Washington Benefit Exchange: The Immigrant Community Health Landscape

February 22, 2023

The Opportunity

CHNW and IRHA partnered with Atrómitos and MCG Consulting, to conduct a landscape scan of the Washington State immigrant communities to inform Washington Health Benefit Exchange’s (WAHBE) future marketing, system design, and outreach efforts for the expanded health insurance coverage option for individuals without federally recognized immigration status. Individuals without federal immigration status will have access to coverage under the state’s 1332 waiver and the state premium assistance program, Cascade Care Savings.

It is imperative that WAHBE have a comprehensive understanding of the health needs of immigrant communities, as well as linguistically and culturally appropriate engagement strategies and approaches to ensure that those who need health insurance are aware of and can access such coverage.

Goals

Through a comprehensive landscape scan, we sought to assess the following:

1. The current awareness of health coverage options among immigrant communities, specifically among immigrants without federal immigration status.
2. The current level of awareness and trust of WAHBE and its partners within immigrant populations.
3. Areas where additional education or support for the eligible population may be needed and most impactful.
4. Relevant opportunities for outreach and engagement to immigrant populations in Washington State that WAHBE should prioritize and how such outreach should be conducted.

Approach

The Landscape Scan was conducted in two parts:

Research and Analysis
During the Research and Analysis phase, Atrómitos conducted an environmental scan which included a literature review and data analysis of WA immigrant communities, specifically, and health status, health needs, and engagement approaches of immigrant communities, generally. We utilized multiple data sources and methods to develop a comprehensive and detailed understanding of the eligible population. For the literature review, we focused on the health needs and health access behaviors of immigrant communities in WA, specifically, as well as throughout the United States.

We collaborated with WAHBE to identify the domains for data acquisition and research as well as data sources. The domains included in the Landscape Scan were (a) access to care; (b) perceptions of healthcare providers and institutions; (c) trusted or prioritized sources of health information by population; (d) identified health concerns by population; (e) awareness of health resources; and (f) identified barriers to accessing health resources. We then used these domains to help guide our background research and literature review.

Stakeholder Engagement
In partnership with MCG Consulting, who led the stakeholder engagement work, Atrómitos conducted electronic surveys and conducted focus groups, while MCG Consulting led the key informant interviews with members of immigrant communities, health care providers, and individuals that provide navigation and other support to members of immigrant communities. The interview and focus group guides and questions used in the surveys were developed based on Atrómitos’ findings from the Research and Analysis phase.

Because of limitations in engaging directly with individuals who are immigrants without federal immigration status, Atrómitos recommended the use of an electronic survey. The survey was developed in partnership with MCG Consulting. Atrómitos programmed the survey into Qualtrics and it was distributed throughout the state by various community-based organizations (CBOs) through contacts cultivated by CHNW, IRHA, MCG Consulting, and Atrómitos. CHNW translated the survey into nine different languages, which were selected based on findings obtained during the research and analysis phases that identified the top most spoken languages among immigrants in Washington.

MCG Consulting created a marketing toolkit consisting of social media and email templates, Atrómitos created social media graphics, and frequently asked questions, to help promote the survey. Atrómitos led the data analysis of the survey responses, while MCG Consulting coded and themed the other stakeholder engagement data.

Landscape Scan Report
Atrómitos integrated the results of the Research and Analysis and Stakeholder Engagement into a Landscape Scan Report. This comprehensive report addressed (a) the current level of knowledge among immigrant communities about health coverage options available; (b) where additional education and community engagement is needed in each immigrant community; (c) where individuals without federally recognized immigration status are accessing healthcare services in WA State; and (4) organizations within communities that present opportunities to support connecting individuals to healthcare affordability programs on Health Plan Finder (HPF).

• Literature Review
  • During this project, we completed an extensive literature review to obtain a comprehensive and detailed understanding of the population. Relevant domains and search terms for the literature review were determined based on our initial background research findings. A total of 50 articles were included in the final literature review, which included primary research (quantitative and qualitative), secondary research, commentaries, and calls to action. We found that 1) Immigrants generally face unique and pervasive barriers to receiving healthcare, 2) Disparities experienced across immigrant populations in social determinants of health exacerbate health conditions, 3) Perceptions of the availability, accessibility, and suitability or adaptiveness of healthcare services can be improved, and 4) The health needs of immigrants must also be considered in the context of the local and global political and social environment.
• Immigrant Health Community Survey
  • There were 131 responses to the Immigrant Health Community Survey across the English, Korean, Spanish, Tagalog, and Vietnamese surveys. Of this number, 49 respondents (37.4%) reported being U.S. citizens or legal permanent residents, while 79 respondents (60.3%) were undocumented. Across the surveys, the majority of U.S. citizens or legal permanent residents (55.1%, 27) reported being likely or very likely to enroll in free or low-cost health insurance if available. Undocumented immigrants had higher rates, with 94.9% (75) respondents reporting being likely or very likely to enroll in free or low-cost health insurance. Among all respondents, the cost was the most frequently reported factor for preventing individuals from getting free or low-cost health insurance.
• Key Informant Interviews
  • The major themes identified during the key informant interviews were that cost, cultural and language differences, immigration status, and the social determinants of health remain top barriers to accessing healthcare services, whereas trust, initiating primary care, and CBOs partnering to increase access to care are facilitators to accessing healthcare services. There is also room for significant improvement in regards to increasing access to care at both the provider- and system-levels. Recommendations to increase enrollment in insurance coverage among immigrants include (a) simplifying the enrollment process, ensuring clear information and messaging; (b) conducting broad outreach to all immigrant communities; and (c) guaranteeing the health insurance program name is not linked to immigration status.
• Focus Groups
  • The themes discovered during the focus groups were complimentary of the findings from the key informant interviews. The barriers to accessing healthcare services included cost, lack of legal status, cultural and legal differences, and the social determinants of health, while language and interpretation were the main facilitators. Participants reported making immigrants feel safe as a key recommendation for increasing access to care. Additionally, recommendations to increase enrollment in insurance coverage included (a) expanding the outreach model and appropriately funding resources for the immigrant communities; (b) ensuring clear information and messaging; and (c) simplifying the application process and resources, and translating materials into different languages.

Conclusion

At the conclusion of the research and analysis phase and stakeholder engagement, Atrómitos and MCG Consulting produced a 72-page report presenting the research and stakeholder engagement plan findings, along with recommendations and next steps. The findings were organized into five key themes and recommendations:

1. WAHBE needs to immediately engage in a robust education campaign for the people who will be trusted resources of those eligible to enroll, as many of the CBOs and other organizations engaged were unaware of the coverage options soon to be available to the population.
2. The newly eligible population has critical areas of need related to primary care, behavioral health, medication management, transportation, social determinants of health, language access, and telehealth, and these need to be considered in benefit design and outreach materials.
3. Patient education on accessing and using appropriate care, along with health literacy, will be essential once coverage becomes available.
4. Providers and clinical staff need significant education on how to best work with immigrant populations to gain and build trust
5. Outreach and enrollment will need to be tailored to immigrants to ensure coverage, including increasing and investing in more navigator support tailored specifically to the population.

The report recommended specific next steps to advance the recommendations including that:

• WAHBE should connect with other state agencies to learn what has worked and what has not in outreach and engagement with immigrant communities.
• WAHBE needs to explore and establish new community partnerships with regional and immigrant population-specific organizations trusted within communities, as this will be essential to enroll immigrant populations in the new coverage options.

WAHBE is now using the findings and recommendations in the next phase of this initiative to carry out a comprehensive education and engagement campaign.