Lawton and Rhea Chiles Center for Healthy Mothers and Babies, University of South Florida Arrival Health and Health Care Utilization Baseline Report: 2007 Prepared for the Bureau of TB and Refugee Health, Florida Department of Health June 2010 Javier Vazquez, MPH Ken Baugh, PhD Bobbi Markiewicz, PhD Marianna Tutwiler, MPA, MSW
This project is funded by the Florida Department of Health, Refugee Health Program, with grants from the U.S. Department of Health and Human Services, Office of Refugee Resettlement. Lawton and Rhea Chiles Center, USF 2
Table of Contents Introduction... 4 Definitions and Caveats... 4 Definitions... 4 Caveats... 5 Method... 7 Overview... 7 Identification of the Refugee Cohort... 8 Implementation of the Technical Solution... 8 Data Clean-up... 9 Results and... 10 Florida s Arrivals... 10 Utilization and Findings of Domestic Health Assessments... 14 Medicaid Application and Enrollment... 31 Utilization of Medical Services... 48 Providers... 66 Haitian Arrivals... 69 Conclusions... 76 Appendix A... 77 Appendix B... 87 Lawton and Rhea Chiles Center, USF 3
Introduction Florida is consistently one of the states with the largest number of arrivals 1 in the country. These individuals originate from various foreign countries, fleeing these distant nations due to a fear of persecution to pursue a new life. Their past experiences and cultures may have adversely affected their well-being by exposing these individuals to communicable diseases which could potentially have an impact on the general public s health upon their arrival in Florida. Therefore, it is crucial to study the health status and health care seeking behavior of these arrivals in order to facilitate their new beginning and ensure a road to self-sufficiency, while concurrently protecting the health of Florida s citizens. Upon arrival in Florida, refugees and individuals granted asylum (asylees) are eligible for a domestic health assessment to identify any communicable diseases or chronic health conditions. Indicators such as country of origin, immigration status, and region of Florida have all been telling factors in how and to what extent these individuals access health care. Therefore, it is vital to discern these occurring differences in order to improve the health care utilization of the arrival population. As a result, arrival data were gathered and analyzed for this report. These data identified over 35,000 arrivals resettling in Florida between January 1, 2007, and December 31, 2007. The purpose of this study is to analyze the health status and health care seeking behavior of these arrivals during that time period and to compare these data with data from a previous report which analyzed a cohort of over 128,000 arrivals entering Florida between January 1, 2003, and December 31, 2006. 2 Furthermore, due to findings that many Haitian arrivals are not utilizing the health care system, 3 this report will analyze the differences in health care utilization between Haitian arrivals and asylees as a whole, as well as, the common conditions Haitians are diagnosed with after a domestic health assessment. Definitions and Caveats Definitions Refugees - Individuals who have fled their country due to a well-founded fear of persecution based on their race, religion, nationality, social group, or political opinion. These individuals apply for and are granted this status prior to entry into the U.S. They are eligible for domestic health assessments, Medicaid benefits, and refugee resettlement benefits beginning the date the individual meets the definition of a refugee and arrives in the U.S. Asylees - Individuals who leave their home country for reasons similar to those of refugees (fear of persecution based on their race, religion, nationality, social group, or political opinion), but travel to the U.S. on their own. Once in the U.S., these individuals apply for asylum protection. They are eligible for domestic health assessments (DHAs) and Medicaid and other refugee benefits beginning the date the individual is granted asylum but not refugee resettlement benefits. Cuban and Haitian asylum applicants are eligible for domestic health assessments and Medicaid benefits during the asylum application process. 1 In this report the term arrival refers to the following groups refugees, asylees, Cuban or Haitian entrants, all of whom are foreign individuals with an immigration status eligible for refugee benefits. 2 Markiewicz, B., Baugh, K., Tutwiler, M., Vazquez, J. (2009). Refugee Health Status and Health Care Utilization Report. Lawton and Rhea Chiles Center for Healthy Mothers and Babies, University of South Florida. Prepared for the Bureau of Tuberculosis and Refugee Health, Florida Department of Health. 3 Ibid. Lawton and Rhea Chiles Center, USF 4
Parolees - Individuals granted parole for humanitarian reasons or for emergent or compelling reasons of significant public benefit. In some cases, parole is authorized prior to the individual s arrival in the U.S. Parole may also be granted at the port of entry once the individual has arrived. Only Cuban and Haitian parolees are eligible for domestic health assessments, Medicaid benefits, and refugee resettlement benefits. Cuban or Haitian Entrant - Individuals from either Cuba or Haiti whose immigration status is either a parolee, asylum applicant, or an individual in removal proceedings. They are eligible for domestic health assessments, Medicaid benefits, and refugee resettlement benefits beginning the date the individual meets the definition of an entrant. Voluntary Resettlement Agency (VOLAG) - Non-governmental voluntary agencies that are under contract with the Department of State to provide resettlement services for refugees. When a graph refers to the date of arrival, it means date of arrival for refugees, entrants, and parolees but refers to the date asylum was granted for asylees. Except where otherwise specified, enrollment in Medicaid means enrolled in Medicaid or Refugee Medical Assistance. Arrivals apply for Medicaid. If they meet the categorical and financial criteria to receive Medicaid, they are enrolled in Medicaid. If they meet the financial but not categorical criteria for Medicaid, they receive medical benefits through Refugee Medical Assistance. Codes defining preventive care are listed in Appendix A. Codes for treatment of different conditions are listed in Appendix A. Caveats For all graphs depicting specific types of medical care, only arrivals who received all medical care through a Medicaid fee-for-service arrangement are included. Many arrivals in the cohort modified the type of coverage they had one or more times, sometimes receiving care through a Health Maintenance Organization (HMO) and sometimes receiving it through a fee-for-service arrangement. During the time frame of the current study, HMOs were not required to report encounter-level data to the Agency for Health Care Administration to receive reimbursements. Therefore, treatment level data are not available for time periods during which an individual was enrolled in an HMO. Therefore, graphs depicting medical treatment sought by arrivals only include data from about 29% of the arrivals in the cohort: arrivals enrolled in fee-for-service Medicaid from the time of enrollment through December 31, 2009. On graphs that break down data by voluntary resettlement agency (VOLAG) providing resettlement services, VOLAGs represented on the graphs served at least 10 arrivals during the timeframe of the study. Data from other VOLAGS are combined in the other category. It should be noted that, generally, Cubans and Haitians do not have VOLAGs to assist them with resettlement. Therefore, VOLAG data just apply to arrivals classified under the immigration status of refugee (about 11% of all Florida arrivals). However, the Parolee Orientation Program (POP), served by Church World Service and Catholic Charities, provides limited services to arrivals classified as parolees, including assistance applying for benefits. Additionally, arrivals can be sponsored by a relative (REL) already living in Florida who can provide assistance. Any graph depicting a time lag between date of arrival and another event uses the date of arrival for entrants, refugees, and parolees and the date asylum was granted for asylees. Personal communications with data owners indicate that, although the data field is called date of arrival in source data, for asylees, the date really records date asylum was granted because, on that date, the asylee Lawton and Rhea Chiles Center, USF 5
becomes eligible to receive services available to refugees. However, Cuban and Haitian asylum applicants qualify for refugee services as soon as they apply for asylum. Since the results below depict asylees as a sub-population that does not take full advantage of available health services, it is important to understand how their entrance to the U.S. differs from other arrivals. As stated above, except for Haitian and Cuban asylum applicants, asylum applicants are not entitled to resettlement services until asylum is granted. It would be beneficial to understand what percent of applicants are ultimately granted asylum and the timeframe between application and asylum being granted. The Immigration and Nationality Act states in Section 208(d)(5) that the initial interview for asylum applications filed on or after April 1, 1997 should take place within 45 days after the date the application has been filed, and a decision should be made on the asylum application within 180 days after the date the application is filed, unless there are exceptional circumstances (Immigration and Nationality Act). This 6 month processing time is said to include both the affirmative asylum decision reached by a U.S. Citizenship and Immigration Services (USCIS) Asylum Officer, as well as, the defensive asylum decision reached by an Executive Office for Immigration Review (EOIR) Immigration Judge. This 6 month period has long been the targeted processing time goal. The goal, however, has historically not been achieved. In October 2003, the average cycle time for an asylum application was 34.6 months. 4 This long cycle time was particularly due to the number of backlog cases. Backlog cases, for numerous reasons (unexpected number of applications, not enough staff, wait for background check, etc.), take longer than 6 months to be completed. By the end of 2003, there were approximately 217,800 backlog asylum applications. 5 In 2004, to alleviate the problem, the USCIS introduced the Backlog Elimination Plan to rid itself of the backlog and achieve a 6 month cycle time by the end of fiscal year 2006. 6 By August 2004, the average cycle time was reduced to 23 months. 7 In July 2005, the average cycle time was 11.47 months, and by June 2006, the average cycle time had been reduced to 8.07 months. 8 As of February 2009, the national average cycle time is 6 months for asylum applications and there is no current backlog. 9 So, the asylum recipients in our cohort generally experienced an average of between 8 and 35 months between application for asylum and awarding of asylum. However, presumably, asylum applicants from 2009 forward will be granted asylum within an average of the six month time frame. The available data regarding the percentage of asylum applicants granted asylum are incomplete. Summary tables can be found in Appendix B. The percent of adjudicated affirmative asylum cases granted asylum was 34% and 41% for federal fiscal years 2003 and 2004 respectively; more recent data are apparently unavailable in the public domain. Defensive asylum grant rates ranged from 37% in FFY 2003 to 46% in FFY 2007. Rates between federal fiscal years 2006 and 2008 have remained between 45 and 46 percent. Since parolees and entrants from countries other than Cuba and Haiti are not entitled to resettlement or medical benefits, these arrivals were eliminated from the cohort before data were analyzed. 4 USCIS Backlog Elimination Plan Fiscal Year 2004 Third Quarter Update, 2004 5 USCIS Backlog Elimination Plan, 2004 6 Ibid. 7 USCIS Backlog Elimination Plan Fiscal Year 2004 Third Quarter Update, 2004 8 USCIS Backlog Elimination Plan, 2006 9 USCIS Processing Time Goals, 2009 Lawton and Rhea Chiles Center, USF 6
