Presented at Enroll America's 2015 State of Enrollment conference.

1. © 2015 Enroll America and Get Covered America
EnrollAmerica.org | GetCoveredAmerica.org
Providing Access for the
Undocumented and Families with
Mixed Immigration Status

2. Immigrants and Health Care
Reform
Steven P. Wallace
UCLA Center for Health Policy Research
http://dornsife.usc.edu/csii
http://healthpolicy.ucla.edu

3. Acknowledgements
Funding for my research on this topic has
been provided by The Commonwealth
Foundation, The California Endowment,
The UC Global Health Institute, and the
Health Initiative of the Americas.

4. A few key points
! Immigrants are part of
all communities
! ACA will benefit
immigrants but not
undocumented
! Access to health care
for all improves the
health of workers,
families, and
communities

5. http://migrationpolicy.org/sites/default/files/datahub/State_Metro_ACS2010_Total_FB.pdf
41.3 million immigrants in U.S.

6. Population without Health Insurance, by
region of birth and race/ethnicity,US 2013
52.3%
49.2%
19.6%
12.0%
17.3%
Mexican immigrants Central American
immigrants
Immigrants from
other regions
US-born
nonHispanic whites
African Americans
Leite, Paula, Xochitl Castaneda, Steven P. Wallace, et al. Migration & Health. Mexican immigrants in the US: A 10 year
perspective. Mexico, DF: Secretaría de Gobernación/Consejo Nacional de Población, October 2014.
http://healthpolicy.ucla.edu/publications/search/pages/detail.aspx?PubID=1341.

7. Mexican Immigrants w/ no Medical
Insurance by Occupation, U.S. 2013
33.9%
38.6%
48.2%
65.5%
65.5%
71.5%
Executive, professional
Sales, admin, office
Skilled laborers
Service
Agriculture
Construction
Source: Migration and Health 2014. Mexican Immigrants in the U.S. 10 years of perspective

10. Undocumented immigrants w/ no
insurance 2012 & estimated 2016
undocumented
immigrants,
%
w/
no
insurance,
2012
undocumented
immigrants,
%
w/
no
insurance,
2016
%
uninsured
who
are
un-­‐
documented
2012
%
uninsured
who
are
un-­‐
documented
2016
US Ave. 61.0 61.5 9.8 24.5
California 57.0
58.5
19.5 40.8
Florida 68.3 69.2 12.3 33.8
Georgia 72.9 72.8 10.2 28.1
Illinois 67.0 67.5 7.5 18.4
New York 50.1 52.1 11.0 16.0
Texas 74.0 74.3 16.1 37.8
Source: Undocumented and Uninsured: Barriers to Affordable Care for
Immigrant Populations .
http://healthpolicy.ucla.edu/publications/Documents/PDF/undocumentedbrief-
aug2013.pdf

12. Deportation fears
150,000
200,000
250,000
300,000
350,000
400,000
450,000
2002 2007 2013
Photo Courtesy of ICE
www.dhs.gov/yearbook-immigration-statistics-2013-enforcement-actions

13. http://www.migrationpolicy.org/data/unauthorized-immigrant-population/state/US
Evolving “status” of
undocumented immigrants
! California, Washington, Massachusetts, Minnesota, New
York, and Washington, D.C. extend state-funded
insurance to DACA recipients.

14. Executive Action for California
971,000
377,000
77,000
-­‐
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
Parents
that
will
be
eligible
under
deferred
action
because
of
citizen
and
LPR
children
Previously
immediately
DACA-­‐
eligible
Newly
DACA-­‐eligible
with
different
age
and
year
of
arrival
benchmarks
Who
Might
Benefit
in
California
From
Deferred
Action
for
Parents
(DAPA)
and
Deferred
Action
for
Childhood
Arrivals
(DACA
&
DACA-­‐Plus)
Preliminary
Estimates
Center for the Study of Immigrant
Integration
http://dornsife.usc.edu/csii

