IMMIGRANTS SPEAK OUT ABOUT THEIR EXPERIENCES ACCESSING MEDICAID AND HEALTH CARE SERVICES FINDINGS FROM METROPOLITAN DC MAY 2000 Kyle Anne Kenney, MPH
INTRODUCTION Background of Study The Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) established new and complex eligibility rules for public benefits for legal immigrants, and made ineligible for most federal public benefits several categories of previously eligible legal immigrants. The Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) of 1996 established certain procedures for determining the admissibility of immigrants and heightened fears that the use of public benefits, even the legitimate use of Medicaid, could jeopardize immigrants ability to become legal permanent residents or US citizens. It was anticipated that the combined effects of these two laws would result in a substantial reduction in the use of Medicaid as well as in the use of health care services by immigrants. This study, funded by The Robert Wood Johnson Foundation, was designed to examine the effects of the 1996 welfare and immigration reform laws on the ability and willingness of immigrants to access Medicaid and health care services. The primary research goals were: (1) to examine how state and local officials have implemented the new Medicaid eligibility requirements for immigrants; (2) to describe how the implementation of these requirements is affecting immigrants access to health services; and (3) to explore whether immigrants are discouraged from the legitimate use of Medicaid and other health services. The study used a case study approach and was conducted at four sites: Chicago, Illinois; Metropolitan Washington DC; San Diego, California; and Brownsville, Texas. Five research questions provide the analytic framework for conducting the research and data analysis: (1) How have the 1996 welfare and immigration laws affected immigrants ability to apply for Medicaid? (2) How have the 1996 welfare and immigration laws affected immigrants willingness to apply for Medicaid? (3) How have the 1996 welfare and immigration laws affected immigrants ability and willingness to seek primary health services? (4) How have the 1996 welfare and immigration laws affected immigrants ability and willingness to seek emergency health services? and (5) How have the 1996 welfare and immigration laws affected immigrants health-related quality of life (vis-à-vis their effects on immigrants ability and willingness to apply for Medicaid and/or seek health services)? A unique aspect of this research involved the extensive use of focus groups and individual interviews with immigrants. This approach allowed us to examine directly immigrant families : (1) experiences with changing eligibility criteria; (2) perceptions about and experiences with the process of applying for, and getting access to, Medicaid; (3) willingness and ability to seek health care services; (4) willingness and ability to seek Medicaid and health care services for their children; and (5) health-related quality of life associated with changes in access due to the 1996 welfare and immigration reform laws. Focus of this Report The purpose of this report is to present a separate overview of the issues discussed by immigrants in interviews and focus groups conducted during the site visit in Metropolitan DC. 1
The Metropolitan DC site visit report includes data gathered from immigrants as well as from several types of informants including state and local officials, safety net providers (SNPs), and representatives of community-based organizations (CBOs). Data gathered from immigrant interviews and focus groups in Metropolitan DC were incorporated into the larger report as they were relevant to the impact of the 1996 welfare and immigration reform laws; 1 however, in this separate report, we provide a more detailed presentation of the immigrants personal experiences and opinions concerning their ability and willingness to access Medicaid and health care services. While this report includes issues not directly linked to the changes in the laws, presenting the concerns of immigrants in greater breadth and depth contributes to a richer understanding of the context for immigrants experiences with Medicaid and health care. Policy and Research Context The 1996 Welfare Reform and Immigration Reform Laws For immigrants, the passage of federal welfare reform meant much more than ending the entitlement to cash assistance. The law restricted noncitizen eligibility for a wide range of public means-tested benefits, including TANF, Food Stamps, Supplemental Security Income, and Medicaid, and gave states broad new authority to set social welfare policy for immigrants. PRWORA essentially bars legal immigrants from means-tested benefits for which they were previously eligible for at least five years. For the first time since welfare was created, legal immigrants are now eligible for significantly fewer benefits than citizens. These reforms thus represent a turning point in the history of US immigration policy. 