“ THEY ALWAYS CALL ME ”: A STUDY OF HOW COMMUNITY HEALTH WORKERS BUILD A CULTURALLY &...

“THEY ALWAYS CALL ME”: A STUDY OF HOW COMMUNITY HEALTH WORKERS BUILD A CULTURALLY

& LINGUISTICALLY COMPETENT WORKFORCE & HELP IMMIGRANTS GET HEALTH INSURANCE IN

NEW YORK CITY

Maysoun Freij1, Danielle Holahan2, Adam Gurvitch3, Jenny Rejeske4, Linda Weiss1

1 New York Academy of Medicine

2 United Hospital Fund3 National Immigration Law Center4 New York Immigration Coalition

Diversity RX Conference Baltimore, MD October 18-21, 2010

Background• Among the 2.5 million uninsured in New York State:

– 29% under age 65 are non-citizens1

– 18% (140,000 out of 800,000) of those estimated to be eligible but uninsured (EBU) are non-citizens2

• Non-citizens are three times more likely than citizens to be uninsured 3

– 36% versus 12% respectively

1 Holahan D, Cook A, Powell L. New York’s Eligible but Uninsured. United Hospital Fund 2008.2 Holahan D, Cook A. Characteristics and Health Insurance Coverage of New York’s Noncitizens. United Hospital Fund 20093 Cook A, Lawton E, Holahan D. Health Insurance Coverage in New York, 2008. United Hospital Fund 2010.

“They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Purpose of Study• Understand immigrant concerns with health

insurance coverage in order to promote informed decision making and overcome widespread reluctance to enroll. - Gain insights about these sensitive issues from trusted

community health workers• To inform policy discussions about:

– How to optimize immigrant enrollment in current health insurance programs.

– How to design coverage expansions that are appropriate for immigrant populations.


Purpose of Study continued..Though immigrants have been identified as a large segment of the uninsured population of New York, as well as a significant portion of those eligible for public insurance but uninsured, little primary research has focused on the real and perceived barriers to health insurance faced by this population, and the roles of community health workers in addressing these barriers.

– This research seeks to fill this gap.


Methods and AnalysisThis e-poster focuses on data collected in 2009 through 10 qualitative interviews with community health workers serving immigrant communities in New York City.

• Data were collected as part of a larger qualitative study involving six focus groups with three immigrant communities in New York City: Mexican, Korean, and Russian-speaking.

Analysis•Transcripts of semi-structured open ended interviews were coded using NVivo software•Analyzed for themes and patterns


Sampling of Participants

Community health workers (CHWs) were selected using strategic sampling for those who serve the same population being sampled for the focus groups (Mexican, Korean or Russian-speaking) or that serve another low income and/ or immigrant population in New York City.


Description of Participants

Enroller/ Health Advocacy Interviews (N=10)

• 2 Russian-speaking• 2 Korean• 1 Spanish-speaking• 1 Arab• 1 Balkan• 1 Haitian• 1 South Asian• 1 Caucasian


Institutional Contexts• Six of the ten interviewed worked for community

based organizations (CBO’s) or agencies licensed by the state to process public health insurance applications (Medicaid and Medicaid Managed Care)

• Seven worked for CBO’s that specialized in services for immigrants from particular ethnic groups or geographic regions

• Three worked for agencies that were not immigrant focused, yet served a large and diverse array of immigrants


Professional Histories & Backgrounds of CHWs

• Experience as a CHW ranged from 1-10 years– Several discovered careers by seeking services at

their place of employment– Previous careers included being a teacher, a health

educator, an academic, a communications specialist, administration, food management

• One was a recent college grad who wanted to work with immigrants from her community

• Nine out of ten were bi- or multi-lingual


Immigrant Services Career Ladder

• Several were able to build new careers in the U.S. through immigrant service agencies– One Russian-speaking CHW reported:

• I learned English here. I was taking classes and getting certified as an office specialist. I started as an office specialist, then the health facilitated enroller position opened up and I got a promotion. It’s one of those immigrant stories.

– Others went from an immigrant service organization to one that serves the general public


Learning the health care system• All CHWs interviewed learned about the intricacies of

the U.S. and N.Y. health care systems on the job– One discovered the difficulties of being without

insurance when her husband suffered a heart attack while uninsured.

– 6 out of 10 participated in the New York Immigration Coalition’s Immigrant Health Access and Advocacy Collaborative , a citywide workgroup that offered intensive training on local and national health care systems, insurance eligibility, affordable health care, and language access

• They also participated in advocacy to improve immigrants access to health care in New York City


CHWs Job Description (official)• Educate clients about eligibility for public insurance

based on income and immigration status• Complete applications for public insurance

• Describe how to collect documentation of income and immigration status

• Describe how to use health insurance• Translate forms and materials• Educate those ineligible for public insurance due to

restrictions based on income and immigration status about financial assistance when receiving medical care


CHWs Job Description (unofficial)

• Gain the trust of clients (mostly immigrant) who are skeptical and/ or fearful of government services

• Logically and clearly explain systems and requirements for health insurance that have evolved over decades and that are not inherently logical

• Convince people to be patient and accept that obtaining health insurance coverage may require multiple tries and people may experience gaps in coverage


Specialized Responsibility

• CHWs address immigrant specific concerns such as – Public Charge

• Concern that enrollment in public health insurance will negatively impact immigration process

– Sponsor Liability• Concern that an immigrant’s sponsor will have to pay

for his/ her use of public health insurance

– Language and Cultural Barriers


Definition of Public Charge• During the application process for lawful permanent

residence (green card), United States Citizenship and Immigration Services may deny someone a green card if they are determined to be a public charge, or primarily dependent on the government for subsistence. – Even though there is guidance which excludes public

insurance (when not used for institutionalization/ long term care) from those benefits that could result in a public charge determination, many immigrants still believe that by using public health insurance they will be denied a green card.


