This study aims to determine the probability of accessing health coverage within immigrants by comparing those who are citizens and those who are not. The study also identifies barriers to health coverage among immigrants and best practices that can enhance the accessibility of healthcare in the United States. The qualitative research methodology will be used to answer the research questions. The research design for the study is phenomenological. The study will be conducted in various community healthcare centres in the State of Maryland. The study will provide new knowledge concerning health coverage in the United States for both citizens and immigrants.

Keywords: Immigrants, undocumented immigrants, barriers to healthcare, health coverage, private health insurance

Introduction

Local health departments (LHD) and Community health centres (CHC) have for long been the main source of healthcare for many people in the United States, including those who cannot afford to pay for care due to the lack of health insurance. The demand for LHDs and CHCs increased significantly after the enactment of the Affordable Care Act of 2010 (ACA). However, more than 36 million individuals in the United States remain uninsured under the ACA. While most people who are uninsured are US citizens, non-citizens are more likely to be uninsured as compared to citizens. In 2018, statistics indicate that less than one in ten (9%) of US citizens were uninsured while four in ten (45%) of immigrants in the US were uninsured (De Trinidad Young & Wallace, 2019).

Additionally, children whose one parent is a non-citizen are likely to be uninsured (8%) as compared to those whose parents are citizens (4%). Emerging evidence suggests that policy changes in immigration have increased fear among immigrants about their children and families taking part in the insurance coverage programs. For instance, changes to the public charge policy contribute to the fears that may result in coverage declines. Declines in coverage would have considerable implications for the overall health outcomes of immigrants and their families (Khullar & Chokshi, 2019).

Moreover, immigrants are eligible for affordable coverage, but not enrolled as a result of misinformation and complex eligibility rules (Zhen-Duan, Jacquez, & Vaughn, 2017). Regardless of whether immigrants are insured or not, they are likely to continue seeking services at LHDs and CHCs because of enabling services, trusted relationships and locations in the community. This paper aims to determine the probability of accessing health coverage within immigrants by comparing those who are citizens and those who are not. Besides, the study aims to explore the barriers that immigrants face in accessing health coverage and best practices that can improve healthcare coverage among immigrants and their families.

Problem Statement

The ACA was enacted in 2010 to increase health coverage in the United States. However, most immigrants have been unable to access health coverage. In recent years, public attention has been focused on the ethnic and racial disparities in access to healthcare services. Evidence suggests that Hispanics have the highest rates of uninsurance among all communities living in the US. However, there has been little focus on health coverage among immigrants in the country. About two-thirds of Asians in the US and Hispanics are foreign-born (Zhen-Duan, Jacquez, & Vaughn, 2017). The numbers of immigrants in the US have increased significantly over the past few years and are disproportionately uninsured. As a result, immigrants have significant implications in state and federal efforts to enhance healthcare access.

In 1996, Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) restricted the eligibility of immigrants to Medicaid (Zhen-Duan, Jacquez, & Vaughn, 2017). This implied that those immigrants who were admitted in the country after 1996 could not access coverage. These immigrants could only access coverage only in their first five years of residence for emergency cases. Historian, immigrants who were admitted legally in the US could access Medicaid and other health benefits. However, the policy change suggested considerable policy changes which increased immigrant fear to apply for Medicaid. Even if immigrants were eligible and uninsured, these policy changes suggested that legal immigrants should avoid health coverage.

In 2010, ACA expanded Medicaid program and introduced market place for affordable health insurance. However, undocumented immigrants are not eligible to enrol to Medicaid, Medicare and other health coverage programs. The Centre for Medicaid and Medicare issued rules indicating that undocumented immigrants are not eligible for these coverage options (Soto Mas & Jacobson, 2019). As a result, most immigrants are unable to access health coverage programs. This implies that they are unable to access quality healthcare services.

