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A UVM blog Migrant Health: Ear to the Ground

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“Stuff Got Missed”

By Naomi Wolcott-MacCausland

Elisa reached out this week after receiving a bill in her name for over $200 and a final reminder notice on a bill in her mom’s name of over $400. She was perplexed, as was I, since we submitted a sliding fee application for the family along with registration paperwork back in October prior to making their appointments and been told that the family would just have to pay a nominal fee. Since the first bills started to arrive, we had followed up on two prior occasions and been told the clinic’s sliding fee had been incorrectly processed and both times we had been assured it would be remedied. With yet another round of bills, we hopped on a three way call with billing at the clinic so I could interpret and explained the situation. In the case of Elisa’s bill, we explained we had received an email over a month ago confirming that the bill would be reprocessed and the amount lowered. In the case of the mom, the clinic had no record on the account that the sliding fee had been added to her account. The billing representative reviewed the notes and said “looks like some stuff got missed.” She sent an email off to the folks who handle the financial assistance applications and told us we would be hearing from someone soon. We are still waiting and in the meantime I am trying to assure the family, who has no income while they navigate the asylum seeking process, not to stress out, to have faith in a system that requires at least three calls to fix a mistake that without a correction will put the family on a debt collectors list.

If this was just occasional call that we have to make together with clients to fix billing errors, maybe it wouldn’t feel like such a big deal. People are overworked, they make mistakes, stuff gets missed. But we spend an obscene amount of time calling about bills that we have already called about that should have been resolved and resubmitting paperwork that we already submitted because despite being submitted as a complete application it somehow got misplaced or separated from the account in question. For as many cases as we help clients resolve, I can only imagine how many more mistakes go unfixed or unnoticed. And for most of our clients, the whole process of billing and applying for financial assistance or health insurance is an unfamiliar process made even more challenging to navigate when there is a language barrier as well as work schedules in service industries that often make it impossible to make a call to a clinic during normal business hours. For our team, what makes this time spent on resolving payments even more frustrating is that there are so many people who request our support to navigate access to needed health care services who we could be helping if we weren’t on the phone buried under the health care systems administrative burden.

Laboring alone

By Naomi Wolcott-MacCausland

Sarita, one of the 20+ pregnant women we have helped access prenatal care, car seats, WIC, and health insurance, was strongly advised by phone to go to the hospital to be induced out of concern for the health of her baby. She and her husband have struggled to find stable housing for their growing family since they arrived a few months ago and work for her husband has been inconsistent. He is a day laborer at the whims of weather and job contracts. Without a way to communicate with her husband or her child at school, no public transportation in her rural town and with limited English skills, Sarita wondered out loud if it would be ok to wait until tomorrow to go to the hospital. The medical provider explained that, though rare, fetal death was sometimes associated with her condition. I heard an audible gasp as Sarita processed this information that I shared via a WhatsApp call (the only communication method available to her at the time) and decided she would to go to the hospital right away. I reached out to a professional contact who had offered to help with last minute transportation needs. She was unavailable but shared that another friendly neighbor was around and willing. Sarita was dropped off at the hospital alone. At check in at labor and delivery, Sarita called me to interpret as she signed some forms. When asked to sign a consent to bill, she paused and asked aloud how she was going to pay for the costs. I stepped out of my role as interpreter to remind her that her health insurance was in process and we hoped she would be notified of enrollment very soon.

We were in touch into the evening with labor progressing slowly. Unsure when the baby would arrive and concerned that her husband wouldn’t get enough sleep to work the next day, he stayed home with their other young child. I woke up at daylight just after receiving a picture of her healthy baby, born earlier that morning. I thought about my time in the hospital after giving birth and the many family and friends who checked in – the comfort I had in knowing that through the exhaustion I was fully supported and could ask for whatever I needed or wanted. I offered to stop in and help coordinate additional supports as needed. Sarita said she would welcome a visit. When I asked if she had a craving for anything Sarita responded “Could you help me buy a pastelito?” Luckily I clarified as I first thought she meant a savory turnover-like stuffed pastry. What she actually wanted was a vanilla cupcake.

