Washington – No group of people in Connecticut is more likely to be uninsured than the state’s Latinos, and Obamacare won’t change that.
The Hispanic community is facing unique hurdles signing up for the Affordable Care Act. Some of those barriers were anticipated by both the Obama administration and administration of Gov. Dannel P. Malloy. Others took supporters of the ACA by surprise.
Obstacles to ACA enrollment in the Hispanic community included cultural factors, lack of information about Obamacare, financial limitations and fears of giving the federal government information in the belief it could be used to deport family members.
The end result: Latinos, who make up 25 percent to 30 percent of the uninsured in Connecticut but only 14 percent of the state’s population, are expected to remain over-represented in the ranks of the uninsured for years -- despite Obamacare.
One problem that could have been predicted is related to culture. Latinos, especially newcomers and older Hispanics, are less likely to use the Internet or have broadband at home than other Americans. Yet the principal way to sign up for the Affordable Care Act in Connecticut is through the website Access HealthCT.com, named after Connecticut’s insurance marketplace.
“When they set up the health exchanges, they were not thinking of Latinos or other low-income populations," said Sophia Segura-Perez of the Hartford–based Hispanic Health Council.
Segura-Perez said a lot of the marketing for Access Health CT drives people to the website.
“Just by doing that, we’ve left a lot of people out of the picture,” Segura-Perez said. “The Latino population has not been targeted. It took some time to get our voice out there, to say, ‘We are here.’”
Segura-Perez is one of dozens of bilingual “assisters” in the state hired by Access Health CT who are helping to enroll Latinos in the ACA. The Hispanic Health Council is one of six “navigator” organizations in Connecticut tasked with enrolling people in Obamacare.
But the Hispanic Health Council, which covers Greater Hartford, has been able to enroll only about 100 people a month, most of whom are Latinos who prefer signing up for health care face-to-face.
Segura-Perez said many Hispanics also have problems enrolling through the Access Health CT call center because they can’t afford to buy many minutes on their cellphones, and phone registration is a lengthy process.
Elena Rios, president of the National Hispanic Health Foundation and a strong supporter of the ACA, said the problems Latinos face in enrolling in health insurance is nothing new.
“Hispanic enrollment in every single public program, even the school lunch program, is dismal,” Rios said.
Not Affordable Care
The U.S. Department of Health and Human Services says that nationwide, nearly 8 in 10 uninsured Latinos may qualify for Medicaid, the government-run health program for the poor, or a similar program for children known as the Children’s Health Insurance Program (CHIP). Other Hispanics may qualify for tax breaks that would lower their monthly insurance premiums.
But Rose Pudlin, director of community programs at the Fair Haven Community Health Center in New Haven, said even with a reduced premium, many Hispanics think the cost of health insurance is too high. She said they would rather pay a penalty to the IRS for their decision to remain uninsured, especially since the penalties for low-income people are nominal this year.
‘It’s heartbreaking because these people need insurance, but they really can’t afford it,” said Pudlin, who manages a group of assisters.
Low- and moderate-income Americans, or households that earn $45,960 a year or less, are eligible for the federal tax breaks that can substantially reduce monthly premiums.
But private insurance offered though Access Health CT, available in policies labeled bronze, silver or gold, also carries deductibles and co-pays that have to be paid out of pocket. The more coverage and the lower the co-pays and deductibles, the higher the premiums. And buying even a "bronze” insurance plan, the least expensive, can be too costly for many Hispanics.
“It’s a great idea in theory,” said Latrona Kelly, deputy director for the immigrants' rights group, Junta for Progressive Action, of the ACA. “But there are still challenges to getting affordable health care. It’s an additional bill for people living paycheck to paycheck.”
The process of enrolling Latinos in person can also be laborious and slow.
Pudlin said it often takes three or four visits to sign someone up in the exchange, and it’s a victory when the process is completed.
She says “it will continue to be the case” that Latinos are most likely to remain uninsured.