2 Essentially the law created a fundamental distinction between legal immigrants who were lawfully present in the US before the law passed (immigrants arriving before August 22, 1996 or pre-enactment immigrants) and those immigrants arriving on or after August 22, 1996 (postenactment immigrants). States were given the option to bar most pre-enactment immigrants from TANF and nonemergency Medicaid programs; only two states chose to enact this option. 3 States are required to bar most post-enactment immigrants from federal means-tested benefits (i.e., nonemergency Medicaid, SSI, Food Stamps, TANF, and the state Children s Health Insurance Program (CHIP)) for their first five years in the United States. PRWORA also introduced changes in terminology in that legal immigrants are now categorized as qualified, and certain groups of PRUCOLs (persons residing under color of law) and undocumented immigrants are now categorized as not qualified (the term unqualified is also used). With the notable exception of certain PRUCOLs who were, in effect, moved from legal to not qualified, all immigrant groups that were formerly legal became qualified. 4 The term 1 The Metropolitan DC site visit report as well as all other site visit reports and the overall synthesis report of the study are available at www.gwu.edu/~chsrp. 2 Zimmerman and Tumlin, (1999). Patchwork Policies: State Assistance for Immigrants Under Welfare Reform, Urban Institute, May, p.16. 3 Alabama opted not to provide TANF benefits to pre-enactment eligible immigrants and Wyoming opted not to provide preenactment eligible immigrants nonemergency Medicaid. See Zimmerman and Tumlin, (1999). Patchwork Policies: State Assistance for Immigrants Under Welfare Reform, Urban Institute, May, p.22. 4 Certain PRUCOLs represent a striking example of a group of individuals who lost the most as a result of PRWORA as they were legally residing in the US yet are now in the unqualified category with illegal/undocumented immigrants and are eligible for only emergency Medicaid. The categories of PRUCOLs so affected by these provisions of PRWORA include: indefinite stay of deportation, indefinite voluntary departure, deferred action status, residing under supervision of INS, and suspension of deportation. Little information is available about these PRUCOLs and, to our knowledge, we did not interview any of these 2
qualified is used in the law to distinguish among categories of immigrants for the purpose of eligibility for public benefits. However, being a member of a qualified immigrant category does not necessarily mean that eligibility for public benefits is available. PRWORA essentially created three groups of qualified immigrants in terms of eligibility for public benefits. For pre-enactment legal permanent residents (LPRs) with fewer than 40 qualifying work quarters, states can decide whether to provide federal benefits; they will receive federal matching funds for these benefits; states must provide benefits to pre-enactment LPRs with 40 qualifying work quarters. Most, but not all (e.g., veterans), post-enactment LPRs are barred from receipt of federal public benefits for the first five years after their arrival. All other categories of qualified immigrants (e.g., refugees, parolees, LPRs with more than 40 work qualifying quarters) are eligible for federal public benefits for five to seven years depending upon the program. After the five-year bar, states may opt to provide federally-funded public benefits to post-enactment LPRs although they must provide benefits to those with 40 work quarters. In dealing with these new groups of immigrants, the distinction between being a qualified immigrant and being eligible for public benefits must be clearly understood (i.e., a qualified immigrant is not necessarily an eligible immigrant). PRWORA represents a substantial and unprecedented shift in (i.e., devolution of) immigration policy from the federal to the state level. State officials now have substantial discretion to determine which types of immigrants will receive which kinds of public benefits. The law also imposes greater financial responsibility on states choosing to extend benefits to noncitizens/legal immigrants who have been barred from receiving federal public benefits by PRWORA. These provisions mean that: (1) there will be variability by state in terms of coverage and access for immigrants/noncitizens arriving in the US on or after August 22, 1996; and (2) assessing the experiences of immigrants will require knowledge about particular choices made by states with respect to eligibility for public benefits. The provisions of the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 (IIRIRA), enacted by Congress subsequent to the passage of PRWORA, also have implications for access to Medicaid. Briefly, this law, designed to codify practices of the Immigration and Naturalization Services (INS) concerning the admissibility of immigrants, increased the reporting and verification requirements for federal and state agencies that administer public benefits and focused attention on the issue of public charge. 