Two days after the birth of her health baby, she was discharged, returning home to a packed 2 bedroom household of 6 adults and 7 children. Two days later, over the weekend, Sarita reached out saying she had a fever and wanted to go to the hospital. We called the on-call provider who went through a series of question about abdominal pain and other symptoms. The provider wanted to how high her fever went and Sarita said she felt really hot. She didn’t have a thermometer so the provider recommended getting one – a nearly impossible task due to living far from any store with a thermometer and a lack of transportation. The provider reviewed reasons Sarita should go to the Emergency Department – sustained fever, heavy bleeding, abdominal pain… She made a note in the chart for a nurse to reach out on Monday to check in. In the meantime, I reached out to a Spanish speaking friend who happened to be nearby. She was warm but had no fever when the friend showed her how to use the digital thermometer.

Early Tuesday morning, Sarita wrote me from the Emergency Room. She had arrived by ambulance after a rough night of fever and chills – she said she just knew something was really wrong. She was ultimately diagnosed with a blood infection connected to the birth a few days earlier. The recommendation was to be admitted for intravenous antibiotics but when Sarita was told she could not get admitted with her days old baby, she asked about getting discharged. With all adult family members working in unstable jobs that often come with fear of getting fired for missing work and no social network, Sarita was facing an impossible choice – her health vs caring for her newborn. Behind the scenes, we began conversations about whether an informal network of Spanish speaking moms I knew could take turns in the hospital helping take care of the baby in a way that would allow Sarita to stay with him and continue to breastfed. In the meantime, a fantastic social worker/patient advocate from within the hospital and I reached out to a medical provider in a leadership position at the hospital who fully understood the complexities and health risk that lay at the center of this case. Ultimately, Sarita was allowed to keep her baby at her side for the duration of her multi-day hospital stay.

Sarita’s health and the health of the family, like so many of the families we work with, continues to be impacted by the intersection of multiple social determinants of health: economic stability, safe housing, social and community context, transportation, and language access. The family is recovering from a parasitic infection that ultimately impacted the all families in the small apartment building due to close living quarters. Insurance covered the cost of treatment for the children while the most of the parents who are ineligible for insurance paid out of pocket. Sarita recently cancelled a well-child check for her kiddos due to needing to take on the responsibility of caring for another baby in the household while the parents worked. All while Sarita is at risk for mental health issues as she is socially, linguistically, and culturally isolated in a rural community while sleep deprived, caring for her own infant.

Sarita has demonstrated significant strength, calm, and determination in the face of so many challenges over the past few months. While both she and I recognize the important role our program has been able to play in helping her and her family navigate some of the health challenges in the short-term, there needs to be resources dedicated to ensuring newly arrived immigrants can acquire the knowledge and skills needed to set the family up for successful integration in the long-term through orientation about and access to transportation, secure housing, stable employment, affordable childcare, English classes, community connections, and health services.

H2A Farmworkers in Vermont

By jclare

Seasonal agricultural workers come to Vermont to fill the employment gap faced by local farmers. In Vermont, they are mainly from the island of Jamaica. The program hinges on a pattern or event that makes it temporary so, you will find most farmworkers here between April and November each year, for the growing season working in ground crops, apple orchards, or processing facilities. As a Jamaican national with family members and friends who have come as migrant workers and Community Health Worker, I bring a unique and critical perspective about prominent health needs, barriers and the role that culture plays.


A little history on the H-2 program in the US
The H-2 visa program that allows foreigners to temporarily work in US industries with labor shortages started in the 1950s. It now consists of 2 visa types: H2A (agricultural) and H2B (non-agricultural). There are several participating countries. However, since most workers in Vermont are Jamaicans, the focus is placed on that nationality in this context. The program is a significant one that highlights bilateral agreements between the US and Jamaica. Jamaica would provide temporary agricultural labor to fill the increasing need in the US. Business owners must be able to demonstrate a shortage of domestic labor or an absence of willing or qualified US workers for seasonal work.

Farmworkers in Vermont
Over 400 temporary agricultural workers are hidden and underserved throughout the State as a marginalized group of black men coming from a developing country in the Caribbean where resources are scarce. Despite resource scarcity in their home country, many would rather wait to return home to see a doctor especially due to fear and cost. I met two workers who have been coming to Vermont on the farm work program for over 25 years spending more time in Vermont than at home in Jamaica! There are many others serving more than a decade, with newer workers averaging 3-8 years. Many have relayed to me that they have never interacted with the health care system here before. When asked the reasons for this, their responses have fallen in two categories. “I have never seen a doctor in Vermont” or “I don’t really know where to go but one time I needed to go, and my boss took me.” Let’s dive into this further. The lack of access to health care is for a plethora of reasons. They stem from institutional barriers due to their marginalization or personal barriers or often a combination of both.

