Barriers to Health Coverage for Hispanic Workers: Focus Group Findings

EXECUTIVE SUMMARY

This study explores the importance of health insurance in the lives of Hispanic workers and the obstacles they must overcome when seeking coverage. It is based on eight focus groups with 81 low- and moderate-income Hispanic workers (households with incomes of $35,000 or less), 22 of whom were insured and 59 of whom were uninsured. The focus groups were convened from March 28 to April 10, 2000.
Key Findings
Relative Importance of Health Insurance

• Hispanic workers want affordable health care coverage. Uninsured focus group participants said they feel vulnerable without health coverage and worry about keeping their uninsured children healthy.
• Meeting basic needs is the first priority. Uninsured participants explained that they are struggling financially—even though some hold two or more jobs—and must keep their living expenses to a minimum. Buying health coverage takes a back seat to other basic expenses, such as food and rent.
• Securing a job, with or without health coverage, is the first priority when seeking employment. Only a few of the uninsured said they asked about health coverage when applying for their current job. More important to them at the time was actually getting the job and finding out about the salary. Also, because many uninsured participants found their job through friends, they knew up front that the employer did not offer health insurance.
• Insured workers give higher priority to health coverage. Insured focus group participants stood apart from their uninsured counterparts in that they placed a high priority on health insurance in their job search. Many of these participants said they were looking for a job with health coverage, and most asked about coverage before taking the job. Only a few insured participants would leave their current job for one that does not offer health insurance.
• Perceived or actual need for health services may be an important motivator for obtaining health insurance. Those who seemed to value coverage most were the ones who perceived a greater need for health care—that is, they thought they may need to use medical services in the near future.
• Workers who have paid large medical bills out-of-pocket—or have chronic health care needs—value health insurance. Participants who have previously incurred large medical expenses understand the benefit of having health coverage to pay those bills. They also worry about contracting a serious illness or developing a chronic condition in the future. Uninsured participants who have not faced large medical bills do not associate serious health conditions with health coverage.
• Those with children place a high value on coverage. Both uninsured and insured participants said they feel that health coverage is important because of their young children. While these parents are willing to go without insurance for themselves, they worry about keeping their uninsured children healthy.

Barriers to Coverage

• Many employers do not offer health coverage, or offer it only to certain employees. Many uninsured participants said they work for companies that do not offer health insurance—often small firms with fewer than 50, and frequently fewer than 10, employees. Others had been informed that they are ineligible for the company health plan, which is sometimes available only to management or full-time workers.
• Some are influenced by past negative experiences with health coverage. A number of uninsured participants were not satisfied with their previous coverage, which they said did not cover enough health services and was too expensive.
• Low-wage jobs and temporary work do not usually come with health benefits. Participants noted that Hispanics are often able to obtain only low-wage jobs, which typically do not offer health coverage. Others mentioned that some Hispanic workers have a "temporary mindset": because they plan to stay and work in the United States for only a short time, they consider health insurance unnecessary. Such reasoning leads these individuals to take seasonal jobs which, again, are unlikely to have health benefits.
• Some Hispanic workers do not perceive a pressing need for health coverage. A number of young and healthy uninsured participants questioned the value of health coverage at this point in their lives, since they are rarely ill and almost never go to the doctor. Some think about coverage only in terms of routine medical care—for example, treating the flu—and not for more serious, and potentially more expensive, medical needs.
• Language barriers pose a problem. Many participants said that materials and other information about health insurance options are not in Spanish. They feel they may be missing opportunities for coverage because of language barriers. They also want more access to Spanish-speaking physicians and other health care providers.
• Immigration concerns weigh heavy in decisions to participate in health plans. A few participants reported they are worried about signing up for their employer's health plan because of the risk of questions about their immigration status. Immigration concerns prevent some uninsured Hispanics from enrolling themselves or family members in government programs like Medicaid and the State Children's Health Insurance Program (CHIP).

