“MUTUAL RESPONSIBILITY”:

A STUDY OF UNINSURED IMMIGRANT

PERSPECTIVES ON HEALTH INSURANCE IN

NEW YORK CITY by Maysoun Freij, Jenny Rejeske, Adam

Gurvitch, Amanda Ferrandino, and Linda Weiss

Participating Organizations

New York Immigration Coalition New York Academy of Medicine United Hospital Fund

Korean Community Services Shorefront YM-YWHA El Centro Del Inmigrante

Background

In New York State: 29% of uninsured under age 65 are non-

citizens 18% of UHF’s 2005 Estimate of Eligible

but Uninsured (EBU) are Non-Citizens (140,000 out of 800,000 EBUs)

Non-citizens are nearly three times more likely than citizens to be uninsured (34% versus 11% respectively).

Purpose of Study

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. Offer enrollers and outreach workers

understanding of immigrant concerns about health coverage in order to promote informed decision making and overcome widespread reluctance to enroll.

Methods and Analysis

Qualitative Data Collection Six focus groups

2 Spanish 2 Russian 2 Korean

10 enroller/ health advocate interviews

Analysis Coded using NVivo software Analyzed for themes and patterns

Distribution of Participants

53 uninsured participants were screened and surveyed for participation in focus groups Participants were assigned to focus groups

based on their eligibility for public insurance. Number of Focus Group Participants by Insurance Eligibility Category

N=48

Eligibility Category Korean (n=22)

Russian (n=14)

Spanish (n=12) Total

Eligible but Uninsured 14 7 2 23 Ineligible: Over-income 8 7 0 15 Ineligible: Due to Immigration Status 0 0 10 10

Distribution of Participants continued:Enroller/ Health Advocacy Interviews

(N=10)

2 Russian 2 Korean 1 Spanish 1 Arab 1 Balkan 1 Haitian 1 South Asian 1 general population

Findings

Similarities/differences Among 3 ethnic groups: Russian/

Korean/ Spanish Between those eligible for public

insurance & those ineligible based on income or immigration status

Between immigrants and general population

Cross Ethnic Group Differences

Spanish: Mostly likely to report experiencing

discrimination when seeking health care Korean:

Most concerned that using public health insurance may affect immigration status

Only participants to report association between social stigma and public insurance

Russian: Most likely to report relying on non-

practicing medical providers from home country.

Cross Ethnic Group Similarities 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

Eligible vs. Ineligible for Public Insurance

Differences: Among those over income for public insurance

Koreans more likely to have purchased private insurance in past

Russians more likely to have had employer based coverage in past

Among those ineligible due to immigration status More likely to experience discrimination

Similarities between both eligible and ineligible: Concern about cost and quality of coverage

Among the Eligible but Uninsured Barriers to public insurance

enrollment included: Lack of information about eligibility

Recertification problems Documentation of income Immigrant specific Issues

Immigrant vs. General Population

Immigrant Differences: Concern about consequences to

immigration status from using public insurance and/or medical debt Public Charge and Sponsor Liability

Language and cultural barriers when navigating the health insurance system

Trusting the government

Example: Public Charge

A Korean man who was eligible for public insurance but not enrolled explained:

“I used to have Medicaid, but terminated it when someone told me that I shouldn’t

use such benefits...I even have diabetes, and need more than

$150 just to pay for my medications.”

Example: Sponsor Liability

One enroller 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.”

Example: Language/ Cultural Barriers

A Korean health advocate 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.”

Example: Trusting the Government

South Asian Health Advocate 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.”

Similarities with the General Population

Cost of health care without insurance Cost of purchasing insurance Impact of economic crisis Issues with documentation of income

Self attestation

Issues to Consider: Immigrant Specific Proactively address immigrants’ concerns about

the potential consequences of enrolling in public health insurance (e.g. public charge, sponsor liability). Clear and consistent messages, including from

government. Promote linguistically and culturally appropriate

communication throughout the health insurance system, including at enrollment and renewal of coverage.

Increase resources for community based health advocates who help immigrants navigate the health insurance and health care system.

Issues to Consider: Overlap with General

Population Continue to promote the availability of

public health insurance coverage. Simplify and reduce the documentation

necessary to enroll in public health insurance and maintain coverage. State should continue to allow the use of

self-attestation of income Eliminate documentation when 3rd party

match is available

Issues to Consider: Overlap with General

Population 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

Contacts For Further Information

Maysoun Freij, PhD, MPHSenior Researcher/ EvaluatorNew York Academy of Medicinemfreij@nyam.org / 212-822-7377

Jenny Rejeske, MSHealth Advocacy Coordinator

New York Immigration Coalitionjrejeske@thenyic.org / 212-627-2227 x 223