H2A workers have legal status in the country for the number of months their contracts are for. In that time, they have access to some rights and are ineligible for others. For example, they qualify to get a qualified health insurance plan that they pay a monthly premium to maintain but do not qualify for social security benefits or federal health care programs like Medicaid despite being income eligible.
One very interesting thing that blew my mind was that even after decades of farm labor across the state, many Vermonters are unaware of the existence of Jamaican farmworkers and the role they play in the State’s food system.

Health Needs
Most of the men who come to work on the farms are healthy enough (meaning an ability to work the long hard hours required for the job and the absence of significant impacts of chronic illness). However, we have found hypertension and diabetes to be quite common among Jamaican farmworkers. For those who have been diagnosed and are on medication, they try to bring as much medications as they can with them from Jamaica. Often, they are able to bring 2-3 months’ worth – not enough to last the 6 to 10 months that will be in Vermont. This results in them going many months without medications. The mindset behind this is that they will just have to deal with their health when they return home. Many are fearful of the cost of care and medications should they go to a doctor in Vermont. For those who have tried to access care at a local clinic for ongoing management, they have faced many barriers.

Registration paperwork in some cases is 6-15 pages long. To establish care, especially for a chronic condition, most clinics require previous medical records, which are very challenging to obtain from Jamaica. Even if they find a local clinic that accepts patients without medical records in unique circumstances, many are scheduling establishing care visits months into the future. Additional barriers include lack of access to personal transportation and the reality that missing work means missing out on pay. Clinics are generally not open after work ends in the evenings. Workers are fearful of requesting time off during the workday, and that if health issues are disclosed then they will not be asked to return in future years. This will significantly impact their ability to provide for their families. The cost of both clinic visits and prescriptions are of concern.

This is where Bridges to Health, an initiative within Migrant Health Programs of the University of Vermont Extension, fits in. We have been advocating for equitable health care access for farm workers (and migrant workers in general) across the state for over a decade. This work requires creative problem solving to coordinate health appointments. Whenever possible we support clients in accessing care at a free clinic for the uninsured (where they often offer evening hours) or community health centers that offer a financial assistance program or sliding fee scale. In the case of many Jamaican workers who do not live near a free clinic with evening hours and face the myriad barriers described above, access to a brick-and-mortar site remains out of reach. To counter this, we have been successful in select counties in bringing screenings and consults to the farms on evenings and weekends in collaboration with the UVM Medical Centers Family Medicine Residency Program and volunteers with our program. Using good RX, we are often able to help workers with chronic health issues in accessing low-cost prescriptions.

Farmworker Health from a Cultural Standpoint
Even with the support we can provide, there are key cultural factors that influence how and if a Jamaican worker is open to treatment for health issues. As a nation of 3 million people, the number one cause of death in Jamaicans is hypertension and heart disease (PAHO 2021). Workers are aware of these conditions in society often with a close connection- either in an immediate or extended family member. Yet many are resistant to the use of pharmaceutical drugs as a response to any ailment. Some believe that even if you do take the medication, it usually is a one-off case where once they have completed one dose/bottle/treatment, there is no need to repeat. Many times, they just stop taking the pills because they “feel fine”. I’ve ran into cases where farmworkers who were prescribed medications, when followed up by a provider will disclose that they finished the bottle of pills and threw it out as they don’t believe or even understand the concept of “refills.”

Another side to this is that many are family focused to the point where it is hard for them to prioritize their health. In their eyes, they can’t afford to lose money that their family needs to survive (as many are the sole providers in their households spanning multiple generations). They struggle to see the connection between being in good health and their ability to provide in a sustainable way. Unfortunately, in addition to family history and cultural beliefs and norms, diet plays a role here. It is more complex to address as our diet is at the cornerstone of our culture, ‘wellbeing’ and source of fulfillment.