In this report, we generally use the median instead of the average. If there are extreme cases, they can pull the average towards the extreme. Under such circumstance the median (the middle entity in the group) gives a more realistic picture of the average. The reader may notice that the total number of arrivals on any one graph may vary from other graphs. These differences are a result of missing data for the characteristics being depicted. Method Overview The refugee health care study utilized five data sources from four administrative agencies to identify the population of refugees, asylees, parolees, and Cuban/Haitian entrants entering Florida between January 1, 2007, and December 31, 2007, and to ascertain the basic demographic characteristics, health conditions, and medical services of this population. The data sources represent administrative databases maintained by the Centers for Disease Control and Prevention, the Florida Department of Health, the Florida Department of Children and Families, and Florida s Agency for Health Care Administration. Because of their dissimilarities in structure and content, as well as the amount of random error they contain, merging the sources posed a number of technical challenges. The solution to these challenges entails two components: creating a quasi-relational database to both unite the different sources while simultaneously retaining their separation, and employing a probabilistic matching methodology to circumvent random data error. A quasi-relational database can be defined as a database containing multiple tables (i.e., component files) with internal database keys used to join the tables. In contrast to a relational database, the component data have not been subjected to the technical process of normalization. Rather, the table design essentially follows that of the original data sources, i.e., each of the five sources becomes a separate table. Where the source data do not fit a flat file structure, multiple tables are used from a single source. Creation of primary and foreign keys to join the tables completes the database. The second aspect of the technical solution a probabilistic matching methodology involves use of multiple sets of criteria for identifying records as belonging to the same refugee. After review of random error patterns in the data sources, nine sets of criteria were established. 1. Alien number, date of birth 2. Alien number, year of birth, first name 3. Alien number, year of birth, arrival date, gender 4. Alien number, month of birth, day of birth, arrival date, gender 5. Alien number, month of birth, day of birth, first name 6. Alien number, first name, arrival date 7. First name, date of birth, arrival date 8. Last name, first name, date of birth 9. Last name, first name, month of birth, day of birth, arrival date (excluding January 1 as a month/day of birth) When two or more records matched on any one of the nine conditions, they were regarded as belonging to the same person. Both direct and indirect matches were generated: If records A and B matched on criteria 1, and records B and C matched on criteria 2, records A and C were regarded as matching. The use of multiple criteria prevents random data error, e.g., clerical mistakes in recording an alien number, from occluding likely matches. On the other hand, probabilistic matching also introduces the possibility Lawton and Rhea Chiles Center, USF 7
of mistakenly matching records that belong to different persons. No set of matching criteria can fully resolve the considerable amount of random error present in the source data. Identification of the Refugee Cohort Unique arrivals entering Florida between January 1, 2007, and December 31, 2007, were identified using five data sources from four administrative agencies: The Electronic Disease Notification System (EDN) based on the refugee s overseas medical screening, from the Centers for Disease Control and Prevention Refugee Domestic Health Assessment System (RDHAS), from the Florida Department of Health Refugee Services Data (RSD), based on individuals receiving services sponsored by the Office of Refugee Services at the Florida Department of Children and Families The FLORIDA System, based on arrivals who apply for Medicaid, also housed in the Florida Department of Children and Families. The Medicaid ID number assigned by the FLORIDA System is then used to obtain medical encounter data from the Agency for Health Care Administration Any person verified as an arrival in any one of these data sources became a member of the cohort for analysis using the method described below. Implementation of the Technical Solution In implementation, the two components of the technical solution are interactive to produce the final match of data sources. The following steps describe the process. 1. Import all source data files into separate SAS files. 2. Standardize the format of all variables designated for use in matching (alien number, last name, first name, date of birth, gender, arrival date). 3. Eliminate duplicate records. 4. From each source file, extract a file containing only alien number, last name, first name, date of birth, gender, and arrival date. 5. Append all records from the files generated in step 4 into a single file. 6. Unduplicate the file generated in step 5 to retain one record for each unique combination of alien number, last name, first name, date of birth, gender, and arrival date. 7. Assign each record in the file generated in step 6 a unique identification number. 8. Employ the nine matching criteria in a vertical matching of records in the file produced in step 7. Matched records are reassigned the lowest identification number among the matching records. This identification number becomes the refugee ID number, an internal database key for joining the tables. 9. Using the file produced in step 8, the refugee ID is distributed back to each source file by matching on alien number, last name, first name, date of birth, gender, and arrival date. 10. A new file is generated from the file in step 8 containing only the unduplicated refugee ID. 11. Data elements required for the analysis that allow summarization in a single value (date of birth, gender, country of origin, etc.) are added to the file generated in step 10 by matching that file to the individual source files on refugee ID. Discrepancies between files are resolved by a majority vote among the sources. 12. Calculated fields needed for the analyses (age at arrival, months between arrival and Medicaid enrollment, etc.) are generated for the file in step 11. Lawton and Rhea Chiles Center, USF 8
More generally, completion of these steps results in the following: All of the original source files (Medicaid excluded) have a generated record key (refugee ID) for use in matching with any of the other source files. Two new tables have been created: a refugee alias table (step 8 above) and a refugee table (step 12). The refugee table contains one row per refugee, with most of the fixed information needed for the analysis included. The refugee alias table contains multiple records per refugee based on variations in the matching criteria (i.e., alien number, last name, first name, date of birth, gender, and arrival date). The refugee alias table serves only to link the refugee table with the tables representing the original source files. The last step involves incorporating the Medicaid data into the database. Because the Medicaid data were obtained based on the Medicaid ID number in the FLORIDA system, the refugee ID from that source is distributed to the Medicaid data by matching on the Medicaid ID. Once this is done, all of the original source files are integrated into the database by internal database keys, and the technical solution to matching the data sources is complete. Subsequent queries using table keys and standard SQL programming techniques have easy access to information from any of the five sources or combination of those sources required to address substantive issues. Data Clean-up Although the probabilistic matching methodology circumvents a certain amount of random data error, the accuracy of the matching is ultimately commensurate with the accuracy of the data. Short of external research involving individual case review, data clean-up can only seek to identify and resolve inconsistencies in the source data. Because this entails a considerable amount of manual scrutiny, it is labor intensive, and practical constraints of project deadlines and budget limit its scope. To establish priorities, records with only one data source (i.e., those not matching to another source) in the EDN file were targeted for review. These were cross-matched to the refugee alias table described above on selected data elements and/or partial data elements, such as date of birth or a majority of digits in an alien number. The resulting matches were manually scrutinized to identify obvious clerical errors in a data element, such as an addition of a digit or reversal of digits in an alien number. Errors so identified were manually corrected in the source data files. Following the manual correction of these records, the matching process described above was repeated to produce the final database. Lawton and Rhea Chiles Center, USF 9
Results and Florida s Arrivals Figures 1 through 4 were created to describe the cohort s demographics, immigration status, region of resettlement, and age distribution. Figure 1: Figure 1. Immigration Status by Country of Origin* 10 9 8 7 6 5 4 3 Asylees Entrants Refugees Parolees Note: Cases with missing data are not displayed. 2 1 Country of Origin In 2007, Florida received 35,678 arrivals. Over 52% of these arrivals are parolees, with the remaining arrivals made up of asylees (19%), Cuban and Haitian entrants (18%), and refugees (11%). The majority of arrivals are parolees due to the fact that 76% of Florida s arrivals originate from Cuba, and 68% of these Cuban arrivals are parolees. The second highest total of arrivals originate from Haiti (13%). Refugees make up the majority of arrivals from Burma (93%), Burundi (99%), and Vietnam (10). Asylees make up the majority of arrivals from China (78%), Colombia (96%), Haiti (76%), Peru (88%), Russia (68%), and Venezuela (99%). Comparison to 2003-2006 data The percentage of arrivals classified as a parolee dropped by five percentage points in 2007 from the 57% calculated for years 2003 through 2006. Additionally, the percentage of arrivals originating from Cuba fell by 2 percentage points. Cuban arrivals classified as parolees fell by 3 percentage points. The classification of Burmese arrivals has changed quite drastically. Previously, 52% of arrivals from Burma were classified as asylees. In 2007, 93% of these arrivals were classified under the immigration status of refugee. Lawton and Rhea Chiles Center, USF 10
In 2007, most of the arrivals from Russia (68%) were asylees, whereas 68% were classified as refugees in the previous report. New countries of origin with large populations of arrivals were seen in 2007. Burundi and China had significant numbers of arrivals entering the country. Figure 2: Figure 2. Age Groups at Arrival by Country of Origin* 10 9 8 7 6 5 4 3 2 65 and over 45-64 25-44 18-24 14-17 5-13 Under 5 Note: Cases with missing data are not displayed. 1 Country of Origin Arrivals between 25 and 44 years of age make up the largest group (47%) overall. This particular age group s percentage ranges from 22% for Burundian arrivals to 51% for Cuban arrivals. Approximately 54 and 45 percent of arrivals from Burundi and Haiti, respectively, are children under 18 years of age. Overall, 21% of arrivals are children under 18 years of age. Those over the age of 65 represent the smallest group of arrivals (3%) overall with percentages ranging from 1% for Haitian arrivals to 12% for Vietnamese arrivals. Comparison to 2003-2006 data The percentage for the group of arrivals between 25 and 44 years old was virtually identical for both data sets. Additionally, this group of arrivals made up the largest percentage among the entire arrival population for both data. The overall percentage of arrival children under the age of 18 remained unchanged. Lawton and Rhea Chiles Center, USF 11
Figure 3: Figure 3. Florida Region of Resettlement by Country of Origin* 10 9 8 7 6 5 4 Central Northeast Southeast Southwest Tampa Bay Other Counties 3 2 1 Country of Origin For this figure, as well as, all other figures referring to regions of Florida, the following table defines which counties constitute each region: Region Central Northeast Southeast Southwest Tampa Bay Other Description Orange and Seminole Counties Duval County Broward, Miami-Dade, and Palm Beach Counties Collier and Lee Counties Hillsborough, Pasco, and Pinellas Counties The 47 other Florida counties of resettlement The majority of arrivals (78%) settle in the Southeast region. This is due to the fact that the majority of arrivals from the top four countries of origin settle in the Southeast Region: 84% of all Cuban arrivals, 67% of all Haitian arrivals, 6 of all Colombian arrivals, and 58% of all Venezuelan arrivals settle in the Southeast. The Tampa Bay region is the second most popular resettlement location with 7% of the overall arrival population. This region received 34% of Vietnamese arrivals, 17% of Burmese arrivals, 14% of Peruvian arrivals, and 11% percent of Colombian arrivals. The overwhelming majority of Burundian arrivals (99%) and a large number of Burmese (48%) settle in the Northeast Region. Fortythree percent of Chinese arrivals settle in other counties of Florida. Lawton and Rhea Chiles Center, USF 12
Comparison to 2003-2006 data The Southeast continues to be the region where most arrivals settle; with the percentages of overall arrivals settling in this region remaining unchanged. The majority of Cubans, Haitians, Colombian, and Venezuelans continue to settle in this region. Additionally, similar overall percentages of Burmese arrivals settle in the Northeast region. More Russian arrivals are seen settling in the Southeast region and less in the Northeast region. Peruvians are increasingly settling in the Southwest and Northeast regions and no longer settling in the Central region. However, the majority of Peruvians continue to settle in the Southeast region. Figure 4: Figure 4. Immigration Status by Resettlement Area of Florida* 10 9 8 7 974 131 4,131 24 99 5,638 345 282 402 234 530 Asylees Entrants Parolees Refugees 6 5 4 3 49 655 15,472 781 1,304 211 452 Note: Cases with missing data are not displayed. 2 345 1 139 1,993 90 568 278 Central Northeast Southeast Southwest Tampa Bay Other Counties Area of Florida The majority of entrants (88%), parolees (84%), asylees (63%), and refugees (54%) settle in the Southeast region. This is partially due to the fact that Cubans have the highest overall totals for entrants, parolees, and refugees when compared to other countries and most Cubans settle in the Southeast. Additionally, Haitians have the highest overall total of asylees when compared to other countries and most Haitians also settle in the Southeast. However, the distribution of these arrivals between the major regions of Florida differs. Overall, parolees make up 52% of all arrivals and 57% of the Southeast region arrivals, 52% of the Southwest and Tampa Bay region arrivals, 23% of the Central region arrivals, 11% of the Northeast region arrivals, 31% of arrivals from all other counties. Asylees compose 19% of all arrivals and 65% of the Central region arrivals, 23% of the Southwest region arrivals, 16% of the Tampa Bay region arrivals, 15% of the Southeast region arrivals, 14% of the Northeast region arrivals, and 36% of arrivals from all other counties. Lawton and Rhea Chiles Center, USF 13