Purpose

The purpose of this study is to determine the probability of accessing health coverage within immigrants by comparing those who are citizens and those who are not. Furthermore, the study aims to explore the barriers that immigrants face in accessing health coverage and best practices that can improve healthcare coverage among immigrants and their families. The study compared the eligibility criteria between US citizens and immigrants and how it impacts the accessibility of health coverage to the later.

Research Questions

The following research questions will guide this study:

RQ1: What is the probability of accessing health coverage among US immigrants?

RQ2: What are the barriers faced by immigrants face accessing health coverage?

RQ3: What are the best practices that can improve healthcare coverage among immigrants and their families?

By answering these research questions, the study will provide significant new knowledge on the challenges that immigrants go through in accessing health coverage in the United States. Furthermore, it will give insights on how the country can improve health coverage among immigrants.

Significance of the study

This study will provide new knowledge concerning health coverage in the United States for both citizens and immigrants. Besides, the study will review policy changes that create fears among immigrants on accessing health coverage, particularly Medicaid. While legal immigrants are eligible for health coverage, the complexity associated with the existing healthcare policies prevent them fr. This is important because it highlights the need for increasing awareness about health coverage policies among immigrants in the United States. This study will also provide new knowledge on the barriers to accessing health coverage among immigrants in the country. This is important as it can help the policymakers, scientists and practitioners to develop strategies for increasing accessibility of these programs among the immigrants.

Literature Review

This section provides a review of the existing knowledge concerning immigrant’s access to health coverage in the United States. The section will also compare and contrast the debates, methods, theories and controversies associated with health coverage in the US. Various research studies will be reviewed to evaluate the existing literature on the topic. This section will be arranged in three themes accessing care, namely; Immigrant’s barriers to care, Health programs for which immigrants are eligible and best practices. This section will be important in identifying the gap in research on the topic of health coverage among immigrants. Finally, a succinct summary capturing the main points in the section will be provided.

Immigrant’s barrier’s to care.

In the US, there are no laws in all government levels that prevent immigrants, including the undocumented ones from accessing quality care (Sangaramoorthy & Guevara, 2017). Furthermore, there are no laws that prevent healthcare providers from providing services to undocumented immigrants. However, evidence suggests that most federally funded health programs limit eligibility based on the immigration status of immigrants. While these restrictions are clearly outlined, they are misapplied by eligibility workers, providers and immigrants to all health services.

Olukotun, Mkandawire-Valhmu & Kako, (2019) conducted a qualitative study aiming to evaluate barriers to healthcare among immigrants in the United States, particularly African immigrant women. The study used a semi-structured interview with a sample size of 24 undocumented African immigrant women. The finding of the study suggested that there are many obarriers to access o healthcare services among African immigrant women, including cultural and linguistic barriers, being considered a public charge and reporting immigrant status. The study suggested various approaches that can be adopted by policymakers and researchers to address the health needs of undocumented women.

These findings were supported by Adekeye, Adesuyi & Takon, (2018) who carried out a quantitative study aiming to assess the barriers to healthcare among cancer patients in the African American immigrants. The study utilized a survey to collect data from the participants during a health fair. Descriptive analysis was used for data analysis. Most of the participants were low-income earners and were uninsured. The health fair provided an opportunity for providers to provide awareness/education, free health screening and follow-up resources. The findings of this study indicate the importance of health fairs in the communities, particularly among uninsured and low-income immigrants.

In another study, Jacquez et al., (2016), carried out research aiming to health care needs, healthcare barriers, perception of healthcare and healthcare use among Latino immigrants. The researchers administered 518 surveys and carried out focus groups among 34 Latino immigrants. The findings of the study indicated a wide range of barriers to healthcare among Latino immigrants, including discrimination, documentation status, lack of quality interceptors and language. The findings of the study suggest that a shortage of established healthcare infrastructure and social support networks exacerbate act as barriers to accessibility of quality healthcare among Latino immigrants in the US. The study recommended that these barriers can be addressed by policy changes.