Conclusion
In short, farmworkers have been coming to Vermont for decades to ‘till the soil’. Regrettably, the nature of the H2A program puts wellbeing on a back burner. For many workers, their health takes second priority to the work and related income that allows them to provide for their families. We know that the strenuousness of the job will only deteriorate their health at a much faster rate. For those with chronic health concerns, my concerns are exorbitant. As a state that is greatly benefited by those who contribute years of backbreaking labor, my hope is that there can be statewide support to ensure that programs like ours can grow and be sustained as an approach to addressing farmworker health. As an individual, you can seek out ways to volunteer and promote funding for our program, centering marginalized migrant community members while contributing to social justice and equity.

So You Can Just Call Them Up and They Will Drive Someone to the Doctor?

By Naomi Wolcott-MacCausland

I had pulled off to the side of a rural road to attend to an urgent health referral while doing farm visits with a new work collaborator for Huertas, our kitchen garden project. The farmworker in need of support described ongoing stomach pain. He didn’t have a fever or localized pain where his appendix should be but he was groaning with discomfort while we were on the phone. It was a Friday afternoon and he did not have a primary care provider or transportation. I spoke to him about the three levels of care: primary, urgent and emergency care and explained that the current options for same day care would be urgent care or the emergency department – both located 30 minutes from his home. He said he didn’t think he had a life threatening illness but was really worried and, when asked, he said he felt he needed to be seen the same day. He could get a ride later in the evening when a co-worker got off work which would limit his options to the Emergency Department. The day before, we had put out a last minute request to our health access volunteers to get a newborn to a blood draw appointment to check potentially dangerous bilirubin levels and had received two offers. I called the one who had not transported earlier in the day and stars seemed to align. She was willing to switch up her afternoon plans to get the farmworker to urgent care and back home.

My passenger was astonished to learn we have a small but committed group of volunteers across different areas of the state who are willing to be on a list of people we can email, call or text to ask about their availability to transport im/migrants (most often people they have never met) to health appointments. Over the next month, 9 volunteers transported to 18 different appointments, making it possible for clients from mere days old to 40 years old to receive needed health care services. While we try to give as much advanced notice as possible of upcoming needs to the 30 to 40 active volunteers who have slogged through a lengthy application process, we are often looking for support for health needs that need to be attended to within the week and sometimes the same or next day.

Vermont is full of kind and generous people who make the state and people’s lives in it better through volunteerism and philanthropy. Health Access Volunteers through Bridges to Health are among the most rare and cherished volunteers, individuals who are so committed to health care for all that they are willing to take on a role that is irregular, hard to plan for, often requires driving long distances, can easily take half a day especially if picking up a prescription is needed, and often involves inviting ill or injured strangers into your car with whom you can’t communicate well. It is not a role that many want to (or can) take on, but is one that is a vital lifeline for many of the im/migrant adults and children who we serve. At our first annual volunteer appreciation picnic this year, we asked those in attendance about their motivations for volunteering and this is a bit of what we heard.

I wanted to make a difference after personally experiencing injustices in the health care system. I’ve become motivated to learn Spanish and I’ve made so many great connections. I like to bring awareness to these issues and to this work that I am doing. I share stories and the experiences that I’ve had. It has been a lot of fun!

In my life, I’ve frequently been the new person in town. I know what that feels like. I’d like to help others in that position and give back to the community.

I learned about the opportunity through a friend I met doing other volunteer work and could feel the joy he got from meeting all different types of people. I love the contacts I have made and relationships I have created. They are significant to me.

It is a personal and political choice. I’ve been in healthcare all my life and having access to health care is critical for all. I see the disconnect between so many different realities. We don’t want immigrants but we want our milk? How is that possible? So many issues could be solved by opening our doors. This is a great and rewarding activity for retirement – connecting with my neighbors who I might not otherwise meet.

I feel so lucky that I have retirement benefits and a nice working car with air conditioning. I wanted to give back. But the workers have given back even more to me.

Our volunteers are an amazing and diverse collection of individuals united in their desire to help others, better their communities and support healthcare access for all Vermonters. Some volunteer with us multiple times a month, and some only a few times a year. No matter the frequency, our volunteers are the often unseen champions that make our work possible, and we so appreciate them. We always welcome interested individuals to apply to volunteer with us or to reach out with questions, more information can be found here on our website: https://www.uvm.edu/extension/agriculture/migrant-health-programs. Our application process is not short, but includes the steps we feel are necessary in considering the unique characteristics of the populations we support.

