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Background: Undocumented communities face significant structural barriers when accessing healthcare and social services in the United States. Policies such as public charge and heightened immigration enforcement may contribute to unmet basic needs and could provide insight into potential interventions to support these communities especially during times of high stress. Prior to recent expansions of Medi-Cal eligibility in California, many undocumented individuals remained excluded from public insurance programs. Evaluating needs during this pre-expansion period is critical not only for identifying persistent care gaps beyond healthcare access, but also for informing responses to evolving policy changes that may again limit coverage for undocumented populations. 

Objective: To examine the relationship between immigrant-related stressors, healthcare access and food insecurity among undocumented patients enrolled in a primary care access program through secondary analysis. 

Methods: A cross-sectional secondary data analysis was conducted of participants enrolled in a primary care pilot program from 35 rural and urban counties in Central and Northern California. Of the 12,137 participants enrolled in the program, 212 participated in phone interviews and were included in this data analysis. Immigrant-related stressors were assessed using three self-reported measures: limited English proficiency impacting ability to connect with others, perceived safety when leaving their home, and avoidance of seeking medical care due to their status. Associations with food insecurity were also evaluated. 

Results: Participants were predominantly female (75.9%), aged 26-44 years (60.4%), and had a low English proficiency (with 91.9% reporting “not at all” or “not very well”). 27% reported the inability to afford medical care in the prior six months. Food insecurity was reported by 15.2% of the participants. Public charge concerns were significantly associated with food insecurity (p=0.02), as was feeling unsafe leaving the home due to their immigration status (p=0.04). Participants who reported being unable to afford medical care had a significantly higher rate of food insecurity (58.0% versus 22.3%, p<0.0001). English language proficiency, age, education, travel to clinic and chronic conditions were not significantly associated with food insecurity. 

Conclusions: Among undocumented participants enrolled in this primary care program, we identified the intersecting structural and immigration-related barriers that extend beyond access to healthcare. While the pilot program improved access to primary care, our findings reveal that undocumented communities continue to experience food insecurity, particularly during periods of heightened immigration enforcement. 

This pilot program was implemented in 2019, prior to the expansion of Medi-Cal eligibility for undocumented immigrants in California. Although subsequent expansions improved access to care, recent policy changes and restrictions to Medi-Cal eligibility, coupled with increased immigration enforcement, may reintroduce or intensify barriers. As a result, the association observed between inability to afford healthcare and food insecurity may become more pronounced. 

These findings highlight the need for interventions that address food access through community-based strategies alongside sustained care. They also suggest that food insecurity may serve as a marker of broader policy-related stressors, emphasizing the importance of screening for social and structural vulnerabilities among patients who present to care. This work emphasizes that improving health equity in undocumented populations requires not only expanding access to care, but also addressing underlying social determinants that shape health outcomes.