Definition: Sponsor Liability• In order to sponsor a relative to emigrate to U.S. , an

individual must sign a federal affidavit of support (form I-864), which attests to his or her responsibility for repayment of any means tested public benefits that the sponsored immigrant uses, including Medicaid. However, the final federal regulations requiring States to enforce sponsor liability have not yet been issued. – The risk to the sponsor’s financial well-being may

cause reluctance on the part of sponsored immigrants to enroll in coverage or even seek health care.


Reports of Clients’ Health Care Seeking Behaviors

Clients typically: • Avoided seeking health care because they lacked

insurance– Feared cost of health care

• Faced language barriers• Sought health care on visits to home country

– Received medicine from home country• Wanted health insurance

– Favored government health insurance for all– Favored sharing costs of premium


Reported Interest in Health Insurance

• Many enrollers and health advocates described their clients’ desperate interest in health insurance, yet its inaccessibility. A CHW explained:– They know [insurance], they want it. And that’s

the amazing thing. It always comes down to how much it costs. Really, I’ve met so many people. They all want health insurance. If it was only affordable .”


Barriers to Health Insurance

• CHWs identified the following barriers to public insurance enrollment including:– Lack of information about eligibility– Recertification problems– Documentation of income– Immigrant Specific Concerns

• Public Charge• Sponsor Liability• Language/ Cultural Differences


Findings Related to How Community Health Workers Address Immigrant Concerns


Views on public charge

• A Korean CHW explained that her clients would rather pay something for health insurance than risk public charge, such as when their children are eligible for free public health insurance. She explained: – It’s interesting…they are worried about when the child is

enrolled in Medicaid…about “what if there’s a problem when they’re applying for a green card?” They want to apply for Child Health Plus rather than Medicaid… and pay the co-pay or whatever the money for Child Health Plus. Child Health Plus, they never, never worry


CHWs address pubic chargeA Russian-speaking CHW described the difficulty of convincing their clients that it is safe to apply for public health insurance, particularly when lawyers give conflicting information.

My clients’ immigration lawyer told them to cancel their health insurance before going to the interview in Federal Plaza, the interview for the green card. Even though I provide a copy (of information about public charge from USCIS) on how it works, [my clients] preferred to cancel it.


Success Convincing Immigrants Public Health Insurance will Not Affect Immigration Status

Russian speaking CHWs claimed to successfully convince clients that using public health insurance will not result in a public charge determination

• Every year we have clients that come to us first and we tell them "here, look at this information" and they know that it’s not true [that you must cancel insurance to get a green card.] It’s happening less and less.

•None of the CHWs has had a client denied a green card for using public health insurance, nor reported knowing anyone who was denied for this reason.


Uncertainty Remains about Public Charge

South Asian Health CHW explained:They ask me, ‘are you SURE?’ ‘Can you guarantee that

won’t happen?’ And I’m like, well… I personally don’t feel very confident [telling them it’s safe to use public benefits]. I mean, I let them know that

technically it’s not going to happen… we have never heard about anyone being arrested or denied for

these things… But, I just wonder.


Addressing Sponsor LiabilityOne CHW recalled the following case:

I know a guy who is Spanish and his wife is Yemeni. Her mother came to visit, and had an emergency case. They were scared to take her

to the hospital. I told him to trust me and to get Emergency Medicaid. He didn’t and so

went online to make sure it was true. She got Medicaid and was in the hospital for 4 days. It

was kidney failure, so it was really serious.


Addressing Lack of Information/ Language Barriers

An Arab CHW recalled:We had a family from Yemen, they are here legally but they didn’t speak the language, and they didn’t know anything [about public health insurance eligibility]. They were here for seven months and she was pregnant—for seven months! Imagine, they are qualified!

• The CHW spoke to clients in their native language, and explained the health insurance system so that family could access care.


Addressing Language/ Cultural Barriers

A Korean CHW explained:

They need help. It’s as simple as that. They don’t have confidence in their linguistic ability and – it even sounds like a cliché at this point –

but navigating the health care system in the U.S., even if you are fluent in English is such a damn hard thing to do, excuse my language.


CHWs RecommendationsCHWs in this study offer the following fundamental recommendations to improve access to health care for immigrants: •Increase language access at all points of the health care system, from enrollment in insurance to encounters with medical providers•Simplify and reduce the documentation necessary to enroll in public health insurance and maintain coverage. •Create an affordable buy-in option for comprehensive public health insurance.

– Include those left out of federal health reform• e.g. non-immigrant visa holders & undocumented

immigrants “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Conclusion: CHWs Trained to Help Immigrants• Proactively address immigrants’ concerns about the potential

consequences of enrolling in public health insurance (e.g. public charge, sponsor liability).

• Provide linguistically and culturally appropriate communication throughout the health insurance system, including at enrollment and renewal of coverage.

• Help immigrants navigate the health insurance and health care system, thereby increasing access to health care and health insurance among vulnerable populations.

• Build an culturally and linguistically competent workforce that can benefit entire health systems adapting to increasingly diverse populations.

• Will continue to be important advocates for immigrant communities as new coverage options and pathways become available in the coming years through health reform and the potential for confusion and misunderstanding of new rules heightens.


Participating Organizations• New York Immigration Coalition• New York Academy of Medicine• United Hospital Fund• Korean Community Services• Shorefront YM-YWHA• El Centro Del Inmigrante

For further information, feel free to contact: Maysoun Freij, PhD, MPHNew York Academy of [email protected] / 212-822-7377


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