By Teresa Wiltz
The Pew Charitable Trusts (October 10, 2014)
As patient access manager at La Clinica del Pueblo in
Washington, D.C., William Joachin helps Latino immigrants access health care.
One in four Latinos living in the U.S. does not have health insurance.
In the "sala de espera," or waiting room, at La
Clinica del Pueblo, a community health center in Washington, D.C., signs in
Spanish encourage patients to "Empower yourself!" and sign up for
insurance coverage through the Affordable Care Act.
Adults slump in chairs, scribbling on application forms,
texting friends, waiting. In a tiny office a few feet away, William Joachin,
the center's patient access manager, faces down the frustrations of trying to
navigate the federal health care program for the thousands of mostly Central
American immigrants who flood the clinic each year. He's not alone.
A year after open enrollment for the ACA began, one in
four Latinos living in the U.S. does not have health insurance, according to
new census data, more than any other ethnic population in the country-and most
states have few backups in place to help those in the coverage gap. Latino
immigrants are the hardest hit: Foreign-born Hispanics are more than twice as
likely to be uninsured than are U.S.-born Hispanics, according to census data
compiled by the Pew Research Center. (Pew also funds Stateline.)
A variety of factors account for this, including a lack
of culturally specific outreach programs, language barriers, financial
concerns, frustration with the ACA's complexities and fears that applying could
jeopardize a family member's immigration status.
Illustrating some of the challenges was the woman in
Joachin's clinic who grew up in a Honduran refugee camp and couldn't read and
write. As a legal resident, she's eligible to purchase health insurance through
the exchanges, he said, but she doesn't know how to spell her name. With help,
she first applied back in March and is still waiting.
There are also the former activists who fought against
the government in El Salvador during the civil war in that country, and are
exceedingly wary about any form of government program, even health insurance.
Then there's the "mixed status" family with the
son a citizen, the mother with temporary protected status, the father with a
green card, the grandmother with a visa and the uncle seeking asylum.
"That's when it gets complicated," Joachin
says.
"Immigrants want to do the right thing, want to buy
health insurance," said Sonal Ambegaokar, senior attorney at the National
Health Law Program. "But unfortunately, we put up barriers for them to get
access. When we talk about a streamlined health enrollment system, we should
really mean that it's for everybody."
The Uninsured
Fifty-six percent of noncitizen immigrants in the U.S.
are Latino, many of whom are in the country illegally and are not eligible to
purchase health insurance through the health exchanges, even if they can afford
to pay.
Nationwide, 25 percent of Latinos do not have health
insurance. Naturalized citizens from Latin America fare better than
noncitizens; 21 percent are uninsured, compared to 49 percent of other Latin
American immigrants who are not citizens. (About 14 percent of all U.S.
residents do not have insurance.)
Overall, children are more likely to have health
insurance, thanks to a number of safety net programs, including Medicaid, the
joint federal-state health care program for the poor, and the federal Child
Health Insurance Program (CHIP). Despite this, Latino children are more than
twice as likely as white children to be uninsured, according to the National
Council of La Raza (NCLR), a Hispanic civil rights and advocacy organization
based in Washington. One in six Hispanic children does not have health
coverage.
By comparison, one in 10 African-American children does
not have health insurance, while one in 11 Asian-American children is
uninsured. Latino children also account for the largest share of children in
the U.S. who are eligible for programs like Medicaid/CHIP, but are not
enrolled.
Further complicating matters, health advocates say, is
most states have done little to remedy the issue. Twenty-four states have
chosen not to expand Medicaid to more residents under the federal health care
law, including Texas and Florida, which have the second- and third-largest
Latino populations in the country.
In Texas, 50 percent of the state's Latinos are
uninsured, according to NCLR, and Florida has the third-highest rate of
uninsured at 36 percent. In California, which has the highest percentage of
Latinos, nearly 60 percent are uninsured, according to the California
Healthcare Foundation.
"Just with (Florida and Texas) alone, as long as
they don't pass Medicaid expansion, we're going to be left with millions of Latinos
uninsured," said Alejandra Gepp, associate director of the NCLR's
Institute for Hispanic Health. "This costs millions. The cost to (states),
having this large segment of uninsured people is huge, because people end up
using the emergency room as services. By the time someone gets diagnosed with
diabetes in an emergency room, it might be too late."
Complicating Factors
The number of Latinos with health care coverage has
increased 5.3 percent since the ACA took effect, according to the Robert Wood
Johnson Foundation. But many remain uninsured.
