SALT LAKE CITY — If you live in Utah but you don't have U.S. citizenship, odds are you don't have health insurance, either.
Of the state's 152,000 noncitizens — many of them undocumented — just under half are insured, according to estimates released late Wednesday by the U.S. Census Bureau.
"Citizenship is huge," said Pam Perlich, director of demographic research at the University of Utah’s Kem C. Gardner Policy Institute. “Those living here without legal residence, the people in the shadows, often do not have basic insurance coverage."
Gloria, a Salt Lake single mother of four, is one of the nearly 79,000 immigrants in Utah who lack coverage. In January, doctors told her she was starting to have a stroke when her joints locked up and the flow of blood to her brain slowed, she said. She went to the emergency room and received a bill for $3,000.
The 43-year-old says too little sleep and too much stress are to blame for the stroke: She works from 2 a.m. to 1 p.m. as a cook, then picks up her children from school and worries about bills.
A permanent legal resident who arrived in the U.S. in 1999 from Oaxaca, Mexico, she makes too much to qualify for Medicaid, the federal health insurance program for low-income people, and cannot afford other options, she said through a translator at Comunidades Unidas. She requested the Deseret News use only her first name.
She "would be living under a bridge" if she opted for her employer's family plan, which takes $380 from each paycheck, she said.
Utah's 48 percent rate of insured noncitizens lags behind the national average of about 57 percent, according to the census numbers. The Beehive State is slightly above neighboring Idaho, with 47 percent, and trails Arizona's 54 percent.
It's a different story for Utahns born in the U.S., where 9 in 10 are insured, on par with the national average, and naturalized citizens in Utah come in at 84 percent.
There are several reasons why, health care advocates say.
Undocumented people don't qualify for Medicaid or coverage under former President Barack Obama's health care law, notes Luis Garza, executive director of Comunidades Unidas.
And some fear that signing up children who were born in the U.S. will put family members without paperwork on the radar of immigration enforcers.
"That has a lot to do with fear in the current political climate" under President Donald Trump's administration, which has ordered stricter immigration enforcement, Garza said.
But Utahns needn't worry, said Kolbi Young, spokeswoman for the state Division of Medicaid and Health Care Financing.
"They can apply for programs without that fear of being reported, and get their kids covered," Young said. Her division is seeking to get the message out by sending representatives to knock on doors in neighborhoods and talk to people in libraries.
An emergency Medicaid program also grants coverage to some undocumented Utahns who would qualify if they meet every requirement besides citizenship, but it's set aside only for same-day emergency care. The program served 4,668 Utahns in fiscal year 2016, at a cost of about $21.5 million to the state Medicaid program, Young said.
Those without papers still can get private insurance through employers, said Comunidades Unidas' Maria Montes, but some of her clients tell her those plans come with premiums of $250 to $500 per family member.
Basic health coverage can also escape Utahns who are here legally but aren't citizens, including refugees and families with visas, as well as people with temporary work permits or green cards. Many don't know where to go for help, advocates say.
Some simply must wait.
Those who become permanent legal residents have a five-year wait period for coverage through the state or federal governments, said Randal Serr, director of Take Care Utah.
Despite advocates' efforts, Serr said his group expects the gap to grow if a U.S. Senate health care proposal becomes law, because it would block people applying for asylum or green cards in the U.S., or others with student or work visas, from enrolling.
In Utah, immigrants who haven't gone through the naturalization process make up 5 percent of the state's 2.8 milllion residents, according to the estimates.
The census report didn't consider whether people are in the U.S. illegally, but it’s safe to assume roughly two-thirds of the 152,000 noncitizens are, Perlich said.
She points to Pew Research Center data estimating that about 100,000 people are living in Utah without papers, according to Pew Research Center estimates for the year 2014, the most recent available.
Utah’s undocumented, Perlich notes, are overwhelmingly Latino. That ethnic group has the lowest rate of coverage in Utah, according to the data released to the public late Wednesday.
And its children are faring poorly in the Beehive State, where enrollment of Hispanic children is the lowest nationally, according to previously released 2015 census data. About 1 in 6 Hispanic in children in Utah are not insured.
Gloria doesn't want her kids to fit the trend. On Wednesday, she signed them up for the Children's Health Insurance Program, which is open to youngsters whose parents make too much money to qualify for Medicaid.
Gloria said she previously refrained from enrolling them because "I didn't want to be a public burden," but decided to ask Comunidades for help signing up after she realized they hadn't had a physical in almost two years.
But for herself this summer, Gloria is going without care, even though she sometimes feels her left cheek start to tingle and the back of her neck swell — the same symptoms signaling the initial stroke. When that happens, she tries to relax and focus on how much her kids need her, she said.
After her stroke, a doctor ordered follow-up care and prescribed her medication for the following four months. The bills are on her counter, unopened, she said.
"I'm scared of what they might be," she said.