“Why didn’t they ask for help from someone who speaks Spanish?”: Challenges to Medicaid Enrollment for Immigrants

Dec 2, 2024 Immigration Research Initiative

Introduction

People may unfairly lose Medicaid coverage, even if they qualify for the program, when they are required to go through an arduous and complicated application process every year. This is a longstanding flaw in the system, and it is especially challenging for immigrants who may not be familiar with the health care coverage system in the United States and whose first language may not be English.

During the COVID-19 pandemic, states implemented a continuous enrollment provision, a rule that required them to automatically renew Medicaid coverage for recipients until the end of the public health emergency, which meant that Medicaid recipients did not have to go through the hoops of completing an annual renewal application. Once renewals were required again, 25 million people lost Medicaid coverage. It is hard to estimate how many of these individuals are in fact eligible for Medicaid and were simply denied due to paperwork errors, difficulty obtaining required documentation, incomplete applications, or abandoned applications, but analysis by KFF indicates that a substantial number of the people who lost coverage were in fact eligible.

To better understand and highlight the particular challenges immigrants face when enrolling for Medicaid that can lead to denials or incomplete applications, Immigration Research Initiative (IRI) conducted four years of research to gather stories and delve into the ways people not born in the United States experience applying for Medicaid. IRI conducted two national surveys and one New York State survey which together collected over 700 responses. IRI conducted individual interviews with over 40 immigrants who have applied for Medicaid, some with applications that were denied and some with applications that were accepted.

The survey responses and interviews powerfully demonstrate some ways the Medicaid enrollment process can be improved. The stories immigrants told us revealed various challenges they face during the renewal and enrollment process that can be deterrents from successfully completing a Medicaid application which include language access difficulties, location access challenges, experiences of discrimination, unfriendly interactions with Medicaid personnel, required documentation issues, long wait times and more.

Background

During the COVID-19 pandemic, the federal government enacted the Families First Coronavirus Response Act (FFCRA) which declared that during the COVID-19 public health emergency, individuals covered by Medicaid, Child Health Plus (CHP) and the Essential Plan (EP) on March 18, 2020 or those who enrolled after were allowed to remain enrolled without having to go through the annual renewal process until after the public health emergency was declared over. This meant that no one covered by these health insurance programs could have their Medicaid coverage reduced or terminated.

This provision worked well for enrollees. According to KFF, it increased the number of individuals with health insurance and reduced gaps in coverage. This provision has worked well for immigrants, who often experience challenges, such as language access, or who rely on community-based organizations for help, when enrolling for Medicaid.

With the unwinding of continuous enrollment, which required individuals to renew their Medicaid after the declaration of the end of the public health emergency, a host of challenges arose for immigrants.

IRI conducted a survey in 2024 of 462 respondents, to better understand the challenges that immigrants face when enrolling or renewing Medicaid during the unwinding period, which began on April 1, 2023. These survey results build on multiple years of work that includes other national and New York focused survey results and interviews which were published as “‘I Could Not Understand the Form’: Challenges for Immigrant New Yorkers During the Medicaid Unwinding,” “‘Maybe It Is Because I Was Not Born in the U.S.’: Immigrant Stories of Challenges to Medicaid Enrollment,” and “Immigrants’ Experience with Medicaid Enrollment: Challenges and Recommendations.”

Findings

According to an IRI survey, conducted in June 2024, during the Medicaid unwinding period, about a quarter of immigrants (23 percent) found the survey difficult, and over three quarters (77 percent) of the total survey respondents (462 responses) reported that they felt the application or renewal was easy to complete.

23 Percent of Immigrants Found the Medicaid Application Difficult, 77 Percent Said It Was Easy

Source: IRI Survey of 462 respondents.

What is considered “easy” or “difficult” is also a question of expectations.

For example, although a large majority of survey respondents reported that the renewal and application process was easy, many respondents reported getting help with the process. Of the survey respondents who answered a question asking who helped them renew or apply for Medicaid (124 responses), an overwhelming majority of immigrants (94 percent) said they relied on help from others and did not complete the application on their own.

In addition, as we will see, some of the same people who said the process was easy also expressed challenges they faced.

Very Few Immigrants Applied for Medicaid on Their Own, An Overwhelming Majority Got Help with the Application

Source: IRI survey. Based on 124 responses to the question out of 462 total responses

Sources of Help with the Medicaid Application for Survey Respondents

Source: IRI survey. Based on 124 responses to the question out of 462 total responses

Almost all survey respondents received help with their application, with 31 percent relying on community-based organizations, 30 percent getting help from Medicaid personnel, 18 percent relying on family members, and 15 percent receiving help from another source. Very few, only 6 percent of respondents, completed the application on their own.

The fact that they are getting assistance from others may help explain why so many immigrants report that the application and renewal process is easy: they have help with questions or confusion that may arise.

For those who felt that the application was easy, many spelled out that it this was due to the help received from others and wrote: “because someone helped me in Spanish,” “because I got help from someone,” “I had help from a Medicaid representative.”