This position was supported by Nwamu, (2017) who carried out a qualitative phenomenological study to examine barriers to healthcare among Nigerian immigrants. The study had ten participants who were aged between 25 and 50 years and had resided in the United States for more than 16 years. The study used the interpretative phenomenological analysis to capture and code the data obtained. The finding of the study indicates that common barriers to the access of healthcare among Nigerian immigrants include previous bad experiences, cultural differences, acculturation, limited knowledge on the US healthcare system, financial issues and lack of trust in the healthcare system. The study also indicated geographical factors act as barriers to healthcare among Nigerian immigrants.

In another study, Sangaramoorthy & Guevara (2017) conducted a qualitative study aiming to examine immigrant health in rural Maryland. The study specifically focused on barriers to healthcare among immigrants in rural Maryland. 33 informant interviews with immigrants and providers were conducted in this study. The study used qualitative analysis to explore the themes emerging from the study. The findings of the study indicate that non-citizenships status, language barriers, high health expenditure and lack of health insurance coverage as the main barriers to immigrants’ access to quality healthcare services. However, the study recommended that more studies should be conducted to develop strategies for dealing with these barriers.

The above findings were consistent with those of Lightfoot et al., (2019) who aimed to explore barriers to healthcare among immigrants in the United States. The study used photovoice with two groups of adolescent immigrants. The findings of the study indicated various ways in which immigrant experience in the healthcare system affects the lives of immigrant adolescents in North Carolina. The study suggested that to improve their health; it is critical to understand cross-cultural communication, stereotypes, experiences of migration and their ways of life. The findings of the study indicated a wide range of barriers to healthcare among Latino immigrants, including discrimination, documentation status, lack of quality interceptors and language.

Lightfoot’s study was supported byTopmiller et al., (2017), sought to explore barriers to healthcare among Latino immigrants in Hamilton County. The Data analysis in the study was conducted on 439 surveys. Study participants were aggregated by neighbourhood and geographical regions where they live. The findings of the study indicate that immigrant Latinos face considerable barriers to care. Since the ACA does not improve the healthcare options for undocumented immigrants, CHS will continue to provide healthcare services for them. This is especially true in regions where immigrants face significant discrimination and lack of resources. The study suggests that efforts to increase care coverage among immigrants require place-based approaches.

Jang (2016) conducted another study to investigate barriers to healthcare in the United States for Korean immigrants. A mixed-method approach was used with in-depth interviews and survey data. The study analyzed in-depth interview with 120 Korean immigrants and survey data from 507 Korean immigrants. The results of the study suggested that more than half of Korean immigrants in the US face significant barriers to healthcare. The language barrier was identified as the leading cause of poor healthcare accessibility while lack of healthcare insurance followed closely. However, the study indicates that Korean immigrants are active entities who adopt coping strategies for the barriers.

In another study, Zhen-Duan, Jacquez & Vaughnc (2017) sought to assess demographic factors linked to healthcare barriers among Guatemalan and Mexican immigrants in Cincinnati. The findings of the study indicated that Guatemalans who do not have children experienced more barriers to care as compared to those who have children. The study also found that Younger Guatemalans and Mexican women had fewer skills related to healthcare barriers. Furthermore, the findings of the study indicated that the length of staying in the United States is not linked with fewer barriers to healthcare. The study highlighted the importance of disaggregating data to pave the way for more effective strategies to eliminate healthcare disparities for immigrants.

Adunlin et al., (2019) conducted a literature review to evaluate the barriers to cervical and breast cancer screening among immigrants. A thematic analysis of 180 studies suggested a myriad of facilitators and barriers to the screening of these types of cancer both at the system and personal levels. The findings of the study show that personal barriers are immigration status, high cost of care, insurance coverage and lack of knowledge. Furthermore, system barrier identified in this study included insensitive to the needs of patients, lack of interpreter services and poor access to services. The study also found that resources availability and cultural norms at both system and individual level influence screening among immigrants.