While my passenger experienced awe and astonishment learning for the first time about the role of volunteers in our programming, I can say that even after many years of doing this work I still hold those same feelings as I witness our volunteers selflessly showing up again and again in service of migrant workers in their communities. Vermont really is a special place, and working together we can ensure that achieving good health is available to all who call these green mountains (and fields) their home.

Thank you to co-author Claire Bove for her contributions to this post!

Embarrassment and Frustration in the Check Out Line: Challenges Using WIC Benefits

By Naomi Wolcott-MacCausland

When our Community Health Worker met Felicia*, her daughter was two years old. Through the process of helping her set up health and dental appointments, she learned that she had originally been signed up for WIC when she was pregnant, but had never used her benefits because she didn’t understand how to use them. Even though the 40 page booklet outlining what she was eligible to purchase was in Spanish, she said it was confusing and her attempts to use her card were unsuccessful so she stopped trying.

When Ana* was pregnant, a Community Health Worker helped connect her to WIC. They did a shopping trip together so that the Community Health Worker could teach her how to use the card. When she disclosed that she was paying $60 for each ride to the store to use the WIC benefits, we helped her connect to a Bridges to Health volunteer and tried to coordinate shopping trips with medical visits. After a number of times, she felt comfortable selecting the correct items to maximize the use of her WIC benefits. One day recently, she confidently selected all her WIC items and went to check out. After the cashier rung out 16 ounces of tortillas, 1 dozen non organic eggs, a gallon of lowfat (not whole) milk, two 8 ounce packages of cheese, 1 tub of low fat yogurt, two bags of 16 ounce dried beans, two 18 ounce boxes of approved cereal, and around $40 of fruits and vegetables, Ana slid her WIC card through the machine. It didn’t work. Confused and not wanting to cause problems, she fumbled through her wallet and paid out of pocket using money she had been planning to use for essential non-food household items like diapers for her child.

Maria* recently went shopping with a community volunteer who spoke some Spanish. She had the list of her beginning balance and methodically helped her pick out items that seemed to line up. At check out, Maria was $30 over. Both Maria and the volunteer didn’t understand why. The Community Health Worker explained that some of the brands were not WIC approved and that some items were not in line with the size requirements (like the 10 ounce package of cheese). For the next shopping trip, I accompanied Maria and taught her how to look closely at what items were labeled as WIC approved. Having learned from Ana’s experience, I helped Maria requested a balance check at customer service before we started shopping and then methodically selected WIC approved items matching both the WIC approval sticker to the specific quantity listed and any indication that the item needed to be low fat or non fat. We couldn’t find a 48 ounce bottle of WIC approved juice – only 64 ounce containers so we grabbed one to ask at check out if it could be approved. At check out we were told that there is no way of checking if an item is eligible for a particular person’s WIC benefits. We would have to ring everything up and only after sliding the WIC card through could we see if there would be a remaining balance to pay out of pocket. We decided not to risk it with the juice but had the cashier ring everything else up. A message popped up on the screen asking if we approved of the $77.94 amount. I could see the cashiers screen and noticed that the total balance was $82.53. I asked if we could remove the item that was not eligible. The cashier said they were unable to tell which item was not eligible. In the meantime, a line of 5 shoppers had formed, Maria looked uncomfortable and I was frustrated. Maria pulled two crumpled dollar bills from the bottom of her purse and said “this is all I have.”

The experiences of many of the clients we work with combined with my own recent experience, left me wondering how many people forgo their benefits or do not maximize the use of their benefits because the system is confusing and leaves people vulnerable to being embarrassed at the check out line unsure how to proceed and in some cases unable to bring home the food items they desperately need.

Felicia wasn’t provided adequate support to ensure she could actually utilize her card when she was first enrolled in WIC. In the case of Ana, her WIC card had been frozen unbeknownst to her because she had not completed a WIC educational activity that she did not know she had to complete. She has no cell service where she lives so can only communicate via web-based messaging and calls. And in the case of Maria, after a close examination of the receipts, I realized I had inadvertently selected two WIC approved items that together were more than the allowed allotment. In all three cases, there are solutions. Newly enrolled WIC participants can get an in-store orientation and participants who do not use their benefits for months in a row should receive follow up to offer support. Web-based messaging and calls (via WhatsApp) should be utilized to ensure WIC participants without phone services know about required activities and appointments. WIC participants should be taught to do a benefits check prior to shopping (though for many of our clients who speak languages other than English, requesting the check is as challenging as understanding the beginning balance list). And there should be a way to swipe a WIC card ahead of a scanning items so that as items are rung up, the customer can see what is covered and choose whether or not to pay out of pocket for those items.

