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“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 Freij 1, Danielle Holahan 2, Adam Gurvitch 3, Jenny Rejeske 4, Linda Weiss 1 New York Academy of Medicine 2 United Hospital Fund 3 National Immigration Law Center 4 New York Immigration Coalition 1 Diversity RX Conference Baltimore, MD October 18 -21, 2010

Background • Among the 2. 5 million uninsured in New York State: – 29% Background • Among the 2. 5 million uninsured in New York State: – 29% under age 65 are non-citizens 1 – 18% (140, 000 out of 800, 000) of those estimated to be eligible but uninsured (EBU) are non-citizens 2 • 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 2009 3 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 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Purpose of Study continued. . Though immigrants have been identified as a large segment 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Methods and Analysis This e-poster focuses on data collected in 2009 through 10 qualitative Methods and Analysis This 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Sampling of Participants Community health workers (CHWs) were selected using strategic sampling for those 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 Russianspeaking) or that serve another low income and/ or immigrant population in New York City. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Description of Participants Enroller/ Health Advocacy Interviews (N=10) • 2 Russian-speaking • 2 Korean 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Institutional Contexts • Six of the ten interviewed worked for community based organizations (CBO’s) 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Professional Histories & Backgrounds of CHWs • Experience as a CHW ranged from 1 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Immigrant Services Career Ladder • Several were able to build new careers in the 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Learning the health care system • All CHWs interviewed learned about the intricacies of 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

CHWs Job Description (official) • Educate clients about eligibility for public insurance based on 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

CHWs Job Description (unofficial) • Gain the trust of clients (mostly immigrant) who are 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Specialized Responsibility • CHWs address immigrant specific concerns such as – Public Charge • 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Definition of Public Charge • During the application process for lawful permanent residence (green 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Definition: Sponsor Liability • In order to sponsor a relative to emigrate to U. 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Reports of Clients’ Health Care Seeking Behaviors Clients typically: • Avoided seeking 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Reported Interest in Health Insurance • Many enrollers and health advocates described their clients’ 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. ” “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Barriers to Health Insurance • CHWs identified the following barriers to public insurance enrollment 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 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Findings Related to How Community Health Workers Address Immigrant Concerns “They Always Call Me: Findings Related to How Community Health Workers Address Immigrant Concerns “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Views on public charge • A Korean CHW explained that her clients would rather 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, they never, never worry “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

CHWs address pubic charge A Russian-speaking CHW described the difficulty of convincing their clients CHWs address pubic charge A 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Success Convincing Immigrants Public Health Insurance will Not Affect Immigration Status Russian speaking CHWs 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 had a client denied a green card for using public health insurance, nor reported knowing anyone who was denied for this reason. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Uncertainty Remains about Public Charge South Asian Health CHW explained: They ask me, ‘are 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Addressing Sponsor Liability One CHW recalled the following case: I know a guy who Addressing Sponsor Liability One 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Addressing Lack of Information/ Language Barriers An Arab CHW recalled: We had a family 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Addressing Language/ Cultural Barriers A Korean CHW explained: They need help. It’s as simple 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

CHWs Recommendations CHWs in this study offer the following fundamental recommendations to improve access CHWs Recommendations CHWs 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 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. “They Always Call Me: A Study of How CHWs …” Freij 9/15/10

Participating Organizations • • • New York Immigration Coalition New York Academy of Medicine 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, Ph. D, MPH New York Academy of Medicine [email protected] org / 212 -822 -7377 “They Always Call Me: A Study of How CHWs …” Freij 9/15/10