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Lessons Learned from a Program to Sustain Health Coverage After September 11 in New York City's Chinatown





This is the first study conducted to assess the health needs of the worker population in Manhattan's Chinatown and its utilization of health care services. The study relates specifically to two groups of Chinatown adults: one that chose to enroll in a temporary health care program for workers affected by the terrorist attacks of September 11, 2001, and a second group that did not enroll in the program.

Performed by the Asian American Federation of New York (AAFNY), this study had two goals. The first was to identify and understand the factors that facilitated or hindered people's decisions to participate in this health care program. The research team also wanted to provide insights that public and private service providers could apply in designing and implementing other programs that serve immigrant populations.

Many of the findings in this report can be more broadly applied to a range of health service programs that are designed to serve immigrant populations. The study illustrated several key lessons. For this immigrant population, the source of information, a person's prior experience with health insurance and their immediate health needs were factors that influenced how people made decisions about accessing health care services.

Researchers learned, for example, that to gain the confidence of the community and stimulate participation, the source of information about this health care program had to be a trusted individual. Only a "trusted" person was able to effectively conduct outreach and respond to the needs of eligible participants.

Researchers also noted that potential program participants often did not enroll because of their lack of understanding about health insurance in general, and their fears related to their undocumented immigrant status.

The September 11th Fund Health Care Program

This study focused on the Health Care Program (HCP) that is part of the Ongoing Recovery Program (ORP) of the September 11th Fund. Implemented in August 2002, the HCP had an enrollment deadline of January 31, 2004. It provides up to 12 months of free health care coverage to workers ineligible for public health insurance programs and cannot afford to pay private health insurance premiums. Enrollment requires a two-step application process. Individuals must first enroll with Safe Horizon, a New York City victim's assistance program that manages enrollment and outreach for the ORP HCP, and then enroll with one of the four participating health service sites.

Eligibility for the HCP program is based on several criteria. Individuals must have worked between September 11, 2001, and January 11, 2002, south of Canal Street; or within the boundaries of Broadway, Canal, Delancey, and Essex streets; or at Ronald Reagan National Airport. They must have lost a job, missed four weeks of paid work, or experienced at least a 30 percent loss in overall income prior to January 11, 2002. Individuals also must be currently unemployed, or be underemployed, with at least a 30 percent income loss since September 11, 2001. Finally, they must be ineligible for public health insurance programs but unable to afford private health insurance premiums.

The September 11th Fund reported that as of November 2003, some 14,000 individuals had accessed the health care program in the more than 15 months since its inception. More than 60 percent of enrollees spoke Chinese.

Study Methodology

The research team conducted 12 focus group sessions with a total of 94 participants. All were of Asian descent and employed in Chinatown before September 11, 2001. This study consisted of two populations: six "enrollee" groups that were comprised of individuals enrolled in the HCP, and six "non-enrollee" groups that were comprised of individuals who had completed either none or only one-half of the two-step enrollment process. Middle-aged females from the garment industry—one of the groups most impacted by the September 11 attacks—comprised the majority of focus group participants.

Factors That Influence Health Insurance Decisions

Source of Information

The study illustrated that participants relied heavily on trusted friends, family or coworkers for information. Fifty percent of enrollees and 64 percent of non-enrollees reported learning about the program through word-of-mouth.

Trust was particularly an issue for undocumented individuals who were fearful because of their immigration status. Some people rejected the program unless they heard about it from a reliable source. The issue of trust also played a role in the fear clients had in sharing personal information. Many were hesitant to provide their phone numbers and other contact information to service providers because of their fears about their immigrant status.

Many people were prompted to enroll after they were able to meet service providers. All four service providers reported that their presence at Safe Horizon information sessions increased their enrollment numbers.

The September 11th Fund's collaboration with Community Based Organizations (CBOs) was key to overcoming the wariness of participants. CBOs were able to reach underserved populations such as the Fujianese, a major Chinatown subgroup, because of their knowledge of and relationship with the community.

Prior Experience with Health Insurance

A person's prior experience with health insurance also influenced their decision to sign up for the insurance program. Enrollees were more than twice as likely to have had past insurance coverage than non-enrollees, many of whom had no previous health insurance coverage. Specifically, 74 percent of non-enrollees never had health coverage, while the same was true for less than one-third of enrollees (29%).

Non-participants had strong misconceptions about insurance. "Even if I had September 11 insurance, I don't think it would be good," expressed one non-enrollee. "The appointment times would be too long. If one gets sick, he will not get immediate care through his September 11 insurance. It is useless. I would rather pay for a private doctor out of my own pocket."

Non-enrollees had heard about various health care programs, but many automatically assumed that they would be ineligible. This trend was quite common among undocumented immigrants, who are ineligible for most government programs. Fear about immigration status influenced many people's decision not to enroll in the program: "We're afraid that we might be arrested because we are undocumented," said one focus group participant. Many Fujianese were not disinterested in the program, but did not enroll because they were unaware of the program or had incomplete information about it.

Participants reported varying degrees of familiarity with insurance and health care services. Those people familiar with the health care system tended to demonstrate a more informed approach to using their health insurance, for example, by using more preventive-care services.

People who lacked health insurance often delayed receiving medical services, and these participants instead endured pain or illnesses as long as possible. Non-enrollee groups were less educated, knew minimal English and were more recent immigrants. Often, they also lacked health insurance.

The terrorist attacks influenced the health care needs and frequency of treatment for people who did not enroll in the program. In the years after September 11, this group reported the highest levels of need and service use for dental and mental health services and for prescription drugs. There were significant increases in the use of emergency room and mental health services, as well as a decline in the use of traditional medicine.

