Barriers to health care access hurt immigrants, their families, and the city. Without regular access to affordable care, many immigrants suffer from preventable illness and injury, and might impose significant costs on the public safety net in the form of avoidable hospitalizations and procedures to treat conditions that could be managed through primary and preventive care. While the Affordable Care Act increased access to health insurance for many New Yorkers by expanding eligibility and providing financial subsidies, undocumented* adults are not eligible for Medicaid or permitted to purchase coverage on the state's insurance exchange.
In 2013 approximately 63.9%, or 345,000, of the City’s undocumented individuals were uninsured. The uninsured rate for undocumented immigrants is more than three times that of other noncitizens in New York City (20%) and more than six times greater than the uninsured rate for the rest of the City (10%).
While the federal government has given hospitals that see high rates of uninsured and publicly insured patients supplemental funding to assist with paying for the undercompensated and uncompensated care they provide, the ACA will reduce this funding, called Disproportionate Share Hospital (DSH) payments, under the assumption that hospitals will have less need for funding to offset uncompensated care as more Americans gain health insurance. But in cities like New York, where a large number of undocumented immigrants will remain uninsured, this funding decrease means less money for hospitals, particularly public hospitals such as HHC, that will continue to treat a significant number of uninsured patients.
The City is already undertaking several initiatives that help to improve and expand immigrants' access to health care services:
Expanding Safety-Net Primary Care Capacity: The City is helping to create new community health clinics operated by FQHCs in high need neighborhoods. This initiative will expand primary care capacity and address inequality in access to primary care across New York City.
Transforming HHC: Like other large hospital systems, HHC is transforming from a healthcare system focused on delivering inpatient services to the already sick to a model centered on preventive care and wellness.
Creating a Modern Health Care Workforce: In February 2015, the Department of Health and Mental Hygiene (DOHMH) launched an initiative to place community health workers at the forefront of patient-centered care delivery in communities of need.
Immigrants face barriers to accessing health care beyond the challenges faced by the uninsured population at large. The workgroups identified six major barriers to health care access for immigrants.
1. Lack of affordable care
Health care in the United States is expensive and navigating and paying for care is complicated. Many immigrant New Yorkers are not aware of existing affordable insurance options, which include Child Health Plus for all children regardless of immigration status, Medicaid and/or New York State of Health marketplace premium subsidies for immigrants with certain statuses, the forthcoming Essential Plan, or affordable options to access care for the uninsured, such as federally qualified health centers (FQHCs) and HHC Options. In addition, many immigrants are not aware that residents of New York State, regardless of age, gender, race, or immigration status, may qualify for financial assistance for hospital medical services under the Hospital Financial Assistance Law (HFAL) which provides that all hospitals in New York State must have financial assistance programs with policies for determining eligibility for discounted care.
2. Inadequate cultural and linguistic competency among health care providers
The Task Force found that immigrants often fear obtaining health services because they believe that they will have trouble understanding resultant diagnoses and treatment options. Some New Yorkers travel long distances just to receive health care services in areas with a familiar immigrant presence. In some cases, immigrants cannot locate culturally aware providers even if they travel across the city.
3. Limited service delivery and provider capacity
Immigrants, as well as many other New Yorkers, face challenges in locating providers that are culturally sensitive, operate during hours that are convenient to working individuals, and are geographically accessible. The need for multiple visits to address an ailment or injury discourages timely use of services and makes the emergency department a rational choice for "one stop shopping." As a result, there is overuse of emergency department (ED) services in New York City.
4. Lack of knowledge and understanding of care and coverage options available for immigrants
Fearing questions about immigration status, many immigrants do not seek to enroll in public insurance programs. Lack of knowledge about eligibility for CHP, Medicaid, and sliding fee scale programs such as those at HHC facilities or FQHCs may discourage many eligible individuals from taking advantage of these programs.
5. Lack of access to high-quality interpretation services
For New York City's immigrants, a lack of access to medical interpreters is a key barrier to health care access. The effects of insufficient language accessibility in health care include: worse access to care, worse care, and worse health outcomes for Limited English Proficient (LEP) patients as compared to non-LEP patients.
6. Lack of knowledge and understanding of language and translation services available to immigrants and health care providers
In addition to the lack of access to high-quality interpretation services, many immigrants are unaware of their legal rights to language access and the availability of language access services in health settings. Simply knowing one’s legal rights — and exercising those rights to obtain adequate language services — will go a long way towards providing adequate care.
The Task Force developed the following recommendations to increase access to health care services among immigrants in New York City.
1. Create a direct access health care program to provide uninsured immigrants and others with access to coordinated primary and preventive health care services.
All individuals, regardless of immigration status, should have access to affordable health insurance coverage. In the absence of action at the federal and state levels to extend access to health insurance options through public health insurance eligibility and access to financial subsidies on the Marketplace, the City should launch a direct access health care program to provide improved access to healthcare for those left behind by federal and state efforts.
2. Expand the capacity of the New York City health care system to provide culturally and linguistically competent primary and preventive health care services to immigrants.
Expanding the ability of providers to provide culturally and linguistically competent care should accompany capacity building initiatives to ensure that immigrant populations have improved access to health care.
3. Conduct public education and outreach on health care and coverage options for immigrants and the organizations that serve them.
Expanding the capacity of New York City providers to care for immigrants must be coupled with efforts to increase awareness of services among immigrants. The Task Force recommends mobilizing a focused initiative to provide consumer outreach, education, training, and engagement on the various available care and coverage options for immigrant New Yorkers.
4. Increase access to high-quality medical interpretation services.
Patients and providers who speak different languages must be able to communicate effectively to ensure health care services are appropriate and effective. The Task Force recommends actions that will boost both supply and demand of interpretation services, including recruitment and training of new medical interpreters.