The power of local autonomy: expanding health care to unauthorized immigrants in San Francisco

I analyse the mechanisms through which an inclusive local policy environment in the integrated city-county of San Francisco operates to improve unauthorized immigrants’ access to and utilization of health care. Within – but not outside – the bounds of this inclusive local context, committed providers reported being able to provide attention to unauthorized immigrants without worrying about the direct costs of doing so; to buffer, marshal resources, and advocate for individual unauthorized patients; and to exert substantial autonomy in deciding how to approach lack of legal status in their patient–provider interactions. These results highlight the potential and limitation of sub-national policies seeking to ameliorate unauthorized immigrants’ health vulnerability in a hostile US federal context.