The group in general showed a lack of sophistication about health insurance. For those with the most limited exposure to the U.S. health care system, employer-sponsored insurance was a foreign concept. Said one immigrant, "My employer did not buy insurance for me. Why does he have to?" Participants did not fully understand rules about health care programs and insurance, and often did not look beyond erroneous information received from their friends, relatives or co-workers. Consequently, very few had been proactive in pursuing health insurance.

Language barriers also limited the health care options available to this immigrant population: "I was not satisfied and had not used the service at all because we were limited to using the clinic in Queens only. It was too far away and I did not know how to take a bus to get there. The staff in the clinic spoke English only. So I paid to see a private doctor out of my own pocket," said one participant.
HCP was able to overcome the lack of a sophisticated understanding of health insurance and language barriers through their simplified application process. By accepting alternative forms of documentation, and with the aid of well-informed staff members, many more individuals were able to enroll in the program.

People who were members of a union before they lost their jobs were most aware of the availability of COBRA. But most of them could not afford COBRA and chose not to participate: "I paid $40 for a visit and medicine," says one. "I have no money. I don't even have enough food. How can we afford health insurance? Insurance is a luxury for me."

A few individuals had difficulty maintaining health coverage because programs were unresponsive to their attempts to enroll: "After September 11," says one, "I had temporary Disaster Relief Medicaid. In August 2002, when I applied for Safe Horizon, they told me that I am eligible for Medicaid but there was no reply from them."

Immediate Health Needs

An individual's immediate health needs also influenced the decision-making process. People with past coverage were more aware of their own health needs. They knew lab tests were an important aspect of preventive health care, and were aware of their chronic medical conditions.

People who chose to enroll in the health program reported little change in how frequently they accessed health services. There were no changes reported in their need for prescription drugs or emergency room care. The largest change, an increase of 5.77 percent, was in the need for dental services. People who reported accessing health service more often used dental and surgical services more, but decreased their reliance on emergency rooms.

The cost of insurance and paying for health care services is a constant worry for many immigrants and low-wage workers. Many participants only visited unlicensed doctors for treatment because of their lower costs. One participant complained, "Can't afford the licensed doctors, very expensive." Another said, "If I am sick, I go to see my private (no license) doctor because I am undocumented. My husband will go to the emergency room. He receives emergency benefits."

The HCP's four health providers were the Affinity Health Plan's Sunrise Program; the Chinatown Health Partnership at Charles B. Wang Community Health Center; the Chinatown Health Partnership at Lutheran Family Health Centers, Sunset Park; and the Union Health Center, the primary care and multi-specialty ambulatory health center providing healthcare to the active and retired members of the Union of Needletrades, Industrial, and Textile Employees (UNITE).

Drawing from their experience with employer-sponsored private health insurance, enrollees who chose the Affinity Health Plan liked the extensive network of providers, the comprehensive services covered, as well as the freedom of choice. People who selected the Charles B. Wang center were also pleased with the experience, and noted the friendly staff and good follow-up. "Even though I missed my appointment, they followed up and reminded me to go again," recalled one enrollee. Enrollees in the Sunset Park program, meanwhile, cited the efforts of personalized outreach that eventually helped them choose this site. Enrollees who chose the Union-sponsored health provider were satisfied with services, but wanted a better dental plan, shorter waiting times to see a doctor and a more convenient location.
Some enrollees, however, recognized shortfalls in the HRP program, particularly in the area of limited coverage. "First, the insurance does not cover hospitalization. then dental insurance only covers simple procedures. Bigger surgeries like implants and bridges are not covered," commented one participant.


Based on these findings, the AAFNY research team developed a series of recommendations geared for public and private service providers in designing and implementing programs to serve immigrant populations.


  1. Program Design
  2. Complete a thorough needs assessment to ensure health insurance access for underserved groups in the community and to accommodate the community's special circumstances in a culturally and linguistically appropriate manner. A community's unique characteristics must be taken into account when implementing programs.

    Specifically, this can be accomplished by:
    • gathering comprehensive information about subpopulations from communitybased organizations, since many are absent from formal data sources such as the 2000 Census;
    • accepting alternatives to standard documentation requirements to accommodate the cash-based nature of Chinatown businesses; and
    • increasing language access to the health care system for those with limited English proficiency and little or no prior health insurance experience.
  3. Conduct comprehensive community health education campaigns to build awareness of preventive health care and available public and private insurance programs. This can be accomplished by:
    • providing long-term community education efforts focused on the benefits of health maintenance, prevention, insurance, and service providers through the use of workshops, educated frontline staff, and public service announcements; and
    • supplementing media outreach with individual contact through local communitybased organizations.
  4. Provide automatic enrollment, personal attention, variety of choices, and/or education on how to make simple comparisons when offering a choice in provider. Simplifying the enrollment process, providing assistance, or educating the client about choices in providers will help facilitate enrollment into health programs.

  6. Policy
  7. Provide continuing coverage for current program participants who have no alternatives when the program ends. To continue the efforts of the September 11th Fund at the program's conclusion, local and state governments should investigate ways to insure the dislocated working population affected by the attacks of September 11.
  8. Expand health coverage accessibility by streamlining the enrollment process into government-sponsored and other health insurance programs. States should have the option of increasing accessibility to health insurance programs by streamlining enrollment, minimizing the duplication of applications, and integrating information from various program databases to maximize clients' ability to access different programs.
  9. Encourage joint employer- and union-sponsored health insurance for workers in Chinatown and other immigrant communities. Major business sectors in the Chinatown community, such as the restaurant, retail and service industries, should be encouraged to follow the unionized garment industry's lead in providing employer sponsored insurance.


Publication Details



Lessons Learned from a Program to Sustain Health Coverage After September 11 in New York City's Chinatown, Shao-Chee Sim and Carol Peng, The Commonwealth Fund, July 2004