5 In addition, IIRIRA changed the deeming law to hold immigrant sponsors legally responsible for new immigrants at a higher income level. This law has heightened concerns among immigrants that PRUCOL immigrants. These immigrants represent a very small group, albeit a group quite adversely affected by the changes created by PRWORA. The majority of PRUCOLs, however, were unaffected. 5 An alien who is likely at any time to become a "public charge" is ineligible for admission to the U.S. and is ineligible to adjust status to become a legal permanent resident. An alien who has become a public charge can also be deported from the US. "Public charge" means an alien who has become (for deportation purposes) or who is likely to become (for admission/adjustment purposes) primarily dependent on the government for subsistence. The INS will consider the receipt of cash benefits for income maintenance purposes and institutionalization for long-term care at government expense in determining dependence on the government for subsistence. In deciding whether an alien is likely to become a public charge, the law requires the INS to take certain factors into account, including the alien's age, health, family status, assets, resources, financial status, education and skills. Government officials examine all of these factors, looking at the "totality of the circumstances" concerning the alien. No single factor will be used as the sole basis for finding that someone is likely to become a public charge. www.ins.usdoj.gov/graphics/publicaffairs/questsans/public_cqa.htm [accessed 4-18-00]. 3
any use of public assistance, even a legitimate use of Medicaid, could interfere with an immigrant s ability to become an LPR or petition to bring relatives to the U.S. 6 Just as we began our site visits in the Spring 1999, the INS issued regulations clarifying the grounds for public charge and specifically noting that any use of the Medicaid (except long-term care) and CHIP programs would not by itself subject an immigrant to the risk of being labeled a public charge. Medicaid Coverage for Immigrants in DC, Maryland, and Virginia Post-PRWORA As discussed above, PRWORA transferred the substantial authority to states to determine the public benefits for which immigrant groups are eligible. In addition, we focused our site visit not only on Washington DC but on the surrounding counties in Maryland and Virginia that comprise Metropolitan DC to achieve a complete understanding of the impact of the welfare and immigration laws on the immigrant community in DC. DC, Maryland, and Virginia have each opted to continue Medicaid eligibility for preenactment LPRs or those immigrants who arrived to the US before August 22, 1996. The District of Columbia has not chosen to provide state-funded Medicaid coverage to postenactment immigrants. The District has never provided district-funded prenatal care to undocumented immigrants and does not currently provide funds for prenatal care for any category of post-enactment immigrant not otherwise eligible for Medicaid. Maryland has chosen to provide state-funded Medicaid coverage to post-enactment LPR children under the age of 18, and full-time students expected to complete high school before the end of the calendar year, and pregnant women. Maryland also provides state funding to make prenatal care services and certain pharmacy benefits available to PRUCOLs and undocumented immigrants. Virginia opted to provide state-funded Medicaid coverage to two groups: post-enactment LPR children under the age of 19, and immigrants who were receiving Medicaid and living in long-term care facilities on June 30, 1997, which could include some post-enactment LPRs. Virginia has never provided state-funded prenatal care services to immigrants either pre- or post-enactment of the 1996 laws. METHODS FOR COLLECTING DATA FROM IMMIGRANTS Design of Data Collection Four members of the project team conducted the Metropolitan Washington, D.C. site visit from October 4 to October 7, 1999. One final focus group was conducted on October 22, 1999. The focus groups and interviews took place at different locations including five communitybased organizations, and three community health centers in Washington, D.C. and in parts of Southern Maryland and Northern Virginia. Contacts at the site visit locations recruited immigrants to participate in the study either by posting a flyer in their facilities explaining the project and how to sign up, or by approaching clients they believed would be interested in participating. The contacts scheduled the focus groups, found private settings for the meetings to take place, and arranged for refreshments. 6 Brady, S. (1998) One in Ten: Protecting Children s Access to Federal Public Benefits Under the New Welfare and Immigration Laws, National Association of Child Advocates, Issue Brief, April. 4