Pudlin worries that the false notion that the ACA will solve the problem of the nation’s uninsured will result in a lack of support for clinics like hers that serve those without health coverage.
“Our biggest fears are that our funds will be cut,” she said.
Shut out of ACA
Connecticut has several advantages over other states. Its exchange website has operated fairly smoothly, and the state has decided to implement the ACA’s provision that expands Medicaid to adults with incomes up to 138 percent of the federal poverty level ($15,856 for an individual).
A Supreme Court challenge to the ACA resulted in a 2012 decision that upheld the constitutionality of most of the health care law, but determined that states could opt out of the law’s provision that expanded Medicaid. In a blow to White House efforts to maximize coverage of the uninsured, several states with large Latino populations, including Texas and Florida, decided against expanding their Medicaid coverage, leaving Latinos to fall through a crack in the ACA.
That’s because people shut out of Medicaid are also unlikely to earn enough to qualify for premium tax credits that begin at 100 percent of the federal poverty level. That means an individual must earn at least $11,670 to qualify for federal help in buying a health insurance policy.
“We’ve gotten used to saying to people, ‘you don’t qualify for that program because you make too much money.’ Now we say, ‘you don’t qualify for the ACA because you make too little money,’” said Jose E. Camacho, executive director of the Texas Association of Community Health Centers.
While Connecticut does not have the same problem as Texas, many Latinos in the state are shut out of the Medicaid program for other reasons.
One is that immigrants who lack permanent legal status are not allowed under the ACA to enroll in Medicaid or even shop for a private policy on a state insurance exchange.
Danilo Machado, a 20-year-old student at The University of Connecticut's Stamford branch, said he was uninsured until he enrolled in the school's health care program.
“Thankfully, I haven’t had any major health issues,” he said.
Machado received provisional legal status under a program implemented by the Obama administration aimed at helping undocumented children.
A native of Colombia, Machado, a sophomore majoring in English, worries about what will happen when he graduates and loses his health coverage.
“I’m hoping I’m legal by then,” he said.
Others shut out of the state’s expanded Medicaid coverage include legal residents who have been in the United States less than five years.
They can buy private insurance on the exchange and are eligible for tax breaks, but many of them don’t know it, said Kate Gervais, who manages the state’s navigator and assister programs.
“It takes a while to get the message across,” Gervais said.
Another stumbling block to Hispanic enrollment has been the delay in rolling out the Access Health CT website. While the English-language site went up on Oct. 1, the first day of the open enrollment period, the Spanish-language website was not operational until late February, about a month before the end of enrollment March 31.
Kevin Counihan, the CEO of Access Health CT, said he wanted to make sure the Spanish-language website was more than just a literal translation of the English-language website.
“It required building a second website,” he said.
But several assisters interviewed for this story said the Spanish-language website is difficult to read. Rather than use it, they say they translate and interpret the English-language website when they are trying to enroll Latinos.
Counihan said that in the first two weeks of operation, the Spanish-language website has signed up about 1,400 people.
“Is that good enough? Who knows?” Counihan said.
He said he does not know how many Connecticut Latinos have signed up for health coverage because, for the first six weeks of operation, application forms did not ask about ethnicity. After that, Access Health CT adopted the federal application form which does ask about ethnicity and race, but makes answers to those questions voluntary.
Counihan said he hopes to determine how many Hispanics have enrolled after the close of the enrollment period on March 31.
“It’s the hardest segment to reach,” he said of the Latino community.
And the hardest -- specific -- target? According to Counihan, it's a 37-year-old Hispanic man.
Perhaps that’s why Access Health Ct features a young Hispanic male in a Spanish-language YouTube video aimed at promoting enrollment. The young man, identified as Oscar Maldonado from Norwalk, says he worked for 14 years in restaurants and could not afford health insurance – until now.
A television ad aimed at Latinos features Hartford Mayor Pedro Segarra pitching the ACA. Another ad promises those who signed up for coverage they’d have a chance to win tickets to a concert featuring the rapper Pitbull.
