Immigrants Access to Healthcare Report

Transcription

LATINO IMMIGRANTS AND ACCESS TO HEALTHCARE
IN THE GREATER RICHMOND AREA
Research Study Report
Prepared by:
Saltanat Liebert, Carl Ameringer, Cynthia Cors, and Mona Siddiqui
Virginia Commonwealth University
Submitted to the Richmond Memorial Health Foundation
November 2012
CONTENTS:
1
INTRODUCTION ................................................................................................................ 4
2
BARRIERS TO ACCESS TO SAFETY-NET FACILITIES FACED BY THE
IMMIGRANT POPULATION .................................................................................................... 4
3
4
5
THE IMMIGRANT POPULATION AND SAFETY-NET FACILITIES ...................... 7
3.1
Immigrant Population in the Greater Richmond Region....................................... 7
3.2
Overview of Safety Nets ..................................................................................... 12
3.3
Free Clinics ......................................................................................................... 12
3.4
Federally Qualified Health Centers ..................................................................... 14
APPROACH AND CONDUCT OF STUDY.................................................................... 15
4.1
Research questions .............................................................................................. 15
4.2
Methodology ....................................................................................................... 15
4.3
Targeted locations and choice of facilities .......................................................... 16
QUESTIONS ASKED AND SUMMARY OF RESPONSES.......................................... 16
5.1
Country of origin ................................................................................................. 17
5.2
Respondents’ Gender and Marital Status ............................................................ 18
5.3
Health Status of Respondents.............................................................................. 18
5.4
What was the problem? ....................................................................................... 19
5.5
Did you see a doctor, nurse, dentist, or another specialist?................................. 20
5.6
Where do respondents turn for health care.......................................................... 21
5.7
Did anyone take you there? ................................................................................. 22
5.8
How did you know where to go?......................................................................... 22
5.9
What did the doctor do for you?.......................................................................... 23
5.10
Did the doctor explain why you were sick? ....................................................... 24
5.11
Were you given any drugs/prescriptions? Did you get them filled? ................... 27
5.12
Were any tests or procedures performed when you went to see the doctor?....... 29
5.13
Did you see anyone else for the problem?........................................................... 29
2
6
7
5.14
Do you have a chronic condition? ....................................................................... 30
5.15
Do you get treatment for chronic condition?....................................................... 31
5.16
How often do you go to the doctor? .................................................................... 32
5.17
Are you happy with the care that you receive when you go to the doctor?......... 34
5.18
Do you ever go to the emergency room?............................................................. 37
5.19
Which hospital do you go to for emergency care? .............................................. 37
5.20
Why do you go to that emergency room? ........................................................... 38
DISCUSSION OF FINDINGS........................................................................................... 39
6.1
Language Barrier................................................................................................. 39
6.2
Financial Barrier.................................................................................................. 41
6.3
Barriers Due to Administrative Bureaucracy and Immigration Status................ 42
6.4
Transportation Barrier ......................................................................................... 43
CONCLUSION ................................................................................................................... 43
3
1
INTRODUCTION
This report contains the findings and results of a three-month survey of the
Hispanic/Latino immigrant population in the Greater Richmond area conducted between
June 22, 2012 and September 30, 2012. The primary purpose of the survey was to
determine the nature and extent to which Hispanic/Latino immigrants currently use the
healthcare facilities that comprise the Greater Richmond Patient Centered Medical Home
Collaborative (the “Collaborative”). Financial support for the survey was provided by
the Richmond Memorial Health Foundation (the “Foundation”) on behalf of the
Collaborative. Members of the Collaborative include Capital Area Health Network,
CrossOver Ministry, Daily Planet, Free Fan Clinic, Goochland Free Clinic and Family
Services, Love of Jesus Clinic, and Virginia League for Planned Parenthood.
The researchers initially met with administrators and providers from each of the
Collaborative members (with the exception of VLPP) in order to determine the nature
and extent of healthcare services that members provided to the Hispanic/Latino
immigrant community and the best way to proceed with the survey. Based on the
knowledge gained in these initial meetings, the researchers focused their efforts on four
clinic sites—Goochland Free Clinic, CrossOver Clinic’s Hull Street location, the Fan
Free Clinic, and the Daily Planet. Under the direction of Dr. Saltanat Liebert, two
Spanish-speaking VCU students recruited and interviewed a total of 101 uninsured
Hispanic/Latino immigrants (1) from the four clinic sites; (2) from Spanish-language
churches; (3) from fairs and festivals that Hispanic/Latino immigrants commonly
attended, (4) from CrossOver clinic’s Lay Health Promoter Program; and (5) from Bon
Secours’ Care-a-Van sites.
The findings set forth in this report reflect the first-hand accounts, detailed descriptions,
and perceptions of the persons interviewed. Those interviewed related the healthcare
they received, where they went for care and why, the types of illnesses or conditions they
suffered, the nature and extent of the treatment they received, the barriers to care that
they faced, and their perceptions of the people they met and cared for them. Every
attempt has been made in this report to let those interviewed tell their own stories, to let
them describe what they’ve experienced without detailed comment or explanation.
2
BARRIERS TO ACCESS TO SAFETY-NET FACILITIES FACED BY THE
IMMIGRANT POPULATION
Immigrants face several barriers in accessing healthcare, including immigration status,
lack of health insurance, lack of information, cultural/linguistic barriers, fear of detection
and deportation, and fear of bureaucratic hurdles and of exorbitant fees charged by
healthcare providers.
Immigration status. Immigrants in the United States can be categorized into two large
groups: legal immigrants, who arrived in the United States with valid visas or for
4
permanent residency, and undocumented migrants, who arrived with valid visas but
overstayed them (remained in the country after their visas expired) or entered the United
States surreptitiously without appropriate visas. Legal immigrants typically include the
following individuals: 1) foreign nationals with US citizen family members who
sponsored them for legal permanent residency (LPR) for purposes of family
reunification; 2) highly skilled foreign workers who are sponsored for H1-B or other
types of employment visas (such as H1-C, H-3, L-1, O-1, P-1, P-3) by American
employers; and 3) unskilled or lesser-skilled foreign workers sponsored for H-2A and H2B visas. Permanent immigrants are barred from federal means-tested public assistance
for five years after their arrival (which coincides with when most 1 are typically eligible
for US citizenship), while foreigners on employment and other types of non-immigrants
visas are not eligible for public assistance at all. Undocumented immigrants are barred
from all types of public assistance with the exception of a narrow set of specified
emergency services and programs 2 .
The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of
1996 states that undocumented immigrants are ineligible for most state and locallyfunded benefits. The restrictions on these benefits parallel the restrictions on federal
benefits. However, the PRWORA allows the states to provide undocumented migrants
with state and local benefits that otherwise are restricted. Respective state legislatures
would need to pass laws allowing this population to access specific state-funded public
benefits. Public assistance that is co-funded by the federal government can not be
included though, as it’s considered federal benefit under the law. 3
Lack of health insurance. Employment circumstances of legal and undocumented
immigrants vary significantly. Highly-skilled immigrants typically hold jobs that provide
(or enable them to purchase) health insurance for themselves and their families. Lesserskilled and undocumented immigrants often work in lower-paying or hourly jobs that do
not provide health insurance.
Regardless of employment circumstances, immigrants tend to be insured at much lower
rates than the native-born Americans, whose rate of healthcare coverage is estimated at
1
Foreign nationals who became legal permanent residents based on marriage to US citizens are eligible to
apply for US citizenship after 3 years of LPR status.
2
These services and programs include “treatment under Medicaid for emergency medical conditions (other
than those related to an organ transplant); short-term, in-kind emergency disaster relief; immunizations
against immunizable diseases and testing for and treatment of symptoms of communicable diseases;
services or assistance (such as soup kitchens, crisis counseling and intervention, and short-term shelters)
designated by the Attorney General as (1) delivering inkind services at the community level, (2) providing
assistance without individual determinations of each recipient’s needs, and (3) being necessary for the
protection of life and safety; and to the extent that an alien was receiving assistance on the date of
enactment, programs administered by the Secretary of Housing and Urban Development, programs under
title V of the Housing Act of 1949, and assistance under Section 306C of the Consolidated Farm and Rural
Development Act,” Congressional Research Service. (2012). Unauthorized Aliens’ Access to Federal Benefits:
Policy and Issues. Washington: Congressional Research Service, p.9.
3
Congressional Research Service. (2012). Unauthorized Aliens’ Access to Federal Benefits: Policy and Issues.
Washington: Congressional Research Service.
5
87.8 percent in one study 4 and at 85 percent in another 5 . A recent nationallyrepresentative survey 6 showed that only one-third of recent legal immigrants had health
insurance. An earlier study 7 estimated 46 percent of legal immigrants and 59 percent of
undocumented immigrants to be uninsured in 2009. Uninsured undocumented immigrants
are thus essentially confined “to the bottom of the health hierarchy.” 8
Lack of information. Previous research demonstrates that the migrant population in
general is unaware of free or low-cost health care providers. Free clinics and FQHCs do
not generally advertise, relying on word of mouth 9 . In contrast, emergency rooms are
highly visible advertising their services on highway billboards and elsewhere.
Consequently, some uninsured immigrants turn to emergency rooms even in nonemergencies, resulting in significant costs that they are often unable to pay. At the other
end of the spectrum are immigrants who, frightened by such costs, avoid emergency
rooms even in life-threatening health situations. An example from a recent study
illustrates this point:
The director of a community clinic in north San Diego relates the case of a
Mexican boy suffering from a brain haemorrhage. His parents took him to a
distant clinic – the only place they knew would provide free care – driving past
the emergency rooms of several hospitals. By the time the boy arrived at the
clinic, it was too late – he died on the spot. 10
Linguistic and cultural barriers. Lack of proficiency in English and cultural differences
present significant obstacles for immigrants’ access to healthcare. Many hospitals and
clinics do not have bilingual staff and/or interpreters and some do not have American
Telephone and Telegraph (ATT) Translation Service even though “by law, hospitals and
community clinics must provide medical translation.” 11
Linguistic problems in medical setting can result in serious and, sometimes fatal,
mistakes. A recent report states,
4
Portes, A., Fernandez-Kelly, P., & Light, D.(2012). Life on the edge: immigrants confront the American health
system. Ethnic and Racial Studies, 35(1), 3-22.