Although it is positive that immigrants are able to find others to help, the paperwork should be simple and easy enough for typical applicants to understand and complete on their own, regardless of which language the paperwork is provided in

Additionally, relying on family members or friends to help with applications is not always the best option. These individuals are not professionals, and may not be familiar with the paperwork. This can lead to errors that ultimately result in denials even if individuals are eligible. It is also common for parents whose English is not strong to rely on their English-speaking children to help with paperwork and to provide translation. This is also not a good option because the responsibility should not be on children and the technical language may be too complicated for them to translate or explain.

On the other hand, help from community organizations can lead to positive experiences. Some respondents specifically expressed that help from community-based organizations made the process easy: “because an organization helped me fill out the form,” “it was through my work center,” “because the social worker was explaining things to me and she filled out the form.”

Community-based organizations are trusted voices in immigrant communities. Oftentimes immigrants turn to them for help with things like Medicaid applications. That is positive for all involved, but this can put a strain on the capacity of the community-based organizations unless the group is being funded to provide these services.

Some respondents commended the ease of language access provided by the Medicaid agency: “because they gave me the request in Spanish,” “it was easy because it was in Spanish.” While many immigrants in the survey spoke a language other than English, over three quarters of respondents (82 percent) said they received the application in their native language. Providing applications in other languages can help increase successful completion of Medicaid applications.

Some survey respondents expressed that Medicaid staff had assisted them with their application and that is why they found it easy. This is the best option. Even when the Medicaid staff are helpful, however, this is not a form of help that is accessible to all due to geography and transportation issues, business hours coinciding with work hours, long waits for phone and in-person assistance, and availability of translation and interpretation services.

Those who did not have help with their application expressed a number of challenges, from language access to technology access, issues with documentation, a lack of knowledge of the process and experiences of xenophobia and discrimination.

Administrative and Cultural Challenges to Enrollment

Language Access

Many immigrants expressed concerns related to language access. Many people had difficulty understanding the questions even if they received the application form in their native language. Over and over in our interviews we heard: “I don’t understand the questions,” “Because I don’t understand some questions,” “I don’t understand some phrases.”

One respondent noted that the constant changes to the applications makes the process difficult: “Why do they change the application frequently? The questions change and get complicated.” Another respondent felt that keeping track of changes was hard: “you have to be aware of one or another change every year.”

Even though translated documents in other languages can be provided to individuals to help make the process easier, challenges still arise due to the quality of the translation. One respondent noted that the hardest part of the application process was “the language” and that although they had access to documents in their native language it was still hard to complete because “the translation was not very good.” It is important that translated documents are of high quality, and free from jargon and technical vocabulary.

Another respondent had difficulty receiving help in her native language and asked: “Why didn’t they ask for help from someone who speaks Spanish?” Another respondent noted how hard it was to find someone to help them in their native language: “The most difficult thing was to find someone who can speak Spanish.” When asked what would make the process easier a respondent said: “To have someone who speaks my language to help me.” Another respondent noted how when she got someone to help her “I didn’t talk for a long time because they didn’t provide help in Spanish.”

Another respondent frustratingly noted that you wait “a long time and they don’t reply to you in Spanish.” Even when respondents turned to Medicaid personnel for clarification, there was still confusion: “what they explained was not understood.”

When asked what could be done to make the process easier a respondent said: “Have more people who speak Spanish.”

Ensuring that the application uses simple vocabulary that can be easily understood, regardless of the language it is translated into is not only good for immigrants, it is good for all who wish to apply. This can eliminate confusion among native English speakers as well.

Technology Access

Many immigrants had difficulties with technology access that caused the application to be challenging for them. One respondent noted that they technological issues which made the online application difficult to complete: “I think the challenge was the internet.” Another respondent complained about the difficulty of reaching a live person for technical support: “Online Medicaid representatives never respond.”

Location Access

Many immigrants who qualify for Medicaid coverage may not own a car or have money for transportation to get to the Medicaid office to submit required paperwork or to seek help with the application process. The subway and bus system makes this less of a problem in New York City, but it can be a very big obstacle in other parts of the state and around the country. One respondent from Texas noted that “if you go personally, the means of transport is a challenge.” Another respondent said that they could not go to the Medicaid office for help, “because I can’t drive.” Some Medicaid offices are simply not accessible using public transportation.

Required Paperwork and Documents

The application process can be particularly hard for immigrants because they may face challenges in providing some of the required documentation. It can be difficult for many immigrants to get exactly what they need to prove their eligibility, such as notes from employers. One respondent expressed that the process was hard “because they [Medicaid personnel] ask for my account statement and I couldn’t deliver the paper.”

Another respondent attributed the difficulty of completing the application simply “because of the requirements they ask for.” Another respondent found all the requirements to be overwhelming: “due to all the paperwork that needs to be submitted.” Another respondent felt similarly: “because they ask for a lot of requirements in order to qualify.”

