Communicating to Drive Health Coverage Enrollment Among Non-Citizen Populations

Gabriela Gomez and Melissa Morales, GMMB

Introduction

As states continue to explore ways to close the health coverage gap, many are considering policy changes to ensure communities traditionally excluded from health insurance access, such as non-citizen individuals and families, have an opportunity to enroll in quality, affordable health coverage. At the federal level, the Biden-Harris administration recently announced a plan to expand health coverage access allowing individuals in the Deferred Action for Childhood Arrivals (DACA) program to enroll in Medicaid or the health insurance Marketplace with subsidies and cost-sharing reductions. The Department of Health and Human Services (HHS) released the proposed rule to expand healthcare access for DACA recipients on April 26, 2023.

While designing new programs that extend coverage to non-citizen populations is one part of the puzzle, building awareness of these programs in a way that reaches and moves non-citizen audiences to action will require a thoughtful approach that is rooted in research and employs culturally and linguistically responsive tactics. This expert perspective offers insights on common barriers along the enrollment journey and communications recommendations to effectively drive consumer behavior. Even if a state is not implementing new policies, these insights may still be applicable to reach the approximately 1.6 million uninsured non-citizens potentially eligible for Medicaid or the Children’s Health Insurance Program (SHADAC analysis of 2021 American Community Survey).

To help inform state strategies to best serve this population and enroll them in new coverage options, State Health Value Strategies (SHVS) conducted qualitative research with Latino/a adults, which included a mix of U.S.-born and naturalized citizens and non-citizens, many of whom were living in mixed-status households. The study sought to understand the barriers to coverage, perceptions, and understanding of access to care in the U.S. We supplemented our analysis with findings from qualitative research conducted by the California Health Care Foundation which explored effective messaging strategies to communicate a new health coverage expansion in the state and promote enrollment among newly eligible Latino/a, Chinese, and Korean immigrants in Los Angeles County. This expert perspective shares insights from the above-mentioned qualitative research and communications strategies to drive outreach and enrollment with non-citizen populations.

Creating Awareness of New Health Programs

While non-citizen audiences are aware of the benefits of health coverage, they are often unaware of the options that exist and whether they are eligible. This has led to the incorrect assumption that non-citizen communities are not interested in enrolling in health insurance. On the contrary, research shows that many non-citizens are enthusiastic about the prospect of healthcare but because they believe that they are ineligible for coverage, they fail to seek out information. In fact, many non-citizens often travel to their other countries to access more affordable healthcare. A common misconception among non-citizens is that the health coverage options that are available have income cut-offs that are too low to help them. This could result in some individuals foregoing care. It is critical then that information about new health programs explicitly state eligibility criteria, emphasize affordability and income limits, and explain the full scope of medical services.  

Emphasizing Legitimacy of New Health Programs or Plans

Given non-citizens’ experience with and sensitivity to misinformation, ensuring all communications are developed with a focus on credibility is important. Contrary to popular opinion, research has shown that the non-citizen community places trust in the government and prefers to receive information about health coverage options through official government entities, particularly the state government. While community-based organizations and other community stakeholders play an important role, the information and related collateral they disseminate must come from an official source, preferably a state health agency.

Mitigating Fears Around Public Charge

The chilling effects of the 2019 changes to the public charge rule continue to persist in immigrant communities, deterring their access to healthcare and insurance enrollment. Although the public charge policy related to government health programs is no longer in effect, non-citizen communities continue to forego enrollment in health insurance for fear that doing so will jeopardize a person’s immigration status now or in the future. This fear is particularly acute among non-citizen and mixed-status households where individuals may be concerned for themselves and their family members, regardless of their personal immigration status. State health agencies and relevant stakeholders must double down on efforts to counter this misconception and assuage fears at the outset of an individual’s enrollment journey by clearly and prominently stating that enrollment in the program will not affect a person’s current or future immigration status. Where possible, states should consider partnering with consulates representing dominant immigrant populations. Consulates often hold community resource events where health information can be shared in a trusted space.

Motivating Individuals to Access Care

Enrollment is just the start; health literacy barriers can result in people not accessing the primary and follow-up care needed to maintain their health. Educating people on how to access care will require the creation of linguistically appropriate materials that detail how enrollees can use their new health plan. Even with health coverage, many non-citizens feel that they are unlikely to find culturally competent healthcare professionals and will need guidance and support to find a suitable doctor, set up an appointment, and understand what they will need to pay upfront. It is also important to ensure enrollees have access to providers and support staff who can speak the language and answer any questions they have on their care or their new health coverage.

Conclusion

As states consider policies and programs to increase non-citizens’ access to health coverage, successful outreach efforts to draw newly eligible individuals should aim to address common barriers facing non-citizens at all stages of the healthcare enrollment process. Insights from the research examined suggest take-up of health coverage could benefit from messaging and materials that convey the legitimacy of new health coverage options and narrow the knowledge gaps that exist around eligibility, affordability, and specific services covered by the health plan. Communication recommendations include:

• Cultivating trust: Prominently displaying a state seal or other official symbol will help lend credibility to the information communities are receiving about new health coverage options and show that it is reliable and trusted. It is advisable to have trusted messengers distribute information from the same source (e.g., state health agency).
• Countering misinformation: Outreach collateral should address public charge concerns by clearly communicating how the policy will no longer penalize individuals seeking to access available health-related benefits.
• Ensuring transparency: From messaging to printed collateral, state health agencies should aim to include specific and detailed information about eligibility, examples of income thresholds, and services provided by the health plan, so non-citizen audiences feel they are making an informed decision about their health coverage.
• Employing cultural competency: Immigrant communities are diverse, therefore consumer-facing content should strive to reflect those cultural differences when appropriate. Steps like building in time to research the dominant subcultures of the communities you want to serve and adjusting the messaging you disseminate can help your communication feel relatable to potential enrollees. Similarly, be thoughtful about the creative assets you develop and employ visuals that are reflective of the population you want to engage.

SHVS has created a toolkit, Reaching Non-Citizen Communities: Resources to Support State Outreach and Education to Drive Healthcare Enrollment, which contains message research insights, messaging to drive enrollment in existing programs and through outreach partners, as well as template resources for states. SHVS’ Supporting Health Equity and Affordable Health Coverage for Immigrant Populations series examines a range of strategies that states have at their disposal to help extend coverage to immigrant populations.