Entrants make up 18% of the arrival population and 21% of the Southeast region arrivals, 19% of the Southwest region arrivals, 9% of the Tampa Bay region arrivals, 3% of the Central and Northeast region arrivals, and 14% of arrivals from all other counties. Individuals classified as refugees make up 11% of the arrival population. Refugees compose 72% of the Northeast region arrivals, 23% of the Tampa Bay region arrivals, 9% of the Central region arrivals, 7% of the Southeast region arrivals, 6% of the Southwest region arrivals, and 19% of arrivals from all other counties. Comparison to 2003-2006 data The majority of arrivals settling in the Central region continue to be asylees. In fact, the overall asylee population settling in the Central region increased by 10 percentage points in 2007 from 55% in the previous report. The percentages of asylees settling in the remaining regions remain unchanged. Parolees continue to be the dominant immigration status of those arrivals settling in the Southeast, Southwest, and Tampa Bay region. There was a decrease of five points in the percentage of parolees settling in the Southeast and a decrease of six points in the percentage of parolees settling in the Southwest region. The percentage of parolees settling in the Tampa Bay region remains unchanged. The Northeast continues to be the only region with an arrival population primarily classified as refugees. In fact, the percentage increased from 63 to 72% in 2007. This change could be due to the increase in refugee classification of Burmese arrivals from 48 to 93% in 2007. Previously, 52% of Burmese were asylees and 48% were refugees. In 2007, 93% of Burmese were refugees and 7% were classified as asylees. Utilization and Findings of Domestic Health Assessments Summary: Florida s Arrivals 35,678 total arrivals in 2007 o Cuban/Haitian Parolees - 52% o Asylees - 19% o Cuban and Haitian entrants - 18% o Refugees - 11% 76% originate from Cuba 47% are between 25 and 44 years of age 78% settle in the Southeast region As required by the U.S. Office of Refugee Resettlement (ORR) and the U.S. Department of State (DOS), all arrivals are eligible for and should receive a domestic health assessment and/or immunizations, at no charge, within 90 days of arrival. 10 However, through an annual contractual agreement with the DOS, VOLAGs are responsible for ensuring their clients (only refugees are eligible) are receiving a domestic health assessment within 30 days of arrival. If a VOLAG is not able to achieve this 30 day requirement, they must provide a written explanation of the reason for the delayed assessment. Due to the fact that VOLAGs are only funded to serve refugees, figures depicting VOLAGs are representative of mostly refugees, with the exceptions being the POP and REL (neither of which are VOLAGs) which represent parolees and arrivals sponsored by a relative, respectively. The Department of State prefers domestic health assessments be conducted on all arrivals within 30 days from the date of arrival or, in the case of an asylee, 90 days from the date asylum is granted. For this reason, time between arrival and domestic health assessment, from 0 up to 90 days from the date of arrival is an important time frame to focus on and analyze. 10 45 CFR 400.107 Lawton and Rhea Chiles Center, USF 14
Figure 5: Figure 5. Arrivals* with Domestic Health Assessments by Region of Florida 7 66.8% 68.8% 6 56.7% 52.6% 5 43.7% 4 37.1% 3 2 27,236 2,510 1,502 1,507 911 1,471 1 Southeast Tampa Bay Southwest Central Northeast Other Counties Southeast: Broward, Palm Beach, and Miami-Dade Counties Tampa Bay: Hillsborough, Pasco, and Pinellas Counties Southwest: Collier and Lee Counties Central: Orange and Seminole Counties Northeast: Duval County The Northeast and Southeast regions of the state have the highest rates of domestic health assessments among its arrivals, with 69% and 67%, respectively. This could be partially due to the fact that most arrivals (72%) settling in the Northeast region are refugees and eligible for assistance from a VOLAG. Additionally, most arrivals (83%) settling in the Southeast region are Cuban and, as Figure 7 shows, 73% of all Cuban arrivals receive domestic health assessments. The remaining regions of the state have lower rates: 57% in the Tampa Bay region, 53% in the Southwest region, 44% in the Central region, and 37% in the other counties of the state. Comparison to 2003-2006 data The Northeast and Southeast regions continue to have the highest percentages of assessments. There was a slight increase in both regions, with the Northeast increasing by four percentage points and the Southeast increasing by 3 percentage points. The Central region continues to have the lowest percentage of arrivals with assessments even though there was a very slight increase of 1 percentage point. Overall, every region, as well as the group of remaining counties under Other Counties, had an increase in the percent of arrivals with assessments. Even though these were all slight increases, it is encouraging to note the gains in performance. Lawton and Rhea Chiles Center, USF 15
Figures 6a through 6b: Figure 6a. Percent of Persons with Domestic Health Assessment by Immigration Status* 8 77.1% 77.3% 7 6 5 47.1% 4 3 28.1% 2 1 1,885 3,104 14,316 2,933 Asylees C/H Entrants Parolees Refugees Figure 6b. Percent of Persons with Domestic Health Assessment by Immigration Status* - RDHAS Data Only 10 9 98.3% 92.3% 93. 8 7 6 5 58. 4 3 2 4,987 2,976 1 1,748 12,563 Asylees C/H Entrants** Parolees Refugees **C/H Entrants includes individuals classified under Appear I-862, Order I-220A, EWI, and C/H Entrant Figure 6a shows that as an overall group, 62% of all arrivals receive domestic health assessments. At 77% each, refugees and parolees are the groups most likely to receive a domestic health assessment. Lawton and Rhea Chiles Center, USF 16
The high rate for refugees could be explained by the fact that they are eligible for VOLAG assistance. The high rate for parolees could be explained by the fact that according to Figure 1, 98% of all parolees are Cuban, and according to Figure 9, 73% of all Cuban arrivals receive domestic health assessments. At 28% and 47%, asylees and Cuban and Haitian entrants, respectively, are the least likely to obtain domestic health assessments. These lower rates can be partially explained by the fact that these groups are not eligible for VOLAG assistance. However, the immigration status for most Cuban arrivals makes them ineligible for VOLAG assistance, yet Cubans are obtaining domestic health assessments at a high rate (73% obtain domestic health assessments) so the difference might not necessarily be due to the resettlement services provided by VOLAGS. Figure 6b, containing only data from RDHAS, shows higher rates of domestic health assessments for all groups of arrivals when compared to Figure 8a. This is due to the fact that Figure 6a captures a larger cohort of arrivals some of who are not recorded in RDHAS. Data from RDHAS show that 89% of all arrivals captured by that database receive domestic health assessments as opposed to 62% from the more extensive data in Figure 6a. If the Refugee Health Program (RHP) knows about an arrival, it is very likely that the person will have a domestic health assessment. For instance, RHP is not notified when an arrival applies for or is granted asylum and when a derivative asylee (an asylee arrives to follow a family member who has already been granted asylum) arrives in Florida. Therefore, there is no way to contact these individuals to encourage them to have assessment. Comparison to 2003-2006 data Overall, when comparing Figure 6a to the previous data, the assessment percentage of arrivals classified as asylees has dropped (a three percentage point decrease), while an increase has occurred in the assessment percentages of those classified as Cuban and Haitian entrants (3 point increase), parolees (4 point increase), and refugees (4 point increase). Comparison of Figure 6b with the previous data corroborates comparison findings from Figure 6a. The RDHAS database shows a decrease in the assessment percentage of asylees (16 point decrease) and an increase in the assessment percentages of Cuban and Haitian entrants (1 point increase) and parolees (6 point increase). The percentage of refugees receiving assessments in the RDHAS database remains the same. This signifies that while we are seeing higher percentages of Cuban and Haitian entrants, parolees, and refugees receiving assessments, fewer asylees are completing the assessments. Additional efforts should be made to ensure provision of domestic health assessments for asylees. Lawton and Rhea Chiles Center, USF 17
Figure 7: Figure 7. Arrivals* with Domestic Health Assessments by Country of Origin PERU CHINA RUSSIA HAITI VENEZUELA COLOMBIA VIETNAM CUBA BURMA 8.3% 2 15.7% 13 17.7% 11 22.1% 1,028 24.4% 192 28.2% 404 72.5% 37 73. 19,684 77.3% 486 BURUNDI ALL OTHER 33.3% 313 93.4% 71 1 2 3 4 5 6 7 8 9 10 Arrivals most likely to obtain a assessment are Burundians (93%), Burmese (77%), Cubans (73%), and Vietnamese (73%). Those least likely to obtain a assessment are Colombian (28%), Venezuelan (24%), Haitian (22%), Russian (18%), Chinese (16%), and Peruvian (8%). The majority of Burundians (99%), Burmese (93%), and Vietnamese (10) are refugees. The majority of Cubans (68%) are parolees. According to Figure 6a, immigration statuses of refugee and parolee are most likely to receive assessments, with a rate of 77% for both statuses. The assistance provided by VOLAGs to refugees can partially explain the high rates of assessments for those countries with large numbers of refugees. However, since most Cubans (91%) are classified as something other than refugee, making the majority ineligible for VOLAG assistance, something else must explain the high assessment rates for this population. It could be that because most Cubans settle in the Southeast, their family, culture, and the environment and community resources of that region facilitate the overall process of obtaining a assessment. It could also be that parolees, which are 98% Cuban from the data collected for this report, follow a different process or obtain additional information which encourages an individual to obtain an assessment. Arrivals least likely to obtain assessments are from countries where asylee is the dominant immigration status: Venezuela (99%), Colombia (96%), Peru (88%), China (78%), Haiti (76%), and Russia (68%). The arrivals from these countries are mostly classified as asylees and, thus, not eligible for VOLAG assistance. However, as previously indicated, parolees are not eligible for services from a VOLAG but have high rates of assessments. So, either the immigration classification of parolee or the country of origin for Lawton and Rhea Chiles Center, USF 18
those parolees (98% from Cuba) is an explanation for the high rates of assessments. A combination of both or an external variable not analyzed might also serve to explain these results. Comparison to 2003-2006 data Arrivals from Burundi were not captured in the previous report. This is because in October of 2006, at the request of the U.N. High Commissioner for Refugees (UNHCR), the U.S. government agreed to resettle approximately 10,000 Burundians as refugees over the ensuing two years. 11 Between January 1, 2007, and December 31, 2007, Burundians were mostly classified as refugees (99%) and had the highest percentage of assessments (93%). Liberians, on the other hand, were not captured in the 2007 data but were captured in the previous report. Due to improved political conditions in 2006, when Liberia s first female president was elected, the U.S. ended temporary protection status for Liberians and ordered a delayed enforced departure, which would repatriate those living in the United States. 12 Liberians were mostly classified as refugees (97%) during that timeframe and the most likely to complete a assessment (82%). With this in mind, the trend of refugees having higher assessment rates continues regardless of country of origin. It is worth noting the increase in Cuban arrival assessments from 66 to 73%. Most Cubans are parolees so the Parolee Orientation Program (POP) might be responsible for these better assessment percentages. Countries with asylees as the dominant arrival population continue to have the lowest assessment rates. Furthermore, these percentages decreased in 2007. The assessment percentages for Colombians and Venezuelans decreased from 35 to 28% and 27 to 24%, respectively. However, there were increases in the assessment rates of Haitians from 17 to 22%. 11 Kaufman, Stephen. 2006. U.S. Accepting Approximately 10,000 Refugees from Burundi. Accessed: http://www.america.gov/st/washfile-english/2006/october/20061017183816esnamfuak0.9061396.html 12 Marrapodi, Eric and Chris Welch. 2009. Liberians Facing Mass Deportation from U.S. Accessed: http://www.cnn.com/2009/us/02/09/liberians.deportation/index.html Lawton and Rhea Chiles Center, USF 19