5
Kaiser Family Foundation. (2009). Immigrants’ Health Coverage and Health Reform: Key Questions and Answers.
Menlo Park, CA: Henry J Kaiser Family Foundation.
6
system. Ethnic and Racial Studies, 35(1), p. 9.
7
Kaiser Family Foundation. (2009). Immigrants’ Health Coverage and Health Reform: Key Questions and Answers.
Menlo Park, CA: Henry J Kaiser Family Foundation.
8
9
system. Ethnic and Racial Studies, 35(1), 3-22
10
11
6
We learned of terrible cases, such as that of an adolescent girl suffering from
stomach pains who was taken to the emergency room where neither she nor her
parents could properly explain her symptoms in English. The attending doctor
gave her some pills and sent her home where she died of appendicitis. 12
In this study, when asked whether they understood everything that the doctor said, one
respondent recounted her experience, “my husband interpreted for me. He speaks a little
English. I still don’t understand everything though.” Another respondent had a similar
experience “Sometimes I understand, sometimes I don’t. Sometimes when the doctor
speaks Spanish, they only speak a little bit, so I don’t understand everything.”
Fear of bureaucratic paperwork and detection of undocumented status. Some
undocumented migrants are reluctant to turn to clinics and hospitals for needed care
because of fear that their immigration status will be detected and they will be deported.
Such fears are justified. When presented with a plethora of forms to fill out before seeing
a medical professional, immigrants might fear detection based on a lacking or invalid
Social Security number or ID. Law enforcement agencies target areas with high
concentration of immigrants. In San Diego, for instance, agents of the Immigration and
Customs Agency (ICE) “have been known to monitor Spanish radio stations to learn the
location of mobile medical units in migrant neighborhoods.” 13
Fear of enormous bills from healthcare providers. Healthcare bills can be daunting for
many Americans, but they can be particularly insurmountable for uninsured immigrants,
most of whom work in low-wage jobs. As a result, uninsured immigrants delay seeing a
doctor until the problem becomes unbearable, which is often a point when the cost of
treating such a person is exponentially higher. A candid remark from a director of an
emergency room in Florida reported in another study aptly illustrates that fear, “Every
patient who arrives here carries a dollar sign on his forehead… One way or another, he or
she will be billed.” 14 One of the respondents in this study, having received a substantial
bill from the hospital where he was treated, declared “If I don't die from the sickness, I’ll
die from the bill.”
3
3.1
THE IMMIGRANT POPULATION AND SAFETY-NET FACILITIES
Immigrant Population in the Greater Richmond Region
The composition of the immigrant population is difficult to ascertain because of problems
in accurately counting individuals in this population. However, national surveys and
other data sources provide some basic measures of the composition and country of origin
of the immigrant population in the United States. Current estimates from the Migration
12
13
14
7
Policy Institute indicate that the foreign-born population in Virginia was 911,119 in 2010,
representing 11.4% of Virginia’s population. From this population, 39.7 % of the
immigrants came from Asia; 37.1% from Latin America (South America, Central
America, Mexico, and the Caribbean); 11.7% from Europe; 9.8% from Africa; 1.7% from
Northern America (Canada, Bermuda, Greenland, and St. Pierre and Miquelon); and
0.4% emigrated from Oceania. The top ten countries of origin were El Salvador, India,
Mexico, Korea, Philippines, Vietnam, China (including Taiwan), Caribbean, United
Kingdom, and Germany.
2010
Total Population of Virginia
Foreign Born Population of Virginia
Origin Africa
Origin Asia
Origin Europe
Origin Latin America (South America,
Central America, Mexico, and the
Caribbean)
Origin North America (Canada,
Bermuda, Greenland, and St. Pierre
and Miquelon)
Origin Oceania
Number
8,024,617
911,119
Percent
100.0
11.4
9.8
39.7
11.3
37.1
1.7
0.4
The Greater Richmond Partnership estimates the population of the Greater Richmond
region was 936,597 in 2011. American Community Survey (“ACS”) provides some
basic estimates of the foreign born population in the Greater Richmond region. The ACS
2011 one-year estimate indicates that 40,300 immigrants resided in Henrico County,
24,722 immigrants resided in Chesterfield County, 15,449 immigrants resided in
Richmond City, and 590 immigrants resided in Goochland County. Map 1 shows that the
majority of Latinos in Richmond live in the city’s south side. The heaviest concentration
of Latinos is in the area between Midlothian Turnpike and Hull Street Road, north of
Chippenham Parkway.
Immigrants residing in the Greater Richmond region are in close vicinity to many of the
areas free clinics and federally qualified health centers. The immigrant population
residing in Chesterfield County has free or low cost health care access to the CrossOver
Health Care Ministry, Care-A-Van mobile clinic, and Capital Area Health Network’s
Southside Medical Center (located between Chesterfield County and the City of
Richmond). The immigrant population residing in Richmond City has free or low cost
health care access to the Daily Planet, the Fan Free Clinic, CrossOver Health Care
Ministry, Care-A-Van mobile clinic, and Capital Area Health Network’s Main Street
Medical Center, Northside Medical Center, Vernon J. Harris Medical Center, and
Southside Medical Center. The immigrant population residing in Henrico County has
free or low cost health care access to CrossOver Health Care Ministry, Care-A-Van
8
mobile clinic, and Capital Area Health Network’s Glenwood Medical and Dental Center.
The immigrant population residing in Goochland County has free or low cost health care
access to the Goochland Free Clinic & Family Services.
Foreign Born Population of Virginia
Country of Origin
El Salvador
India
Mexico
Korea
Philippines
Vietnam
China
Caribbean
United Kingdom
Germany
2010
Number
Percent
86,413
9.5
65,926
7.2
64,685
7.1
55,764
6.1
46,014
5.1
43,215
4.7
39,115
4.3
28,635
3.1
22,705
2.5
20,533
2.3
Source: Migration Policy Institute
9
10
11
Map 2 above illustrates a high density of not naturalized (non-citizen) immigrants in
areas where there are high densities of Latinos. Free clinics and FQHCs are located at or
near the perimeter of these areas.
3.2
Overview of Safety Nets
In the U.S. health care system, a “safety net” is a locally organized system of health care
delivery intended to fill gaps in access to health care services for the uninsured, lowincome, and other vulnerable populations in medically underserved communities. Safety
net providers are largely comprised of free clinics, community health centers, including
federally qualified health centers (“FQHC”), hospitals, and local health departments.
These providers depend on funding from a variety of sources, including federal, state, and
local government; private corporations; foundations; local health systems; civic and
social groups; faith-based communities; and/or others.
The Greater Richmond region’s 15 safety net is an essential part of the local medically
underserved community, “catching those who would otherwise not have access to
care.” 16 Despite limited resources, safety net providers are striving to meet the needs of
individuals with barriers to accessing health care, such as homelessness, immigrant
status, and language and cultural differences. More than 40,000 individuals in the
Greater Richmond region area benefit from safety net providers every year from services
through local free clinics, FQHC, hospitals, the Virginia Department of Health (“VDH”),
and Virginia League for Planned Parenthood. 17 This study included safety net facilities
that are part of the RMHF Collaborative. In addition, study participants were recruited
and interviewed at Bon Secours’ Care-A-Van mobile free clinic sites.
3.3 Free Clinics
Free clinics are non-profit community healthcare providers for low-income, uninsured, or
underinsured patients at little or no charge to the patient. Free clinics depend on
volunteer medical professionals, including doctors, dentists, nurse practitioners, nurses,
dental hygienists, mental health professionals and others, to donate their time and
expertise and deliver the majority of health care services. Free clinics do not receive any
federal funding, and instead rely on community based or faith based financial and other
support from private individual donors, foundations, and corporations. Free clinics also
cannot bill insurance companies, Medicaid or Medicare for services rendered. Some well
established free clinics in the Greater Richmond region include CrossOver Health Care
Ministry (“CrossOver”), the Fan Free Clinic, Bon Secours Care-A-Van, and the
Goochland Free Clinic & Family Services.
15
For purposes of this study, the Greater Richmond region is identified as the cities of Colonial Heights,
Hopewell, Petersburg and Richmond; and the counties of Chesterfield, Goochland, Hanover, Henrico,
Prince George and Powhatan.
16
Richmond Enhancing Access to Community Healthcare [REACH]. (2007). Bridging the healthcare gap:
A community health services plan for the greater Richmond region. Richmond, VA.
17
Richmond Memorial Health Foundation. (2009). The greater Richmond patient centered medical home
initiative. Richmond, VA.
12
CrossOver, a faith-based safety net provider, is Virginia's largest free health care clinic,
operating in three different locations throughout the Greater Richmond region to provide
comprehensive health care and wellness services to more than 6300 uninsured patients a
year. 18 Services are provided to individuals who are at or below 200% of the federal
poverty line, a majority of whom are the working poor, but do not have enough money to
pay for necessary health care. Approximately fifty percent of CrossOver’s clientele
consists of the Hispanic/Latino population, served by bilingual Spanish-English
volunteers. Services provided include family medicine, primary care, obstetrics and
pediatrics, podiatry, dental and vision care, mental health care, HIV diagnosis and
treatment, and critical medications. CrossOver is also the only free clinic with a licensed
volunteer pharmacist on-site providing free medication for CrossOver patients as well as
patients being serviced at other free clinics in the Greater Richmond region. CrossOver’s
funding comes primarily from individuals, businesses, foundations, churches,
associations, schools, and social groups.
In addition to medical services, CrossOver offers a Lay Health Promoter (LHP) program.