One reason is that immigrants are more likely to be
lower-income and are more likely to be making an hourly wage at construction or
service jobs that don't offer employer-based insurance, according to Jennifer
Sullivan, the director of the Best Practices Institute for Enroll America, a
nonpartisan not-for-profit created to expand health care coverage around the
country.
Even if their jobs do offer health insurance, it's often
cost prohibitive, Gepp said.
"Let's say you're making $10 an hour. After taxes,
you're left with probably a check of no more than $400 a week at most,"
Gepp said. "If you have to pay $200 in health insurance each month, many
decide not to purchase it."
Language is also a big issue. The Spanish language
translation for the federal health insurance exchange was filled with gaffes.
In describing the cost of monthly premiums, for example, the website used the
word "prima" for premium, which also means "female cousin" in
Spanish.
States fared no better with their Spanish language
translations. Oregon used the error-prone Google Translate for its exchange.
California, despite its large Latino population, offers poor translations,
according to Lisa Clemans-Cope, a researcher at the Urban Institute's Health
Policy Institute. There is a Spanish language paper application, but it takes
much longer to fill out, creating yet another barrier for immigrants, said
Ambegaokar.
Middle-class Latinos are more likely to apply online for
insurance, but lower-income Hispanics and more recent immigrants with limited
English skills generally prefer to do so in person through a facilitator or
over the phone, advocates said.
Trust is also a major factor for families who fear that
enrolling in the exchange could jeopardize their immigration status, despite
reassurances from the U.S. Department of Homeland Security to the contrary,
Ambegaokar said. "But if there's an immigration raid in that community,
it's not very reassuring."
Some State Efforts
There are no statewide safety nets in place for
undocumented immigrants and foreign-born residents who are here legally but
have not been in the country long enough to qualify for public health programs,
according to Gepp. People with "permanent residency" status, who have
a green card, must have been in the country for at least five years to qualify
for Medicaid. There is no restriction to get insurance under the ACA as long as
applicants are in the country legally and have a Social Security number.
In California, where Latinos make up 50 percent of the
population, Democratic state Senator Ricardo Lara introduced the Health for All
Act, earlier this year, which would expand health care coverage for all
Californians, regardless of immigration status. Under the bill, some 700,000
undocumented residents would have access to primary health care in 2015. (Young
people who are undocumented and have deportation deferrals are eligible for
Medicaid in the state.)
Currently, California doesn't cover undocumented residents
statewide, but there are various county-level programs that do. California also has state funded Medicaid
coverage for people who are designated as having "Permanent residence
under color of law" (PRUCOL), including youth with Deferred Action for
Childhood Arrivals, and other state-funded coverage for pregnant women
regardless of status, according to Gilberto Mendoza, policy associate with the
National Conference on State Legislatures.
Several other states also provide coverage for pregnant
immigrants, Mendoza said.
The city of San Francisco already has Healthy San
Francisco, which provides health insurance provides health services to
uninsured residents who make up to $54,000 a year, regardless of whether they
are documented. And last week, Los Angeles County launched its $61 million
"My Health LA" plan, a no-cost health plan for residents who cannot
get health insurance, including the city's undocumented residents.
The District of Columbia has the Healthcare Alliance
program, which provides health care for low-income people, regardless of
immigration status. But because the program does not offer mental health and
substance abuse treatment, it does not meet minimum standards for health
insurance as mandated by the ACA, according to La Clinica's Joachin. The
program also is quite complicated, with myriad rules and regulations that make
it tricky to access, Joachin said.
Other states rely on a patchwork system of safety-net
providers, including public and not-for-profit hospitals, migrant health
centers and community health centers like La Clinica which provide primary care
to underserved communities, according to a Hastings Center report on
undocumented immigrants. Illinois, for example, which has the nation's
fifth-largest Latino population, provides coverage for all low-income children
under 19, even if they are undocumented.
In some states, such as Maryland, the quality of care an
uninsured immigrant can receive will vary greatly across counties, said
Democratic Delegate Ana Sol Gutierrez, a Democrat.
"It's hard for me to understand why we prohibit
people from buying health insurance," Gutierrez said. "That's kind of
crazy. I'm not saying (undocumented people) should have the free coverage. I'm
sure many of them would be able to pay."
Dr. Frank Talamantes, Ph.D,
Professor of Endocrinology (Emeritus)University of California
Santa Cruz, California, 95064
Residence: 83 Sierra Crest Dr.
El Paso, Texas 79902
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