The focus groups involved at least three of the project team members except for one focus group that was conducted entirely in Somali and was not attended by project staff. Translators were available for two focus groups with Chinese and Vietnamese immigrants. Five focus groups were conducted in Spanish or translated between English and Spanish by project team members. To recruit immigrants, we worked with members of the community whom the immigrants trusted. Community contacts at the site visit locations recruited immigrants to participate in the study either by posting flyers or by approaching clients they believed would be interested in participating. The contacts scheduled the interviews, found private settings for the interviews to take place, and arranged for refreshments. The focus groups and interviews involved at least two project team members. Most immigrants interviewed were most comfortable speaking Spanish. Three members of the project team speak Spanish and either conducted the interviews in Spanish or translated between English and Spanish. Interview and Focus Group Topics The questions posed to immigrants in interviews and focus groups were designed to reveal their level of awareness about the 1996 welfare and immigration reform laws by asking them about their experiences with, and opinions about, health care, Medicaid, and health insurance in the US in the years prior to and since the changes in the laws in 1996. In addition, demographic information was collected from each immigrant about their age, country of origin, length of time in the United States, immigration status, and Medicaid history so as to allow us to put the immigrants comments into the context of their personal background. While most immigrants were not knowledgeable about the 1996 laws specifically, in many instances they were able to identify changes in their health care seeking behavior or access that had occurred in the years following implementation of the 1996 laws. Immigrant accounts about changes in health care seeking behavior or access coupled with the demographic data collected during the interviews illustrated the effects of the 1996 laws and provided real-life examples of how changes due to welfare and immigration laws affected individuals in the community. Limitations The results of interviews and focus groups are rarely generalizeable and our findings based on these immigrant interviews are not presented as representative of the entire Metropolitan DC immigrant population. Also noteworthy is the particular selection bias of our immigrant sample. These immigrants not only self-selected for participation and thus were probably less likely to be fearful about immigrant-related repercussions, but they were also connected to resources such as community-based organizations or clinics and therefore probably more likely to have knowledge about Medicaid, and about how and where to access health care in Metropolitan DC. Despite these limitations, however, the findings provide a rich and detailed picture of these immigrants personal experiences with respect to accessing Medicaid and health care services prior to and since the immigration and welfare reform laws, and suggest valuable 5
insights regarding the factors affecting immigrants ability and willingness to access Medicaid and health care services. CHARACTERISTICS OF IMMIGRANTS A total of 81 immigrants were interviewed in a total of ten focus groups ranging in size from two to 12 participants (see table of demographics below). There were 72 female participants of whom 38 were from various Latin American countries including 16 from El Salvador, and eight from Mexico. Of the remaining female immigrants, 10 were from Somalia, three were from Ethiopia, 13 were from China, and eight were from Vietnam. There were nine male participants, six of whom were from Vietnam, one from China, one from Peru, and one from Ethiopia. Most immigrants entered the US as pre-enactment legal permanent residents or refugees. Twenty-five of the immigrants from Latin America entered the US without documentation or overstayed their temporary status and are now undocumented; seven of the immigrants who entered the US without documents have since gained legal status four have work permits, two are LPRs and one has become a US citizen. All of the Vietnamese, Somali, and Ethiopian immigrants were refugees who later obtained LPR status or citizenship. Almost all immigrants have been in the US for several years, however, ten arrived in the US after August 22, 1996. Of these ten immigrants, three were LPRs while two were refugees and five were