15. Average = -2.5
http://healthpolicy.ucla.edu/publications/
search/pages/detail.aspx?PubID=1373
State Policies that Affect the Health of
Undocumented Immigrants &Their Families

16. Example of a health policy
http://www.nilc.org/healthcoveragemaps.html

17. California Population Ages 18 -64:
Immigration Status and Health Insurance
California Health Interview Survey, 2009
16.7 17.8
33.6
51.3
Uninsured
U.S. Born
Naturalized Citizen
LPR
Undocumented Immigrant
Wallace, Steven P., Jacqueline Torres, Tabashir Sadegh-Nobari,
Nadereh Pourat, Undocumented and Uninsured: Barriers to
Affordable Care for Immigrant Population. Los Angeles, CA: UCLA
Center for Health Policy Research and The Commonwealth Fund.
August 2013.
http://healthpolicy.ucla.edu/publications/Documents/PDF/
undocumentedbrief-aug2013.pdf

18. California Population Ages 18 -64:
Immigration Status and Diabetes
California Health Interview Survey, 2009
6.7%
9.0%
15.7%
4.4%
9.2%
U.S. Born
Naturalized Citizen*
LPR*
Undocumented Immigrant unadj
Undoc.Immigrant age adjusted*
* Age adjusted to US-born
population

19. Implications

20. Adopt a human rights frame
Universal Declaration of
Human Rights, Article 25
• Everyone has the right to a
standard of living adequate
for the health and well-being
of himself and of his family,
including food, clothing,
housing and medical care
and necessary social
services …

21. Conclusion
! America, and
especially California,
benefits from
immigration
! Health and health
care needs of all
immigrants merit
rational attention

22. Thank you
http://healthpolicy.ucla.edu/about/staff/pages/detail.aspx?StaffID=163

23. Community Outreach Strategies For
Mixed Status Families and
Undocumented Populations
Presented by:
Lupe Delgado
2015 National Conference
State of Enrollment: Getting America Covered
Renaissance Washington Hotel
Washington DC

24. — What to consider when engaging families.
— Who are the important partners?
— Learn how to engage and outreach to individual and undocumented population.
— Assess your current understanding of engaging undocumented population.
— Role of individuals and undocumented population.
— Best practices for meaningful engagement.
Goals and Objectives

25. — Experience in working with Outreach, Enrollment and
Community Residents:
¢ Over 10 years experience in outreach, grassroots organizing and
working with community residents.
¢ 10 years experience in Public Benefit Programs (State and local);
CalFresh (SNAP Ed), Healthy Families, Medi-Cal, and Covered
California. Both new enrollments and re-enrollments.
¢ Worked in community based clinical settings, hospitals, non profit
organizations and public events such as health fairs and forums.
¢ Currently one of ten community partners in Merced’s Prevention Action
Team (PAT) funded by The California Endowment’s Building Healthy
Communities Initiative.

26. Outreaching Principles
— What Does Community Outreach Mean:
¡ Building Trust
¡ Engage Your Residents in Change
¡ Let Them Lead the Advocacy Work
¡ Collaboration
÷ Human Services Agency
÷ Certified Enrollment Agencies
÷ Immigration Legal Services
÷ Schools
÷ Public Health Department
÷ Food Bank
— Know Your Community:
¡ Demographic
¡ Accessibility
¡ Language Spoken
¡ Education
¡ Culture

27. — Community Outreach
¡ Provide information and post
announcements about the Get Covered at
local schools, local faith-based institutions,
community centers, businesses, health
centers, libraries, etc.
÷ Identify existing meetings/events
— Education Forums/Workshops/
Presentations
¡ Educating community members about the
Health Insurance Marketplace (CoveredCA)
÷ Partners
Outreaching Principles

28. EFFECTIVE OUTREACH
— Setting-up resource table to share
information
— School fairs/events
— Creating video by target population
about getting health insurance
— Outreach & Enrollment events
— Townhalls/Forums
— Door-to-door
— Phone bank
— Robo Calls
— Public Service Announcements (PSA)
— Advocacy #Health4All
Outreaching Principles