Figure 8: Figure 8. Time Between Arrival and Domestic Health Assessment by Country of Origin* 10 9 8 7 6 5 4 > 365 Days 241-365 Days 121-240 Days 91-120 Days 61-90 Days 31-60 Days 0-30 Days 3 2 1 Country of Origin Overall, 22,202 assessments were conducted with 21,351 completed within 90 days of arrival (96%). This shows that the majority of arrivals actually receiving assessments are doing so within the preferred 90 day timeframe. All countries, including those under the category of other, have rates higher than 90 percent. Vietnam, with a rate of 92%, is the country with the lowest rate of arrivals receiving their assessments within 90 days. Peru and China, both with a rate of 10, have small numbers of overall arrivals receiving assessments (2 and 13, respectively) so data for these countries are not ideal for analysis or interpretation. For Burmese, with 478 out of their 486 arrivals receiving assessments within 90 days (98%), the analysis is more meaningful. Once again, VOLAGs might be particularly helpful with the Burmese population because of the fact that most of their arrivals are refugees (93%). However, Cubans, with a 96% rate of completion within 90 days (19,645 assessments with 18,912 completed within 90 days) are primarily parolees who are not eligible for VOLAG assistance. Additionally, 95% of Haitians (1,028 assessments with 979 completed within 90 days) with assessments received them within the 90 day timeframe and, according to Figure 7, only 22% of the total population of Haitian arrivals receive assessments. This signifies that although the majority of Haitian arrivals are not receiving assessments, most that do, complete them within 90 days. This could potentially mean that neither VOLAG assistance nor high rates of assessment for a country are indicative of assessment completion within 90 days. As mentioned earlier, Figure 6a shows only 62% of all arrivals receive assessments; however, the majority of those receiving assessments are doing so within 90 days of arrival. According to these data, efforts should be made to identify individuals requiring assessments and ensure provision of the Lawton and Rhea Chiles Center, USF 20
assessment. The completion of the assessment within the 90 day timeframe does not seem to be a major issue when compared to the actual provision of the assessment. Comparison to 2003-2006 data The 2007 data show that all countries of origin have very high percentages (over 92%) of arrivals receiving their assessments within 90 days. This is a performance increase over the findings of the previous report where Colombia, Haiti, Peru, and Venezuela were all under 85 percent. Figure 9: Figure 9. Median Number of Days from Arrival to Domestic Health Assessment by Country of Origin* 70 62.5 60 55.0 57.0 58.0 57.0 50 40 31.0 29.0 36.0 33.0 30.0 30 20 13.0 10 0 Country of Origin When examining median number of days between date of arrival (or date of asylum for those classified as an asylee) and assessment, arrivals from Venezuela, Haiti, Russia, Colombia, and China, with median days ranging from 55 to 63 days, are taking considerably longer to complete their assessments than the remaining countries of origin. With 13 days between arrival and domestic health assessments, Cubans are receiving their assessments earliest, even when compared to countries where the majority of arrivals receive VOLAG assistance. Once again, those countries with large median number of days (Venezuela, Haiti, Russia, Colombia, and China) have at least 68% of their arrival population classified as asylees. Comparison to 2003-2006 data Decreases and increases were seen in the median days between arrival and assessment in some countries of origin. Burma, Peru, Venezuela, and Vietnam all reduced their overall number of median days, while Colombia, Cuba, Haiti, and Russia all had increased median days. Lawton and Rhea Chiles Center, USF 21
Figure 10: Figure 10. Median Number of Days from Arrival to Domestic Health Assessment by Immigration Status* 60 56.0 50 40 30 20 10 10.0 13.0 17.0 0 Asylees C/H Entrants Parolees Refugees There appears to be a relationship between immigration status and the median number of days between arrival and provision of a assessment. The few asylees receiving domestic health assessments (28% of asylees do, Figure 6a) are doing so long after asylum has been granted. With Cubans making up 89% of the Cuban and Haitian entrant population and 98% of the parolee population, and settling mostly in the Southeast region, the environment may be playing a role in the provision of assessments soon after arrival. Refugees, eligible for assistance from VOLAGs, appear to be receiving their assessments shortly after their arrival date as well. Comparison to 2003-2006 data The median number of days between arrival (or asylum granted) and assessment by immigration status has increased by 2 days for each of the following immigration statuses: asylees, for Cuban and Haitian entrants, and parolees. However, the median for refugees has decreased by 3 days. Lawton and Rhea Chiles Center, USF 22
Figures 11a through 11f: Figure 11a. Central Region*: Median Number of Days between Arrival and Health Assessment by VOLAG** 60 50 53.0 40 40.0 30 34.0 20 21.0 10 0 LIRS POP USCCB Other VOLAG *Orange and Seminole Counties * Lawton and Rhea Chiles Center, USF 23
Figure 11b. Northeast Region*: Median Number of Days between Arrival and Health Assessment by VOLAG** 40 40.0 35 30 34.0 32.0 25 27.0 27.0 20 15 10 5 0 CCSA LIRS POP USCCB WRRS VOLAG *Duval County * Figure 11c. Southeast Region*: Median Number of Days between Arrival and Health Assessment by VOLAG 40 37.0 35 30 25 20 18.0 14.0 14.0 15 12.0 12.0 11.0 11.0 13.0 10 6.0 4.0 7.0 5 0 CCSA CWS EMM IRC IRSA LIRS POP REL USCCB WRRS YCO Other VOLAG *Broward, Palm Beach, and Miami-Dade Counties * Lawton and Rhea Chiles Center, USF 24
Figure 11d. Southwest Region*: Median Number of Days between Arrival and Health Assessment by VOLAG 48 47.0 46 45.0 44 42 42.5 40 40.0 40.0 38 36 LIRS POP REL USCCB Other VOLAG *Collier and Lee Counties * Figure 11e. Tampa Bay Region*: Median Number of Days between Arrival and Health Assessment by VOLAG** 50 45 48.0 40 41.0 40.0 35 30 33.0 25 20 15 10 11.0 5 0 CCSA LIRS POP USCCB Other VOLAG *Hillsborough, Pasco, and Pinellas Counties * Lawton and Rhea Chiles Center, USF 25
Figure 11f. Other Counties*: Median Number of Days between Arrival and Health Assessment by VOLAG 70 60 62.0 50 40 35.0 30 20 22.0 25.0 29.0 10 For this set of figures, as well as all other figures referring to VOLAGs, the following table serves as a guide to abbreviations: 0 CCSA LIRS POP REL USCCB Other Code CCSA CWS EMM IRC IRSA LIRS POP REL USCCB WRRS YCO Other VOLAG *All Florida counties excluding Duval, Collier, Lee, Orange, Seminole, Hillsborough, Pasco, Pinellas, Broward, Palm Beach, and Miami-Dade. * Description Community Christian Service Agency Church World Service Episcopal Migration Ministries International Rescue Committee Immigration and Refugee Services of America Lutheran Immigration and Refugee Service Parolee Orientation Program Relative of an arrival (not a VOLAG) U.S. Conference of Catholic Bishops World Relief Refugee Services Youth Co-Op Other VOLAGs serving less than 10 clients in the region Various VOLAGs are providing their services in multiple regions of the state (CCSA, LIRS, USCCB, and WRRS). Out of this group of VOLAGs, only WRRS is getting their clients in for assessments under 30 days in all the regions they serve (two regions: Southeast and Northeast). 6.0 Lawton and Rhea Chiles Center, USF 26
The Southeast region, with all nine VOLAGs who serve at least ten clients in the region doing so within the 30 day preferred timeframe, is the best performing. The Northeast region is the only other region with VOLAGs getting their clients in for assessments within 30 days of arrival. Two of their four VOLAGs (CCSA and WRRS) are achieving the goal. The Central, Southwest, and Tampa Bay regions do not have a single VOLAG, serving at least ten clients, getting their clients in for assessments within 30 days of arrival. In all other counties of the state, only CCSA and USCCB have medians below thirty days. It should be noted, however, especially in regions where there is a consistent delay between arrival domestic health assessment, that these delays may be due to backlogs at the Refugee Clinics at county health departments rather than to a lack of commitment to timely scheduling by VOLAGs. Comparison to 2003-2006 data The VOLAGs from the Central region had increases in their median number of days. LIRS had an increase from 34 to 53 days and USCCB had an increase from 32 to 34 days. The Northeast region had VOLAGs with increases and decreases in their median number of days. CCSA (50 to 27 days) and WRRS (29 to 27 days) decreased their median number of days, while LIRS (29 to 34 days) and USCCB (39 to 40 days) increased their median number of days. The VOLAGs from the Southeast region continue to be the best performing. Additionally, the following VOLAGs from this region reduced their median number of days: CCSA (25 to 14 days), EMM (7 to 6 days), IRC (14 to 12 days), IRSA (12 to 11 days), LIRS (18.5 to 14 days), USCCB (14 to 11 days), WRRS (9 to 7 days), and YCO (30 to 18 days). Only one VOLAG (CWS) from this region had an increase in their median number of days (6 to 12 days). In the Southwest region, LIRS reduced its median number of days from 52 to 40 days, while USCCB experienced an increase from 41 to 42.5 days. In the Tampa Bay region, USCCB reduced its median number of days from 46 to 33 days, while CCSA (37 to 41 days) and LIRS (44 to 48 days) experienced increases in days. For all other counties, CCSA (43.5 to 22 days) and USCCB (46 to 29 days) reduced their days, while LIRS (29 to 62 days) experienced an increase. Again, delays in scheduling domestic health assessment may be a function of county health department scheduling and not VOLAG s lack of commitment. Lawton and Rhea Chiles Center, USF 27
Figure 12: Figure 12. Arrivals'* Most Common Conditions** Identified at Domestic Health Assessment 16,000 9 14,000 12,000 10,000 13,364 68.3% 10,610 80. 9,130 Number with Abnormal Results Percent with Abnormal Results 8 7 6 5 8,000 6,000 43.5% 6,157 34.1% 5,155 5,053 4 3 4,000 2,000 24.1% 27.5% 3,694 3,621 17.4% 17. 3,083 14.7% 2,396 12.4% 2 1 0 Hepatitis A High Cholesterol Height, Weight, Body Mass Urine Abnormality Malnutrition Hepatitis B Hypertension Dental Vision Parasites **HIV is excluded. Hepatitis A yielded the most abnormal results, with over 13,000 arrivals being identified with the condition (68% of all arrivals screened). High cholesterol was not tested on as many arrivals as Hepatitis A, but with 8 of those screened being diagnosed, it was the condition with the highest percent of abnormal results. All other conditions are diagnosed at a rate below 50 percent. Comparison to 2003-2006 data There were increases for all conditions identified in both databases: Hepatitis A (65 to 68%), high cholesterol (53 to 8), urine abnormality (14 to 34%), hypertension (10 to 17%), dental (9 to 17%), vision (10 to 15%), and parasites (11 to 12%). Lawton and Rhea Chiles Center, USF 28
Figure 13: Figure 13. Percent of Arrivals* Tested with Selected Frequent Conditions by Country of Origin 10 9 8 7 6 BURMA BURUNDI CHINA COLOMBIA CUBA HAITI PERU RUSSIA VENEZUELA VIETNAM 5 4 3 2 1 Hepatitis A High Cholesterol Urine Abnormality Parasites Hepatitis B It seems as though country of origin is not a good indicator for the overall health of an arrival. No one country of origin is particularly healthy across all the conditions listed in Figure 15. Some countries have low rates of certain conditions but high rates for others. Haitians and Burmese have high rates of Hepatitis A at 80 and 75%, respectively. Arrivals from Vietnam, on the other hand, have the lowest rates for the condition at 50 percent. High cholesterol was diagnosed for every Burundian screened and 5 or more of the arrivals from all other countries of origin. At 35%, Cubans have the highest rate of urine abnormality. More than 35% of Haitians are diagnosed with parasites, while less than 21% of arrivals from all other countries are. The Vietnamese are the group with the highest rate of Hepatitis B, while rate for all other countries fall below 14 percent. Due to very a small overall number of completed assessments by arrivals from China (13 assessments), Peru (2 assessments), and Russia (11 assessments), results from these countries were not analyzed. Comparison to 2003-2006 data For the most part, there were increases in the diagnosis of all conditions for arrivals regardless of county of origin. For Hepatitis A, there was an increase in the percentage of arrivals diagnosed with the condition in the following countries: Colombia, Cuba, Haiti, Venezuela, and Vietnam. Only those from Burma had a decrease in the percent of arrivals diagnosed with Hepatitis A. Lawton and Rhea Chiles Center, USF 29
For high cholesterol, there was an increase in the percentage of arrivals diagnosed with the condition in the following countries: Burma, Colombia, Cuba, and Haiti. Arrivals from Venezuela and Vietnam experienced decreases in their overall percentage. For urine abnormality, there was an increase in the percentage of arrivals diagnosed with the condition in the following countries: Burma, Colombia, Cuba, Haiti, Venezuela, and Vietnam. Summary: Utilization and Findings of Domestic Health Assessments Highest rates of assessments: Northeast and Southeast regions 62% of all arrivals receive assessments Refugees and parolees are most likely to receive assessments Asylees are least likely to receive assessments Burundians most likely to be screened 96% of all assessments were completed within 90 days of arrival (or asylum granted) Cubans receive assessments soon after arrival (median 13 days) High cholesterol is the most identified condition among arrivals (8 of those tested) For parasites, there was an increase in the percentage of arrivals diagnosed with the condition in the following countries: Colombia, Haiti, Venezuela, and Vietnam. Only the Burmese experienced a decrease in percentage. For Hepatitis B, there was an increase in the percentage of arrivals diagnosed with the condition from following countries: Burma and Venezuela. Arrivals from Colombia, Haiti, and Vietnam all had percentage decreases. Lawton and Rhea Chiles Center, USF 30