Our team has worked closely with WIC staff across the state who share in common our desire to ensure WIC is accessible for eligible families including those who speak languages other than English. They are kind, committed, and responsive to feedback. With limited funding and thus capacity of both WIC staff and community based organizations like ours and policy implementation that happens at a federal level, how can we make sure WIC benefits are in fact a benefit and not a burden for low-income families in Vermont?

Access to health insurance is only a piece of the access to care puzzle

By Naomi Wolcott-MacCausland
*Yesica is a Spanish speaker whose child has health insurance. She received a pile of bills for services that should be covered by this insurance. She didn’t fully understand the bills but definitely understood the $10,535.83 price tag.Without access to a language line to call in the insurance number nor access to a vehicle to show up with the card number in person, she was at risk for the bill to be sent to collections.

In July of 2022, Vermont initiated “a new, state-funded health care program for pregnant individuals and children under age 19 who have an immigration status for which Vermont Medicaid is not available.” The Immigrant Health Insurance Plan (IHIP)is a Dr. Dynasaur look alike program that has the same income eligibility thresholds and much of the same coverage to ensure that the vast majority of children and pregnant women residing in Vermont, regardless of documentation status, have access to affordable and comprehensive health insurance.

When the legislation was being proposed for this new program, our program, Bridges to Health, provided key data and testimony about the potential positive impact on migrant families. At the time, it was estimated that 100 children and 22 pregnant women a year would be eligible for this plan. Since the plan’s inception in July of 2022, our program has enrolled 86% of all the women and children in the state who currently have IHIP. To date, we have 87 clients on IHIP, of whom 72 are children, and 18 applications pending approval. We have assisted an additional 32 children and pregnant women in Dr. Dynasaur.

Of the families we have helped enroll in IHIP and some who have family members enrolled in Dr. Dynasaur, the vast majority were unaware that such a plan existed until we explained it to them. Most often, we are meeting them because they have reached out with a health care need for themselves or a family member or a fellow community member has let us know they are in need of assistance. Our decades plus of outreach to migrant communities in support of access to health and health related services means we were well positioned not only to ensure as many eligible individuals as possible knew about the plan but to assist them in enrolling and utilizing the significant trust we have established to assuage their fears about applying for a government program.

Though our long standing connections to the community has made it relatively easy to share information about the plan, gathering the required information and supporting families through the enrollment process and then utilization of their insurance has been anything but easy. In addition to the application, a number of supporting documents need to be submitted: proof of identity and age, proof of Vermont residency, and proof of income. For many, one or more of these supporting documents requires some additional steps. In one case, the household didn’t have a registered mailing address nor a physical mailbox so we had to assist them in registering with the postal service and install a mailbox according to the required guidelines. Some families who are applying for asylum had their documents seized at the border so only have grainy photographs of their identity and age documents. Many parents of eligible children are paid under the table and are reluctant to ask their employers for a letter due to fear of reprisal.

Currently, there is no online system for submitting IHIP applications so all applications are submitted by mail. Due to prior experiences with mailed health insurance applications going missing, we make copies of everything that is submitted. This has served us well given that, for over 40% of applications, we have had to either resubmit supporting documents that have mistakenly been separated from the application when being processed, refer to submission dates to advocate for retroactive start dates, and/or request assistance from the Office of the Health Care Advocate to move forward cases that were erroneously denied.

We are fortunate to have a health insurance assister on our team as she is often able to move cases along faster than the rest of the Community Health Worker team. However, she has easily spent over a hundred hours on calls to request status updates, advocate for retroactive start dates, correct misspellings of applicant names, confirm that all the required supporting documentation has already been submitted, ask why an approved IHIP number is no longer showing up as active and more. While we have worked closely with Vermont Health Connect to set up and improve systems to make the process easier, each case is unique, complicated, and time consuming.

