Earlier this week, Epicenter’s civics reporter Felipe De La Hoz broke down the workforce challenges newly arrived faced by migrants in New York City — not just what needs to happen for migrants to be authorized to work, but how the city can prepare migrants for work and connect them to available jobs. In other words, he looked at the long-term future of the city’s workforce.
Another crucial future challenge Epicenter looked into: health care access beyond receiving health insurance. As with the jobs situation, beyond the ability to receive a service, what does it take to prepare newcomers to navigate a system that even longtime New Yorkers find complex? How does the city connect limited-English speakers to medical facilities where staff speak their language and they feel comfortable? And how does it empower undocumented immigrants to go to their doctor’s appointments and receive the primary care they need regularly?
A new study sheds light on a temporary NYC program — ActionHealthNYC — that ran from 2016 to 2017 and focused on just this. Epicenter spoke with some of the city health officials and researchers that were directly involved in running the program and then studied the findings of that “experiment.” We asked about lessons learned from ActionHealthNYC and how they helped inform parts of the current NYC Care program.
What’s ActionHealthNYC, anyway?
From May 2016 to June 2017, a New York City program called ActionHealthNYC helped arrange medical appointments for 2,428 low-income undocumented immigrants. It was part of an “experiment” designed to make it easier to access “safety net care”— services to uninsured, Medicaid and other vulnerable patients.
What were the main findings from the new study?
The new study, “Reducing Frictions in Health Care Access: The ActionHealthNYC Experiment for Undocumented Immigrants,” was published in the September issue of the journal American Economic Review: Insights. The major takeaway was that a culturally and linguistically competent program that encourages immigrants to visit primary care doctors reduces costly emergency department visits while increasing more low-cost preventative care like health screenings.
Those who received help — in their preferred language — in scheduling visits with primary care doctors saw a 21% drop in their use of the emergency department. For people with high-risk health profiles who received the same help, the effect was twofold, with emergency department use dropping by 42%. ActionHealthNYC participants were also a lot more likely to get screenings for chronic conditions like high blood pressure and diabetes.
What was special or striking about the study?
For ethical reasons, it’s very rare to run this type of program in a randomized controlled trial (RCT) model, Dr. Jean Bae, a co-author of this study and visiting associate professor at New York University’s School of Global Public Health, told Epicenter. Undocumented immigrants are one of the most vulnerable groups in the United States in terms of health care access, she explained. Unless they can get it through a non-government route, like via their employer or spouse or along those lines, they’re generally blocked from access.
She and others designing the program had a lot of discussion over the controversial move — RCT is considered the golden standard in research, so they still wanted to do it. Oregon state’s 2008 study that expanded public health insurance coverage for low-income adults was one of the only other prominent examples of RCT. The government and funders considered it very important to produce high-quality evidence that shows why it matters.
“So it was baked into the program,” Bae said. “Obviously, we should do it just for humane reasons, to always try to provide enhanced access to care for this population. But we also wanted to produce high-quality evidence that actually shows that this does increase utilization of needed care for this population. And that it could even create some kind of financial savings.” (Bae was referring to a drop in costly emergency department use.)
In order to ensure it was ethical when working with such a vulnerable population, the program was designed so that the undocumented immigrants in the control group were still connected with health care access and given a list of providers. The main difference was that they didn’t have a certified application enroller from the program personally helping set up their initial doctor’s appointments and encouraging them to attend.
What happened to the program?
ActionHealthNYC was only funded for the duration of the one-year study. But the authors told Epicenter that another, longer-term “direct-access” intervention, NYC Care, was inspired by the model. NYC Care, which operates through NYC Health + Hospitals, is a health care access program that guarantees low-cost and no-cost care to New Yorkers who don’t qualify for or can’t afford insurance. It claims that participants get their own membership card, can choose their own doctor and get affordable prescriptions.
What does the study and its experts suggest about the current migrant situation in NYC and migrants’ access to health care?
All three experts involved in ActionHealthNYC and the recent study who were interviewed by Epicenter said they have a problem with the often xenophobic mainstream narrative around the city’s migrant situation.
What Bae said …
Bae reminded us, as Epicenter’s De La Hoz has, that the current migrant situation is not unprecedented. She recalled NYC’s history of immigration since the days of Ellis Island.
“A lot of people who come here without status have an intention of seeking status, whenever that’s possible. And some of the people who were a part of the study may have eventually sought asylum,” Bae said.
She noted that New York State is unique in that, even if you don’t have a green card and haven’t yet been here for five years, you can get Medicaid if you’re a part of an eligible group that includes asylum seekers with a pending status. Those who haven’t yet applied for asylum, despite their intention to do so, are invisible in the health care system until they do.
Some mainstream portrayals of the situation as a “crisis” of resources due to the greater number of migrants arriving in NYC may seem alarmist now, yet this language has been used time and time again. That goes for the time period of this study — between Barack Obama’s and Donald Trump’s administrations.
“One of the key things was, because we didn’t want to explicitly say that this is a study of undocumented immigrants — that would create an incredible amount of challenges in recruiting people, and there’s also privacy concerns if you have a data of just undocumented immigrants — was to always describe the program as just ‘come if you’re an immigrant and do not have health insurance,’ ” says Bae. Researchers then screened all participants for eligibility for health insurance as well as for their study.
What city health officials involved in the study had to say …
“People who are often called asylum seekers here have the same health needs as New Yorkers and the same needs for care,” said Sam Solomon, the executive director of Strategic Policy and Programs at the New York City Department of Health and Mental Hygiene (NYC DOHMH). “It’s not a population of people who are carrying strange and frightening diseases over the borders. These are people who need basic, regular ongoing preventive care and primary care: regular cardiovascular care, regular mental health care, regular vaccinations, etc. And that’s something very important for us to all keep in mind.”
Rishi Sood, executive director of Health Care Access & Policy at NYC DOHMH, agreed.
“In this whole narrative of the current surge of migrants, what we see is this whole, ‘all migrants are vectors of disease,’” Sood said. Addressing all these needs is good for everyone, he added, including the entire system of providers, facilities, and other New Yorkers, “in order to connect everybody into care.”
He offered immunizations as an example: Kids need vaccinations before they go to school not only to protect themselves but all other kids and families.
“The narrative shift that we need nationally on this is that everybody needs their vaccines and everybody needs access to primary care,” Sood said. “And what we hope this program has shown at a local level here is that giving people access to primary care in a more comprehensive way through a direct access program, as we did, is honestly a win-win-win. It doesn’t take away from others. It just makes people healthier over the long term and saves the system money over the long term.”
This is part of a series of articles exploring health inequities in New York funded by a grant from the Commonwealth Fund.