Medicaid Application and Enrollment Eligible arrivals for VOLAG services are provided assistance throughout the Medicaid application process. Those arrivals meeting the income requirements to qualify for Medicaid benefits are provided medical insurance through Medicaid or Refugee Medical Assistance (RMA). Figure 14: Figure 14. Percent of Arrivals* Applying for Medicaid by Country of Origin 10 94.7% 88.1% 88.2% 9 86.2% 8 7 59.7% 64.4% 6 5 46.4% 52.2% 41.7% 49.9% 4 3 25.3% 2 542 72 21 665 23,753 2,425 10 37 392 45 605 1 Country of Origin The countries of origin with the highest percentages of arrivals applying for Medicaid are Burma (86%), Burundi (95%), Cuba (88%), and Vietnam (88%). All other countries of origin fall below 6, with China having the lowest percentage at 25 percent. It is worth noting that arrivals from Burma (93%), Burundi (99%), and Vietnam (10) are mostly refugees, while those from Cuba are mostly parolees (68%) and Cuban and Haitian entrants (22%). Asylee is the major immigration status for those countries with low percentages of arrivals applying for Medicaid. The assistance provided by VOLAGs and the Parolee Orientation Program (POP) soon after date of arrival seems to be resulting in high rates of Medicaid applications for refugees and parolees. An asylee, on the other hand, could be in the country for months before their asylum application has been granted earning substantial wages making them ineligible for Medicaid benefits. Comparison to 2003-2006 data The following countries had an increase in the percentage of arrivals applying for Medicaid: Burma (62 to 86%), Haiti (49 to 52%), and Vietnam (77 to 88%). On the other hand, the following countries had a Lawton and Rhea Chiles Center, USF 31
decrease in the percentage of arrivals applying for Medicaid: Colombia (53 to 46%), Peru (59 to 42%), Russia (81 to 6), and Venezuela (63 to 5). Figure 15: Figure 15. Percent of Persons Applying for Medicaid by Immigration Status* 9 8 81.7% 87.8% 87. 7 6 5 53. 4 3 2 3,555 5,386 16,314 3,304 1 Asylees C/H Entrants Parolees Refugees Refugee, parolee, and Cuban and Haitian entrants are the immigration statuses with the highest percentages of persons applying for Medicaid, while asylee has the lowest percentage. As noted in Figure 14, the countries of origin with the highest percentages of arrivals applying for Medicaid have a majority arrival population of refugees, parolees, and Cuban and Haitian entrants. Asylee is the dominant immigration status of countries with low percentages of Medicaid applicants. Comparison to 2003-2006 data The percentage of persons applying for Medicaid by immigration status did not change very much in 2007. For asylees, the percentage remained the same at 53% of asylees applying for Medicaid benefits. There was an increase of 2% for Cuban and Haitian entrants, parolees, and refugees. Lawton and Rhea Chiles Center, USF 32
Figures 16a through 16f: Figures 16a through 16f represent the percent of arrivals applying for Medicaid by VOLAGs serving at least 10 arrivals entering Florida between January 1, 2007, and December 31, 2007. Refugees are the only group of arrivals eligible for services from a VOLAG, so these figures represent mostly refugees applying for Medicaid. The exception being POP and REL, which are not VOLAGs but provide services to other groups of arrivals including refugees. Figure 16a. Central Region*: Percent of Arrivals** Applying for Medicaid by VOLAG 96.6% 10 85.4% 85.9% 9 8 7 63. 6 5 4 3 2 17 70 67 28 1 LIRS POP USCCB Other *Orange and Seminole Counties Counties VOLAG * Lawton and Rhea Chiles Center, USF 33
Figure 16b. Northeast Region*: Percent of Arrivals** Applying for Medicaid by VOLAG 10 92.1% 97.5% 94.7% 93.2% 9 8 7 64. 6 5 4 3 2 35 195 16 90 248 1 CCSA LIRS POP USCCB WRRS *Duval County VOLAG * Figure 16c. Southeast Region*: Percent of Arrivals** Applying for Medicaid by VOLAG 10 9 82.7% 96.6% 95. 88.4% 92.9% 94.2% 87.3% 94.1% 95.8% 93.8% 95.2% 8 7 64.2% 6 5 4 3 2 43 366 152 524 262 194 3,793 70 415 275 228 7,205 1 CCSA CWS EMM IRC IRSA LIRS POP REL USCCB WRRS YCO Other *Broward, Palm Beach, and Miami-Dade Counties VOLAG * Lawton and Rhea Chiles Center, USF 34
Figure 16d. Southwest Region*: Percent of Arrivals** Applying for Medicaid by VOLAG 10 100. 95.1% 92.5% 9 83.8% 8 7 6 5 4 33.3% 3 11 171 4 39 135 2 1 LIRS POP REL USCCB Other VOLAG *Collier and Lee Counties * Figure 16e. Tampa Bay Region*: Percent of Arrivals** Applying for Medicaid by VOLAG 10 100. 96.8% 95% 91.8% 92. 9 86.4% 85% 22 724 337 183 92 8 75% CCSA LIRS POP USCCB Other VOLAG *Hillsborough, Pasco, and Pinellas Counties * Lawton and Rhea Chiles Center, USF 35
Figure 16f. Other Counties*: Percent of Arrivals** Applying for Medicaid by VOLAG 10 100. 94.7% 98.7% 9 78.4% 8 72.2% 7 6 5 4 33.3% 3 2 12 13 134 7 107 75 1 CCSA LIRS POP REL USCCB Other VOLAG *Florida counties excluding Duval, Collier, Lee, Orange, Seminole, Hillsborough, Pasco, Pinellas, Broward, Palm Beach, and Miami-Dade. * Overall, VOLAGs have very high percentages of arrivals applying for Medicaid. Lutheran Immigration and Refugee Services (LIRS) has the lowest percentages, with 63 and 72%, in the Central region and Other Counties of Florida, respectively. However, in both of those areas, their numbers served are relatively small and they seem to be performing well in the other regions of the state. In some regions of the state (Tampa Bay, the Southwest, and the Northeast), parolees served by the Parolee Orientation Program (POP) are less likely than refugees served by VOLAGs to apply for Medicaid. In addition, although sponsorship by relative is rare, when an arrival is sponsored by a relative, they are less likely to apply for Medicaid. Comparison to 2003-2006 data In the Central region, LIRS (74 to 63%) had a percentage decrease in the number of arrivals applying for Medicaid, while USCCB (84 to 86%) had a slight increase. The Northeast region experienced percentage increases by CCSA (83 to 92%) and LIRS (94 to 98%), while also experiencing a decrease by USCCB (96 to 95%) and WRRS (94 to 93%). Only CWS in the Southeast region had a considerable change in percentage; an increase from 91 to 97 percent. LIRS was the only VOLAG in the Southwest region with an increase in the percentage of arrivals applying for Medicaid (93 to 10). In the Tampa Bay region, USCCB increased its percentage from 91 to 97 percent. Lawton and Rhea Chiles Center, USF 36
Figure 17: Figure 17. Percent of Medicaid Applicants Enrolling in Medicaid by Immigration Status* 10 98.3% 95% 95.9% 9 91.7% 85% 8 82. 75% 2,911 4,940 16,029 3,169 7 Asylees C/H Entrants Parolees Refugees For this figure, Medicaid enrollment represents enrollment in either Medicaid or Refugee Medical Assistance. Parolees, refugees, and Cuban and Haitian entrants who have applied for Medicaid are the most likely to be enrolled, with rates over 90 percent. At 82%, asylees are the least likely group of arrivals to enroll in Medicaid. Once again, this could be due to the fact that most asylees have to wait several months before being granted asylum, which could potentially result in an individual not meeting the eligibility criteria due to substantial wages. In fact, since derivative asylees are arriving to join a family member who has lived in the US for some time and who may be gainfully employed (may even have health insurance coverage), they may not meet the financial criteria for RMA or Medicaid. Comparison to 2003-2006 data The percentage of arrivals applying for Medicaid and enrolling in the program did not change very much in 2007. The percentage for asylee (85 to 82%) and Cuban and Haitian entrants (93 to 92%) decreased slightly, while percentages for parolees and refugees did not change. Lawton and Rhea Chiles Center, USF 37
Figures 18 Figure 18. Percent of Arrival* Medicaid Applicants Enrolling in Medicaid by Region 10 9 8 95.7% 94. 93.8% 79.6% 94.9% 85.8% 7 6 5 4 3 2 21,685 1,907 1,102 624 712 877 1 Southeast Tampa Bay Southwest Central Northeast Other Counties Southeast: Broward, Palm Beach, and Miami-Dade Counties Tampa Bay: Hillsborough, Pasco, and Pinellas Counties Region of Florida Southwest: Collier and Lee Counties Central: Orange and Seminole Counties Northeast: Duval County * The Southeast, Tampa Bay, Southwest, and Northeast regions have very high percentages of arrivals that applied for Medicaid and enrolled. Arrivals from the Central region applying for Medicaid are enrolling at a rate of less than 80 percent. It is worth noting that 65% of the arrivals settling in the Central region are classified as asylees. Comparison to 2003-2006 data The Central region is the only region with a significant change in the percentage of arrival Medicaid applicants that enroll in the program. This region experienced a decrease from 92 to a little less than 80 percent. Lawton and Rhea Chiles Center, USF 38
Figures 19a through 19f: Figure 19a. Central Region*: Percent of Arrival** Medicaid Applicants Enrolling in Medicaid by VOLAG 94.1% 97.1% 95.5% 96.4% 10 9 8 7 6 5 4 3 2 16 68 64 27 1 LIRS POP USCCB Other VOLAG *Orange and Seminole Counties Counties * Figure 19b. Northeast Region*: Percent of Arrival** Medicaid Applicants Enrolling in Medicaid by VOLAG 10 9 100. 99.5% 93.8% 98.9% 100. 8 7 6 5 4 3 35 194 15 89 248 2 1 CCSA LIRS POP USCCB WRRS VOLAG *Duval County **Refugees, asylees, parolees from Cuba or Haiti, and Cuban/Haitian entrants entering Florida between January 1, 2007 and Dec ember 31, 2007 Lawton and Rhea Chiles Center, USF 39
Figure 19c. Southeast Region*: Percent of Arrival** Medicaid Applicants Enrolling in Medicaid by VOLAG 10 100. 99.5% 99.3% 98.9% 100. 99.5% 99.6% 99. 98.2% 100. 99.4% 9 91.4% 8 7 6 5 4 3 2 43 364 151 518 262 193 3,777 64 411 270 228 7,164 1 CCSA CWS EMM IRC IRSA LIRS POP REL USCCB WRRS YCO Other VOLAG *Broward, Palm Beach, and Miami-Dade Counties * Figure 19d. Southwest Region*: Percent of Arrival** Medicaid Applicants Enrolling in Medicaid by VOLAG 10 100. 98.8% 100. 100. 99.3% 9 8 7 6 5 4 3 11 169 4 39 134 2 1 LIRS POP REL VOLAG USCCB Other *Collier and Lee Counties **Refugees, asylees, parolees from Cuba or Haiti, and Cuban/Haitian entrants entering Florida between January 1, 2007 and Dec ember 31, 2007 Lawton and Rhea Chiles Center, USF 40
Figure 19e. Tampa Bay Region*: Percent of Arrival** Medicaid Applicants Enrolling in Medicaid by VOLAG 100. 98.8% 99.4% 98.9% 100. 10 9 8 7 6 5 4 3 2 22 715 335 181 92 1 CCSA LIRS POP USCCB Other VOLAG *Hillsborough, Pasco, and Pinellas Counties * Figure 19f. Other Region*: Percent of Arrival** Medicaid Applicants Enrolling in Medicaid by VOLAG 10 100. 95.5% 98.1% 100. 9 84.6% 85.7% 8 7 6 5 4 3 2 12 11 128 6 105 75 1 CCSA LIRS POP REL USCCB Other VOLAG *All Florida counties excluding Duval, Collier, Lee, Orange, Seminole, Hillsborough, Pasco, Pinellas, Broward, Palm Beach, and Miami-Dade. * Lawton and Rhea Chiles Center, USF 41
For the most part, arrivals applying for Medicaid from all VOLAGs, as well as the non-volags providing services to arrivals (POP and REL), are enrolled in Medicaid. This indicates that most arrivals meet the eligibility criteria as soon as they arrive in the country and that the programs providing assistance are easing the application process for these individuals. Comparison to 2003-2006 data There were no significant changes in the percentage of arrivals enrolling in Medicaid. Figures 20a through 20c: Figure 20a. Percent of Arrivals Enrolled in Medicaid 30 Days from Arrival by Country of Origin* 10 9 85.7% 97.2% 88.5% 8 71.1% 7 6 55.3% 5 4 34.6% 3 24.9% 22.2% 2 14.7% 1 0. 454 70 0 129 20,446 427 0 9 49 27 266 0. Country of Origin Lawton and Rhea Chiles Center, USF 42
Figure 20b. Percent of Arrivals Enrolled in Medicaid One Year from Arrival by Country of Origin* 10 9 86.1% 8 7 6 5 44. 42.3% 39.9% 4 29.4% 33.1% 27.3% 33.3% 26.9% 34.2% 35.1% 3 2 233 62 5 172 6,320 814 2 7 133 13 169 1 Country of Origin Figure 20c. Percent of Arrivals Enrolled in Medicaid Two Years from Arrival by Country of Origin* 10 9 8 76.4% 7 6 49.7% 5 42.8% 43.8% 37.6% 4 31.1% 29.4% 33.3% 30.8% 3 21.3% 23.7% 2 1 165 55 5 222 4,932 958 2 8 146 9 181 Country of Origin Lawton and Rhea Chiles Center, USF 43
