Georgetown University Health Policy Institute
by Sonya Schwartz

I tried to answer this question for a presentation at an immigration conference right before the holidays. Unfortunately, although we are in our second open enrollment season under health reform, we can’t fully answer this question yet. What we do know indicates that we are making some progress but have a lot more work to do to help get families with eligible immigrants covered. Here’s what we do know and some thoughts about what information is missing.

The needle is moving on limited English proficient families’ access to coverage, but it can move much further. While we don’t have enrollment data from HHS that provides information about enrollment for Limited English individuals or national survey data about this yet, snapshots of estimates and enrollment numbers from two state marketplace states foreshadow what we are likely to learn about the rest of the country.

  • In New York, less than one quarter of people with a preferred language of Spanish who were eligible enrolled. 25.2 percent of those estimated to be eligible for the state marketplace had a preferred language of Spanish, but only 6 percent of those who actually enrolled in the state marketplace as of April 2014 had a preferred language of Spanish. However, one bright spot is that New York is close to meeting expectations in coverage for the Chinese language speakers: 3.2 percent of those estimated to be eligible for New York’s marketplace are Chinese speakers, and so far, 3.0 percent of those enrolled are Chinese speakers.
  • In California, less than half of LEP individuals eligible for coverage enrolled. A report by the Greenlining Institute showed that while 40 percent of those eligible for Covered California were limited English proficient, only 20 percent of those enrolled were LEP during the first year of open enrollment.  This is a substantial coverage gap of 20 percentage points.

We have made notable progress on coverage for Latino adults, but many continue to remain uninsured even though they are eligible for subsidized coverage. A survey conducted by the Commonwealth Fund shows that the uninsured rate for Latinos ages 19 to 64 fell 13 percentage points from 2013 to 2014. This is nearly triple the decline in percentage points (5%) or all uninsured adults. The Commonwealth Fund survey shows that the uninsured rate dropped both for Latino adults with dominant language of English and Spanish. An Urban Institute analysis of the Health Reform Monitoring Survey also showed coverage up 5 percentage points for Hispanic adults between Quarter 3 of 2013 and Quarter 2 of 2014. The vast majority of Latinos who remain uninsured are potentially eligible for subsidized coverage based on income, with all but 1 percent of uninsured Latinos having incomes below 400 percent of FPL. Of these Latinos who remain uninsured, more then half are foreign born, with 35 percent were born in the US, 46 percent are foreign born but report being either a US citizen or a permanent resident. About 16 percent of uninsured Latino adults may not be eligible for coverage based on their immigration status.

California in particular is making solid strides on coverage for Latinos and Asians. According to a presentation by Asian Americans Advancing justice, Latinos were 37 percent of those eligible for coverage in the state marketplace, and 28 percent of those enrolled so far; and Asians made up 20 percent of those eligible for coverage in marketplace, and 21 percent of those enrolled so far. In terms of Medi-Cal, Latinos made up 50 percent of those estimated to be eligible and 38 percent of those enrolled so far, while among Asians 14 percent were estimated to be eligible for Medi-Cal and 17 percent were enrolled.

One reason for an enrollment lag in families with immigrants is that the online systems set up for enrollment may not suit the needs of people in immigrant families, particularly if they are limited English proficient. The Commonwealth survey showed that Latinos who predominantly speak Spanish visited the marketplaces at half the rate of those who primarily speak Spanish. It found that 30 percent of Spanish dominant Latinos remained uninsured in spring 2014 in contrast to 19 percent who are English dominant. It also showed that only 19 percent of Spanish-dominate Latinos who are uninsured went to the marketplace to shop for coverage as opposed to 39% of English-dominant.   And, data from the federal marketplace today shows that during the second open enrollment, as of Dec 5, 2014, there were more than 16 million users of healthcare.gov and only 571,220 of CuidadoDeSalud.gov, and that 593,209 had placed calls to Spanish speaking representatives.

We can do better on the policy side, but we also need more data to focus our efforts! There are many ways to improve outreach and enrollment to individuals eligible for coverage who live in immigrant families, I’ve written about them in many of my previous blog posts. But, in addition to these fixes, we also need timely and more specific data to help us assess and monitor our progress and target our energy on the groups that are being left out. If federal and state programs shared available enrollment data about language needs, and also general information about foreign-born applicants, in addition to information about race and ethnicity, it would be a great improvement.

In the coming year, information from national surveys like the American Community Survey will become available that will tell us more about what the first year of open enrollment’s coverage gains looked like for families with immigrants and where to go from there. But if enrollment data continues to be thin, we’ll have to wait yet another year (2016) to know how this second year of open enrollment played out for families with immigrants!