the country illegally.
Shortly after Trump took office, Mangia began preparing for the crackdown that eventually came. He started offering “know your rights” classes in the clinics and made arrangements with staff on where they would hide patients if immigration enforcement agents showed up.
It wasn’t enough to quell fears. By early spring, Mangia noticed an uptick in the number of patients canceling appointments, saying they were too scared to come in. The clinics, which used to have a no-show rate of about 8 or 9 percent, have seen that figure skyrocket to 30 percent since the start of the raids, Mangia said.
In April, he launched a program called Health Care Without Fear to start seeing patients in the mobile clinics in their neighborhoods, or through house calls made by two home visitation teams.
Magdalena, a 52-year-old undocumented housekeeper from Mexico who declined to give her last name, still showed up for a physiotherapy appointment at a St. John’s clinic in south LA one recent afternoon.
She said she wouldn’t describe her feelings as fear: “More like caution,” she said, “to live in fear is not a dignified way to live.”
Still, she’s canceled some appointments related to treatment for a knee injury. “I’ve had to take precautions,” she said.
Budget squeeze
The problems at St. John’s are being felt by clinics around the city. At Venice Family Clinics in West LA and Inglewood, CEO Mitesh Popat began aggressively pursuing telemedicine options for his 45,000 patients three weeks ago.
Clinic staff are calling every patient before their appointment to see if they’d rather have a virtual visit, and they’re calling five minutes after missed appointments to offer the same.
“That’s a short-term solution, we learned those approaches through the pandemic and it can work for a period of time,” Popat said. “Eventually, people need to come in person and actually see their doctor or their nurse practitioner.”
Rethinking ways to treat patients is an expensive proposition. Most of the patients at St. John’s are on Medi-Cal, California’s Medicaid insurance program for low-income people. But Medicaid pays only for care delivered within the walls of the clinic, not home visits and mobile units. For now, Mangia is drawing down the clinic’s reserves, which are boosted by philanthropy and patient donations, but the losses are mounting.
Compounding his financial outlook are looming cuts at the federal and state level.
The sweeping spending and policy bill recently passed by Congress eliminates an estimated $1 trillion in Medicaid funding over the next decade and imposes tougher restrictions on immigrants’ access to insurance and health care.
Yet a more immediate worry for Mangia comes from Democrats in California, especially Gov. Gavin Newsom.
After pushing through an ambitious plan to start providing Medi-Cal to all undocumented immigrants in 2024, the governor and lawmakers hit the brakes in the face of a yawning budget deficit. Passed in June, the new state budget bars undocumented adults from enrolling starting next year. It also cuts back some benefits and imposes $30 monthly premiums on those grandfathered into the program.
“The federal cuts are terrible, and the worst cuts to Medicaid ever — but the state cuts are much worse because the state cuts specifically target immigrants,” Mangia said. “For the governor to be going around the country and talking about how cruel the raids are and how he’s supporting the rights of immigrants … his [budget] significantly cut health care access for millions of immigrant Californians.”
Between cuts at the federal and state levels, Mangia estimates the recent policy shifts will eliminate around $50 million of St. John’s $230 million annual budget.
It’s why he increasingly has been wading into politics. In April, he launched the Health Justice Action Fund, a coalition with other health care providers, and poured $2 million from St. John’s accounts into it for political endeavors.
The group initially ran TV ads in six Republican districts, trying to persuade lawmakers like Ken Calvert, David Valadao and Young Kim to vote against Congress’ Medicaid cuts. Now Mangia is focused on Sacramento, where he plans to spend August lobbying lawmakers to delay cuts or find a way to raise revenue and avoid them.
If all else fails, his Plan C is to look local. Before the state started expanding Medi-Cal to include undocumented people in 2016, Los Angeles County had a program to pay for their care. Mangia is looking at ways to return to that model if need be.
“I think most [clinics] are keeping their heads down and hoping for the best, and allowing those of us that are willing to kind of take it on the chin to lead the efforts,” Mangia said. “I don’t want to think about cutting all of this back until we’ve given it the fight that I think we could give it.”
For the patients who rely on Medi-Cal, the cuts aren’t just scary — they feel existential. Teodora, a 77-year-old undocumented woman from Mexico who declined to give her last name, is one of them.
After visiting a St. John’s clinic in south LA one recent afternoon, she said she’s been on Medi-Cal for the last 15 years to manage her diabetes, treat her longstanding knee problems and to help with other health issues that have arisen along the way.
The last few months have brought new levels of uncertainty for her and her adult son. Like other mothers, she worries he will be picked up in a raid, and said the immigration crackdown makes her nervous to come to her appointments at the clinic.
The cuts to Medi-Cal fill her with a different kind of fear. Teodora’s face crumpled as she spoke about what they mean for her, eyes filling with tears as her voice wavered.
“If they take it away,” she asked, “how am I going to get better?”