Figures 20a, 20b, and 20c show the percent of arrivals enrolled in Medicaid after 30 days, 1 year, and 2 years of arrival (or asylum granted), respectively. Figure 20a depicts the percent of arrivals enrolled in Medicaid after 30 days of arrival (or asylum granted). The majority of arrivals enrolled in Medicaid after 30 days of arrival originate from countries with large populations of refugees, parolees, and Cuban and Haitian entrants. Countries with high percentages of asylees are not being enrolled soon after asylum has been granted. The assistance provided by VOLAGs and the Parolee Orientation Program seem to have an impact on the decision to apply for Medicaid benefits. Only 53% of asylees apply for Medicaid, while the percentage for refugees, parolees, and Cuban and Haitian entrants is in the eighties (see Figure 15). It is not necessarily safe to assume that the wages asylees earn while waiting for their asylum to be granted makes them ineligible for Medicaid benefits. In fact, the majority of asylees applying for Medicaid ultimately enroll (82%). So the fact that asylees are not applying in general and not enrolling soon after becoming eligible for benefits is probably due to the lack of knowledge about the application process and the Medicaid system as a whole and lack of assistance in completing the application. Figure 20b shows the percent of arrivals enrolled in Medicaid after one year of arrival (or asylum granted). A high percentage of arrivals from Burundi (86%) continue to be enrolled in Medicaid 1 year after arrival. This continued enrollment could signify that arrivals from Burundi are not yet economically independent, earning incomes low enough to qualify for Medicaid benefits. However, there are large decreases in the percentages of Burmese, Cubans, and Vietnamese arrivals, countries with arrivals mostly classified as a refugee, parolee, or Cuban and Haitian entrant. Unlike the arrivals from Burundi, the Burmese, Cubans, and Vietnamese appear to be earning wages substantial enough to make them ineligible for continued Medicaid benefits, hence the drop in percentages of these arrivals after 1 year. Additionally, comparing one day enrollments to 30 day enrollments, there are increases in the percentages and absolute numbers for China, Colombia, Haiti, Peru, and Venezuela. The increases by these countries, which have the majority of their arrival population classified as asylee, in Medicaid enrollment after 1 year of arrival indicate that asylees are not applying for Medicaid as soon as they are granted asylum. It is possible that these asylees are not aware of the potential benefits they may be eligible for until months after their asylum is granted. Figure 20c shows the percent of arrivals enrolled in Medicaid two years after arrival (or asylum granted). Once again, there is a decrease in percentage of arrivals enrolled in Medicaid from countries with significant numbers of their arrivals classified as refugees, parolees, and Cuban and Haitian entrants. This means that these individuals are becoming financially independent and are no longer eligible for Medicaid benefits. On the other hand, countries with arrivals primarily classified as asylees have increased percentages and absolute numbers of enrollment in Medicaid once again. This signifies the continued postponement for asylees to apply for benefits and, more importantly, could indicate that asylees are not becoming financially independent as quickly as refugees, parolees, and Cuban and Haitian entrants. If increasing numbers of asylees are enrolling in Medicaid two years after being granted asylum, this implies that their earnings are still very low considering they have lived in the state for at least two years. The fact that the number of refugees, parolees, and Cuban and Haitian entrants enrolled in Medicaid is continuously decreasing every year indicates that the resettlement services provided by VOLAGs, as well as those services provided by the POP, are preparing a path to selfsufficiency and economic independence for these individuals. This is something that is not being experienced by asylees two years after their asylum has been granted. So, one can assume that it would be beneficial for asylees to receive similar services in order for them to become self-sufficient faster and spend less overall time enrolled in Medicaid. Lawton and Rhea Chiles Center, USF 44
Comparison to 2003-2006 data There seems to be a similar trend in terms of arrivals enrolled in Medicaid 30 days and one year after arrival (or asylum granted). Countries with mostly refugees, parolees, and Cuban and Haitian entrants have high percentages of their arrivals enrolled in Medicaid 30 days after arrival. Additionally, after one year of arrival or asylum granted, the percentages for countries whose arrivals are mostly comprised of asylees increase and the percentages for countries with mostly refugees, parolees, and Cuban and Haitian entrants decreases. The only difference observed occurs at two years after arrival (or asylum granted). Previous data show all countries with similar percentages of arrivals enrolled in Medicaid (around 3). However, recent data show countries with large numbers of asylees have significantly higher enrollment percentages than countries with mostly refugees, parolees, and Cuban and Haitian entrants. It could be possible that asylees are recently experiencing hardships earning wages and becoming financially independent and, thus, remain eligible and enrolled in Medicaid. Figure 21: Figure 21. Arrivals' Medicaid Assistance Category by Length of Enrollment* 7 6 5 4 30 Days 365 Days 3 2 1 Assistance Category This figure represents the Medicaid Assistance categories arrivals were enrolled in 30 and 365 days after enrollment began. All arrivals enrolled in Medicaid are represented by one of the Assistance Categories. The percentages are calculated by the number of arrivals enrolled in a specific category as a percent of those covered in all categories for 30 and 365 days, respectively. Lawton and Rhea Chiles Center, USF 45
The following table summarizes the Assistance Categories from Figure 21: Covered by Refugee Medical Assistance Covered by Medicaid Code Definition Code Definition MRR Direct Assistance Medical Assistance full coverage MAU Medicaid for low income families (unemployed parent) full coverage MREI Extended Medicaid for Earned Income Full coverage continues for a specified time despite income increase MAR Medicaid for low income families (deprived child) full coverage MRMC NRR Medical coverage for children born after 9/30/83 Full Coverage Direct assistance (medical noninstitutional) Limited to noninstitutional care MEI MMC MS Transitional Medicaid due to caretaker earned income full coverage for a limited amount of time Medicaid for children born after 9/30/83 full coverage SSI Medicaid for persons receiving Social Security disability benefits full coverage Within 30 days of enrollment in Medicaid, the majority of arrivals are covered under MRR (6), MAU (17%), and MAR (12%). The 6 covered under MRR obtain their benefits through Refugee Medical Assistance (RMA). MREI, MRMC, and NRR are assistance categories covered under RMA but these categories represent less than 3% of all the arrivals enrolled in Medicaid after 30 days of enrollment. After 365 days of enrollment in Medicaid, virtually no arrivals are classified under the categories covered through RMA. The medical benefits arrivals receive through RMA are for a length of 8 months after initial enrollment, so no arrivals should be receiving RMA benefits one year after enrollment and, for the most part, this is the case. Ninety-seven percent (97%) of those enrolled in Medicaid after one year of initial enrollment receive full benefits from Medicaid. There are 27,056 arrivals, approximately 76% of the total arrival population of our cohort, receiving benefits from one of the Medicaid Assistance Categories at 30 days after initial enrollment. At 365 days after initial enrollment, there are 12,534 arrivals, approximately 35% of the total arrival population of our cohort, receiving benefits. Comparison to 2003-2006 data The only significant changes have been an increase in the MRR assistance category (49 to 6) after 30 days of enrollment, a decrease in the MAU assistance category (24 to 17%) after 30 days of enrollment, and a decrease in the MEI assistance category (35 to 31%) after 365 days of enrollment. Lawton and Rhea Chiles Center, USF 46
Figure 22: Figure 22. Percent of Arrivals* with No Initial Health Assessment who Enrolled in Medicaid by Country of Origin 10 9 8 7 59.2% 6 51. 48.7% 5 40. 38.9% 41. 42.9% 4 35.3% 34.7% 3 22.9% 27.3% 2 1 73 2 16 400 4,312 1,483 6 18 289 6 217 Country of Origin * Fifty-one percent (51%) of arrivals who did not complete a domestic health assessment enrolled in Medicaid. There is some variation between countries of origin, with a low of 23% for China and a high of 59% for Cuba. All other countries of origin fall somewhere between. This figure is important in terms of identifying arrivals that have not completed their assessments. More than half of all arrivals who did not complete a assessment enroll in Medicaid; meaning that if county health departments were to be notified of an arrival that has enrolled in Medicaid, they can potentially reach more than half of the arrival population without their required assessment. Better yet would be if the county health department could be notified of all arrivals who have applied for benefits and not completed their assessment rather than those who have been enrolled. This will capture even more of the arrival population without a completed assessment. Summary: Medicaid Application and Enrollment Burma, Burundi, Cuba, and Vietnam have the highest percent of arrivals applying for Medicaid Refugees, parolees, and Cuban and Haitian entrants are most likely to apply for Medicaid Asylees are the least likely to apply for Medicaid and are least likely to be enrolled VOLAGs have a very high percentage of clients applying for Medicaid Asylees delay application for Medicaid 51% of arrivals not completing a health assessment enrolled in Medicaid Lawton and Rhea Chiles Center, USF 47
Comparison to 2003-2006 data There were mostly decreases in the percentage of arrivals with no domestic health assessment who enrolled in Medicaid by country origin. Colombia (45 to 39%), Cuba (67 to 59%), Peru (41 to 27%), Russia (60 to 35%), Venezuela (50 to 49%), and Vietnam (54 to 43%) all had lower percentages of arrivals with no assessment enrolling in Medicaid. Only Burma (38 to 51%) and Haiti (37 to 41%) increased. Utilization of Medical Services Data for this section are derived from the approximately 29% of our total cohort that enrolled in Medicaid through a fee-for-service (FFS) provider. Figure 23: Figure 23. Percent of Arrivals* Enrolled in Medicaid** Having at Least One Service within Eight Months of Arrival 10 9 8 85.1% 83.9% 82.7% 87.8% 7 6 63.2% 71.2% 5 4 3 2 6,360 224 534 724 220 337 1 Southeast Northeast Tampa Bay Southwest Central Other Counties Southeast: Broward, Palm Beach, and Miami-Dade Counties Tampa Bay: Hillsborough, Pasco, and Pinellas Counties Region of Florida Southwest: Collier and Lee Counties Central: Orange and Seminole Counties Northeast: Duval County **Includes fee-for-service Medicaid only. Overall, approximately 83% of arrivals enrolled in FFS Medicaid received at least one service within 8 months of enrollment. The arrivals in the Central region have a much lower utilization rate than the other regions. Arrivals settling in the Central region are mostly asylees and might not have had the same introduction to the Medicaid system as a refugee. On the other hand, because asylees are usually in the country for several months before becoming eligible for Medicaid benefits, their overall health might be better and they may not require as many medical services. Comparison to 2003-2006 data Lawton and Rhea Chiles Center, USF 48
All of the regions had decreased percentages (ranging from 5 to 10 percentage points) of enrolled arrivals having at least one service within eight months of arrival (or asylum granted), with the exception of the Southwest region which experienced no change. Figure 24: Figure 24. Percent of Arrivals* Enrolled in Medicaid** Who Received a Service within Eight Months of Arrival by Country of Origin and Domestic Health Assessment Status 10 98% 96% 94% 92% 9 88% Screening No Screening 86% Country of Origin **Includes fee-for-service Medicaid only. Figure 24 compares the percentages of all arrivals that enrolled in Medicaid, received a assessment, and received a service within 8 months of arrival (or asylum granted) to those who enrolled in Medicaid and received a service within 8 months of arrival (or asylum granted) but did not receive a assessment. It seems as though most arrivals who enroll in Medicaid, regardless of whether they received a assessment or not, receive a service within 8 months of enrollment. At 91%, Vietnam is the country of origin with the lowest percentage. Additionally, it is worth noting that Vietnam is also the country of origin with the largest difference between arrivals with assessments and those without completion of one, with the difference being approximately 9 percentage points. Comparison to 2003-2006 data There are no significant differences in the data. Over 9 of arrivals enrolled in Medicaid are receiving a service within 8 months of arrival (or asylum granted) regardless of receiving a domestic health assessment. Lawton and Rhea Chiles Center, USF 49
Figure 25: Figure 25. Percent of Arrivals* Enrolled in Medicaid** Having at Least One Service within Eight Months of Arrival 10 9 94.3% 90. 8 7 74.2% 6 5 57.1% 4 3 2 1 1,018 1,575 4,940 921 Asylees C/H Entrants Parolees Refugees **Includes fee-for-service Medicaid only. This figure shows that, from all arrivals enrolled in FFS Medicaid, parolees and refugees are more likely to access medical services within 8 months of arrival (or asylum granted). The majority of Cuban and Haitian entrants and asylees who enroll in FFS Medicaid also receive at least one medical service within 8 months but their rates are much lower. Overall, 83% of all arrivals enrolled in FFS Medicaid receive a service within 8 months. Comparison to 2003-2006 data There are some differences in the percent of arrivals enrolled in Medicaid having at least one service within 8 months of arrival (or asylum granted) by immigration status. Overall, the percentages decreased slightly for all immigration status groups: asylees (63 to 57%), Cuban and Haitian entrants (77 to 74%), parolees (97 to 94%), and refugees (95 to 9). Figures 26a through 26e: Figures 26a through 26e show the extent of the treatment seeking behavior of arrivals diagnosed with a condition during a assessment with respect to their country of origin. When a condition is diagnosed, it is the responsibility of the county health department to provide the arrival with a referral for proper treatment. Additionally, VOLAGs are tasked with seeking the proper treatment for specific conditions any of their clients may have. Appendix A provides a list of treatment codes. Lawton and Rhea Chiles Center, USF 50