The LHP program offers free health care education classes in English and Spanish at
local community centers, churches, and the Richmond City Jail. The LHP program is
designed to meet the low income and uninsured community’s need for basic health
knowledge on preventing diseases, chronic disease management, health related
complications, and accessing and navigating health care resources. Individuals who
participate in the program and complete the required number of classes graduate as Lay
Health Promoters, providing health education for their family, friends, and neighbors.
The Fan Free Clinic in Richmond also provides medical treatment for individuals who
are at or below 200% of the federal poverty line. 19 Approximately 22% of their clientele
consists of the Hispanic/Latino population and other immigrants. Services provided
include adult general medicine, chronic disease management, specialist referrals,
gynecology/birth control, pregnancy testing, pediatrics/immunizations, sexuallytransmitted disease testing and treatment, HIV testing and treatment, mental health
counseling, and a transgender clinic. In addition to medical services, this clinic also
offers social services, advocacy services, and health education and outreach such as
Hispanic/Latino family events.
Contributions from individuals, organizations,
businesses, civic groups, and faith communities are a vital source of funding for the Fan
Free Clinic’s clients and services.
Bon Secours Care-A-Van (“Care-A-Van”) is a unique mobile free clinic that partners
with local churches and community services in twenty-two different locations to provide
primary health care to uninsured adults and children in medically underserved
communities in the greater Richmond region. 20 Each Care-A-Van provides walk-in
18
CrossOver Health Care Ministry. (2012). About us. Richmond, VA: Retrieved from
http://www.crossoverministry.org/.
19
Fan Free Clinic. (2012). Home. Richmond, VA: Retrieved from www.fanfreeclinic.org.
20
Bon Secours Virginia Health System. (2012). Care-A-Van mobile health services. Richmond, VA:
Retrieved from http://richmond.bonsecours.com/about-us-mission-and-outreach-outreach-care-a-van.html.
13
service on a first come, first served basis for about eighteen to twenty-two individuals a
day, serving in total, approximately 14,000 individuals a year. Care-A-Van performs
routine evaluation and treatment of common acute illnesses, including gastritis and
heartburn, minor skin rashes, minor musculoskeletal pains, respiratory infections, urinary
tract and bladder infections, headaches, ear aches, and pink eye, chronic conditions such
as diabetes and hypertension, immunizations for schools, pregnancy tests, sports
physicals, children’s health insurance enrollment, health education services, and referrals
to specialists. Care-A-Van providers also refer patients requiring additional services by
appointment to the St. Joseph’s outreach clinic at St. Joseph’s Villa. The Care-A-Van
team is a English/Spanish bilingual team consisting of an attending medical director,
nurse practitioners, registered nurses, patient care technicians, licensed practical nurses,
drivers, registrars, and outreach workers. There is always a Spanish speaking trained
medical interpreter on site to provide access for many of the Hispanic/Latino patients
who may not speak English. Care-A-Van is funded by Bon Secours Richmond Health
System and donations through the Bon Secours Richmond Health Care Foundation.
The Goochland Free Clinic & Family Services is a private non-profit corporation
providing health care and basic human services to Goochland community residents in
need of assistance. 21 Services provided include medical care, dental care, housing
assistance, clothing, and food. This clinic is financially supported by individual
donations, and donations by foundations, local businesses, churches, government,
corporations, other non-profit organizations.
3.4 Federally Qualified Health Centers
FQHC are designated health care safety net providers receiving some federal funding
from the Health Resources and Services Administration under the Public Health Service
Act to deliver comprehensive primary health care to individuals in medically underserved
communities, regardless of their ability to pay. FQHC provide uninsured patients low
cost health care services on a sliding fee scale, taking into consideration income and
household size. FQHC’s also bill insurance companies for patients eligible or enrolled in
Medicaid or Medicare. In order to maximize limited resources, FQHC may collaborate
with other private and public providers, pharmacies, nursing homes, and local businesses.
Two well established non-profit FQHCs in the Greater Richmond region include the
Capital Area Health Network (“CAHN”) and the Daily Planet.
CAHN provides health care to the underserved, uninsured, Medicaid, and Medicare
patients in five locations throughout the Greater Richmond region, including the Vernon
J. Harris Medical Center, Main Street Medical Center, Northside Medical Center,
Glenwood Medical and Dental Center, and Southside Medical Center. Services provided
at the five CAHN medical centers range from primary adult and pediatric medical and
dental services, mental health care, social services support, HIV/AIDS care, medication
services, specialty referrals, patient education, and free transportation.
21
Goochland Free Clinic & Family Services. (2011). 2011 Annual report of philanthropy. Richmond, VA:
Retrieved from www.goochlandfreeclinicandfamilyservices.org.
14
The Daily Planet provides comprehensive health care services to those who are homeless,
or at risk of homelessness. Services at the Daily Planet include a full range primary
health care clinic for adults and children; behavioral health clinic for assessment,
evaluations, counseling and therapy; routine and preventative dental health treatment, eye
care services; and case management to address barriers in resolving homelessness.
4
APPROACH AND CONDUCT OF STUDY
Under the direction of Dr. Saltanat Liebert, two Spanish-speaking VCU students
interviewed 101 uninsured Latino immigrants in the Greater Richmond Area to
understand their healthcare needs and how their needs are being met.
4.1 Research questions
A number of research questions guided the study:
1. Where do Hispanic/Latino immigrants go for care?
2. What factors determine where Hispanic/Latino immigrants go for care?
3. What are the most commonly occurring illnesses or needs (acute or chronic) for
which Hispanic/Latino immigrants seek healthcare services from clinics in the
PCMH collaborative?
4. How are their needs being met?
5. How much and what type of care do they get? (This last question is necessarily
broad and includes services such as prenatal care, specialty referrals, prescription
drugs, etc.)
4.2 Methodology
Mixed methods. The research team conducted a qualitative study comprising in-depth
semi-structured interviews with Hispanic/Latino immigrants. The team also conducted
interviews with clinic personnel, primarily with directors or managers. The research team
worked through clinic staff and clinical care coordinators to determine a recruitment
approach consistent with snowball sampling.
Snowball sampling. Participants were recruited primarily via a snowball sampling
method based on referrals beginning with those identified by clinics and other
organizations who serve this Richmond population. The selection of persons to interview
was purposive: only potential participants who were born in Mexico or countries in
Central or South America and who self-reported having no health insurance could
participate. Interviews were conducted until a point of data saturation was reached, which
means the point at which researchers receive no new information.
Interview questions. The team prepared a list of questions to guide the interviews and
two Spanish-speaking research assistants were recruited. Interviews were either recorded
or research assistants documented participants’ answers during or after the interview.
15
Ethical considerations. In order to protect respondents’ privacy, the research team did
not ask about immigration status, and did not propose to obtain data or clinical
information of a personal nature. Researchers did not collect identifiable information
from research participants (including name, date of birth, telephone numbers, social
security numbers, address, etc.) If such information did arise during the course of the
interview, it was not recorded and not used in subsequent portions of the research. With
interviewees’ permission, the interviews were recorded. If study participants did not want
the interviews to be recorded, the interviewers took detailed notes during and after the
interviews. Study participants did not receive any compensation for their participation in
the study.
IRB approval. The Institutional Research Board (IRB) protocol was submitted on April
12, 2012. It contained detailed information about the study, a research plan, and a list of
interview questions and information sheet in both English and Spanish. The protocol
qualified for exemption and was approved by the VCU IRB on May 29, 2012 (VCU
IRB#: HM14370). In the approval memo, the IRB asked that researchers document
receipt of informed consent after potential participants were informed of foreseeable risks
and possible benefits. The team edited the survey to include a checkbox documenting that
informed consent was received.
4.3 Targeted locations and choice of facilities
The clinics targeted are members of the Collaborative. The researchers met with clinic
leaders to gain a better understanding of the nature and extent of the services they provide
to the immigrant community as well as any specific barriers or challenges involved in
providing such services. Researchers discussed the PCMH model of care and care
coordination with Collaborative members. One purpose of facility interviews was to
understand appropriate communities and geographical neighborhoods of immigrants to
be used to obtain the interview sample. Among the members of the PCMH, several
clinics were thought to be better sources of participant interviews than others. Those
clinics that self-reported in the facility interviews as having a large group of patients of
Hispanic/Latino origin were contacted first. These included Goochland Free Clinic and
CrossOver Clinic’s Hull Street location.
In order to receive a complete picture of how uninsured immigrants access healthcare, it
was necessary to recruit and interview at non-clinic (and non-Collaborative) settings.
Therefore, in addition to interviewing patients of the Collaborative clinics, researchers
recruited study participants at Spanish-language churches, fairs and festivals targeting the
Latino population, and Bon Secours’ Care-a-Van sites.
5
QUESTIONS ASKED AND SUMMARY OF RESPONSES
The interviewees were asked the following questions:
1. Country of origin?
2. Insurance status?
16
3. Have you ever been sick in the US?
4. What was the problem?
5. Did you see a doctor (dentist, nurse, other type of provider)?
6. Where did you go to see the doctor?
7. Did anyone take you there? Was anyone with you?
8. How did you know where to go?
9. What did the doctor do for you?
10. Did the doctor explain why you were sick? Did you have any
trouble understanding what the doctor told you? Did the doctor speak
Spanish? Did anyone else help (explain things to you)?
11. Did you return to the doctor for care? Were you supposed to? (Why not go?)
12. Were you given any drugs/prescriptions? Did you get them filled? Take them?
Need any help in taking your medications?
13. Any tests/procedures?
14. Did you see anyone else for the problem? (If so, what type of doctor/provider and
how long wait for appointment?)
15. Do you have a chronic condition (interviewer explains what that is and provides
examples of common conditions)?
16. Do you get treatment for that condition? What type of treatment do you get?
17. How often do you go to the doctor (clinic)? Why? Why not?
18. Would you go more often if you could? Explain.
19. Are you happy with the care that you receive when you go to the doctor (clinic)?
20. Do you have to pay for the doctor's services?
21. Do you ever go to the emergency room?
22. What hospital do you go to for emergency care?
23. Why do you go there?
24. Gender?
25. Age?
26. Race?
27. Ethnicity?
28. Marital Status?
What follows is a summary of the interviewees’ responses to the questions asked.
