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Connecting Eligible Immigrant Families to Health Coverage and Care: Key Lessons from Outreach and Enrollment Workers
Beginning in 2014, the Patient Protection and Affordable Care Act (ACA) will significantly expand coverage for low- and moderate-income families through an expansion in Medicaid eligibility and by making tax credits available to help individuals purchase coverage through new Health Benefit Exchanges. Given their high uninsured rate and limited access to private and public coverage, one group who could significantly benefit from this coverage expansion is lawfully residing immigrant families. However, in order for them to realize this potential benefit, it will be important to address the barriers eligible immigrant families often face to enrolling in coverage and accessing needed care.
This report draws on the experience of outreach and enrollment workers who serve immigrant communities to identify the role of Medicaid and CHIP for immigrant families, key barriers eligible lawfully residing immigrant families face to enrolling in coverage and accessing care, successful strategies to overcome these barriers, and considerations for health reform. It is based on findings from four focus groups that were conducted during July and August 2011 with outreach workers who serve immigrant communities in California, the District of Columbia, and Florida.
The Role of Medicaid and CHIP for Immigrant Families
Medicaid fulfills a number of roles for immigrant families. Focus group participants stressed that Medicaid and CHIP coverage provide immigrant families access to preventive and primary care, including prenatal care, as well as care for chronic conditions. Several noted that, without this coverage, obtaining health care would prove too financially burdensome for low-income immigrant families and require them to make difficult choices between paying for food or rent or health care. Participants also emphasized that, when families obtain Medicaid and CHIP coverage, they often receive health education and connect to other social services, which contribute to an overall increased understanding of health and broad improvements in their quality of life.
Barriers to Coverage and Care for Eligible Immigrant Families
Fear was an overarching coverage barrier that emerged in all of the focus group discussions. Participants identified two distinct fears that deter eligible immigrant individuals and families from applying for coverage. One is that receiving health care benefits will result in them being considered a “public charge” and prevent them from obtaining permanent residence. A second fear, often present among mixed status families—such as U.S.-born children living with an undocumented parent—is that applying for coverage for eligible family members may expose other family members to risk of deportation.
“Not only do they get medications and healthcare,
but they also get nutrition advice, advice on raising
their kids to grow up healthier and have less medical problems when
they are adults. So I think just having that access to
[Medicaid and CHIP] increases their quality of life
immensely.” Outreach Worker,
“…They have the fear, you know, that they sign on anything for any type of resources, they won’t be
able to get permanent status.”
Outreach Worker, Los Angeles
Burdensome and confusing application processes and difficulty meeting documentation requirements were also consistently identified as enrollment barriers. Participants said that applying for coverage often requires long wait times on the phone or in-person, and that it is difficult for families to take time away from work to complete the application process. Moreover, participants felt that eligibility workers in local offices are not always welcoming or helpful when families do take the time to attempt to enroll. They identified administrative challenges, such as applications not being received or getting passed back and forth between programs. Moreover, they highlighted difficulties immigrant families often face in meeting documentation requirements, particularly since they often work in seasonal jobs and/or are paid in cash and may be highly mobile. Participants noted that many of these difficulties carry over to renewal processes, often leading to losses in coverage at the point of renewal. Language and literacy issues, as well as limited access to technology, also were identified as key enrollment challenges. Participants noted that individuals who do not speak English or who have low literacy levels often have difficulty understanding forms and notices. Further, they identified numerous instances of individuals encountering problems obtaining translation assistance. Several participants also noted that, as the enrollment process moves increasingly online, enrollment may become more difficult for immigrant families because of limited computer access and low levels of computer literacy. After enrolling in coverage, immigrant families also face numerous challenges to accessing needed care. Participants described how limited transportation options and language barriers can make it difficult for families to navigate their way to appointments. Further, once an individual arrives for an appointment, they may continue to face language barriers if there are no staff members available that can provide medical interpretation services. Immigrant families may also experience fears and confusion related to navigating an unfamiliar and complicated health care system. Participants noted that many immigrant families require education on how to obtain services under a managed care plan and assistance identifying participating providers. It was further noted that, in some cases, individuals are assigned to a primary care provider who may not have an existing relationship with the family, may not be accessible to the family, and/or may not have the capacity to provide culturally and linguistically appropriate services. Challenges accessing specialty care were also identified. In particular, participants described problems finding participating specialists, as well as lengthy referral processes for specialty care.
“I think most of the barriers we see with the people that
we serve is not only that they don’t understand or they don’t know, but also the paperwork…. It is a lot of paperwork, it is a lot of
proof they are requesting, a lot of information that many
of them don’t have.” Outreach Worker,
“I think it really is about just leaving people behind and
kids that are more vulnerable to not being
insured, whether they are Hispanic or whether they
are rural, whether they are Haitian immigrants…if they
don’t have computers in their home or their parents, for one reason or another,
can’t access it they are going to be left behind. And those are the kids that are
most vulnerable.” Outreach Worker, Florida
“You can do really great eligibility [work] and get
them the benefits, but if you don’t do the teaching and education on how you use [the benefits]…you are not actually getting anybody access because they just
have no idea that that doesn’t mean go to the ER.”