But most Spanish-language marketing consist of dubbed English-language ads.
Nevertheless, Jason Madrak, chief marketing officer for Access Health CT, said there is a sustained effort to enroll Latinos.
Those efforts included canvassing potential enrollees at the Puerto Rican parade and the Ray Gonzalez jazz festival. There is also a half-hour show promoting the Affordable Care Act that has run for months on the Spanish-language Telemundo television channel. And Obamacare ads air on Spanish-language radio.
Outreach also included the hiring of Andrea Ravitz, whose title is “multicultural marketing manager.”
Ravitz said she partnered with supermarkets to distribute flyers in stores selling the ACA.
“We went to places where people feel comfortable,” she said.
Yet even Counihan concedes Latinos are likely to remain over-represented among the nation’s uninsured.
“I believe so, but I can’t prove it yet,” he said.
AccessHealthCT received about $146 million from the federal government to set up and promote the exchange. Counihan said about $15 million was spent on marketing. But there was no separate budget to reach out to Latinos.
Afraid of Obamacare
The federal government has had its own problems enrolling Latinos.
A major failing involved the Spanish language website, CuidadoDeSalud.gov, which did not launch until early December, two months after the English-language HealthCare.gov website.
When it was finally functional, CuidadoDeSalud.gov was criticized for containing grammatical and translation errors so severe that site users derided it as being written in "Spanglish."
Like Connecticut, the federal government has no figures on Hispanic enrollment.
But California does, and it’s not happy about them.
The state has spent millions of dollars in outreach to Hispanics, who represent 50 percent of California’s uninsured people.
In January, 28 percent of Californians who enrolled for coverage identified themselves as Latino, an improvement over the period from October through December, when it was 18 percent.
“We are not where we want to be,” said Lizelda Lopez, spokesperson for Covered California, the state’s health insurance exchange.
One problem that cropped up in California, and in many other states, including Connecticut, blindsided the White House.
Latinos often come from “mixed” families -- a term used if one or both parents are undocumented, but their children are not. Many of these families hesitate to provide the personal information needed to register for health care because they fear the information will be turned over to U.S. Immigration and Customs Enforcement, or ICE.
Those concerns prompted Jeh Johnson, secretary of the U.S. Department of Homeland Security, to broadly distribute a statement in Spanish two weeks ago that said ICE has implemented a policy prohibiting it from using marketplace enrollment information for immigration purposes.
“Undocumented immigrants are not eligible to enroll in the health care marketplaces,” Johnson said. “Even so, I’ve heard that some people who live in the United States and are eligible to enroll in the marketplace are hesitant to do so because they fear the information will be shared with immigration officials and used to deport undocumented family members. That’s not true.”
In early March, Vice President Joe Biden held a roundtable discussion with representatives of the nation’s largest Latino organizations, who have partnered with the White House in promoting the ACA, to urge them to disseminate the message that enrolling in a state marketplace would not put family members in jeopardy.
Meanwhile, President Obama has taken to the airwaves in the past week, urging Latinos to sign up for health care.
“The main thing for people to know is that any information you get, you know, asked with respect to buying insurance, does not have anything to do with … the rules governing immigration,” Obama said in an interview with Spanish-language Univision Deportes.
“If you have a family where some people are citizens or legally here, and others are not documented, the immigration people will never get that information,” Obama said.
Gervais said assisters in Connecticut are facing the same problem with potential enrollees.
“They think that having an undocumented member in your family means your family is in danger,” she said.
But even Latinos who have legal status are shying away from signing up for care.
Segura-Perez of the Hispanic Health Council said she recently tried to enroll a young Latino man who had a green card and is waiting for his citizenship. But the young man decided to remain uninsured.
“He didn’t want to do anything that would hurt his chance to become a citizen,” she said.
Counihan said it will take years to bring the numbers of uninsured Latinos down and reach many others who don’t have health care.
“This is a four- to five-year implementation,” he said.