“You Wouldn’t Believe Me If I Said It Was Because of the Language Barrier”: Administrative and Cultural Obstacles to Medicaid Enrollment

Mar 7, 2023 Immigration Research Initiative

Medicaid is intended to increase access to healthcare for vulnerable populations, however, administrative and cultural barriers in the Medicaid enrollment system often prevent marginalized groups, such as immigrants, from receiving the quality care that they are eligible for and deserve.

A Need for Increased Translation Services and Cultural Competency

When asked to share the most difficult part of applying to the Medicaid Program, many respondents to the Immigration Research Initiative (IRI) survey highlighted that the Medicaid application uses technical jargon that is not easily understood. This technical jargon is even harder for immigrants whose first language may not be English, and for those who have a lack of understanding of the healthcare system in the United States. When a respondent sought clarification about questions on the Medicaid application, they expressed that the questions “cannot be explained clearly” by the staff members, so “the registration cannot be completed successfully.”

Stunned that the Medicaid office did not have the help they needed, one person was forced to find their own solution. “You wouldn’t believe me if I said it was because of the language barrier, but I brought a translator to deal with it,” they told us.

Language barriers can make it exceedingly difficult for applicants to get questions answered and to complete the Medicaid application. A respondent noted that they wish they could “Register in a familiar language.”

Title VI of the Civil Rights Act of 1964 states that no person shall “on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.” States and agencies failing to provide access to materials and services in other languages has been considered discrimination based on national origin under this federal law.¹ Not providing interpretation services and translated materials for non-English speaking applicants prevents many immigrants from accessing Medicaid and can be considered discrimination based on national origin.

Some states have enacted their own state-level language access laws to increase access to services for people whose first language is not English. Public education is needed to make it clear when these services are available, and each state should be holding government agencies, such as the Medicaid office, accountable to ensure that translated documents and interpretation services are being offered and used when needed. No applicant should have to rely on family members or bear the financial burden of hiring their own translator when a state mandates that translation services be provided.

And, while many respondents told us about the challenges of language, many also suggested a need for a broader kind of cultural competence. As one person put it, “The most difficult thing is that the differences in culture and education make it very tough for us to communicate.” Medicaid personnel should be answering questions, providing clarification, and connecting applicants with services in ways that are sensitive to their cultural backgrounds, to ensure that all eligible applicants can successfully enroll for Medicaid.

Delays So Long They Discourage Enrollment

Long waiting periods can be a large barrier for both immigrants and U.S.-born applicants. Some respondents expressed feelings of neglect and avoidance by the Medicaid staff when applying for Medicaid. “Nobody wanted to talk to me, and I waited there for a long time,” one respondent shared. Another said: “The difficulty is that I have to wait a long time and I may not get the results I want.” Often application approval or denial wait times are extended when applicants must give missing documentation or are waiting for documentation from other government agencies, an issue that may be particularly acute for immigrants. “Their office process is killing me” said one survey respondent. Long governmental processes can create mental and emotional fatigue and anxiety during the application process as applicants worry about their approval the longer the wait becomes. Sometimes the process can also have an adverse impact on their jobs. As one respondent reported, “I’m so busy with work that I don’t have time to deal with it most of the time. I always go when I ask for leave, but it will affect my work.”

One respondent felt that the Medicaid personnel made “too many unreasonable demands.” Many times, it can be hard for immigrants to get the required documentation that is needed such as notarized letters from previous employers they may not have great relationships with. Too many requirements can be overwhelming and stressful for applicants and can deter them from applying.

In many instances survey respondents noted a shortage of staff at their Medicaid office. A survey respondent recalled, “There is too little help available” and another respondent suggested that the Medicaid office needs “more staff members to help out.” Another respondent also suggested an increase to staffing levels because the shortage created longer wait times, but they also noted the lack of staff may be due to costs: “Could increase the number of Medicaid workers, which limits the speed at which he can apply. But it will cost the government a lot of money.”

Long wait times can also be a result of ineffective service. Some respondents highlighted that the little help they received from the Medicaid staff was slow and not useful. One person explained: “The most difficult thing is the staff not being serious and kept dragging their feet.” Another expressed that the way that the Medicaid staff interacted with them made them feel powerless: “The work process of the staff makes me feel so helpless.” A respondent shared that staff “not helping me when I needed it most” was one of the most disturbing aspects of the application process.

Offices that Are Not Accessible or Visible

Some survey respondents also told us they had difficulty getting to a Medicaid office location. Medicaid offices are not always in locations that make it accessible for people who use the public transportation system, which was expressed by a respondent who suggested that the Medicaid office be moved and “Have it at somewhere prominent.” A survey respondent recalled that “the place was hard to find,” while another recalled that “I got lost.” Other respondents referred to the location of the Medicaid office as “inaccessible” and having a “transport problem.” When public service buildings are in locations that are hard to get to, it can prevent eligible applicants from enrolling or receiving assistance with their applications.

The level of frustration with enrollment can reach a boiling point among some of our most vulnerable community members. One respondent expressed their despair with the interaction of Medicaid with immigrants: “Oh God, just make it easier, make immigration easier.” The Medicaid program, like all other safety net programs, should make the process easier for applicants, not more difficult. However, the Medicaid staff, as well as various systemic and cultural barriers, can make immigrants feel discouraged and helpless during the Medicaid application process. These barriers are embedded in the healthcare system and include language access difficulties, long waiting periods, and a lack of help with the application. The experience of these cultural and systemic barriers coupled with the lack of aid from the Medicaid staff can often result in inaccurate and incomplete applications and a lack of trust in safety net programs.

For those who can navigate the extensive and complicated process, however, the results are worth the effort. “The formalities were so complicated that it took me a long time to get through. But it was a great policy and it saved me a lot of money,” one respondent recalled.

1
Language Access Legal ‘Cheat Sheet,’ New York Lawyers For the Public Interest, Inc. https://www.nylpi.org/images/FE/chain234siteType8/site203/client/Language%20Access%20Legal%20Cheat%20Sheet%20Final%20-%20February%202012.pdf