Despite the complications and many hours spent, we are thrilled that all children and pregnant women in Vermont regardless of immigration status can get comprehensive health insurance if they are income eligible. We must applaud those who pass and uphold legislation and budgets that create access to health insurance while, at the same time, recognizing that health insurance addresses just one of many barriers that many im/migrant families face in receiving needed health care services. To fully utilize health insurance benefits, an individual must find and become an established patient at a health and dental clinic that accepts their insurance, which means filling out the many registration, patient health history, and release of information forms that are challenging for many, particularly those with limited English skills. Once established as a patient, appointments need to be made. This is another challenge for those with limited English given that most locations, even if they offer language access on site, cannot consistently connect to an interpreter when a patient calls in. Finally, transportation is necessary. The vast majority of our patients do not have access to their own transportation and public transportation is very limited especially across rural Vermont. A great benefit of IHIP and Dr. Dynasaur is that medical transportation can be arranged for free as long as it is scheduled far enough in advance. Yet again, the language barrier presents a significant problem as systems are not set up to allow limited English speakers to connect to an interpreter.

We estimate that between ongoing communication with applicants, navigating systems challenges with Vermont Health Connect, helping reconcile billing issues, enrollment in medical and dental homes, and making appointments, and coordinating transportation, we spend 8-10 hours per person to help establish care. Additional time is spent to coordinate follow up, acute, and prenatal care.

Increased coverage for children and pregnant women has resulted in the im/migrant population receiving more comprehensive and preventative health care services but access to health insurance is only part of the puzzle. Improving access to care requires using a wide lens to fully understand needs, barriers, and opportunities within community and clinical settings and programing like ours that can tailor our supports to directly address the gaps one person at a time.

The Cost of Care Labyrinth

By Naomi Wolcott-MacCausland

Dario* is in his 40’s and has been struggling with pain and sleep quality due to the impact of a back injury. Prior to being connected to us, he presented a number of times at the Emergency Department, unaware of where else he could get care. After receiving the exorbitant bills, he was reluctant to go to follow up appointments with the specialists that had been recommended to him. He ultimately was established with a primary care provider who thought physical therapy could be helpful for his pain and long term health but was reluctant to refer him due to high out of pocket costs as an uninsured patient.

Dora* is entering her second trimester of pregnancy and just recently reached out to us about prenatal care options in her area. She is currently ineligible for insurance because, despite only making minimum wage, she and her partner work 132 hours a week to support immediate and extended family members which puts her over the income threshold to qualify. She was charged $260 for the initial visit (equivalent to 21 hours of work at her current hourly rate) and it is recommended that she be seen for 8 more visits leading up to her due date.

Lina’s* young daughter had worsening and inexplicable pain in a joint. After a series of primary care and specialists appointments, blood work showed significantly elevated levels of white blood cells. After being admitted into the Children’s Hospital, a biopsy and additional blood work, she was diagnosed with a fungal respiratory infection that had entered his blood stream. She was discharged with a prescription for a daily medication that she was to take for a year. When Lina showed up to pick up the prescription she was told that it would be $3000 a month ($36,000 for the year).

Martin* presented at the Emergency Department with severe abdominal pain. They ruled out the need for any emergency procedures and it was recommended he follow up with a specialist for an endoscopy. His initial hospital bill was $5852 with an additional $505 bill from the company the hospital contracts with for diagnostic equipment.

Joseph* is a seasonal agricultural worker with hypertension. He was about to run out of the medication he brought from home and was set up a Community Health Center after 10 weeks of back and forth about whether or not they would see him without him being able to successfully get medical records from home. He was charged $170 for the appointment and his medication that was supposed to be sent to a low cost pharmacy was sent to a local pharmacy instead where it cost over $300 for the month. With a salary of $14.99 an hour, the initial cost of the appointments and meds was more than 32 hours of work in the fields.

Leo* was in a horrific car accident where he was pulled out of the vehicle with the jaws of life. He was brought intermediately by ambulance to the trauma center at a Vermont hospital where he was admitted for over a month incurring over a hundred thousand dollars of health related costs.