5.1
Country of origin
Country of Origin
El Salvador
Mexico
Guatemala
Honduras
Dominican republic
Ecuador
Peru
Frequency
Percent
35
33
18
7
2
2
2
34.7
32.7
17.8
6.9
2.0
2.0
2.0
17
Colombia
Nicaragua
Total
1
1
101
1.0
1.0
100.0
The respondents’ countries of origin mirror the demographic composition of immigrants
in Virginia. Over 37 percent of the immigrant population in Virginia is Latino, and the
majority comes from El Salvador and Mexico. Among respondents, the largest share –
34.7 percent -- came from El Salvador. The next largest group – 32.7 percent -- was
immigrants from Mexico. Guatemalans made up 17.8 percent of the sample. Other
countries of origin included Honduras, Peru, Colombia, Dominican Republic, and
Ecuador.
5.2
Respondents’ Gender and Marital Status
Gender
Female
Male
Total
Frequency
Percent
72
29
101
71.3
28.7
100
The majority of respondents, 71.3 percent, were women. It is likely that the sample had a
larger proportion of females than their share in the general Latino population because
research shows that women are more likely than men to seek medical care.
Marital status
Married
Single
Other*
Separated
Widow
No answer
Divorced
Total
Frequency Percent
47
46.5
32
31.7
14
13.9
3
3
3
3
1
1
1
1
101
100.1
*Other typically meant that an interviewee is living with someone.
5.3 Health Status of Respondents
More than three quarters of respondents (78.2 percent) reported having been sick or
seeking medical care for other reasons, such as pregnancy, during their stay in the United
States. The following sections of the study are based on interviews with 83 respondents
who reported having been sick or seeking medical care since their arrival in the United
States.
18
Have you ever been sick?
Frequency
No
No but
Yes
Total
5.4
Percent
18
4
79
101
17.8
4
78.2
100
What was the problem?
Health complaint/condition
Frequency
Percent*
Pregnancy/delivery
Hypertension
Diabetes
Headaches
Stomach aches
Flu
Gastritis
Kidney infection
Car accident
Check up
Chest pain
Declined to answer
High cholesterol
Migraines
Multiple unnamed problems
7
6
5
4
4
3
3
3
2
2
2
2
2
2
2
8.4
7.2
6.0
4.8
4.8
3.6
3.6
3.6
2.4
2.4
2.4
2.4
2.4
2.4
2.4
Occupational injury
Ovarian cysts
Sore throat
Throat infections
Uti
Vision
Abdominal pain
Alcohol abuse
Anemia
Back pain
Breast cancer
Broken hand
Colon
Cysts
Dentist
Dizziness
Eyes
Family planning
Fever
Fractured arm
2
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2.4
2.4
2.4
2.4
2.4
2.4
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
19
Gall bladder
Half the face is paralyzed
Hemorrhoids
Infections
Inner ear infection
Instantaneous abortion
Intestinal issue
Kidneys (kidney failure)
Knee replacement due to occupational injury
1
1
1
1
1
1
1
1
1
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
Lost vision
Lupus
Respiratory
Sleeplessness
Spontaneous abortion
Surgery on cervix and breasts
Thyroid
Traumatic brain injury due to occupational accident
1
1
1
1
1
1
1
1
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
Tubal pregnancy
1
1.2
Tumor in stomach
1
1.2
Tumor in the head
1
1.2
Undiagnosed
1
1.2
Vaccines
1
1.2
Vaginal infections
1
1.2
Vaginal prolapse
1
1.2
Virus
1
1.2
Vomiting
1
1.2
*Some respondents mentioned more than one condition; thus the sum of percentages adds up to more
than 100
Respondents’ health concerns (or reasons for seeking medical assistance) vary
significantly. Common issues include pregnancy/child birth, hypertension, and diabetes.
It is also likely that due to language barrier and/or low level of education, respondents
may not know their diagnosis, only the original symptoms. Some of the respondents
interviewed were unable to explain their diagnoses. One respondent, for instance, said
“They operated on my cervix and on my breasts.” Even when the diagnosis is translated
into Spanish, some individuals might not be able to understand/remember the condition.
Another respondent reported, “They had to take this thing of out my head. They had to
open my head up. It was big, the size of a lemon.”
5.5 Did you see a doctor, nurse, dentist, or another specialist?
Study participants were asked whether they were seen by a doctor, nurse, or other type of
provider. The vast majority of respondents reported being seen by a doctor. Yet, some
clinics only have nurse practitioners as full-time staff. It is, therefore, likely that
respondents didn’t know they were seen by a nurse.
20
Seen by
“Yes” Frequency
“No” frequency
Doctor
75
3
Nurse
0
n/a
Dentist
2
n/a
Specialist
4
n/a
No response
5
n/a
Three respondents reported being sick but did not see a medical specialist. One
respondent reported not seeking medical care despite being sick “Because I don’t have
medical insurance” (Interviewee #1). Another self-medicated: “I have no insurance, so I
went to the pharmacy... I took over the counter medicine from the pharmacy.”
(Interviewee # 105) The third interviewee who said that he/she had not been seen by a
doctor was in line at a Care-a-Van clinic at the time of an interview hoping to be seen by
a doctor for stomach pain.
5.6
Where do respondents turn for health care
Facility
Free clinic
Care-a-van
Hospital
Chippenham
Emergency room
Health department
Patient First
No response
MCV
Private doctor
Bon Secours (Patient
First refused him)
Bon Secours via 911
Hospital in Iowa
Mechanicsville
Pharmacy
Total
Frequency
Percent
29
15
7
5
5
5
4
3
3
2
1
34.9
18.1
8.4
6.0
6.0
6.0
4.8
3.6
3.6
2.4
1.2
1
1
1
1
83
1.2
1.2
1.2
1.2
100.0
21
5.7 Did anyone take you there?
Over half of immigrants rely on their social network (friends and family) to accompany
them to medical care facilities. In the case of occupational injuries, coworkers took the
respondents to hospitals.
Did anyone take you?
Frequency
Percent
Friend
Myself
Family member
23
22
20
27.7
26.5
24.1
No answer
Ambulance
Myself/need ride
7
4
3
8.4
4.8
3.6
Coworker
2
2.4
1
1
83
1.2
1.2
100
Boss
Clinic interpreter
Total
Three respondents also stated that without a personal vehicle or reliable public
transportation, they had a hard time getting to healthcare facilities for urgent or routine
care.
My friend told me where it was and I went. Sometimes though I can’t get to my
appointments. Poor people sometimes can’t get to the clinic because they can’t
drive. Or they have to work. And they don’t have insurance. When I need to go to
the clinic I ask someone for a ride, but if I can’t find a ride I walk. (Interviewee
#3)
######
When I need to go to the clinic I pay for a ride. Sometimes it is cheap, sometimes
it is expensive. It depends on who is driving. (Interviewee #7)
5.8
How did you know where to go?
How did you know where to go?
Frequency
35
9
8
6
5
4
2
Friend
Family member
Close to home
Church
No answer
Health dept told me
Community
22
Percent
42.2
10.8
9.6
7.2
6.0
4.8
2.4
Employer took me
Neighbor
Ambulance took me
Care-a-van referral
Free clinic referral
Hospital
Medicaid*
I passed by the hospital
Referral from MCV
Other
The only hospital there
I went where I thought no SSN was required
Total
2
2
1
1
1
1
1
1
1
1
1
1
83
2.4
2.4
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
100.0
*While the patient’s Medicaid application was being processed, a staff member at
Medicaid recommended she use a free clinic for her immediate healthcare needs.
As originally hypothesized, migrants’ social networks are important in directing them
where to go for care. A large share – 58 percent – of respondents decided where to turn
for care based on the advice of their friends, neighbors, or family member. Another 7.2
percent received advice from their church.
5.9 What did the doctor do for you?
In response to the question “What did the doctor do for you?” respondents provided a
variety of answers. The most common – 25 percent – said they were examined by a
doctor. Another ten percent were also given medications or prescription for medications.
What the doctor did
Exam
No answer
Exam/medicine*
Exam/prescription
Exam/tests
Referral to specialist
Referral to ER
Attended to me
Referral for surgery
Routine care/physical
Vaccines
Birth
Birth control
Blood pressure
Blood test
C-section
Cast
Cured my finger
Frequency
21
8
5
5
4
4
3
2
2
2
2
1
1
1
1
1
1
1
23
Percent
25.3
9.6
6.0
6.0
4.8
4.8
3.6
2.4
2.4
2.4
2.4
1.2
1.2
1.2
1.2
1.2
1.2
1.2
Dental work
Diagnosed breast cancer
Discussed treatment options
Glasses
HIV test
Hospitalized
Mammogram
Mammogram/PAP
Physical
Pregnancy test
Put in apparatus on my chest**
Put screws in
Referral but didn't go b/c of money
Relieved pain
Removed cockroach from ear
Stabilized after accident
Stitches
Treatment stopped due $
Waiting to be seen
X-rays
Total
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
83
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
1.2
100.0
*The difference between exam/medicine and exam/prescription responses is that in the
former, doctors (nurses) actually gave patients medications; in the latter response patients
received prescriptions that needed to be filled elsewhere.
** the respondent was not sure what that apparatus did
5.10 Did the doctor explain why you were sick? Did you understand what the
doctor told you?