Another study conducted by Reynold & Childers (2020) sought to advance knowledge in health coverage by evaluating the strengths of various factors for cardiovascular risks screening among various immigrant groups. Data for the study was obtained from the National Health Interview Survey. The findings of the study indicated that health service factors, including no place for care and lack of insurance are predictors of preventive screening. The findings of the study also showed that immigration and socioeconomic-related factors are not predictors for preventive screening. These findings outline that processes that result in healthcare disparity among immigrants in the US.

Health Programs for which Immigrants are Eligible

Many citizens or immigrants in the US are eligible for affordable care options but remain uninsured. People who are eligible but not insures are the result of misinformation among immigrants, lack of proper training of eligibility workers and enrollment assisters and complexity associated with eligibility rules. This section reviewed some of the major public health coverage options for both legal and undocumented immigrants that could enhance health coverage in the US, particularly among the immigrants.

Programs available for both Legal and undocumented Immigrants

Numerous programs are available regardless of the citizenship status of an individual (Martin, 2019). This includes services and programs that exempted from the PRWORA. Programs and services that are not considered “federal public benefits” and local or state-funded services or programs.

Ortega et al., (2018) conducted a study focusing on health coverage among Latino immigrants. The study had a sample size of 51,386 individuals. The findings of the study indicate that various health programs are available to both legal and documented immigrants in the country. While PRWORA restricted access to coverage by immigrants, there are various exemptions. Programs and services that were exempted from PRWORA include Medicaid and “Short-term, non-cash, in-kind emergency disaster relief”. Furthermore, treatment of communicable diseases and assistance for immunization was also exempted. The study suggested that Immigrants could access healthcare services under these programs.

These findings were supported by another study conducted by Martin (2019) who aimed to explore ways of providing comprehensive Health Care for immigrants who are unable to access healthcare insurance, including Medicare and Medicaid. The study suggested that most of these people obtain coverage through state-based programs, private insurance or employer-based plans. The other immigrants remain uninsured, relying on options such as emergency department services under the PRWORA, free clinics and out-of-pocket. Those who do not have enough money to pay for their services are unable to access care. This explains the disparity of healthcare among undocumented immigrants in the US.

Martin’s (2019) findings were supported by De Trinidad & Wallace, (2019) who sought to explore the various health programs available for undocumented immigrants in the country. The study suggested that numerous integration and criminalization policies have significant impacts on the access to healthcare services in the country. The study suggested that various programs are available to undocumented immigrant including charity care, school lunch and breakfast, women infants and children, family planning services and community health centres. The study also suggested that there are state-funded programs available to these group, including healthy kids and Illinois’ All Kids program.

Private Health insurance

Documented immigrants can purchase health insurance through the ACA’s market places (Zallman et al., 2018). Furthermore, undocumented immigrants can apply for premium tax credits and health insurance on behalf of other family members as long as they are qualified. While immigrants need to show proof of immigration status or citizenship to buy health insurance through the market place, there are no such restrictions on private health insurance which can be purchased externally.

Buchmueller et al., (2016) sought to document how health insurance under the ACA impacted the lives of Hispanic, White and Black adults in the US. Data for the study was obtained from the American community survey to investigate the changes in the percentage of adults who are covered by private insurance, covered by Medicaid and uninsured. The findings of the study indicate that 25.8% of Blacks and 40.5% of Hispanics were uninsured compared to 14% of white individuals. The study found a larger gap in private insurance. The study concluded that the ACA has substantially reduced ethnic/racial disparities in health coverage.

These findings were supported by Zallman et al., (2018) who aimed to investigate the premiums paid by immigrants to private insurance. The study used nationally representative data to determine the premiums paid by immigrants. The study found that immigrants were able to access private health insurance. However, they accounted for 12.6% of all premiums paid to private insurers. The study indicated that the annual premiums paid by immigrants were more than their care expenditure. The findings suggested that policies limiting immigration had the potential of reducing the numbers of individuals with private insurance. This is an indicator that most immigrants were able to access private health insurance.