Lack of Knowledge

Navigating the health care system in the United States can be difficult for anyone, but it is especially challenging for immigrants who are not familiar with how the system works, how to complete the application, and what is required in the U.S. Many survey respondents expressed that there is not enough information about the enrollment or renewal process available to them to help with them complete the application. One respondent said: “I didn’t have enough information.” Another said it was difficult for them “because I didn’t know how to do it.”

Another respondent stated that they had difficulty completing the application “because I don’t understand how the service actually works.” Another respondent also acknowledged their lack of knowledge about the process “because it’s something totally new for me.”

Making this process clear enough for immigrants to understand it would likely also have the benefit of making it easier to understand for many U.S.-born who have trouble with the application.

Long Wait Times

Long wait times, both in-person and on the phone, while trying to receive help with the Medicaid application can be frustrating and time-consuming. Long wait times can also make the process more difficult, and in some cases may keep people from the health care coverage they need even if they qualify. One respondent noted in frustration: “They let me wait for more than an hour and when they replied, they told me that my question could be solved without calling and they disconnected the call without an answer.”

When asked what the hardest part of the application was a respondent said: “they take a long time.” Another similarly said “having to wait” was the most difficult part. Another pointed out the “wait in line” was very challenging. Some individuals may have to take time off of work to get to a Medicaid office during their business hours, and having to wait long periods of time can be frustrating and just not doable for some.

What is considered long in this survey was left up to the perspective of the individual. A survey respondent was optimistic and noted that an hour in line was not long for them and they waited longer on the phone: “If it’s on the phone it takes a long time, but if I go to the office, it’s fast— an hour.”

To read more about in-depth experiences of administrative and cultural challenges, see IRI’s short reports:

Xenophobia and Discrimination: “Maybe it was because of my immigration status”

Of the survey respondents, 13 percent said that they felt they were treated unfairly by Medicaid staff due to their gender, immigration status, race or other characteristics.

Many immigrants attributed to their unfair treatment to xenophobia, a dislike of or prejudice against people from other countries. One respondent thought their unfair treatment by Medicaid staff was due to their undocumented status, which was obvious to staff because they did not have a Social Security number. Despite qualifying for state-funded Medicaid, which in some states is available to some immigrants who are undocumented, the respondent felt they were treated harshly “Because I’m not a documented person and I don’t have a Social Security number.” Two other respondents felt similarly due to their immigration status and said: “I felt discriminated against because I had no documentation” and “Well, because I was a person who had no papers.” Another respondent felt that they were treated unfairly not because of legal status, but simply, “well, because we are migrants.” Another survey respondent felt like they were treated unfairly “due to language.” While another felt that it was “due to not speaking in English.” What is being reported here is not challenges with the language, but discrimination.

Other survey respondents attributed their unfair treatment to racism, “they see that [a person is] Hispanic and don’t want to help them.” Another respondent stated simply: “because they are racist.” Yet another explained that historical racism is nothing new in U.S. systems: “racism has always existed…preferences are always there.”

Another respondent suggested that Medicaid staff should just provide help, “don’t focus on nationality.” When asked what could be done to make the process better a respondent said: “I would like for there to not be discrimination.”

Another respondent felt that there was a “lack of empathy of female civil servants.”

Experiencing discrimination and xenophobia from individuals who are supposed to help can deter people from successfully completing a Medicaid application. Of those that responded to the question (124 responses), 30 percent of survey respondents relied on Medicaid personnel for help with the application. They are supposed to be a resource to turn to when individuals need help with the application. Being met with discriminatory interactions can make the application process uneasy and harder, and cause people who are eligible to not receive coverage due to unsuccessful completion of the application.

To read more about in-depth immigrants’ experiences of discrimination and xenophobia see IRI’s short reports:

“It Depends on the Person”: Immigrant New Yorkers Experiences of Discrimination and Unwelcoming Medicaid Personnel

For recommendations, from IRI with input from survey respondents and interviewees, on how to address these challenges, see:

Although the Families First Coronavirus Response Act (FFCRA) was temporary, it helped reduce gaps in Medicaid coverage. Gaps in coverage can be caused by challenges, like the difficulties expressed by immigrants in this report, which can lead to denials and incomplete or abandoned applications. States should learn from the success of the COVID-19 rule and implement similar measures that eliminate yearly renewals and rely on financial data already gathered from enrollees. Enacting a permanent measure for automatic renewals would help reduce the number of denials to eligible individuals.

Health insurance can be a matter of life or death for some individuals suffering, and it is important to everyone. No one who is eligible for Medicaid should be uninsured due to complicated and confusing bureaucratic processes.

Medicaid agencies were created to provide a vital service to those who need and qualify for it. The challenges expressed in this report should be taken seriously and changes should be implemented to ensure equal and fair access to Medicaid for all. One interviewee summed up the lack of effort on behalf of the Medicaid agency: “People who could make things better aren’t making it better.”