Frequency
Yes
Yes, through interpreter
No answer
Yes, doctor spoke Spanish
No
I brought someone to translate
Yes, I speak English
I don't understand everything
If interpreter is there
Yes, I speak a little English
I don't understand the doctor
Other
Sometimes I don't understand
Total
25
18
7
7
6
5
4
3
3
2
1
1
1
83
24
Percent
30.1
21.7
8.4
8.4
7.2
6.0
4.8
3.6
3.6
2.4
1.2
1.2
1.2
100.0
Most respondents – 59 percent -- understood what the doctor said because interpretation
was available (either on the phone or in person), or because they spoke English, or the
doctors spoke Spanish. Respondents, understandably, were happiest when the doctor they
saw spoke Spanish and seemed likely to achieve better health outcomes as a result. As
one respondent stated,
The doctor examined me. She speaks Spanish. When I go into the exam room it is
just her and I. No one else is there. Well, sometimes another doctor sees me, but
he speaks only a little Spanish. So then they have someone to interpret. But I don’t
like that. If my doctor isn’t there, I would rather just come back. I think he
[another doctor] is a good doctor, but because he doesn’t speak much Spanish he
can’t understand me.
My doctor speaks Spanish very well. She explains everything to me. She told me
about cholesterol and how to lower my cholesterol with changes in my diet. I used
to have my cholesterol at 230 and now it is 209. She was really happy with the
changes I made to lower my cholesterol so much. She told me that was really
good. (interview #3)
Another respondent simply reported his satisfaction, “They [doctors] treat me really well.
They speak my language and that makes me really happy.” (Interviewee #11)”
At least six percent of respondents brought their friends or family members to interpret at
medical appointments. Presumably, such interpreters were not medical professionals and
were not familiar with medical terminology and medical practice in the U.S. Moreover,
their level of education/literacy may have been insufficient to convey complete and
accurate medical information as illustrated by the following statement: “At Stony Point
my husband interpreted for me. He speaks a little English. I still don’t understand
everything though” (Interviewee #54). It is also common for recent immigrants to bring
their minor bilingual children to appointments to interpret. That is problematic on many
grounds (psychological stress on the children, their lack of understanding of medical
terminology, an unhealthy power balance between a bilingual child and a non-English
proficient parent, etc). Some doctors, justifiably, object to minors interpreting at medical
appointments.
The doctors at the free clinic don’t speak Spanish. This is our problem. They don’t
speak Spanish. Well, I speak a little English. I can talk about my teeth, and I
understand. When I need to talk about other things I have trouble. I have a
daughter who is 15. She is a great translator. She speaks Spanish and English.
But when I want to bring her to the free clinic to help me translate, they say I
can’t bring her because she is a minor. I say, I only am bringing her because she
is going to help me. But they don’t listen to me. I want to bring my daughter to
help me, I trust her and I want her to help. She can translate really quickly. She
speaks both languages, she is bilingual. Thank God she is! (Interviewee #6)
In clinics where interpretation is not always available, limited English proficient patients
can have significant difficulties as illustrated by the following respondent’s experience:
25
The doctors do explain everything, but always in English. Sometimes I leave the
clinic with many doubts. I try to understand everything, but I can’t. I understand,
but sometimes I don’t understand everything. I sometimes can follow along, but
then don’t understand a word. “What could it be?” but I don’t know, so I have
many doubts. It is really difficult for me. I know that there are others who don’t
understand anything. It must be really hard for them. (Interviewee #6)
######
Q: Did the doctor explain why you were sick?
A: When you don't speak English they don't explain. You can ask. They just
translate a little bit. (Interviewee 143)
Quotations below demonstrate the range of experiences that respondents reported with
regard to understanding doctors:
They [doctors] explain everything to Viola 22 , and she explains it all to me. The
doctors don’t speak Spanish, so she has to help. None of the doctors at the clinic
speak Spanish, so she has to interpret for us. When I am sick and need to go to the
clinic, and she is not there to interpret, I don’t go because it is not worth it. They
won’t even understand what I am saying, and I won’t understand them. They will
not understand me. (Interviewee #4)
######
Viola interprets when she is there. There are others who speak Spanish. I don’t
know why they don’t get more people who speak Spanish. There are a lot of
people who could help when Viola can’t. Many people in our community could
help out. (Interviewee #6)
######
Most of the doctors I see use interpreters. Sometimes in person. Sometimes over
the phone. I like the interpreters that are in person better than over the phone.
Sometimes when I have trouble hearing on the phone they are short and don’t
want to repeat what they said. It is also hard when they deliver very heavy news.
When that happens it makes you think, Am I going to die? What does this mean?
It takes a little while to think about it, and by then you haven’t heard what the
interpreter on the phone has said. They sometimes don’t like to repeat themselves,
but they can’t see that I am thinking myself. I also don’t like it much when it is a
man interpreting. It is a little embarrassing to talk about all of the issues I am
having. Especially if the problems are about my vagina or something like that.
But I ask anyways because I know I have to. But it can be very embarrassing. If I
don’t ask, I will not get the information that I need. (Interviewee #22)
22
Viola is a bilingual (Spanish-English) part-time staff member at one of the clinics. Her name has been changed in
this report to protect her identity.
26
5.11 Were you given any drugs/prescriptions? Did you get them filled?
Medication/prescription received
Yes
No
No answer
No, vaccines
Pain medication only
Pharmacy refused to dispense b/c of immigration
status
Self-medicated
Total
Frequency
63
11
5
1
1
1
Percent
75.9
13.3
6.0
1.2
1.2
1.2
1
83
1.2
100.0
Three quarters of the respondents (75.9 percent) who reported having been sick since
their arrival in the United States reported receiving either medication or prescription from
doctors they saw. Thirteen percent did not receive medication or prescription at their visit
to the doctor. One respondent, who reported not seeking medical care for lack of
insurance, self-medicated: “I took over the counter medicine from the pharmacy.”
(Interviewee #105)
One interviewee reported that the pharmacy where she usually received her prescription
was no longer dispensing medication to her because of her undocumented immigration
status:
The social worker normally fills out a form she turns into the pharmacy and I pick
up the medicine at DaVita Dialysis. But now the social worker told me I could no
longer get the medicine because the pharmacy found out about my immigrant
status. (Interviewee #104)
The quotations below illustrate various experiences that respondents have had receiving
medication and filling their prescriptions:
The doctor gave me a prescription. And I always take my medicine. I used to get
my prescription filled at K-Mart, but now it is closed. So I go to Krogers. That is
the closest place. When I went to Wal-Mart they told me that I had to fill out more
paperwork. I have to pay for my medicines. I pay 10 dollars for each medicine,
every 3 months. I have one high blood pressure medicine and another medicine
that I pay 10 dollars every 3 months. I take my blood pressure medicine once a
day. I have always had my medication. I can’t miss taking this medicine.
(Interviewee #3)
######
I need to go to the pharmacy to get my medicine. I give them my prescription, and
27
they give me my medicine. I need to pay 5 dollars for every prescription. The free
clinic doesn’t have a pharmacy, but there are 3 different pharmacies I can go to.
At each of them all of my medicine is only 5 dollars for every prescription.
When I had surgery at the hospital they gave me a prescription. I tried to get my
medicine at the pharmacy there but it was really expensive. They told me to bring
my prescriptions to the free clinic, and that they would give me other
prescriptions so I could pay for my medicine. Otherwise they were too expensive
and I wouldn’t have been able to get them. (Interviewee #4)
######
At the Care-A-Van they have medicine, but they sent me to CrossOver to get one
prescription that they didn’t have…I also get medications filled at Wal-Mart.
(Interviewee #16)
######
“Yes, I was given a prescription for a pill and a cream. I got them at CVS. I like
to go to CVS because they have the discount card. (Interviewee #47)
Another respondent apparently receives phone calls from a nurse who checks up on her.
The respondent asks her questions about medication, as reported below:
Q: Do you need any help in taking your medications?
A: No, I now know how or the nurse calls to check on me. If I need something I
call her.” (Interviewee #110) [It was unclear from which clinic the nurse is
because the respondent has been to several clinics, a specialist, and a hospital.]
Some respondents also order medication online. This is problematic because the
medication is not prescribed by a medical professional and it’s unclear whether it helps to
improve a patient’s condition or whether it may actually harm him or her.
The medicine I used to get was getting too expensive. So I started ordering
medication on the internet. I have one pack of powder I take with orange juice
everyday. It has to be with orange juice. This helps with my memory. It helps my
brain cells grow. I order that from Canada. It is 101 dollars for 30 packets. I also
order a vitamin from Canada. That helps when I am not feeling well and calms
me down. It is good for my brain. Since I have been taking these two things I
haven’t had as many convulsions. The vitamins also help with my cholesterol. It is
a little high, but it is more or less under control now with the vitamins.”
(Interviewee #33)
Another interviewee reported that his cholesterol level is high. In response to the question
whether he gets treatment, he reported: “Yes, I take a vitamin I order from Canada on the
internet.” (Interviewee #33)
This phenomenon is likely to be more widespread as there is a perception in the
community that vitamins are a cure-all and people take them for conditions that require
actual medication.
28
5.12 Were any tests or procedures performed when you went to see the doctor?
Tests done
Frequency
Percent*
All “Yes” responses including:
59
Yes
39
47.0
Blood test
6
7.2
PAP smear
5
6.0
X-rays
5
6.0
Mammogram
4
4.8
Blood pressure
2
2.4
Ultrasound
3
3.6
Colonoscopy
1
1.2
Dental x-rays
1
1.2
Dialysis
1
1.2
Thyroid test
1
1.2
HIV test
1
1.2
Blood exam and panel
1
1.2
Urine test
1
1.2
No
15
18.1
No answer
9
10.8
*Total does not add up to 100% because some respondents had more
than one test
Almost half of respondents, 47 percent, reporting receiving a test(s) during their visit to
the doctor (clinic) but most of them could not specifically identify what the test was.
Eighteen percent of respondents did not have tests when they saw a doctor.
5.13 Did you see anyone else for the problem?
Saw anyone else for the
problem
No
No but went for another issue
No b/c of cost
Yes
Clinic referral
MCV for delivery
No answer
Total
Frequency
Percent
42
2
1
24
4
1
9
83
50.6
2.4
1.2
28.9
4.8
1.2
10.8
100.0
While over half of respondents did not see any other medical professional for the health
problem they reported, one third did. In some cases the free clinics or the Care-a-Van
clinic gave them a referral to see a specialist, while in others respondents went to other
clinics or hospitals. At least one respondent did not seek further medical care fearing the
29
high cost. The real number of individuals postponing a visit to a doctor is likely to be
higher, because many respondents did not specify whether they did not see a doctor
because the health problem they experienced was successfully treated or for other
reasons, such as costs or availability of timely appointments.
