Immigrants face barriers on health care site

February 13, 2014

(WBEZ/ Odette Yousef)
Martin Jurado and Graciela Guzman help uninsured people enroll in health plans on Illinois’s healthcare exchange. Most of their clients are immigrants whose applications still face hurdles on the site.

More than two months after the Obama administration declared healthcare.gov working “smoothly for the vast majority of users,” immigrants who try to sign up are still encountering serious glitches.

On Wednesday, federal officials trumpeted the fact that more than 1 million people signed up for private insurance in January, with Illinois accounting for nearly 89,000 of those enrollees. With fewer than 40 days until the deadline to enroll without incurring a penalty, much of the attention has turned to so-called “young invincibles,” a term for young, healthy people who will likely have lower health care costs.

There’s no similar focus on immigrants, WBEZ has found, who continue to face significant hurdles with identity and citizenship verification, and faulty determinations of eligibility for Medicaid. In Illinois, the task of finding and navigating around those barriers often falls to scrappy enrollment specialists who work directly with those clients at community health centers. On top of their jobs, they are finding themselves tasked with bringing the glitches to the attention to state and federal authorities, and lobbying for them to be fixes.

Illinois, which is one of seven states to engage in a state-federal partnership, relies on the federal site to handle the enrollment function for plans offered on the state’s insurance marketplace. Under the Affordable Care Act, immigrants are required to have insurance if they reside lawfully in the U.S. – even if they are not citizens.

“Since November I have frequently made visits, and every time I made a visit I’ve stayed at least 3-4 hours,” said Zejna Belko, a 51-year old Bosnian immigrant who described her attempt to enroll in the healthcare exchange with the help of enrollment counselors at the Hamdard Center on Chicago’s far North Side. “We’ve also had individuals from other agencies try to help us out.”

Belko, who’s lived in the U.S. with a green card for 16 years, said she’s spent up to 30 hours working with enrollment specialists. Still, they haven’t even been able to start her application because the system cannot verify her identity. So far, Belko has twice mailed identifying documents, such as copies of her green card and social security card, to the Department of Health and Human Services, to no avail.

“My blood pressure rises,” she said through a translator. “I get very frustrated and angry because I’m an honest person and I’m not hiding anything, and I don’t understand what the problem is. I just want to get health care coverage.”

In a small health center in Wicker Park, Graciela Guzman said she sees these cases all the time. Most frequently, the issues with identity verification is done via checking an applicant’s credit history – something Guzman said many newer immigrants don’t yet have.

“They haven’t been here long enough to be considered ‘bankable,’” she said. “Like a lot of them have been paid by cash. Maybe they don’t have banks. Maybe they don’t own property. So the system has a harder time just finding them.”

The Morning Shift: How an ACA enrollment specialist is helping immigrants in Chicago

Guzman works with a team of five enrollment specialists at PrimeCare Community Health, a small clinic based in St. Elizabeth’s Hospital in Chicago’s Wicker Park neighborhood. About half of their clients are immigrants. Her team encounters hurdles to enrollment so frequently, they’ve managed to cobble together a complicated flow sheet of workarounds. For identity verification problems, they’ve found that calling the federal Health Insurance Marketplace Call Center, and later uploading or mailing a client’s identification documents, usually helps to get an application started

But there are other barriers. Through trial and error, they found success in ignoring the site’s directions to fill out information completely, and instead repeatedly clicking “continue and save” when they get an error on citizenship verification. The most significant challenge, however, appears not to have a workaround.

“Most of our clients receive incorrect eligibility determinations, that tell them that they’re eligible for Medicaid,” said Guzman.

This is the case for lawful permanent residents whose incomes would qualify for Medicaid, but who are barred from enrolling in that program because they’ve lived in the U.S. less than five years. Once the site directs an enrollee to apply for Medicaid, it does not allow them back onto the private healthcare exchange, where these clients should be.

“We have brought this to the attention of our federal counterparts,” said a state spokesman, “and we believe they have been working to address it by adding new questions to healthcare.gov late last week that will allow people to get through to the Marketplace once they have been issued a denial.”

In other words, immigrants are advised to apply for Medicaid even when they know they are ineligible for it, just to receive a denial. But since Medicaid eligibility was expanded under the Affordable Care Act, a backlog in applications has led to significantly longer processing times. 

Guzman and her team of so-called “navigators” say, as they discover glitches, they’ve relayed them to state and federal officials. So far, they have enrolled more than 600 immigrants to the healthcare exchange. In addition to the discoveries they’ve made about getting through the technical difficulties, the team is also working out ways to handle the unexpected emotional impact of the job.

“On our days off, we’re constantly thinking about patients, which is like ludicrous,” said Martin Jurado, who works with Guzman at PrimeCare. “I don’t think anybody else does that. You know? Somebody that you’ve barely met, you barely know, yet you know everything about their life, what they’re going through, and you’re carrying that, and a lot of people didn’t tell you that, starting off the bat.”

Guzman found that blogging helps her process their experiences. She writes of frustrations with the healthcare exchange website, but also about clients that stick in her head.

“People really weren’t hearing the complexity of the website, they weren’t hearing people’s fears and difficulties in getting through the website,” she said. “And so we wanted to share some of what’s going on.”

Together, she said, they have come to realize they are witnessing a moment: droves of people are coming out of the shadows because the law requires them to – and they’re coming with needs that extend far beyond just health care.

“We get them comfortable and primed, hopefully, for enrollment,” she said, “but then they’ll turn around and kind of like almost offhandedly be like, ‘so you helped me with this, can you help me with housing? Can you help me with food stamps? I have some domestic stuff going on, where do I go?’”

Guzman said she believes they’re on the frontier of a new phase. She, Jurado, and the rest of their team will stick around after the crush of enrollment ends March 31st, helping people change or update their health plans. But she said they’ll also continue to serve as access points to community resources when immigrants don’t know where to go.

Odette Yousef is WBEZ’s North Side Bureau reporter. Follow her @oyousef and @WBEZoutloud