undocumented. The three post-enactment LPRs include two Chinese immigrants who are insured through their employers and one uninsured Salvadoran who is uninsured and cannot access public benefits for her disabled daughter who is also a post-enactment LPR. Over half of the 81 immigrants had received Medicaid in the past, primarily for child delivery and labor. Fifty of the immigrants are uninsured while 22 immigrants currently have Medicaid, most of whom are Vietnamese and Somali refugees and Chinese immigrants; nine immigrants are privately insured. The children of 36 immigrants are covered by Medicaid while children in seven families are covered by Maryland or DC CHIP programs, and children in six families have private health insurance. The children in 28 of the immigrant families are uninsured and are mainly in Latin American families. Five immigrant participants do not have young children. Twenty-four of the 81 immigrants reported being currently employed, and many women mentioned that their husbands are working. 6
Table 1. Demographic Profile of Immigrants Interviewed METROPOLITAN WASHINGTON DC Total Number of Participants 81 Region of Origin Africa 14 (10 from Somalia) Asia 28 (14 from Vietnam) Latin America 39 (16 from El Salvador) Eastern Europe 0 Language Preference Residence (ave. length) Immigration Staus At Entry 17 English 23 Spanish 14 Vietnamese 13 Chinese 10 Somali, 4 Ethiopian 7.4 years 31% pre-enactment LPRs 5% post-enactment LPRs 30% refugees/asylees 26% undocumented 8% other Current 8% naturalized citizen 53% pre-enactment LPRs 5% post-enactment LPRs 31% undocumented 11% other Gender 72 Female ( 88%) Age (ave.) 34 years Currently Employed 28% Insured Status, Adults Medicaid 26% Private 9% Uninsured 65% Children U.S. Born 51% Insured Status, All Children Medicaid 57% CHIP 9% Uninsured 29% Private 6% 7
FINDINGS We did not find differences among immigrants living in DC, Maryland, and Virginia in terms of the impact of welfare reform based on their jurisdiction of residence. However, we did find notable differences in experiences accessing Medicaid and health care among types of immigrants such as refugees versus pre and post-enactment LPRs and pre-enactment LPRs versus undocumented immigrants, and also among immigrants of different languages and cultural backgrounds. Immigrants Ability to Access Medicaid Intermediaries Facilitate Access to Medicaid for Immigrants Immigrants in Metropolitan DC are largely dependent on community-based organizations and safety net providers to inform them about their Medicaid eligibility and to help them to navigate the health care system. Primarily because of language barriers and due also to the lack of outreach on the part of the Medicaid offices about government assistance programs, immigrants rely on CBOs and SNPs for information and support. These intermediaries in DC, Maryland, and Virginia often coordinate access to health care for immigrants and connect eligible immigrants to Medicaid programs either through outstationed enrollment in clinics or through their own informal contact with Medicaid workers. In some instances, SNPs offer formal outstation enrollment services while assistance at CBOs and other clinics is informal and the workers or organizations have established relationships with Medicaid offices in order to help their clients apply for Medicaid. Immigrants at a Chinese community-based organization in DC stated that their social worker at the organization facilitated their enrollment into Medicaid programs. Immigrants explained that they were uninformed and had difficulty navigating the Medicaid system because of the inability to speak English; therefore, the social worker at the CBO filled out forms for them, coordinated with the Medicaid office to complete the application process, and translated when necessary. One Chinese immigrant was not informed that she should apply for Medicaid when she delivered a child in 1997; however, upon her second pregnancy, she was informed by the CBO representative that her delivery could be paid for by Medicaid. Many of the immigrants interviewed had Medicaid for their children but had never gone to the DC Medicaid office because the social worker took care of everything. Maybe we could ve had Medicaid in the past, but we didn t know. [Chinese woman, LPR] It would be a lot harder without [our social worker]. Probably impossible. [Chinese woman, LPR] Hispanic immigrants at one clinic in DC explained that their access to Medicaid was facilitated by their social worker at the clinic. The immigrants felt that the clinic was one of the few trusted sources for information about Medicaid and immigration issues. They also discussed how there were no other sources for information aside from their clinic. One Salvadoran 8