Some patients also reported going to different clinics depending on where the specialists
they needed were located:
I am here for the dentist because I need to have my molars taken out. They hurt a
lot. I normally go to another CrossOver to see the doctor, this is my second time
here because I need to see the dentist. (Interviewee #34)
######
I used to have insurance and I would see a private doctor. Now I am here because
I have a pain in my back. Normally I go to CrossOver in Chesterfield, but the
bone doctor is here today. (Interviewee #29)
######
I sometimes want to go because my throat or ears hurt, but to go to a private
doctor is too expensive. I have to wait for the Care-a-Van. (Interviewee #55)
######
I see a diabetes specialist all the way in Henrico. They give me the appointment at
the Care-a-Van. I have not been in a while because the last time I had an
appointment I had no one to take me and I lost the appointment. (#110)
5.14 Do you have a chronic condition?
Chronic condition
No
Yes
Diabetes
High blood pressure
Kidney issues
Migraines
Undiagnosed intestinal issue
Don't know
No answer
Total
Frequency
54
17
1
1
1
1
1
2
5
83
Percent
65.1
20.5
1.2
1.2
1.2
1.2
1.2
2.4
6.0
100.0
One quarter of respondents, 22 individuals, reported that they have a chronic condition. It
is likely that many respondents are unaware whether or not they have a chronic condition
because most do not get a regular physical exam.
30
5.15 Do you get treatment for chronic condition?
Receive treatment for chronic
condition
No answer
No
Not yet
Occasionally
Frequency
Take a vitamin
Yes
Total with chronic condition
Percent
4
2
1
1
18.2
9.1
4.5
4.5
1
13
22
4.5
59.1
100.0
Of the 22 respondents who reported having a chronic condition (including one respondent
who reported having an undiagnosed condition), thirteen receive treatment. Two
respondents with chronic conditions do not receive treatment, and one has registered with
a free clinic to seek treatment. One respondent stopped taking medication for her chronic
condition as stated below:
I took pills [for high blood pressure] but felt worse, so I stopped taking them. It's
been five years. (Interviewee 141)
At least one of the respondents self-medicates, as illustrated in an excerpt below:
Q: Do you have a chronic condition?
A: Yes. I have a little high cholesterol.
Q: Do you get treatment for that condition? What type of treatment do you get?
A: Yes, I take a vitamin I order from Canada on the internet. (Interviewee #33)
Some respondents receive some type of treatment but do not seem to change their
behavior to effectively manage their chronic conditions. For instance, respondents with
hypertension and high cholesterol said they took medication but only one respondent
reported changing her diet and exercising:
At the Love of Jesus clinic they helped me lose weight. I had to change my diet
and now I walk 30 minutes to an hour everyday. This has helped a lot.
(Interviewee #19)
Other respondents regularly take their medication but do not appear to have made other
life style changes, such as exercise and diet.
They told me that I have to walk everyday, but I don’t do it. They also talked to me
about changing my diet. I can’t eat so much fatty foods. I am fat, but it is a lot of
work to lose weight. So far I have lost 7 pounds. (Interviewee 29)
######
Q: Do you get treatment for that condition [high cholesterol]?
A: Yes. I get pills that I need to take for everything. I am also supposed to change
my diet. (Interviewee #50)
31
######
Q: Do you have a chronic condition?
A: Diabetes.
Q: Do you get treatment for that condition? What type of treatment do you get?
A: I check my sugar every three to six months. At home I take insulin and a pill.
(Interviewee 110)
5.16 How often do you go to the doctor?
How often do you go to the doctor?
Frequency Percentage
Regularly:
Every 2 weeks
Monthly
Every 2 months
Every 3 months
Every 3 to 6 months
Every 6 months
Yearly
Often b/c I am pregnant
24
2
4
2
6
3
2
3
2
28.9
2.4
4.8
2.4
7.2
3.6
2.4
3.6
2.4
Rarely:
5 or more years ago
If doctor tells me to
More than once
Once
Only during pregnancy
Only if emergency
Not often
24
3
1
2
5
1
6
6
28.9
3.6
1.2
2.4
6
1.2
7.2
7.2
Never:
Never, couldn't get an appointment
Never
No b/c of no insurance
As needed
No answer
Total
4
1
2
1
25
6
83
4.8
1.2
2.4
1.2
30.1
7.2
100.0
About 29 percent of respondents reported going to see a doctor regularly: from every two
weeks to once a year. The same share of respondents go to see a doctor rarely: their
answers ranged from “I only go if it’s an emergency” to “More than 5 years ago” to “I
only went during pregnancy.”
While respondents were not asked if they get a regular physical exam, several mentioned
that they did: “When they give me an appointment. I have to come back in 8 weeks for the
32
gastritis. Otherwise my exam is every year.” (Interviewee #41)
The paperwork required by clinics deters some patients from seeking treatment as
reported by the following interviewee: “Before I was at Fan Free. But they were asking
for a notarized letter. So I didn't get it notarized so I stopped going.” (Interviewee #143)
Several respondents said that it took so long to be seen by a doctor (2 months or more),
that by the time their appointment date approached, they were no longer experiencing
symptoms. One interviewee’s story is typical:
I went to CrossOver to get an appointment for my cough. I filled out the
paperwork and then I was given an appointment almost 2 months later. By then
my cough was gone so I didn’t go. I am not a patient there now. I have never seen
a doctor there. #48)
Quotations below demonstrate the variation in the frequency with which respondents
utilize clinics/medical facilities:
Q: How often do you go to the doctor (clinic)?
A: When I need to. When I can’t take it anymore, I call them up and say “I can’t
take it any more. I need an appointment.”
Q: Would you go more often if you could?
A: Yes. When Viola isn’t there to interpret for me, I do not go. I would like to be
able to go all of the time when I need to. (Interviewee #4)
######
A: I only went because I had a problem, now I will go back for the follow-up visit.
Other than that, I don’t go. (Interviewee #7)
######
A: Only when I have to. But when I was pregnant I went to the doctor here at
CrossOver sometimes three times a month. I had a lot of problems during my
pregnancy. Once the whole side of my body went numb. I also had a vaginal
infection. I vomited a lot during my pregnancy too. Now I only go when I have to.
(Interviewee #13)
######
A: I go to the dentist about once a month. I have a lot of problems with my teeth. I
have gone to the Care-A-Van for my teeth too, but they don’t have all of the
equipment and things they need. At the Daily Planet they do. That is why I go
there for my teeth. (Interviewee #40)
33
######
It has been a year [since I saw a doctor]! I am not sick, I go when I am sick.
(Interviewee #52)
######
I just see the dentist every six months. I am not fifty-sixty years old to be seeing
the doctor, but I do get pap smears done. (Interviewee #109)
######
Q: Would you go to the doctor/clinic more often if you could?
A: Yes, but it’s expensive and it’s a bureaucratic process. You have to apply for
the help, wait for the visit and for them to accept you. You miss work. By that time
you're not sick anymore. (Interviewee #123)
######
A: The truth is I just come when I am sick, so not too often. I go to the Ob/Gyn
every two years. To come to the Care-a-Van is to difficult. I have three kids I
cannot leave them at home from 4AM. The Care-a-Van comes at 8:30AM. They
take ten out of thirty, or take another ten in the afternoon.
Respondents who rarely see a doctor (or not at all) reported they do not go because of
lack of insurance:
A: The last time I went was five years ago.
Q: Why not?
A: I didn't need to go. I have gone to an Ob/Gyn twice.
Q: Would you go more often if you could?
A: Yes, if I could. But I can’t without insurance. (#111)
######
Q: “How often do you go to the doctor (clinic)?
A: When it hurts a lot enough to spend the money. There is no money.
(Interviewee #138)
5.17 Are you happy with the care that you receive when you go to the doctor
(clinic)?
Patient satisfaction
Yes
No
No answer
Not sure
Frequency
65
7
6
4
34
Percent
78.3
8.4
7.2
4.8
Mostly
Total
1
83
1.2
100.0
Most interviewees, 78.3 percent, were happy with the care they received. Many were
quite emphatic and emotional:
Very happy. I have a really good doctor that speaks Spanish. They do really good
exams, and make sure I have everything done that I need. If I need a blood test, I
get a blood test. They do every thing. I have no problems speaking with the doctor
and I feel comfortable to tell her everything. She knows my whole record and has
made sure everything is under control. I don’t need to ask for things because they
make sure I have everything.
My doctor is a woman who has a lot of humility. She has a nice way of doing
things. She is a good person. She treats everyone really well. This is why I keep
going back to her. (Interviewee #3)
######
Yes. More than happy. More than happy because they have helped me so much. If
it wasn’t for them I wouldn’t be here with you. I wouldn’t be able to be here to
talk about this. For this reason. I am thankful. They do so much for me, and I
can’t even pay them back. They have done so much for me and my family. Not
only for me and my family, but for many families. (Interviewee #4)
######
Yes. At Chippenham they saved my life. I was in a coma for 2 weeks. (Interviewee
#50)
######
Well, yes. They are the only people that help me. (Interviewee #51)
Excerpts from interviews below demonstrate the respondents’ level of satisfaction with
the care they received:
Yes. They treat me really well. They speak my language and that makes me really
happy. (Interviewee #11)
######
Yes. They treat people well here. I feel that they have really helped me out. I also
was able to go to St. Mary’s where they have more equipment. If it wasn’t for
them I wouldn’t have been able to go there for tests. I am not sure yet about
CrossOver because I just started coming here for the medications they didn’t have
at the Care-A-Van. (Interviewee #16)
######
Yes. They help me here. I don’t go to the Care-a-Van because they have very long
35
lines. Some people arrive at 6:00 am and wait until 2 to see someone. That is a
very long wait. Here I get an appointment, and the most I wait is about an hour or
hour and a half. (Interviewee #20)
It should be noted though that when participants were interviewed at a clinic location,
they may have been reluctant to say anything other than “yes” in response to the question
“Are you happy with the care you receive?”