Due to the relatively small numbers resulting from the separation of the data by country of origin, analysis will only be conducted on those groups of arrivals with 15 or more cases with a diagnosed condition. Figure 26a. Percent of Arrivals* Diagnosed with High Cholesterol Seeking Treatment by Country of Origin** 6 53.8% 5 4 3 2 12.1% 1 0. 0. 1.4% 1.5% 0. 0. Country of Origin **Excludes arrivals enrolled in Medicaid managed care plans. Lawton and Rhea Chiles Center, USF 51
Figure 26b. Percent of Arrivals* Diagnosed with Hepatitis B Seeking Treatment by Country of Origin** 25% 23.5% 2 19. 15% 1 8. 5% 0. 0. 0. 0. 0. Country of Origin **Excludes arrivals enrolled in Medicaid managed care plans. Lawton and Rhea Chiles Center, USF 52
Figure 26c. Percent of Arrivals* Diagnosed with Hepatitis A Seeking Treatment by Country of Origin** 25% 2 15% 13.6% 10.4% 1 7.9% 4.9% 5% 0. 0. 0. 0. 0. 1.6% 0. Country of Origin **Excludes arrivals enrolled in Medicaid managed care plans. Figure 26d. Percent of Arrivals* with Urinalysis Abnormalities Seeking Treatment by Country of Origin** 25% 23.3% 2 15% 10. 1 5.3% 5.7% 5% 0. 0. 0. Country of Origin **Excludes arrivals enrolled in Medicaid managed care plans. Lawton and Rhea Chiles Center, USF 53
Figure 26e. Percent of Arrivals* Diagnosed with Parasites Seeking Treatment by Country of Origin** 14% 12.4% 12% 1 8.7% 8% 6% 4% 2% 0. 0. 0. 0. 0.4% 0. 0. 0. Country of Origin **Excludes arrivals enrolled in Medicaid managed care plans. Data for Figure 26a illustrates that less than 2% of Haitians and Colombians seek treatment for high cholesterol, while 12% of Venezuelans do. More than half of Cubans (54%) are seeking treatment for cholesterol. Figure 26b shows that very few arrivals are seeking treatment for hepatitis B, with 24% of Burmese, 19% of Cubans, and 8% of Haitians doing so. As depicted in Figure 26c, most arrivals diagnosed with hepatitis A go untreated. In fact, only 14% of Burmese, 1 of Cubans, 5% of Haitians, and 2% of Venezuelans seek treatment, while arrivals from Burundi and Colombia go untreated for hepatitis A. Figure 26d shows very few arrivals seeking treatment for urine abnormality. Only 23% of Cubans, 6% of Haitians, and 5% of Colombians were treated for the condition. Figure 26e shows that only twelve percent (12%) of Cubans and less than 1% of Haitians are seeking treatment for parasites. Diagnosed arrivals from Burma, Colombia, and Venezuela go untreated for the condition. Overall, there were 11,817 diagnosed cases and only 2,853 cases were treated. Only 24% of diagnosed cases were treated. Comparison to 2003-2006 data There are no significant differences in the percentages of arrivals diagnosed with a condition and their treatment seeking behavior. Overall, there continues to be a very low number of arrivals seeking treatment for identified conditions. Figures 27a through 27e: Figures 27a through 27e represent the treatment seeking behavior of arrivals diagnosed with a condition by area of the state. Once again, due to the small numbers resulting from the separation of Lawton and Rhea Chiles Center, USF 54
data by area of the state, analysis was conducted only on areas with 15 cases of a diagnosed conditions. Appendix A provides a list of treatment codes. Figure 27a. Percent of Arrivals* Seeking Treatment for Diagnosed High Cholesterol by Area of Florida** 6 52.7% 5 4 33.3% 31. 3 19.5% 2 15.5% 1 0. Northeast Southwest Tampa Bay Southeast Central All Other Area of Florida **Excludes arrivals enrolled in Medicaid managed care plans. Figure 27b. Percent of Arrivals* Seeking Treatment for Diagnosed Hepatitis B by Area of Florida** 2 20. 18% 17.1% 16% 14% 13.3% 14.3% 12% 1 8% 6% 4% 2% 0. 0. Northeast Southwest Tampa Bay Southeast Central All Other Area of Florida **Excludes arrivals enrolled in Medicaid managed care plans. Lawton and Rhea Chiles Center, USF 55
Figure 27c. Percent of Arrivals* Seeking Treatment for Diagnosed Hepatitis A by Area of Florida** 12% 10.6% 1 8.5% 8% 5.9% 5.6% 6% 4.4% 4% 3.1% 2% Northeast Southwest Tampa Bay Southeast Central All Other Area of Florida **Excludes arrivals enrolled in Medicaid managed care plans. Figure 27d. Percent of Arrivals* Seeking Treatment for Diagnosed Urine Abnormalities by Area of Florida** 25% 22.4% 2 16.7% 14.9% 16.7% 15% 1 5.6% 5% 0. Northeast Southwest Tampa Bay Southeast Central All Other Area of Florida **Excludes refugees enrolled in Medicaid managed care plans. Lawton and Rhea Chiles Center, USF 56
Figure 27e. Percent of Arrivals* Seeking Treatment for Diagnosed Parasites by Area of Florida** 12% 10.9% 9.8% 1 8% 6% 5.1% 4% 2% 1.2% 0. 0. Northeast Southwest Tampa Bay Southeast Central All Other Area of Florida **Excludes arrivals enrolled in Medicaid managed care plans. Data for Figure 27a display 53% of arrivals seek treatment in the Southeast region, while the Southwest (33%), Tampa Bay (31%), and Central (2) regions all have much lower percentages. Figure 27b shows very few arrivals diagnosed with hepatitis B are seeking treatment. Only 17 and 13% of arrivals in the Southeast and Northeast regions, respectively, are seeking treatment for this condition. Most arrivals diagnosed with hepatitis A, as shown in Figure 27c, are not seeking treatment. The Southeast region has the highest percentage, with 11% of their arrivals seeking treatment. As Figure 27d shows, twenty-two percent (22%) of arrivals diagnosed with urine abnormalities seek treatment in the Southeast, 17% in the Southwest, and 15% in the Tampa Bay regions. Data for Figure 27e displays very low percentages of arrivals seeking treatment for parasites. At 11%, the Southeast has the highest percentage of arrivals seeking treatment. It is clear from Figures 26 and 27 that arrivals diagnosed with a condition are not seeking appropriate and timely treatment. This is not only a concern for the health of the arrivals themselves, it is important for the health of the general public of Florida that these arrivals seek proper treatment. Comparison to 2003-2006 data Overall, when ignoring the regions with small numbers of cases, there are no significant differences in the findings. Once again, there are many arrivals not seeking treatment for identified conditions. Lawton and Rhea Chiles Center, USF 57
Figure 28: Figure 28. Percent of Arrivals* with Preventive Health Services within Eight Months of Arrival by Country of Origin** 9 8 78.7% 83.4% 7 6 65.6% 60. 5 43.4% 4 34.2% 3 23.9% 2 16. 1 Country of Origin **Excludes refugees enrolled in Medicaid managed care plans. Overall, more than 77% of arrivals enrolled in Medicaid received a preventive health service within 8 months of arrival or asylum granted. However, there are some distinct differences between the countries of origin. At 83%, Cubans are most likely to receive a preventive health service, followed by arrivals from Burma (79%), Burundi (66%), and Russians (6). Haitians, Colombians, and Venezuelans are least likely to receive a preventive health service. These countries have high percentages of asylees so they may not be as familiar with the benefits offered by Medicaid as refugees or parolees. It should be noted that the majority of the 77% of arrivals enrolled in Medicaid receiving a preventive health service within 8 months of enrollment are Cuban (94% are). Comparison to 2003-2006 data Only those arrivals from Burma (54 to 78%) and Cuba (82 to 83%) had increases in preventive health services within 8 months of arrival. This would be an expected result for the Burmese population because of their increased number of arrivals classified as a refugee. The percentage change for Cubans is rather insignificant. Significant decreases in utilization of preventive services occurred for Colombians (44 to 24%) and Venezuelans (29 to 16%). Lawton and Rhea Chiles Center, USF 58
Figure 29: Figure 29. Percent of Arrivals* with Preventive Health Services within Eight Months of Arrival by Area of Florida** 8 78. 73.8% 79.8% 7 66.9% 6 56.4% 52.8% 5 4 3 2 1 Northeast Southwest All Other Tampa Bay Southeast Central Area of Florida **Excludes arrivals enrolled in Medicaid managed care plans. As stated in Figure 28, 77% of arrivals enrolled in Medicaid receive a preventive health service within 8 months of enrollment. However, these data may be somewhat skewed because 94% of those arrivals receiving those services are Cuban. When these data are separated by regions of the state, the Central region emerges with the lowest percentage. This could be due to the high percentage of asylees that settle in that region and their lack of knowledge of the services available to them through Medicaid. Comparison to 2003-2006 data The Northeast and Central regions experienced significant percentage decreases in the percent of arrivals receiving preventive health services within 8 months of arrival (or asylum granted). The Northeast region decreased from 82 to 67% and the Central region decreased from 63 to 53 percent. Slight increases in percentages were found for the Southwest (75 to 78%) and Tampa Bay (71 to 74%) regions. Lawton and Rhea Chiles Center, USF 59
Figure 30: Figure 30. Percent of Women* with Medicaid-Paid Deliveries Who Received Pre-Natal Care by Country of Origin** 10 100. 100. 98% 99.4% 100. 96% 95.7% 94% 94.1% 92% 9 91.3% 91.7% 88% 86% Country of Origin **Excludes arrivals enrolled in Medicaid managed care plans. Over 97% of all women enrolled in Medicaid who delivered a baby received pre-natal care. With the lowest percentage at 91%, it does not seem as though country of origin plays a major role in whether a woman receives pre-natal care or not. Unfortunately, there is no way of determining the intensity of prenatal care. Comparison to 2003-2006 data The only significant change occurred in the percentage of Colombian women enrolled in Medicaid who delivered a baby and received pre-natal care; a decrease from 98 to 91 percent. Lawton and Rhea Chiles Center, USF 60
Figure 31: Figure 31. Percent of Women* with Deliveries Who Received Pre-Natal Care by Region of Florida** 100. 100. 100. 100. 98. 97.4% 96. 94. 94.3% 92. 91.9% 90. 88. 86. Northeast Southwest Tampa Bay Southeast Central All Other Region of Florida **Excludes arrivals enrolled in Medicaid managed care plans. Once again, as stated in Figure 30, over 97% of women enrolled in Medicaid delivering babies are receiving pre-natal care. With 92%, the Tampa Bay region s percentage is slightly lower than the rest of the regions; however, with 34 women receiving pre-natal care and 37 total deliveries, the numbers for the region are fairly small which can lead to large percentage changes. Comparison to 2003-2006 data The only significant change was seen in the Tampa Bay region, with the percentage of women dropped from 98 to 92%. Lawton and Rhea Chiles Center, USF 61
Figure 32: Figure 32. Preventive Health Care for Arrival Children* under Five by Country of Origin** 500 450 400 464 40.9% All Children under 5 Children with Preventive Care 350 300 250 200 190 217 150 100 50 0 44.8% 13.5% 29 80. 37 13 10 No 8 Data 5 BURMA BURUNDI CHINA COLOMBIA CUBA HAITI PERU RUSSIA VENEZUELA VIETNAM Figure 32 illustrates preventive health care utilization by arrival children less than five years of age by country of origin. Some countries of origin have very small numbers of children under the age of five. However, when taking into account all the children under five from all the countries of origin, only 29% of these children are receiving preventive care. These percentages do vary somewhat by country of origin. Burundi has the highest percentage at 80 percent. All other countries fall below 45%, with no children from Russia receiving preventive care. However, there are only two Russian children under five in our cohort so that country of origin might not be the best to analyze. Haiti, on the other hand, has 217 children less than five years of age, with only 7% of them receiving preventive health care services. Comparison to 2003-2006 data There are small changes in the overall percentage of children under five receiving preventive health care services. The findings from the 2003 through 2006 data show that 35% of children received some type of preventive care, whereas in 2007 that percentage decreased to about 29 percent. Burma was the only country with a significant difference in percentage. The percentage of Burmese children under five receiving preventive health care services increased from 22 to 45 percent. This could very well be due to the fact that in 2007, Burmese arrivals were more likely to be classified as a refugee. This allows for them to receive assistance from VOLAGs. 15 Country of Origin **Excludes arrivals enrolled in Medicaid managed care plans. 6.9% No Data 2 0. 0 38 18.4% 7 0. 1 0 Lawton and Rhea Chiles Center, USF 62
Figure 33: Figure 33. Preventive Health Care for Arrival Children* under Five by Area of Florida** 600 533 500 400 All Children under 5 Children with Preventive Care 33.4% 300 200 178 100 0 16.1% 18.5% 21.8% 62 65 55 10 12 12 35 61 19 12 Central Other Areas Tampa Bay Southeast Northeast Southwest Area of Florida **Excludes arrivals enrolled in Medicaid managed care plans. 54.3% 19.7% According to the data for Figure 33, 3 of arrival children less than five years of age receive preventive health care services. The Northeast region has the highest percentage at 54%, followed by the Southeast region at 33 percent. The other regions fall somewhere between 16 and 22 percent. The Central region, with the majority of their arrival population classified as asylee, has the lowest percentage. Comparison to 2003-2006 data The Southwest, Southeast, and Tampa Bay regions experienced a significant drop in the percentage of children less than five years of age receiving preventive health care services. The Southeast and Tampa Bay regions each had a decrease of approximately 8 percentage points, while the Southwest had a 31 percentage point decrease. The Northeast region increased its percentage from 47 to 54 percent. Lawton and Rhea Chiles Center, USF 63