29. AVOID THESE STRATEGIES
— Not targeted population on Social
Media
— Not going into the community
¡ Example Schools, community organization.
— Not leaving anything for the
community to follow-up
Outreaching Principles

30. • Get them INVOLVED!
¡ LISTEN to their interest/concerns/needs
¡ IDENTIFY who else is interested/concerned - undocumented
¡ FIND out who are the allies/partners
¡ CREATE access and opportunities for enrollment
Engaging Community Resident Principles

32. — Provide effective messaging to individuals and families to empower them and actively
engage and participate in the enrollment process.
— Provide leadership training to individuals and families by promoting education, health,
leadership, cultural, and generational connections so they can lead the advocacy work.
— Develop a connection by becoming a resource where individuals and families can get
the information they need to make effective decisions on health insurance options.
Engaging Principles

33. Example of Grassroots Training and Empowerment
Leaders provide real life examples of health care costs:
¡ For example:
A doctor’s visit for preventive care runs for about $145.00
A hospital visit averages about $1,349.00
— Empower community residents to spread the word in their community to ensure
community residents have access to affordable health care.
— This type of education is relative to everyone. That’s why they emphasize the
preventative care vs. emergency care.

34. 2014 Outcomes of Effective Outreaching
Education
1369
Outreach
7405
Presentations
15
In coming
calls
407
Phone Bank
296
Referrals
1452

35. 2015 Current Outreach Efforts
Education
421
Outreach
16,542
Presentations
5
In coming calls
189
Community Leaders
Phone Bank 146
Door to door 128
Town hall 56
Forum 263
Referrals
281

36. Most Impactful Outreach
City of Merced Rating 8,000
Merced County overall 150,000

37. Health4All Advocacy
— Deferred Action
Childhood Arrivers
(DACA)
— Deferred Action for
Parental
Accountability
(DAPA)
— Undocumented

38. Leading the Advocacy
— Community residents

39. Collaboration

40. Lupe Delgado
ACA Health Outreach Worker
PARENT INSTITUTE FOR
QUALITY EDUCATION
mdelgado@piqe.org
Phone: 209-230-6371
1124 11th Street
Modesto, CA 95354
Phone: 209-238-9496
Fax: 209-238-9495
www.piqe.org
Contact Information

41. Thank You!!!

42. SERVING THE REMAINING
UNINSURED – MY HEALTH L.A.
STATE OF ENROLLMENT: GETTING AMERICA
COVERED CONFERENCE
PROVIDING ACCESS FOR THE UNDOCUMENTED AND
FAMILIES WITH MIXED IMMIGRATION STATUS
JUNE 11, 2015
Tangerine Brigham
Los Angeles County Department of Health Services

43. Context – Health Care to Uninsured
Episodic
California
• Mandates counties provide life-threatening treatment to indigent persons
• Two funding sources: (1) county and (2) State [decreased after ACA]
• Proposition 187 prohibits undocumented from receiving range of services
Los Angeles
• ≈10 million residents; 4,083 sq. miles; 88 cities and many unincorp. areas
• Estimated 300-400,000 residually uninsured residents
• County direct provider with 4 hospitals and 20 ambulatory care sites
• Since 1990s, County has funded community clinics to care for uninsured
43

44. Los Angeles County Goals
Preserve access to care for uninsured patients
Encourage coordinated, whole-person care
Payment reform
Improve efficiency and reduce duplication
Simplify administrative systems
44

45. My Health LA (MHLA) is Health
Access
¨ Provides health care for uninsured residents regardless of
¤ Employment status
¤ Immigration status
¤ Pre-existing conditions
¨ Not a health insurance plan
¨ Promotes a primary care medical home model
¨ Voluntary program – remaining uninsured not require to enroll
¨ Does not include uninsured patients who seek primary care
services at County clinics
45