Outreach Worker, District of Columbia
Successful Strategies to Overcome Barriers to Coverage and Care
Participants identified a number of creative and successful strategies they have developed to overcome barriers to coverage and care. In particular, participants pointed to the effectiveness of conducting outreach and application assistance through trusted organizations and individuals with strong ties to the immigrant community. The importance of educating families about their coverage options and the enrollment process was stressed. Innovative ideas such as school presentations that encourage youth to educate their community about the availability of coverage were highlighted. Moreover, participants heavily emphasized the value of direct, one-on-one enrollment assistance from trusted individuals with a shared background or experience. Across the focus groups, participants described taking a very active and comprehensive role in helping families obtain and maintain coverage and receive needed care. In addition, participants identified a variety of tools and strategies they have developed to make the process easier for families, including providing families lists of documents they will be required to provide, creating forms to make it easier for families to document income, providing cards that families can present to request translation assistance, and encouraging families to keep records and receipts of all application and paperwork submissions.
Looking Ahead to Health Reform
To fully realize the potential of the coverage expansions under health reform in 2014, it will be important to assure eligible individuals successfully enroll in coverage. Given their high uninsured rate, reaching and enrolling eligible immigrant families will be key to achieving overall success with the expansion. However, doing so will entail effectively addressing the numerous enrollment barriers they face. At a broad level, assuring enrollment systems are transformed to provide the simple, high-quality user experience that is envisioned under reform will be imperative for addressing many of the barriers eligible immigrant families, as well as other individuals, currently face. Doing so will not only require significant changes in processes and systems, but also an overall cultural shift among local eligibility offices that is focused on promoting coverage. Moreover, successfully enrolling eligible immigrant families will likely require targeted outreach efforts and enrollment assistance. As part of these efforts, the findings from these focus groups, as well as other data, suggest the importance of assuring that trusted community organizations and individuals have adequate training and resources to provide outreach and assistance, conducting outreach through varied locations and methods to meet immigrants where they are, adopting enrollment processes that meet the specific needs of immigrant families, and strengthening messages to dispel fears among the immigrant community.
Strategies and Tools to Help Immigrant Families Overcome Barriers to Coverage and Care
Utilizing trusted community organizations and individuals to provide outreach and enrollment assistance Direct one-on-one assistance from individuals with a shared background or experience Educating families about coverage options and the enrollment process Providing families with a list of required documents and identifying alternative options English and Spanish zero income and cash income form to document income Cards that families can present to request translation assistance Keeping records and receipts of all application and paperwork submissions Maintaining contact over time to assist families with renewal and accessing necessary services
“…What actually helps a lot is to have examples of people that have actually gone through it. And our
own staff has been in those situations and have received the benefits. It didn’t affect their Green
Card, they were able to get healthcare taken care of…. So kind of hearing it from community members has
been really helpful for us.” Outreach Worker,
One primary goal of the Patient Protection and Affordable Care Act (ACA) is to significantly reduce the number of uninsured. To achieve this, beginning in 2014, the law will expand Medicaid eligibility and provide tax credits to help individuals purchase coverage through new Health Benefit Exchanges. The Medicaid expansion and new subsidized exchange coverage will significantly increase the coverage options available to millions of low- and moderate-income families who lack access to affordable coverage today. Given their high uninsured rate and limited access to private and public coverage, one group who could significantly benefit from the coverage expansions in the ACA is lawfully residing immigrant families. However, for eligible immigrant families to fully realize the potential opportunity of the expansions, it will be important to address the myriad of barriers they face to enrolling in coverage and accessing needed care.
This brief draws on the experience of outreach workers serving immigrant families to identify the role of Medicaid and CHIP for eligible immigrant families, key barriers eligible immigrant families currently face to enrolling in coverage and accessing care, successful strategies to overcome these barriers, and implications for implementation of health reform. It is based on findings from four focus groups conducted with individuals who provide outreach and enrollment assistance in immigrant communities. BACKGROUND
Overview of Immigrants and Health Coverage Today
Immigrants are a diverse group, ranging in immigration status, length of time in the country, country of origin, race/ethnicity, family status and age. As of 2010, there were 38 million immigrants residing in the United States, accounting for 12.5% of the population.1 This includes 17 million naturalized citizens and 21 million non-citizens, who include both lawfully present and undocumented individuals.2 Moreover, there are many more individuals who live in families with mixed immigration status, such as U.S.-born citizen children residing with non-citizen parents. As of 2009, there were 5.6 million citizen children in the United States living with at least one non-citizen parent.3 Similar to native citizens, the majority of naturalized citizens have employer or other private coverage. However, non-citizens are nearly three times as likely to be uninsured relative to U.S.-born citizens, reflecting more limited access to both private and public coverage (Figure 1). Although non-citizens are as likely as citizens to work, they are often in jobs and industries that do not offer coverage. Further, non-citizens are subject to immigrant-specific eligibility restrictions in Medicaid and CHIP. Since 1996, lawfully residing non-citizen immigrants have been barred from enrolling in Medicaid and CHIP during their first five years in the United States. States were recently provided the option to eliminate this “five-year bar” for pregnant women and children, but do not have the option to waive the waiting period for other adults. Undocumented immigrants are prohibited from enrolling in Medicaid and CHIP.4
Health Insurance Coverage for the Nonelderly, by Citizenship Status, 2010
Medicaid/Other Public also includes CHIP, other state programs, Medicare, and military-related coverage. Data may not total 100% due to rounding. SOURCE: KCMU/Urban Institute analysis of March 2011 Current Population Survey, Annual Social and Economic Supplement