Eight percent of study participants reported being unhappy with care received. For
example, participant 112 said, “No, they told me what I needed but could not help me.
They could not cover my expenses at the hospital.” Other participants unsatisfied with
medical care they received said the following:
Q: Are you happy with the care that you receive when you go to the doctor
(clinic)?
A: Not really. I have had to wait a long time, and they can’t help me here. Now I
am waiting to talk to someone about an appointment at a hospital. I liked the care
in Fairfax because they took good care of me. (Interviewee #23)
######
“I still have the problem. No one tells me what is going on. It affects my life.
Everyone tells me nothing is going on. It bothers me. I went to a doctor close by
but he didn't give me anything. The respondent added that he does not see doctors
for that health problem any more because “I come out more confused.”
(Interviewee # 128)
######
No. At the hospital they can’t take care of me. They told me to fill out an
application when I went to MCV to get services, but I don’t have a social security
number, so I didn’t qualify. Now the only option that I have is CrossOver. Here
they are a lot of people that really don’t need service and they make others wait
who really need to be here. (Interviewee #27)
Some respondents were somewhat ambivalent about their experience at the clinics. One
study participant stated,
Q: Are you happy with the care that you receive when you go to the doctor
(clinic)?
A: I guess so, but there are a lot of things that they are lacking. First, if they have
doctors that are available they should be able to see everyone. Second, they need
more help for people who don’t speak English. It would be nice to use the
translation services on the phone. This is better than a person to interpret because
it is more private. (Interviewee #4)
36
5.18 Do you ever go to the emergency room?
Gone to ED
No
Yes
No answer
Total
Frequency
39
38
6
83
Percent
47.0
45.8
7.2
100.0
Almost half of the respondents have gone to Emergency Departments at least once. Some
respondents go to EDs repeatedly:
I have gone to Chippenham around 5 times for pain. I go because I don’t know if
the pain is serious or not. I have had convulsions. I once was fully paralyzed. It
was terrible. When I was paralyzed I began to vomit and almost died. I needed to
go to the emergency room. (Interviewee 33)
Another respondent, in response to “Where did you go to see the doctor?” responded “I
go to Chippenham. I usually go to the emergency room there.” Similarly, a respondent
with frequent throat infections said, “I have gone to the emergency room three times at
Chippenham for throat infections. I can’t get an appointment at CrossOver quick
enough.” (Interviewee #21)
These responses suggest that some uninsured individuals use EDs as their primary
provider of medical care.
5.19 Which hospital do you go to for emergency care?
ED visited
Chippenham
MCV
No answer
Saint Francis
Saint Mary's
Henrico Doctors
Johnson Willis
Maryland
Patient First
Total*
Frequency
20
7
3
3
3
2
1
1
1
41
Percent
48.8
17.1
7.3
7.3
7.3
4.9
2.4
2.4
2.4
100
*Some patients went to more than one ED, therefore the total is higher than 38 – the
number of respondents who reported having gone for emergency care.
Out of 38 respondents who reported going to EDs, almost half – 48.8 percent -- went to
Chippenham, 17 percent went to MCV, and other respondents went to Saint Francis,
Saint Mary’s, Henrico Doctors, Johnson Willis, and Patient First.
37
One patient reported going to two different EDs for the same problem:
I went to Johnson Willis because I had pain in my bones and in my feet. This is from
the lupus, but I didn’t know that and they didn’t know what I had. At Chippenham I
had the same symptoms, and they didn’t figure out what I had either. I went to one
and then the other because the first one didn’t help so I wanted to try a different
place. (Interviewee #32)
5.20 Why do you go to that emergency room?
Why did you go to that ED?
Frequency
Percent
Near my home
No answer
Ambulance took me
CrossOver referral
Friend
Care-a-van
Goochland referral
B/c another ER didn't help with
pain
B/c of unpaid bills elsewhere
Cheaper than hospital*
My doctors are there
No answer
Passed by it
Thought I'd get financial aid
I just thought of it
Wait was shorter than elsewhere
Went there before
Total
9
6
3
3
3
2
2
1
23.7
15.8
7.9
7.9
7.9
5.3
5.3
2.6
1
1
1
1
1
1
1
1
1
38
2.6
2.6
2.6
2.6
2.6
2.6
2.6
2.6
2.6
100
*respondent went to Patient First because her friend told her it would be cheaper than
going to ED.
Twenty-three percent of respondents who reported having gone to emergency room
decided where to go based on the hospital’s proximity to their residence. Interestingly,
very few respondents – 3 – decided which emergency room to go to because of their
social network (friends, family, church, etc.) This is in stark contrast with their decision
on non-emergency care, where 58 percent of respondents turned to specific healthcare
providers because their friends, family, and neighbors’ recommendation.
One respondent went to MCV because he thought he could get financial assistance there:
I was told that I could qualify for help there, and it is the closest to where I live
and work. I filled out the application and talked to the social workers about the
requirements for the services, but I didn’t meet the requirements. I don’t have a
social security number. I also went there because I heard that they had more
services, and better services. (Interviewee #27)
38
Another went to two different EDs because she had unpaid bills at one of them:
After I went to MCV I went to Chippenham cause I didn’t want them to turn me
away because they knew I didn’t pay my bills. I owe a lot of money. (Interviewee
#34)
6
DISCUSSION OF FINDINGS
An overwhelming majority of the study participants – 78 percent – reported to be happy
with the quality of health care services they receive at free clinics, federally qualified
health centers (“FQHC”), hospitals, and health departments. It is very clear from this
study that free clinics and FQHCs are the only facilities where uninsured immigrant
patients can turn for routine medical care and for managing chronic conditions. In the
absence of free and low-cost clinics, these patients will most likely postpone necessary
treatment and preventative care, which will undoubtedly result in higher levels of ER
utilization.
Specific obstacles that participants reported as impediments to their access to quality
health care include: language barriers, financial barriers, administrative-bureaucratic, and
transportation barriers.
In general, participants utilized free clinics for a wide variety of general medical needs
such as diabetes, hypertension, and cholesterol. Other participants utilized EDs for more
acute or severe medical emergencies, or medical issues arising over the weekend when
the clinics were closed. Also, many free clinics referred patients to specialists when the
need arose, such as a gastroenterologist or gynecologist; hospitals for acute medical
condition and surgeries; and health departments for HIV testing and immunizations.
From the interviews, it appears that many of the participants did follow up with the
referral for more specialized services. For example, a few participants reported that
Goochland Free Clinic referred them to St. Mary’s Hospital for acute conditions.
Likewise, participants utilizing CrossOver reported that CrossOver referred patients to
Chippenham Hospital for more acute medical concerns.
There also appears to be a noteworthy difference between how females and males utilize
health care services. Among the participants in this study, a greater number of females
than males utilized free clinics, emergency rooms, and local health departments. Some
of the males who completed the interview reported that they were at the clinic or hospital
because they were accompanying someone else. Some men did report that they utilized
these services, but more so when it appeared to be an extremely grave situation (serous
injury or acute chronic condition).
6.1
Language Barrier
Many participants reported a positive experience at free clinics and hospitals providing in
person Spanish speaking medical interpreters (“interpreters”). However, if there was no
interpreter, then it was generally not a positive experience; and in some cases, not worth
going at all, as many participants said. Some participants reported an increased amount
39
of frustration at hospitals, hospital clinics, and other free clinics that did not have regular
interpreters. In those cases, participants reported using hand signals and gestures, but
many times left frustrated with a lack of understanding of their medical condition and/or
inability to accurately express their medical concerns. Some participants perceived a
discriminatory attitude from health care service administrators who were not able to
communicate effectively with the participants. Other participants had negative
experiences with telephone interpreters (available at some hospitals), and preferred in
person interpreters.
From all the interviews, it appears that CrossOver Health Care Ministry (“CrossOver”)
and Care-A-Van are the two free clinics that consistently have an in-person interpreter
and/or Spanish speaking medical health care provider available. Thus, the popular free
clinics among the Latino/Hispanic participants seemed to be CrossOver, Care-A-Van,
and Goochland Free Clinic and Family Services (which employs a Spanish-speaking
parti-time staff member). Most participants also reported a positive rapport with the inperson interpreter and/or Spanish speaking medical health care provider at these facilities.








“Sometimes when the doctor speaks Spanish they only speak a little bit, so I don’t
understand everything. When there is an interpreter it is much more clear and I
understand better.”
“If my doctor [who speaks Spanish] is not there, I would rather just come back. I
think he is a good doctor, but because he doesn’t speak much Spanish … he can’t
understand me.”
“…now when I go, they explain everything to [Spanish speaking clinic staff
member], and she explains it all to me. The doctors don’t speak Spanish, so she
has to help…When I am sick and need to go to the clinic, and she is not there to
interpret, I don’t go because it is not worth it. They don’t even understand what I
am saying, and I won’t understand them….”
“Sometimes they use really big medical words in English, and I don’t understand.
It really weighs on me when I can’t understand.”
“Every time I go to the hospital all of the paperwork is in English, and I don’t
know how to fill it out. I ask for help, but they don’t know how to help.”
“Sometimes [Spanish speaking staff member] is there and she interprets for
us…If she is not there, I just try. Now my daughter speaks English so she can
help me. But before when she didn’t speak English I really didn’t understand
much.”
“The doctors at the free clinic don’t speak Spanish. This is our problem…The
doctors do explain everything, but always in English. Sometimes I leave the clinic
with many doubts….I sometimes can follow along, but then don’t understand a
word. ‘what could it be?’ but I don’t know, so I have many doubts. It is really
difficult for me. I know that there are others who don’t understand anything. It
must be really hard for them.”