In another study, van der Goes & Santos (2018) sough to evaluate the factors that inform the gap in private health insurance among white non-Hispanic men and Mexican Americans. National Health Interview Surveys between 2010 and 2013 were used in this particular study. The study estimated that 79.5% of non-Hispanic white men were covered by private health insurance as compared to 44.4% of Mexican American men. The study found that 60% of the Mexican American men were immigrants. The study concluded that the observable differences between the two groups were as a result of characteristics such as immigration status, language and education.

Children’s Health Insurance Program CHIP and Medicaid

CHIP and Medicaid are health coverage programs available to low-income earners and middle-income individuals who are eligible. Immigrants must have an immigration status to be able to meet the eligibility criteria for CHIP and Medicaid (Brooks et al., 2019). However, they must wait for five years before they can apply for these programs after immigration. This coverage can however, be expanded by States to pregnant women regardless of their immigration status and without having to wait for a period of five years. At the moment, fifteen states in the US have been able to expand this coverage to pregnant women without the waiting period.

Brooks et al., (2019) conducted a fifty-state survey to investigate the CHIP and Medicaid eligibility enrolment and costs sharing policies. The survey data indicated that most states in the country had expanded Medicaid to low income earners, significantly reducing health disparities. The data also indicated that the states had implemented a streamlined enrollment that provided an opportunity for immigrants to access health coverage. However, the report suggested that emerging policies could erode enrolment simplifications and coverage gains realized under the ACA. Waivers introduced by the current administration could also act as barriers to coverage and result in considerable losses among eligible immigrants.

Brook’s findings were supported by Seiber & Goldstein, (2019) who aimed to test whether CHIP and Medicaid had been successful in closing the health gap between US citizens and immigrant families. The study used American Community Surveys between 2008 and 2015 to compare the rate of uninsured eligible citizens in native and immigrant families. The results of the study indicate that most states reduced the disparities associated with enrollment by almost a half. These improvements are attributed to outreach efforts and operational changes during ACA and CHIP implementation rather than policy changes. Without these efforts, children in immigrant families may experience large enrollment differentials.

Best Practices

This section outlines the best practices for LHDs and CHCs to improve health coverage among immigrants as presented by previous studies. Numerous studies have outlines various approaches that can be used to enhance care accessibility among immigrant families who at a higher risk of developing serious health issues. It also outlines potential revenue sources to the healthcare systems that can enhance the accessibility of care among immigrant families.

Education and Outreach to Immigrant Communities

Soto Mas & Jacobson (2019) sought to investigate health literacy gaps and suggests educational opportunities for improving healthcare literacy among Hispanic immigrants. The study found that health literacy is closely related to a wide range of health outcomes such as mortality, management of chronic conditions, use of preventive services and hospital admissions. The findings of the study indicate that education and outreach programs to Hispanic immigrants may significantly reduce the negative health consequences experienced by the group. The study notes that health literacy is particularly important for Spanish speakers who have difficulties in understanding English.

These findings were supported by Fernández‐Gutiérrez et al., (2018) who sought to identify and evaluate the impacts of health literacy in enhancing health coverage among immigrants. A systematic review of studies published between 2000 and 2015 was conducted. The results of the study indicated that there were positive changes in health coverage as a result of health literacy among immigrants. The study concluded that health literacy was highly effective in improving the accessibility of healthcare among immigrant groups. However, this study was limited by the facts that most of the studies reviewed had their own limitations, and the review was limited to studies written in English and Spanish.

Use of Emergency Medicaid for Outpatient Services

Swartz et al., (2017) conducted a quantitative study aiming to evaluate access to prenatal care among undocumented immigrant women in the US. The study used difference-in-difference design to investigate the impacts of health service utilization among immigrant women. The sample of the study included pregnancies covered by Medicaid (163, 537), Emergency Medicaid plus (13,344) and Emergency Medicaid (34,320). The results indicate that there was an increase in prenatal care visit by immigrant women after the expansion of prenatal care visit. The study concluded that the prenatal care expansion in Oregon resulted in increased utilization of healthcare services among immigrant women. It also resulted in improved healthcare outcome among undocumented immigrants in the country.

