Exploring uncharted territory

In Washington today, roughly 105,000 undocumented immigrants are living without health insurance. They account for nearly a quarter of the state’s uninsured residents.

But next year, for the first time, those residents will be eligible to access health and dental insurance from the Washington Health Plan Finder, regardless of their immigration status. The state will be the first in the country to make that change.

The expansion comes from something called the Section 1332 waiver, which was approved by the U.S. Department of Health and Human Services in December of last year. The expansion will go into effect Jan. 1, 2024, and is approved through 2028. Open enrollment starts Nov. 1, 2023.

It follows a directive by the Washington Legislature to the Washington Health Benefit Exchange in 2021 to explore coverage pathways for Washington residents who do not qualify for state or federal affordability programs.

The state still needs to determine exactly how much it’s funding in the budget for the transition this year, said Sasha Wasserstrom, the policy director at the Washington Immigrant Solidarity Network.

WAISN is asking the state to provide funding for the expansion, including subsidies for lower- and middle-income immigrants, and an information campaign that works with community organizations.

“This is just a very exciting moment for health access for immigrants, assuming that the programs and implementation are fully funded,” Wasserstrom said. “So this is still up in the air at the moment, although it is expected to happen in 2024.”

What it is

Washington already has some programs that expand health coverage for noncitizens, including Apple Health for children and pregnant people, or Alien Emergency Medical (AEM).

But the 1332 waiver is unique, said Joan Altman, director of government affairs and strategic partnerships at the Washington Health Benefit Exchange. It will allow anyone to use the state website to purchase qualified health and dental plans, which undocumented immigrants were previously excluded from.

Individuals will also be able to purchase health plans for their whole family under one deductible, regardless of immigration status.

“There’s been a lot of iterative work to expand coverage to the waiver population through Medicaid programs, or state-only programs, or through kind of off-exchange, or off-market solutions,” Altman said. “What distinguishes this from those efforts (is) that someone can come in, and with their family members potentially of mixed immigration statuses, purchase a qualified health plan.”

While undocumented enrollees will not be eligible for federal tax credits, some will be eligible for the state’s Cascade Care Savings Plan, which subsidizes health coverage for people who enroll in silver or gold levels and are below 250% of the federal poverty line. In 2022, Washington’s Legislature passed its Supplemental Budget, appropriating $55 million annually to the savings program.

The state is also working toward a Medicaid-equivalent program for adults with income up to 138% of the federal poverty level, regardless of their immigration status. However, it’s unclear just how soon that program will be implemented, said Michael Marchand, chief marketing officer at the Washington Health Benefit Exchange.

“It might either start in 2024 or 2025,” Marchand said. “One thing is certain, is that for 2024, we will have a program for this population moving forward. And if the Medicaid component is not available, all those individuals under 138% would still be able to take advantage of Cascade Care savings.”

The case for expanding

Proponents of the waiver say expanding access to health insurance will help reduce health disparities felt by immigrant populations, and particularly those who are undocumented.

In Washington, more than 60% of undocumented residents have lived in the state for 10 years or more. Those undocumented residents are also less likely to access health care services, and can go undetected for chronic conditions like diabetes and hypertension, leading to worse health outcomes later.

Advocates say aside from better health outcomes for immigrant populations, the expansion stands to benefit all Washingtonians’ health and reduce costs down the line by decreasing the use of emergency medical services.

“The repercussions of people delaying care are huge,” said Jorge Barón, executive director of the Northwest Immigrant Rights Project.

Immigrant workers are also disproportionately exposed to certain health risks in sectors like farming and the service industry, where immigrants account for major sections of the workforce, said Anna Zamora-Kapoor, an associate professor and the community liaison for the Health Equity Research Center at Washington State University.

“These were jobs they could not work from home,” Zamora-Kapoor said. “They had to show up to work, and that exposed them disproportionately to the pandemic. And that’s why we saw that most immigrants had a much higher rate of COVID prevalence, hospitalization and death.”

Implementation

While hundreds of individuals and groups signed letters in favor of the expansion, it will still face hurdles in its implementation. One of the biggest, Barón said, is to overcome is distrust from the communities it’s supposed to serve.

Many immigrant communities, he said, fear using public health programs. That fear was heightened a few years ago, he said, when the Trump administration took action to use what’s called a “public charge” rule — a grounds for denying visas based on an individual’s presumed likelihood to rely on public benefits in the future.

As of December 2022, that policy was changed to make it safe for noncitizens and their families to access health programs for which they qualify. But that fear remains, Barón said.

“I talk to community members all the time who ask me, ‘Is this going to affect me? If I access these services, is that going to make it a problem if I go at some point to apply for a green card?’” he said.

Frank Contreras, a 45-year-old Pullman resident, immigrated from Venezuela in 2018 and is seeking asylum in the U.S. He first purchased health coverage through the state exchange in 2020, but many of his peers remain uninsured, he said.

Contreras, who runs a food delivery service, frequently works and socializes with other immigrants who work at local restaurants, he said.

While some are unable to access coverage because of their legal status, others face language or cost barriers, are misinformed about what programs they may be eligible for, and are distrustful of government programs.

“I believe that some people really don’t want to get involved,” he said. “They just move forward, they stay out of the radar, out of the system.”

Zamora-Kapoor said the waiver is a big step in the right direction to address some of those health disparities. But it isn’t enough by itself. People who qualify under it need to know it exists, and hear about the program from people they trust in their own language.

“We can do a lot of great legislation,” she said. “But if we don’t have our communities behind it ... if they don’t understand it because there are language barriers, because there are a number of barriers that prevent them from accessing it. ... All these efforts are not very fruitful.”

So far, many of Washington’s immigrant communities have little to no knowledge of the waiver, Zamora-Kapoor said. To get people to sign up, the state will need to partner with community-based organizations that work with immigrant communities.

Altman said the state has been working with community partners to that end. The main barriers they’ve heard cited were mistrust of government websites, affordability and language barriers.

Mary Jo Ybarra Vega is an outreach and behavioral health coordinator at Quincy (Wash.) Community Health Center. She said the state will need to work with clinics like hers, which already serve and have the trust of immigrant populations, to make the waiver a true success.

“They’re the ones who are going to probably push it, they’re the ones who are going to be able to sell it,” she said. “They’re the ones who have credibility and trust in the community.”

If people are going to sign up, Contreras said, getting information from sources they trust will be essential.

“They need to reach the real people that need this kind of waiver, need these kinds of benefits,” he said. “And it’s different, when you hear from someone that only speaks English than from someone — they speak the same language as you.”

During the fall 2022 enrollment, the most answered non-English language requests were in Spanish, Vietnamese, Chinese, Ukrainian, Russian and Korean.

Washington’s most-spoken non-English languages among undocumented populations are Spanish, Tagalog, Chinese and Korean.

State employees are working to have the waiver implemented for enrollment by Nov. 1 of this year, Marchand said — but they still have a lot to learn.

“Probably the coolest thing about this program is, it’s never been done before,” he said. “And probably the biggest threat to the program is it’s never been done before.”

Sun may be contacted at rsun@lmtribune.com or on Twitter at @Rachel_M_Sun. This report is made in partnership with Northwest Public Broadcasting, the Lewiston Tribune and the Moscow-Pullman Daily News.