Experiences of administrative and cultural barriers when enrolling for Medicaid can lead to the unsuccessful completion of applications, which in turn reduces individuals’ access to healthcare services that they are eligible for. Survey respondents reported several barriers that can deter individuals, and in particular immigrants, from applying for Medicaid. To reduce and eradicate these barriers the federal government and states need to implement policies that will help increase access to Medicaid for vulnerable populations, such as immigrants.
Many survey respondents relied on the help of others when enrolling to mitigate the administrative issues they face. Many immigrants who enroll for Medicaid rely on the help of family members who speak English better or are more familiar with the process. Others turn to the help of trusted individuals at immigrant-serving community-based organizations who help with Medicaid enrollment. Forty-four percent of respondents had help with enrolling from family members, 29 percent from community-based organizations, who have trained navigators to help provide enrollment assistance with health insurance programs, and 21 percent applied on their own.
The IRI survey asked respondents what recommendations they would make for improvements in the Medicaid enrollment process. The suggestions of these 259 individuals can be summarized in the following seven recommendations.
1. Expand support for community-based organizations to help with Medicaid enrollment. Due to experiencing barriers during Medicaid enrollment, oftentimes immigrant enrollees will turn to the trusted community-based organizations (CBOs) for help including non-profits, community health centers, religious organizations, and others. The staff at these organizations often speak their native language or have interpreting services readily available, provide connections and assistance with enrolling for government programs and educate community members about programs that they may be eligible for. Community-based organizations are paramount when wanting to build trust in any safety net program. States should provide financial assistance to CBOs to expand outreach efforts that target immigrant populations, for them to provide information on the Medicaid program, such as renewal dates, and to assist with enrollment. When immigrants can turn to these trusted CBOs for enrollment assistance it can reduce the number of discriminatory experiences with Medicaid staff, reduce transportation issues because these organizations often located near public transit and in immigrant communities, ensure that the application is completed correctly with all the required documentation, prevent applicants from having to endure long wait times for assistance and reduce language barriers.
2. Increase access to documents in other languages and translators. Federal policies require government agencies to provide language services to ensure that people with limited English proficiency have access to vital forms in their native language. Federal requirements are a good start, but they are not always sufficient. Ensuring that immigrants have access to documents in their native language and interpreting services to communicate clearly with Medicaid staff would help reduce the negative impact of language barriers and help increase the successful completion of Medicaid applications. Some states enacted their own language access policies to address the shortfalls of federal policies. All states should be working towards enacting state-level language access policies to hold government agencies accountable to ensure that all community members, regardless of national origin, have fair access to public services that they are eligible for. However, when crafting these policies, states should keep in mind the various language needs of different areas and regions of their state.
Our survey responses also found that although some government agencies are already required to provide interpreting services and translated documents by their state, oftentimes immigrants trying to enroll for Medicaid are not offered this vital service. Good policies on paper are not enough, a focus on implementation and a mechanism for enforcement are also needed to make sure agencies are accountable to their missions.
3. Make Medicaid offices easier to find and accessible to public transportation. Another point of concern for the survey respondents was the inaccessible, or difficult to find, Medicaid offices. Individuals with low incomes and immigrants may not have access to private transportation and rely on public transportation. Making Medicaid offices visible and accessible by public transit would reduce the barriers to enrollment.
4. Combat conscious and unconscious bias among Medicaid staff. Survey respondents detailed various forms of discrimination including racial bias, xenophobia, religious discrimination, and more. Additionally, many respondents noted that the unprofessional customer service that they endured made them feel devalued and helpless throughout the application process. Medicaid staff are required to assist all applicants with the enrollment process with nondiscrimination. To combat the biases that staff have, diversity training for all Medicaid staff should be a requirement. Government personnel should know and be willing to interact fairly with all community members regardless of race, gender, sex, religion, or country of origin.
Diversity training is an effective way to ensure that Medicaid personnel have the tools and skills necessary to make all individuals feel welcomed and accepted.
In addition, these government agencies should provide clear, easy, and accessible complaint processes for individuals who feel like they have experienced discrimination from staff members. These agencies should also be monitored and evaluated regularly to ensure that discrimination is not occurring and to work to prevent it.
5. Expand public education and outreach. Understanding the complex healthcare system in the United States can be challenging for all, but it is especially challenging for immigrants whose first language is not English. Survey respondents have made it clear that an effort by state governments to promote education about the Medicaid program is needed. Many respondents were not aware that the application could be filled out online. State governments should work with community-based organizations, who work closely with immigrant communities, to conduct outreach to immigrant communities about what the program is, who is eligible and how, where to enroll and how to obtain coverage once enrolled. Additionally, state governments should ensure that education and outreach materials are translated to address the language needs of different communities.
6. Reduce wait times by hiring more Medicaid staff and making the best use of existing staff. Many survey respondents expressed that they had to experience long wait times both on the phone and in-person at the Medicaid office. Long wait times can prevent immigrants from successfully completing the Medicaid application because many people cannot take the time to wait at a Medicaid office due to work conflicts or family responsibilities. Long wait times for approval after applying can also invoke anxiety and nervousness among applicants as they start to worry about their acceptance. To reduce wait times to a reasonable amount of time that does not require people to take off time from work, Medicaid agencies should hire additional staff to help. A survey respondent said, “Efficiency is the key. We can learn from other countries. Productivity is important to a health care system.” To increase efficiency and productivity and ensure that everyone who needs assistance with the application receives it, more staff is needed.
7. Make sure every applicant is treated with the respect and kindness they deserve. The urgent plea of one respondent was: “Please respect people of different colors and give them the same treatment.” Another said, “The most precious thing human beings have is life, life is time, so hope can be simple and quick. If people were not sick, who would waste their time on this.” And, as another summed it up: “Let’s embrace the less qualified immigrants and give everyone more opportunities. That’s why America is strong.”
Systemic and cultural barriers are embedded in the healthcare system, but they can be eradicated with the right changes in policy and practice.