immigrant stated that she had trouble with her child s Medicaid application and was denied three times without explanation until the social worker at the clinic helped her and saw that the application was approved. When asked what other places immigrants trust to for information and assistance about Medicaid aside from the clinic, one immigrant asked, Where else would you go? [Salvadoran woman, undocumented] Unlike most other immigrants interviewed, Somali refugees interviewed at a CBO in Northern Virginia were very knowledgeable about Medicaid and had less trouble with the language barrier. Most had received Medicaid when they initially arrived in the US for a short time, and most had children who are currently enrolled in Medicaid. They reported that there was a specific caseworker at the Fairfax County Medicaid office who speaks Somali and assists applicants with their paperwork. Refugees and low income people are eligible for Medicaid for information we trust the eligibility caseworkers because they know the rules and regulations. [Somali woman, refugee] Application Process In general immigrants in Metropolitan DC reported that they were not intimidated by the application process for Medicaid. The application forms reportedly involved more questions about immigration status and income documentation than before the changes in the welfare and immigration laws, but this did not have a significant effect on immigrants ability to apply for Medicaid. In addition, most immigrants interviewed reported that they had assistance filling out Medicaid applications from CBO or SNP workers, as discussed above. The lack of follow-up from the Medicaid office frustrated many immigrants. They reported that there was no explanation when an application was denied about what was wrong with the application. One woman was denied benefits several months before the focus group for herself and her US-born children and was told after many attempts at getting an explanation that she could not qualify because she was illegal. The woman is, however, an LPR and has been working with staff at her clinic to clarify the error between the INS and the Medicaid office. If something is missing [in the application], you are automatically not qualified. [Mexican woman, LPR] They tell you they are going to call and let you know if you re eligible, but they never call. [Salvadoran woman, LPR] Interaction with Caseworkers Hispanic immigrants in Metropolitan DC complained about Medicaid caseworkers and the treatment immigrants receive in Medicaid offices. The only contradiction to this sentiment was the group of Somali immigrants who felt the caseworkers were very knowledgeable and 9
helpful. In addition, immigrants from Vietnam and China did not have much experience dealing directly with Medicaid caseworkers because CBO staff assist them by contacting the Medicaid office by phone, or translating with the caseworkers for them. Many Hispanic immigrants were assisted by advocates or providers in this manner as well, but many had sought assistance at Medicaid offices in Metropolitan DC and most reports about the treatment received from caseworkers were very negative. According to Hispanic immigrants and others, caseworker errors, misinformation and general unfriendliness and unhelpfulness have existed since before the 1996 welfare and immigration laws were implemented. One Mexican immigrant reported that she was warned by her caseworker that the INS would look at her Medicaid application; another said she was told that only citizens are eligible to apply for Medicaid. One Mexican immigrant was so upset by the disrespectful treatment from her caseworker that out of frustration she took her own application and ripped it up in front of the social worker and said, Thank you! This woman would not go back to finish the application process until a CBO representative encouraged her to do so. Other immigrants highlighted the sentiment that caseworkers are unfriendly: [The caseworkers] act like you owe them something. [Chinese woman, LPR] The caseworkers at the office don t care about you. [Salvadoran woman, undocumented] Sometimes, workers are mean. [Salvadoran woman, LPR] Many Hispanic immigrants in DC and in Maryland stated that African American caseworkers discriminated against applicants of other races and ethnicities, especially those who did not speak English. When you re Hispanic, they don t pay you attention, they put you in the back of the line. [Mexican woman, LPR] One time, they sent us home because the director said if we didn t speak English we couldn t stay. [Guatemalan woman, undocumented] If you don t know how to speak English, [the caseworkers] say Why didn t you bring a translator?! Sometimes they make it real difficult. [Salvadoran woman, LPR] Changes Since 1996 Laws Meant Little to Hispanic Immigrant Community Hispanic immigrants expressed the opinion that the changes in the welfare and immigration laws did not affect the majority of the Hispanic immigrant community in Metropolitan DC because most adults are undocumented while their children are US citizens. There were very few cases of children of these immigrant families who were LPRs and were rendered ineligible for public benefits because of the changes in the laws. In addition, Hispanic women reported that most of the government support for adults is directed only to pregnant 10
