Medicaid Expansion and Healthcare Access: Lessons from Asian American and Pacific Islander Experiences in California

Abstract

Medicaid coverage increases access to care and improves health outcomes for disadvantaged populations. Yet disparities in enrollment and access to care persist. To understand the facilitators and barriers of Medicaid enrollment and accessing care under the Affordable Care Act for disadvantaged Asian Americans and Pacific Islanders. Focus groups and key informant interviews were conducted. Informational barriers to accessing care were pervasive among most new enrollees. Immigrants with limited English proficiency experienced disproportionate difficulties in enrolling and accessing care post enrollment. The simplified, income-based Medicaid eligibility streamlined the enrollment process, but system errors in determining Medicaid eligibility denied coverage for some eligible individuals. To improve access to care, health plans, government agencies, and community organizations might coordinate more closely. Federal and state laws that mandate language assistance by health plans might be enforced to improve access to care for linguistic minorities.

Appendices

Appendix: Focus Group Questions

Medi-Cal Enrollment

• 1. Are you covered by Medi-Cal? Were you covered before or during the implementation of the Affordable Care Act (also known as Obamacare)?

• 2. Have you tried to get information about your eligibility for Medi-Cal?

  • a. (If yes) How did you find out that you were eligible for Medi-Cal? What difficulties have you encountered in getting information?

  • b. (If no) Why have you not tried to get information about that?

• 3. How did you enroll in Medi-Cal? Did you apply on your own or did you get help from other people such as a community enrollment counselor or assister?

If community enrollment counselor or assister:

• 4. How did they help and were they helpful?

• 5. Did they have difficulties in helping you sign up for health insurance coverage? What specific difficulties did they/you encounter during the process?

• 6. Was the enrollment process difficult or easy? What made the process easy or difficult? How do you think the process might be improved?

• 7. Have you tried to enroll in Medi-Cal but been unable to? What were the main obstacles?

Post-Enrollment Healthcare Access

• 8. After enrolling in Medi-Cal, have you been able to access health care services? Why or why not? What barriers did you face in trying to access services?

  • a. Specifically, have you been able to pick a health plan and a primary care doctor?

    How did the process go? Did you need help? Did anybody help? How did they help and were they helpful? Were there problems they couldn’t help with?

  • b. (If primary doctor has been selected) Have you been able to see your primary care doctor when needed? Have you experienced any difficulties?

• 9. Did you experience any other difficulties in getting care? Were they addressed?

  How do you think the process can be improved so that you or other people who have just gotten insurance can see doctors when they need?

Key-Informant Interview Questions

For County Employees

• 1. We understand that low-income residents had been enrolled in the county Low-Income Health Program (LIHP) created to automatically transition into Medi-Cal. What was the process? Was there enough staffing? Did staff need to be trained? If so, what was the training and was the training sufficient?

• 2. We have learned that some people who used to be covered by the LIHP Program didn’t make the transition to Medi-Cal. What do you think caused this problem? How might this problem be addressed?

• 3. Specifically, some people (including those who had been in LIHP) who were found eligible by Covered California were later determined ineligible. What do you think caused this problem? How might this problem be addressed?

• 4. What are other challenges you know about that were encountered in enrolling low-income people in Medi-Cal? Have they been addressed? If so, how? If not, how do you think the challenges should be addressed?

• 5. What was it like working with Covered California (California’s Health Insurance Marketplace)? Where did it work, and where did it not?

• 6. We have learned that some new Medi-Cal enrollees have trouble accessing health care. How might this problem be addressed to facilitate their access to care?

• 7. What other strategies do you think can be taken to improve access to care under expanded Medi-Cal?

For Health Plan Employee

• 1. We have learned that new enrollees in Medi-Cal have trouble accessing healthcare. What can be done to facilitate their access to healthcare?

• 2. What do you think your own organization can do improve enrollee access to care?

• 3. What does your organization do to guide enrollees (or members) with limited English proficiency? What is being done? What more do you think can be done?

• 4. For threshold-language members (5,000+), materials should be translated into their languages. Has it been done? If so, what are those materials? What other translated materials do you think need to be provided to those members?

• 5. We have learned that Health Plans’ in-language help lines are often not answered. What do you think causes this problem? How might this problem addressed? Are there any other means by which new enrollees can be assisted effectively?

• 6. What other strategies do you think can be taken to improve access to care under expanded Medi-Cal?