These findings were supported by Khullar & Chokshi, (2019) who sought to investigate immigrant health and emergency Medicaid reforms. The finding of the study indicates that emergency Medicaid accounts for more than 80% in pregnancy-related care in most states. Various policies have allowed states to cover more prenatal services. The findings of the study suggest that there are public health reasons, medical and economic reasons for states to extend comprehensive prenatal care for immigrant women. This could play a significant role in enhancing the health outcomes of the immigrant group hence promoting the overall wellbeing of immigrant communities in the country.

Summary

In summary, this section presented three themes, including Immigrant’s barriers to care, Health programs for which immigrants are eligible and best practices. Their subthemes were also discussed in this section. The insights provided by this section will be important in identifying the gap in research on the topic of health coverage among immigrants. This section will also show the relationship between the proposed study and the existing literature. In the next section, this paper discusses the methodology and research design that will be used in conducting the study. Finally, the implications of the study will be presented.

Methodology

The main aim of this study is to determine the probability of accessing health coverage within immigrants by comparing those who are citizens and those who are not. Furthermore, the study aims to explore the barriers that immigrants face in accessing health coverage and best practices that can improve healthcare coverage among immigrants and their families. This section will provide the overall approach that will be used to answer the three research questions outlined in the introduction section.

Research Type

This study will be conducted using qualitative methods. The approach will allow the researcher to capture feelings, attitudes and perspectives of the study participants. Also, the data obtained from the study will help to explain things that are difficult to explain using numbers. The approach also provides an opportunity for the researcher to change setting and questions depending o various research circumstances (Connelly, 2016). This flexibility is critical, particularly when studying the accessibility of healthcare among immigrants in the United States.

Research Design

A phenomenological research design will be used to answer the research questions. This search design is well aligned for their study because it is highly effective in studies that aim to understand the experiences of study participants concerning particular phenomena. Besides, this research design will provide a detailed understanding of healthcare coverage among immigrants in the United States.

Sampling

This study will be conducted in various community health centres in the State of Maryland. The participants for the study will include health providers (10) and immigrants (20) in these CHCs. This sample size is small enough to allow the researcher to collect substantial information from each participant. Study participants will be selected using simple random sampling.

Research Instruments

Data for this study will be collected using questionnaires and interviews. The questionnaires will be used to collect data from immigrants while interviews will be conducted on the healthcare providers. Open-ended questionnaires will be used to allow the respondents to provide extensive explanations. Questionnaires are the most appropriate instruments for collecting data from the immigrants because they will allow the researcher to collect data easily and within a concise period of time. Interviews are the most appropriate tools for data collection among healthcare providers because they are open-ended, and this will allow the researcher to obtain in-depth information.

Implications of research to practice and knowledge

This study will provide significant insights on health coverage in the United States for legal and undocumented immigrants. IT will also provide extensive information on the barriers to health coverage among immigrants in the US. These insights can be used by policy makers, practitioners and researchers to develop effective strategies for improving health coverage among immigrants in the country. The study also provides background information that can be used by researchers in the future to advance knowledge in the field.

Ethical Considerations

This study will be conducted according to the principles of ethics. The researcher will obtain permission to conduct the study from the relevant authority prior to the research. Participants of the study will be recruited on a voluntary basis. The researcher will provide all the necessary information concerning the study to allow individuals to understand the benefits and implications of participation. Those who wish to withdraw during the study will be allowed to do so at any stage. The confidentiality and the anonymity of the study subject will be protected (Leibovici, 2016). The data provided by the study participants will only be used to the purpose of this study.

Research Limitations

Like any other study, this research will have various limitations. The small sample size of the study will limit the ability of the study findings to be generalized. The study findings may also be biased as a result of dishonest responses provided by the study participants. Besides, numerous resources are required for data collection, and this may increase the cost of the study and the time taken to complete the research.

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