Figure 34: Figure 34. Percent of Female Arrivals* 14-44 Receiving Women's Health Care by Country of Origin** 5 45% 41.3% 4 35% 31.5% 3 25% 2 15% 25. 22.5% 11.4% 19.5% 20. 14.9% 16.7% 1 5.6% 5% Country of Origin **Excludes refugees enrolled in Medicaid managed care plans. Data from Figure 34 show that 32% of all women between 14 and 44 years of age received some type of women s health care (see Appendix A for ICD-9 and CPT codes). Percentages vary by country of origin. Cuban women are the most likely to receive women s health care services, with 41% doing so, followed by women from Burma (32%), Burundi (25%), and China (23%). All other countries of origin are below 20 percent. Comparison to 2003-2006 data The only country with increases in percentages of women between 14 and 44 years of age receiving women s health care was Burma (26 to 32%). This could very possibly be due to the increase in number of Burmese arrivals classified as refugees in 2007. Russia experienced a significant decrease from 30 to 6 percent. Lawton and Rhea Chiles Center, USF 64
Figure 35: Figure 35. Percent of Female Arrivals* 14-44 Receiving Women's Health Care by Area of Florida** 4 35.1% 35% 31.2% 3 24.3% 25.1% 25% 21. 2 15.9% 15% 1 5% Other Area Central Southeast Northeast Southwest Tampa Bay Area of Florida **Excludes refugees enrolled in Medicaid managed care plans. Figure 35 displays once again that, for percent of women receiving women s health care, the Central region percentages are below that of the other Summary: Utilization of Medical Services regions. As already stated, these low percentages could very well be due to the large number of asylees settling in that region. The Southeast (35%) and Southwest (31%) regions have the highest percentages. Overall, 32% of women between 14 and 44 years of age are receiving women s health care. Comparison to 2003-2006 data 83% of arrivals enrolled in FFS Medicaid received at least one service within 8 months of arrival Parolees and refugees are most likely to access medical services within 8 months of arrival Most arrivals diagnosed with Hepatitis A are not seeking treatment Only 24% of diagnosed conditions received treatment Cubans are most likely to receive preventive health services Most arrival women enrolled in Medicaid who gave birth received pre-natal care Only 29% of arrival children received preventive care Children from Haiti are the least likely to receive preventive care All regions of the state experienced a decrease in the percentages of women between 14 and 44 years of age receiving women s health care. The percentage for the Southwest region dropped the most from 44 to 31 percent. Lawton and Rhea Chiles Center, USF 65
Providers Figure 36: Figure 36. Shares of All Arrivals' Services* for Selected Provider Types by Area of Florida** 10 9 8 7 6 Physician or Osteopath Optometrist or Optician Dentist Physician Asst. or Nurse Chiropractor All Other Providers 5 4 3 2 1 Central Northeast Southeast Southwest Tampa Bay All Other Areas Area of Florida **Excludes refugees enrolled in Medicaid managed care plans. Figure 36 illustrates all the various services arrivals received by provider type and region of the state. In all regions of Florida, physicians and osteopaths provide the most services followed by services from all other providers. Overall, physicians and osteopaths provide 67% of the services, while all other providers provide 27 percent. Comparison to 2003-2006 data Data for the previous report found services provided by a physician or osteopath hovered around 30 percent, with all other providers providing the majority of the services. This report found that, for 2007 arrivals, physicians and osteopaths were providing the majority of the services (67%). Lawton and Rhea Chiles Center, USF 66
Figure 37: Figure 37. Shares of Preventive Services for Female Arrivals* 14-44 for Selected Provider Types by Area of Florida** 10 9 8 16.8% 7.3% 44. 46.1% 34.8% 39.8% 36.2% 7 6 5 2.8% 1.2% 4.1% 2.2% 3.8% Physician or Osteopath Physician Asst. or Nurse All Other Providers 4 75.9% 3 53.2% 52.7% 61.1% 58. 60. 2 1 Central Northeast Southeast Southwest Tampa Bay All Other Areas Area of Florida **Excludes refugees enrolled in Medicaid managed care plans. Figure 37 depicts the type of provider of preventive services for female arrivals between 14 and 44 years of age by region of the state. The majority of the services are provided by all other providers followed by services by a physician or osteopath. There are some differences between the regions of the state. The Central region receives a much larger percentage (76%) of its services from all other providers when compared to the other regions of the state. Comparison to 2003-2006 data For both data sets, all other providers are providing the majority of the services for all regions. However, in the Central region there was a significant increase of services from all other providers (66 to 76%). There were no other remarkable differences between the two time periods. Lawton and Rhea Chiles Center, USF 67
Figure 38: Figure 38. Shares of Preventive Care Services for Arrival Children* 0-5 for Selected Provider Types by Area of Florida** 10 9 8 7 6 Physician or Osteopath Dentist Physician Asst. or Nurse All Other Providers 5 4 3 2 1 Central Northeast Southeast Southwest Tampa Bay All Other Areas Area of Florida **Excludes refugees enrolled in Medicaid managed care plans. Figure 38 represents the type of provider of preventive services for all arrival children five years of age and younger by region of the state. Overall, 88% of all services for children five and under are provided by a physician or osteopath. Dentists provide the second largest percentage of services at 6%, followed by services from all other providers at 5 percent. The Southeast region has the highest percentage of services provided by a physician or osteopath at 91 percent. However, this region has the lowest rate of services provided by a dentist (2%). The Northeast region also has a high percentage of Summary: Providers of Preventive Services physician and osteopath services (89%) and a low percentage for dentist services (6%). The Central, Southwest, and Tampa Bay regions have percentages for physician and osteopath services ranging from 72 to 77% and percentages for dentist services ranging from 20 to 28 percent. Comparison to 2003-2006 data Physicians and osteopaths provide 67% of services to children Other providers provide the majority of services to women between the ages of 14 and 44 Dentists provide 6% of preventive health services for children five years of age and younger The Southeast region has the lowest rate of services provided to children by dentists The majority of the preventive services for arrival children five years of age and younger is provided by a physician or osteopath for both data sets. The only difference between the data is the decrease in all regions of services provided by all other providers. Lawton and Rhea Chiles Center, USF 68
Haitian Arrivals Previous research indicates arrivals specifically from Haiti do not avail themselves to health care services. 13 Due to the fact that most Haitians are classified as asylees (see Figure 1), comparing their health care utilization to that of the overall asylee population will assist in determining differences in health care seeking behavior. Additionally, because these Haitian arrivals are not utilizing the health care services available to them, identifying the most common conditions found during a Haitian s domestic health assessment is crucial in establishing outreach methods geared toward treatment. It is worth noting Figures 39b, 40b, and 41b include Haitian arrivals as part of the overall asylee data. The inclusion of Haitians may skew the results due to the fact that Haitians make up the majority of asylees for our dataset (52% of asylees are Haitian) and many do not seek health care services. So, the gaps in health care utilization between Haitians and asylees from other countries of origin could potentially be larger. Figure 39a: Figure 39a. Haitians* with Domestic Health Screenings by Region of Florida 3 27.7% 27.3% 25% 23.2% 24.3% 19.4% 2 15% 1 5.4% 5% 691 8 66 159 15 89 Southeast Tampa Bay Southwest Central Northeast Other Counties Southeast: Broward, Palm Beach, and Miami-Dade Counties Tampa Bay: Hillsborough, Pasco, and Pinellas Counties *Haitians entering Florida between January 1, 2007 and December 31, 2007 Southwest: Collier and Lee Counties Central: Orange and Seminole Counties Northeast: Duval County Overall, only 23% of Haitian arrivals receive assessments. When these data are separated by region of the state, as Figure 39a illustrates, the percent of Haitian arrivals receiving domestic health assessments does not exceed 28 percent. In fact, only 5% of Haitians in the Tampa Bay region receive assessments. 13 Markiewicz, B., Baugh, K., Tutwiler, M., Vazquez, J. (2009). Refugee Health Status and Health Care Utilization Report. Lawton and Rhea Chiles Center for Healthy Mothers and Babies, University of South Florida. Prepared for the Bureau of Tuberculosis and Refugee Health, Florida Department of Health. Lawton and Rhea Chiles Center, USF 69
Figure 39b: Figure 39b. Asylees* with Domestic Health Screenings by Region of Florida 4 36.1% 35% 3 28.6% 30. 25% 20.1% 23.5% 22.9% 2 15% 1 5% 1,182 81 81 352 30 159 Southeast Tampa Bay Southwest Central Northeast Other Counties Southeast: Broward, Palm Beach, and Miami-Dade Counties Tampa Bay: Hillsborough, Pasco, and Pinellas Counties Southwest: Collier and Lee Counties Central: Orange and Seminole Counties Northeast: Duval *Asylees entering Florida between January 1, 2007 and December 31, 2007 Figure 39b details the percentage of asylees with assessments from each region of Florida. As a group, 29% of asylees receive domestic health assessments. With the exception of the Northeast region, all other regions have asylee assessment percentages higher than those captured for Haitians in Figure 39a. It is clear that in all regions of the state, most asylees are not receiving a domestic health assessment. Lawton and Rhea Chiles Center, USF 70
Figure 40a: Figure 40a. Time Between Haitian Arrival and Domestic Health Screening by Region* 10 9 8 7 6 5 4 > 365 Days 241-365 Days 121-240 Days 91-120 Days 61-90 Days 31-60 Days 0-30 Days 3 2 1 Southeast Tampa Bay Southwest Central Northeast Other Counties Region *Haitians entering Florida between January 1, 2007 and December 31, 2007 Figure 40a shows the time between arrival (or asylum granted) and assessment by region of the state for Haitian arrivals that have received a domestic health assessment. For all regions, 95% of screened Haitians are receiving their assessments within the preferred 90 day timeframe. All regions have over 9 of their Haitian arrivals receiving their assessments within 90 days. Lawton and Rhea Chiles Center, USF 71
Figure 40b: Figure 40b. Time Between Asylee Arrival and Domestic Health Screening by Region* 10 9 8 7 6 5 4 > 365 Days 241-365 Days 121-240 Days 91-120 Days 61-90 Days 31-60 Days 0-30 Days 3 2 1 Southeast Tampa Bay Southwest Central Northeast Other Counties Region *Asylees entering Florida between January 1, 2007 and December 31, 2007 Percentages for the regions in Figure 40b, describing the time between arrival and domestic health assessment for an asylee, do not differ from those percentages in Figure 40a for Haitian arrivals. Overall, the majority of assessments for all regions are being completed within 90 days. Lawton and Rhea Chiles Center, USF 72
Figure 41a: Figure 41a. Percent of Haitians* Enrolling in Medicaid within Six Months of Arrival by Region 3 26. 25.5% 23.7% 20.8% 2 17.9% 1 5.4% 618 8 61 149 14 87 Southeast Tampa Bay Southwest Central Northeast Other Counties Southeast: Broward, Palm Beach, and Miami-Dade Counties Tampa Bay: Hillsborough, Pasco, and Pinellas Counties Region of Florida Southwest: Collier and Lee Counties Central: Orange and Seminole Counties Northeast: Duval County **Haitians entering Florida between January 1, 2007 and December 31, 2007 Data for Figure 41a show 21% of Haitians enroll in Medicaid within 6 months of arrival (or asylum granted). The percentages are low throughout all regions, with Tampa Bay having the lowest percentage (5%) of Haitians enrolling in Medicaid within 6 months of arrival (or asylum granted). Lawton and Rhea Chiles Center, USF 73
Figure 41b: Figure 41b. Percent of Asylees* Enrolling in Medicaid within Six Months of Arrival by Region 4 34. 3 26.3% 27.9% 21.7% 22.1% 2 18.9% 1 1,087 76 75 331 29 148 Southeast Tampa Bay Southwest Central Northeast Other Counties Southeast: Broward, Palm Beach, and Miami-Dade Counties Tampa Bay: Hillsborough, Pasco, and Pinellas Counties Region of Florida Southwest: Collier and Lee Counties Central: Orange and Seminole Counties Northeast: Duval County *Asylees entering Florida between January 1, 2007 and December 31, 2007 All regions for Figure 41b, except the Northeast, are enrolling asylees at a higher percentage within 6 months than Haitian arrivals (see Figure 41a). This demonstrates that Haitians are not applying for Medicaid as quickly as asylees from other countries of origin. Lawton and Rhea Chiles Center, USF 74