Health Care Experiences

• Most uninsured participants said they go to low-cost or free health clinics, or see doctors who charge reduced fees or allow them to pay in installments. A few reported going to a hospital emergency room to receive care for illnesses they cannot cure at home, while a few others said they return to their home country to obtain free or inexpensive treatment. Most participants, however, said that they use over-the-counter medications and home remedies as their first line of defense. Few reported receiving any preventive health services, which they believe would be one of the advantages of having insurance.
• Some participants complained of receiving poor treatment because they are uninsured. When they do visit a clinic or doctor's office, uninsured participants said they are made to wait longer, are rushed through their visits, and are treated in an impersonal manner because of their low income and lack of health coverage.
• The insured have more health care options and are more satisfied. Overall, insured participants seemed more satisfied with their health care, mainly because they have a choice of where and when to get health services and are more likely to have a regular doctor. Their complaints are similar to the uninsured's, however, with respect to long waits, rushed appointments, and impersonal treatment. This suggests larger problems with the health care system.

Health Coverage Preferences

• The uninsured want low-cost, comprehensive coverage. Uninsured participants said they are willing to pay for health insurance as long as fees are reasonable and the coverage goes beyond basic care to include dental and vision care, prescription drugs, and other services. A number of participants said they would pay $50 or more toward a monthly premium.
• Preferences for the source of health coverage—whether employers, the government, or the community—are mixed. Participants liked the idea of payroll deductions in the existing employer-based insurance model, but they did not want their coverage tied to keeping their job. For this reason, some preferred government-sponsored insurance, since people could retain their coverage even if they become unemployed. There was concern, however, that the government would probe into Hispanic workers' immigration status. While participants were unclear about how community-sponsored coverage would work, they found this option appealing because it suggests greater local control and sensitivity to the health needs of Hispanics.
• Many are unfamiliar with, but interested in, CHIP. Few focus group participants knew very much about the CHIP program in their state, although many said they have seen or heard advertisements for it. Since insuring their children is a priority, participants were interested in learning more about the program.

Policy Recommendations
1. Identify more affordable and comprehensive coverage options. Participants suggested that if deductibles and copayments were lower and health plans offered slidingscale premiums, they would be more willing to purchase coverage offered by their employers. No one expects their coverage to be free; workers simply want more affordable coverage that reflects their limited financial means. They also want coverage that includes dental, vision, prescription, and other benefits.
2. Make it viable for small employers to offer, and contribute to, health coverage for their workers. Small employers are often struggling to meet expenses and cannot always afford to provide coverage and share costs with employees. Yet these are the kinds of employers that hire Hispanic workers. Smaller companies, and industries with high numbers of uninsured Hispanic workers, could be targeted for incentives to encourage them to offer employees health coverage and contribute to premium costs.
3. Have all health care materials translated into Spanish. While Spanish-language materials are more available than before, too much information is still not translated, according to participants. This includes information about plans, available doctors, coverage, and programs like CHIP and Medicaid. More widely available Spanish-language materials could also make it easier for Hispanic families to locate Hispanic or Spanishspeaking doctors.
4. Target low- and moderate-income Hispanic working families with information about public programs for which they might qualify. Participants' interest in CHIP suggests a ready audience for information about this and other public programs.
5. Address immigration concerns. Some participants said they want assurances that signing up for their employer's coverage, or for government programs like CHIP, will not have a negative impact on their immigration status. They fear being asked questions about themselves and their families when applying for insurance.
6. Cover the entire family, not just workers and not just children. When they think about health coverage, participants reported, they have their whole family in mind. They do not like that so many of their coverage options let them cover only some family members. CHIP and Medicaid, and even private insurance, should make it easier for entire families to enroll.
7. Create more low-cost health care choices for the uninsured. The uninsured rely on the health care safety net, including doctors and clinics that charge discounted fees and allow payment in installments. As long as affordable and comprehensive coverage remains elusive for many Hispanic workers, they are likely to benefit from additional options for obtaining low-cost health services.