by Maysoun Freij, Jenny Rejeske, Adam Gurvitch, Amanda Ferrandino, and Linda Weiss

1. “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

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

3. 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).

4. 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.

5. 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

6. 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.

7. 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

8. 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

9. 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.

10. 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

11. 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

12. Among the Eligible but Uninsured • Barriers to public insurance enrollment included: • Lack of information about eligibility • Recertification problems • Documentation of income • Immigrant specific Issues

13. 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

14. 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.”

15. 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.”

16. 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.”

17. 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.”

18. 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

19. 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.

20. 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

21. 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

22. Contacts For Further Information Maysoun Freij, PhD, MPH Senior Researcher/ Evaluator New York Academy of Medicine mfreij@nyam.org / 212-822-7377 Jenny Rejeske, MS Health Advocacy Coordinator New York Immigration Coalition jrejeske@thenyic.org / 212-627-2227 x 223