women and it is difficult to find assistance in accessing health care services for non-pregnancy related issues. Supposedly the laws changed, but for Hispanics nothing has changed. [Mexican woman, undocumented] Unless you re pregnant, no one tells you anything. [Salvadoran woman, undocumented] Immigrants Willingness to Apply for Medicaid Immigrants reported that their willingness to apply for Medicaid has not changed significantly in recent years. They are willing to apply for Medicaid for themselves and their children, usually once they are connected with a resource like a CBO or clinic that makes them aware of their eligibility for public assistance, or when their children are sick or injured and they are faced with the potential high costs of treatment. Immigrants reported that they prefer to apply for Medicaid at outstationed enrollment sites including clinics and hospitals where they feel comfortable and respected, and where there is more assistance in their native language. Misinformation about Medicaid eligibility policy was common among Hispanic immigrants and often affected their decision to apply for Medicaid. One undocumented Hispanic immigrant had heard that if a US-born child has undocumented parents, the government can take the child if the parents are killed because the child s social security number denotes a type of ownership by the government. Although this rumor did not deter the immigrant from enrolling her daughter in Medicaid because of the support of clinic workers, it is, however, an example of a general lack of knowledge about the laws and eligibility among the immigrant community. In another example, an undocumented Salvadoran immigrant was scared to apply for Medicaid for her citizen son because she did not have a social security number. This woman also mistakenly believed that her son would not be eligible for Medicaid until she finished paying the hospital for her labor and delivery charges. Immigrants did not report fear of becoming a public charge or fear of the INS as a deterrent to applying for Medicaid for themselves, however, some were aware that other immigrants in the community were concerned about public charge. 7 The issue was recognized in one focus group where two Hispanic immigrants had heard lawyers on the radio advising immigrants not to apply for benefits if they were trying to change their immigration status. Another immigrant had a friend who was an undocumented immigrant from Mexico who refused to apply for Medicaid for her children because of her fear of being deported. The immigrant stated that workers at her clinic were trying to help her friend feel comfortable applying for Medicaid. 7 This finding may be skewed because of self-selection of immigrants participating in the focus groups. Immigrants willing to participate may be less fearful of the public charge issue than those who may have chosen not to participate because of reluctance to discuss these issues. 11
While fear of becoming a public charge was not a deterrent to applying for Medicaid, many immigrants expressed the feeling of stigma attached to the use of public benefits that discouraged them from applying. In one focus group, Hispanic immigrants agreed that applying for benefits gives the impression that one wants to live off the US government and therefore that applying for public assistance should be a very last resort. I would rather work hard to take care of my family on my own than ask for assistance. [Guatemalan woman, pre-enactment LPR] Immigrants Ability and Willingness to Seek Primary Care Services Immigrants reported that they are as willing and able now as in past years to seek primary care services in Metropolitan DC. In DC, and to a lesser extent in the surrounding region, there is a vast network of safety net providers that serve the low-income population and immigrant groups. Immigrants reported that they felt a commitment from the providers to help and care for them. Hispanic immigrants from Maryland and Virginia often travel into DC to access primary care at clinics there because of their capacity to serve immigrants. Many immigrants reported that they had participated in prenatal programs through clinics and paid a fixed fee for each visit leading up to the delivery that was then covered by emergency Medicaid. Factors unrelated to welfare and immigration reform did, however, affect immigrants ability to access primary health care services for themselves and their children include the inability to pay for care and language barriers. Inability to Pay for Care