46. MHLA Program Features
Features Los Angeles County
Implementation Date October 1, 2014
Enrollment Process Web-based (One-e-App)
Insurance Status Uninsured; ineligible for public coverage
Income Threshold At or below 138% FPL
Age Eligibility 6 and over
Services Primary, preventive, diagnostics, prescription drugs; specialty,
emergency urgent care, hospitalization, behavioral health
referrals
Provider Network Over 180 primary care community clinics (primary care
medical home); DHS for other services (e.g., hospital,
specialty, etc.)
Medical Homes Over 180 primary care community clinics
Participant Costs None
County Agency Department of Health Services
46

47. MHLA Web-Based Eligibility &
Enrollment (One-e-App)47

48. Clinical Visit Leads to MHLA
Enrollment48
Enrolled!
Dental is not a MHLA benefit

49. MHLA Designed to be Organized
Health Care
¨ A common eligibility and enrollment system (One-e-App)
¨ Medical home model of care
¨ Broad-based network of community-based primary care providers
¨ Participants can get services immediately after enrolling
¨ Centralized customer service
¨ After enrollment participants get:
¤ ID card with medical home
¤ Participant handbook
¤ Program newsletters
49

50. Participant Demographics (109,000) –
Age, Gender, Housing and Income (5/2015)
50
8%
2%
49%
25%
11%
5%
0%
10%
20%
30%
40%
50%
60%
6 - 18 19 - 24 25 - 44 45 - 55 55 - 64 65+
%ofParticipants
Age
[CATEGOR
Y NAME],
61%
Male,
[VALUE]
Gender
8%
16%
23%
21%
22%
10%
0% 5% 10% 15% 20% 25%
125.01-138%
100.01-125%
75.01-100%
50.01-75%
25.01-50%
0-25%
% of Participants
%ofFPL
Income (Expressed as % of Federal Poverty Level)
Note: 314 participants indicated “Other” for Gender
[VALUE
]
House
d
[VALUE
]
Homel
ess
Housing Status

51. Participant Demographics (5/2015) -
Ethnicity and Language
Ethnicity Top 5 Languages Spoken (99.4%):
51
Ethnicity Percent
Hispanic 94.30%
Asian/Pacific Islander 2.90%
Declined to State 1.38%
White 1.03%
Other or Mixed Race 0.32%
Black/African American 0.18%
Language Percent
Spanish 92.11%
English 6.40%
Thai 0.37%
Armenian 0.28%
Korean 0.23%
q Note that MHLA does not ask applicants their citizenship or immigration
status

52. Strategies
¨ Had clarity of purpose/goals
¨ Created public/private partnership
¨ Used existing delivery system
¨ Engaged community partners/leads on program design and kept informed
¨ Worked closely with local social services agency (intersection with
Medicaid)
52

53. Challenges
¨ Manage expectations with respect to what program is (health access) and is
not (health insurance)
¨ Selection of included and excluded services
¨ Change in health care delivery system for providers serving the remaining
uninsured
¨ Understand financing mechanism (estimated costs, funding and provider
reimbursement)
¨ Ensure appropriate administrative and clinical infrastructure
53

54. Replicability
¨ Relevant to and feasible for communities with multiple safety-net providers
that want to replace the complex, uncoordinated system of care for the
uninsured
¨ Health access model may be more financially feasible than offering health
insurance
¨ Features ripe for replication
¤ Primary care medical home to reduce service duplication and improve care
coordination
¤ Centralized eligibility system to maximize public entitlement and reduce barriers
to entry
¤ Public-private partnership to maximize available resources
¤ Establishment of predictable and affordable participant fee structure
54

55. Implementation Factors
Patient
Centered
Delivery
System
Provider
Payment
Coverage
Expansion
Local Level Reforms Contributing Factors
55
Political
Leadership
Financial
Support
Existing Health
Care Providers
Admin.
Structure

56. Learn More About MHLA
¨ Website: dhs.lacounty.gov/MHLA
¨ Contacts:
¤ Amy Luftig-Viste (aviste@dhs.lacounty.gov)
¤ Tangerine Brigham (tbrigham@dhs.lacounty.gov)
56

57. Questions
57