By Naomi Stark, Georgetown CCF Research Assistant

The Affordable Care Act provided an enormous opportunity for coverage of many immigrant and mixed status families eligible for premium tax credits in the health insurance marketplace. However, due to a variety of enrollment barriers, many of those eligible for these critical benefits are unable to enroll.  Action for Health Justice (AHJ), a network of national and community-based organizations working with Asian Americans (AA) and Native Hawaiians and Pacific Islanders (NHPI), recently published an account of the first open enrollment period for these communities, including concrete and feasible recommendations for improving enrollment in health coverage.

AHJ based the report on information garnered by its network of assistance organizations, estimated to have served more than 200,000 people in the first open enrollment period.  The study found four primary barriers to enrollment, two of which—language access and concerns related to immigration status—are always high on the list when working with immigrant communities.   The other two barriers—low health literacy and the lack of disaggregated data for different cultural and linguistic communities eligible for coverage—are less obvious, but equally instrumental in getting immigrant and mixed status families enrolled in coverage.

AHJ recommendations include:

• Improve training for everyone that has the potential to help immigrant and limited English Proficient communities enroll.   The report encourages improved training for call center operators, interpreters, navigators, and other enrollment assisters to better serve immigrant LEP consumers. The authors recommend cultural competency training, as well as educating assisters on immigrant eligibility rules. Interpreters need to be well versed not only in translation, but also in health insurance concepts and terminology in order to ensure consistent, effective, and accurate transmission of information between assisters and consumers.
• Upgrade the quality of translated materials. The authors promote the development and distribution of more effective translated resources and in-language tools. These tools should be available in all forms for enrollment: websites, online applications, and paper applications; and should be available in a wider variety of language options.
• Retool Call Center process for greater accessibility for LEP Consumers and Assisters. The report recommends developing prompts in multiple languages to allow for automatic transfer to a translator in the appropriate language—thus saving time and resources for both parties. Further, call centers should prioritize hiring bilingual staff and issue specialists who will have greater ease of communication with consumers with particular linguistic, cultural, and status-specific needs.
• Allocate more resources to support in-person assistance.  This includes funding existing community organizations that have experience working with LEP, immigrant and hard-to-reach populations. The involvement of the non-profit sector has the potential to greatly expand ACA outreach activities. There are many organizations with a proven track record of effective service to the communities who have thus far underutilized the ACA expansion of health care access.
• Rethink the enrollment experience—particularly identity verification and immigration status verification—in time for the next open enrollment period. For the next enrollment period, the authors recommend that CMS work with the U.S. Department of Homeland security to clarify policies and rules of implementation. For example, proof of identity procedures have proved a major barrier to enrollment, and need re-tooling. Additionally, an improved system that allows users to follow the status of pending applications should be put in place to mitigate confusion and anxiety. 
• Enforce non-discrimination laws. Nondiscrimination laws require firm monitoring and enforcement for the upcoming enrollment period. Section 1557 of the ACA provision prohibits discrimination on the basis of race, color and national origin, among other protected categories. Addressing the barriers to ACA mandated health-care access is precisely what the law demands.
• Target existing gaps in the health literacy. Consumer education materials should be gauged at existing health literacy levels. In practice, this requires an explanation of essential information regarding the costs and benefits of different health plan options.

The changes that AHJ recommends will require hard work by federal and state officials running the marketplaces and Medicaid/CHIP programs, and their contractors and partners.  However, dissolving these barriers could lead to stark improvements in health coverage for the AA and NPHI community, and myriad other hard-working immigrant and mixed status families.