“The doctor I go to for my kidney infection doesn’t speak Spanish. I use an
interpreter …If I think an interpreter isn’t going to be there, I try to bring
someone who can do it. Can you imagine? Just me and the doctor and we don’t
speak each other’s languages? I would never understand!”
40




“The receptionist looked at me and yelled- ‘What? You don’t speak English?’
She was very rude with me but I didn’t know what to do…I called my boyfriend
….He explained why I was there and everything, but that was a terrible
experience.”
“Many people are intimidated to speak English, and then people say, ‘you are in
the United States, you need to learn English’ It is not that easy. They need to
have the resources to hire people who are patient and provide the best services to
those who don’t speak English…At St. Mary’s they didn’t speak Spanish, but I
brought a friend to interpret. At Fan Free they have a translator on the
telephone…The doctors at [Henrico Doctors] spoke Spanish, and that is why I
went to them. At CrossOver people speak Spanish.”
“I like the interpreters that are in person better than over the phone. Sometimes
when I have trouble hearing on the phone they are short and don’t want to repeat
what they said. It is also hard when they deliver very heavy news. When that
happens it makes you think. Am I going to die? What does this mean? It takes a
little while to think about it, and by then you haven’t heard what the interpreter
on the phone has said.”
“I prefer in person rather than on the phone because you can talk face to face
with them.”
However, in-person interpretation has its drawbacks. One of the clinics relies exclusively
on “Viola,” a part-time staff member, for interpretation. She also happens to know
practically everyone in the small Latino community, so for some clinic patients this
means lack of privacy, which some interviewees lamented.
It also appears that due to a language barrier and/or low level of education, some
respondents do not know their diagnosis, only the original symptoms. One respondent,
for instance, described “They had to take this thing of out my head. They had to open my
head up. It was big, the size of a lemon.”
6.2 Financial Barrier
In general, participants preferred going to free clinics over hospitals because of free
health care services at the free clinics. In acute cases requiring emergency services,
specialists or surgeries at hospitals, participants reported utilizing VCU/MCV,
Chippenham, St. Mary’s, St. Francis, and Henrico Doctors Hospital. For some of the
patients, the hospital bills seemed to be almost worse than the injury. Some participants
expressed frustration at large hospital bills that they are unable to afford.
A few participants reported using home remedies or herbal medications and vitamins
ordered from the internet because it is less costly than obtaining medical services at
hospitals. It is likely that many more individuals self-medicate with questionable
substances because of the high cost of real medication and a perception in the
Hispanic/Latino community that vitamins are a cure-all and people take them as an
alternative remedy for conditions that require actual medication.
Excerpts from the interviews below illustrate the respondents’ frustration with large
41
medical bills they receive:







6.3
“…I went to Lab Corps for tests that the doctor sent me to. They didn’t speak
Spanish there either, and told me if I couldn’t pay they couldn’t do the tests. They
were very rude to me…I had a clot in my lung, and they couldn’t do the test I
needed. I showed them my Access Now card, and they laughed at me. They
laughed as if I was stupid. I am very sick. The cancer I have is very
aggressive…”
“At first I saw a doctor at MCV…I saw him for about 8 months or so, but then he
said he couldn't see me anymore because I couldn’t pay. He abandoned me. Now
I go to CrossOver and I see a doctor at Chippenham.”
“I took my son for a nodule in his nose, which they removed at Chippenham
Hospital. I was charged $12,000…I got a letter. I think what it was financial
assistance of something but it seemed as if it was only for people with legal status,
so I didn’t fill it out. I went to the hospital and talked to the social worker…the
worker filled out the form for me. She said I would have to pay at least $2,000,
which I paid installments of $10 a month.”
“After I went to MCV I went to Chippenham cause I didn’t want them to turn me
away because they knew I didn’t pay my bills. I owe a lot of money.”
“For the first time I was at the hospital I paid some and got some help. If I don’t
die from the sickness, I die from the bill.”
“I need surgery for a ligament but I have not done it due to what they charge.”
Question: How often do you go to the doctor? “When it hurts a lot enough to
spend the money. There is no money.”
Barriers Due to Administrative Bureaucracy and Immigration Status
Some participants expressed difficulty in filling out forms at some hospitals and clinics.
For example, a few participants reported difficulty in filling out the forms only available
in English, notarizing signatures, and the inability to provide a social security number as
requested. In one case, a participant had English-speaking family members accompany
her to fill out forms in English. In another case, a participant left one clinic and went to
another because the second location required less paperwork. A few participants
complained about the length of time involved in applying for services and the length of
time required to get an appointment. Others complained of the long lines at Care-A-Van
and inability to obtain their services if they do not arrive very early in the morning.



“At the hospital…They told me to fill out an application when I went to MCV to
get services, but I don’t have a social security number, so I didn’t qualify.”
Question: would you go more often if you could?
A: Yes, but it’s expensive and it’s a bureaucratic process. You have to apply for
the help, wait for the visit and for them to accept you. Miss work. By that time
you’re not sick anymore…In Maryland their cities are much faster not like here.”
“Before I was at Fan Free. But they were asking for a notarized letter. So I
didn’t get it notarized so I stopped going.”
42
One respondent reported that she is no longer able to fill a prescription to manage chronic
kidney disease because the subsidized pharmacy found out about her undocumented
immigration status.
The social worker normally fills out a form she turns into the pharmacy and I pick
up the medicine at DaVita Dialysis. But now the social worker told me I could no
longer get the medicine because the pharmacy found out about my immigrant
status. (Interviewee #104)
Staff at some clinics also reported that some volunteer specialists to whom they typically
refer their patients refuse to treat undocumented immigrants.
6.4
Transportation Barrier
The participants in this study were able to get transportation considering the fact that
many were interviewed at the clinics or Care-a-Van sites. However, several participants
mentioned that they had to ask friends or family members or pay others for rides to
clinics. If they could not find a ride, they’d miss their appointments.
Several respondents talked about the difficulties they experience getting to their
appointments:
My friend told me where it was and I went. Sometimes though I can’t get to my
appointments. Poor people sometimes can’t get to the clinic because they can’t
drive. Or they have to work. And they don’t have insurance. When I need to go to
the clinic I ask someone for a ride, but if I can’t find a ride I walk. (Interviewee
#3)
######
When I need to go to the clinic I pay for a ride. Sometimes it is cheap, sometimes
it is expensive. It depends on who is driving. (Interviewee #7)
######
Another issue is transportation. There are places where they are services, but no
one can get there.
Lack of reliable transportation probably also explains why some Latino patients miss
their appointments, as the clinic staff reported in some of our interviews.
There may also be a category of Latino/Hispanic individuals (not captured in this study)
who may need medical services, but have transportation barriers impeding their ability to
access clinics or hospitals.
7
CONCLUSION
This report summarizes the results of 101 interviews of uninsured Hispanic/Latino
immigrants who use healthcare services from safety-net providers in the Greater
43
Richmond area. The findings indicate that the majority of immigrants primarily utilize
only a handful of safety-net facilities for several reasons. Specifically, immigrants go to
facilities that employ Spanish-speaking providers or interpreters, provide care that is free,
limit the amount of paperwork or bureaucratic red tape, and are within reasonable
proximity of their residences and communities.
Immigrants’ needs thus constrain the nature and type of facility that they can and will
use. As this survey shows, many immigrants rightly or wrongly perceive that certain
safety-net providers in the Greater Richmond area will not care for them. For many
immigrants, the hospital emergency room is their primary source of care; many others,
however, view the hospital emergency room as their back-up. Based on the findings in
this report, it appears that the Bon Secours Care-A-Van provides a good substitute for the
emergency room and that immigrants frequently use it. Unfortunately, the Care-A-Van
cannot satisfy all immigrants’ needs. The lines at Care-A-Van locations form early and
are quite long. Many immigrants know that they will not be able to obtain care because
of their place in line.
As the literature in this area consistently shows, the healthcare safety net is fragile. Free
clinics, in particular, depend upon community support, philanthropic support, and
providers (doctors, nurse practitioners, nurses, dentists, and many others) who volunteer
their time and expertise. Substantial changes to the environment in which safety-net
facilities operate can jeopardize the limited resources available to uninsured immigrant
communities. The Patient Protection and Affordable Care Act (ACA) is a prominent
example.
While the implementation of the ACA substantially will increase the number of the U.S.
residents who have health insurance, more than 11 million undocumented immigrants
will not be included under the new laws’ provisions. The effect that the ACA eventually
will have on the healthcare safety net in Richmond and elsewhere is potentially
problematic and largely uncertain. There are signs, for instance, that the new law may
hamper immigrants’ access to safety-net providers in the near future: first, by barring
them from purchasing health insurance through state health insurance exchanges; second,
by preventing them from gaining access to insurance through their employers (including
those with existing employer-based insurance); and third, by extending Medicaid
coverage to U.S. citizens but not to undocumented immigrants.
Should a sizeable portion of individuals currently uninsured obtain insurance coverage in
2014, thus providing additional federal funding to qualified health centers (FQHCs) and
ultimately changing the insurance status of many free-clinic patients, free clinics that
presently serve the immigrant population may choose to pursue FQHC status. According
to ECHO (Empowering Church Healthcare Outreach): “One of the major impacts on free
and charitable clinics is the increase in Medicaid eligibility to 133% of the poverty level.
A large number of patients seen at a clinic will now be eligible for coverage. Clinics will
need to determine how this will impact their target population and what changes need to
be made.”
Because those clinics that convert to FQHCs will have to comply with the provisions of
44
the ACA and other federal laws regarding disclosure of citizenship status, the presumed
effect will be to constrain immigrants’ healthcare options even further than currently
exists. As this survey indicates, facilities that provide services to the Hispanic/Latino
immigrant community already are few and far between. Should CrossOver convert to a
FQHC, for example, the loss to the immigrant community would be significant.
45

Immigrants Access to Healthcare Report

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