Uninsured immigrants explained that the inability to pay for care was the most significant factor preventing them from accessing primary care services for themselves and their uninsured children. Immigrants explained that clinics generally charge a fee per visit from $10 to $20 per visit and at places where visits are less expensive or free, there are very long waits to see providers. After we buy rent and the food and the clothes, how can we pay for [health] care? [Mexican woman, pre-enactment LPR] One immigrant s children had Medicaid in the past before the family s income succeeded the eligibility level. The woman noted the differences in her ability to access primary care since becoming ineligible for Medicaid: When I had Medicaid coverage, I used to take my kids to a hospital and clinic. But now I treat them at home unless they are very sick and need special attention. I usually buy them medicine at the counter, in this way I save some money. [Somali woman, refugee] 12
Language Barrier Non-Hispanic immigrants reported that the language barrier is the biggest difficulty they face in seeking primary care services in Metropolitan DC. Fortunately for Hispanic immigrants, there are several clinics in Metropolitan DC that serve Spanish-speaking clients, however, other immigrants stated that it is difficult to find providers who speak their respective native languages. Moreover, non-hispanic immigrants reported that often the same-language providers they are able to find are overwhelmed with patients. The biggest barrier getting health care is the language. [Chinese woman, LPR] With the Medicaid, it was difficult to communicate with my doctor because of the language barrier. [Somali woman, refugee] Once you find [a doctor who speaks your language], he/she is so busy that the wait for an appointment is very long. [Chinese woman, LPR] Immigrants Ability and Willingness to Seek Emergency Care Services According to Metropolitan DC immigrants, the 1996 welfare and immigration reform laws did not affect their ability or willingness to seek emergency care services. As in accessing primary care, inability to pay for care was reportedly a significant barrier to immigrants ability to access emergency health care. Immigrants asserted that hesitation about costly bills is a deterrent to seeking emergency care although many are aware of the options to establish payment plans or apply for emergency Medicaid. Fear of the INS or deportation was not a factor for immigrants in deciding to go to the hospital for emergency care. Fear of going to the hospital is fear of the bills not the INS! [Salvadoran woman, preenactment LPR] Some people are afraid of the high hospital costs but the social workers will help you figure out the bill. [Mexican woman, pre-enactment LPR] Inability to speak English was a considerable barrier to accessing emergency health care services for immigrants, however, they are largely aware of which hospitals provide translators. When I had my baby, I couldn t get any medication for the pain because nobody spoke Spanish at the hospital. [Mexican woman, undocumented] Impact on Immigrants Health-Related Quality of Life Metropolitan DC immigrants reported being largely unaffected by the change in laws. Most immigrants were unaware of the changes in laws and most were able to find support accessing Medicaid and health care through community-based organizations and safety net providers. 13
The work and support of Metropolitan DC CBOs and especially SNPs has mitigated the impact of the laws on immigrants health-related quality of life by connecting immigrants in a network of care where they are able to access adequate health care services regardless of immigration or insurance status. CONCLUSION In Washington DC, Maryland, and Virginia, the 1996 welfare and immigration reform laws prevented most post-enactment LPRs from having access to Medicaid; however, according to Metropolitan DC immigrants, the laws did not have a notable impact on their lives. In addition, immigrants are not intimidated by the issue of public charge or by the INS. Immigrants in Metropolitan DC rely on CBOs and clinic staff to assist them in navigating the Medicaid system. CBOs and SNPs act as intermediaries between immigrants and the Medicaid system. Language barriers, lack of information and mistreatment from caseworkers are all barriers to applying for Medicaid that CBO and SNP workers mitigate for immigrants. Metropolitan DC immigrants are willing to seek primary and emergency care services, especially for their children, but are often prevented from accessing care due to factors such as language problems and inability to pay for care. Immigrants report that although many Metropolitan DC SNPs are dedicated to serving them and providing culturally appropriate and affordable health care services, these providers are often overwhelmed by the demand for their services. 14