In all of the above scenarios, there are opportunities to reduce the price of care that the individuals and families did not know about and in all of these cases, health care system representatives either did not explain, did not explain in a language that the patient understood, or did not know about ways to reduce the out of pocket cost. Dario was eligible for financial assistance at the hospital which means that he is eligible for discounted care at physical therapists that are within the hospital system. Dora was eligible for a 30% self-pay discount for her prenatal visits. Lina’s insurance covers the cost of her medications as long as the provider submits evidence of need for pre-approval. Martin, with a wife and three minor children was eligible for financial assistance at the hospital and if he sends in the approval letter, the diagnostic imagining company will provide a discount as well. Joseph had been incorrectly assessed for the slide fee discount and was eligible for a refund for the provider visit (unfortunately he couldn’t recoup the costs of the medications). Leo was eligible for Emergency Medicaid given his inability to work after the accident which covered the cost of his in-patient care.

In each of these cases, due to extensive outreach and an unwavering commitment to improving access to care for migrant workers and their family members living in Vermont, Bridges to Health either had pre-established relationships with those impacted or a friend, family member, or employer referred them to us. We were able to assist in each one of the above cases to reduce the out of pocket health care costs and support needed follow up care because we have a unique understanding of the individual and systems barriers faced by migrant workers and their family members as well as years of experience navigating similar cases. The cost of care is an issue that we confront with clients on a weekly basis and is often cited as a reason that they have delayed or forgone needed care until their health deteriorates significantly.

It is clear from these cases and the hundreds that we have worked on over the years, that hospitals and health centers are not giving migrant workers and their family members adequate information about or support to navigate the complex and confusing payment, financial assistance, and health insurance systems. How does this impact decisions about preventative care or seeking out needed care in a timely manner? How many cancel or skip appointments or forgo costly prescriptions? What would be the long term costs to both personal health and the health care system if Dario ended up back in the ED when his back pain gets worse, Martin doesn’t get the endoscopy, Joseph rationed his blood pressure medication, Lina’s daughter went without treatment or Dora didn’t get prenatal care? How many more are getting lost in the health care costs labyrinth?

A Person Centered Whole Household Approach

By Naomi Wolcott-MacCausland

“A friend of mine who knew I needed some help suggested I reach out to the [Bridges to Health] Community Health Worker in my area. I came to Vermont about 6 month ago with my partner Maria* and her nephew, Jorge*. We had solid work for a month but the relationship with the employer soured. We are looking for consistent repair and maintenance work but some weeks I only have work for two days and Jorge might just work one day. There are times when we don’t have enough money for food. The Community Health Worker brought us to a food shelf where we can go to make sure we have enough to eat during the weeks that we don’t have a lot of work. I also had some aches and pains and didn’t know what to do. The Community Health Worker got me an appointment at a free clinic [for the uninsured] and recently was able to help my partner Maria* and her nephew Jorge* with their medical needs as well. She also supported me and Jorge to get our driver’s license which means we now have a Vermont identification card and can drive where we need to for work, food and health needs. My brother just joined us here in Vermont so I am hoping she can support him with medical and other needs too. If it wasn’t for the Community Health Worker, we wouldn’t know about or be able to access any of the community resources we now know about. We are so grateful for her help while we look towards a better future.” *Pedro – migrant worker in service industry

“My partner and I have been in Vermont for over 5 years. When we first arrived, and especially when I got pregnant the first time, I didn’t know what to do when faced with health needs. Due to a language barrier, lack of knowledge of services, and without transportation, I needed help every step of the way. Over time, both of us got our driver’s licenses and we moved from one county to another a few years ago. At first, even though it was three hours round trip, we kept going to the same pediatrician, clinic, and dentist because we knew where to go and were already established patients. The distance was hard though because we were both working 60 plus hours a week and had to take our daughter out of school for the full day to go to the pediatrician. We reached out to a Community Health Worker who helped us get a pediatrician close to home and to connect to local health services. When I got pregnant this year, I had heard about an insurance program for pregnant women through Migrant Justice but didn’t know how to apply. A Community Health Worker helped me apply gathering the required paperwork and in understanding the many pages of paperwork that arrived. She also helped me make my first appointment and a referral to WIC. I didn’t receive a call from WIC after the referral so she assisted in contacting them again. I like to be independent. It makes me feel good to be able to navigate services on my own and we do our best to do so. We both speak and understand much more English than when we first arrived so we feel comfortable signing in at a clinic and making follow up appointments. We also both drive so can get to where we need to go. We use an translator app that we can hold over documents in English to translate it into Spanish. But we still struggle to make or change appointments over the phone and we get so much health related paperwork in the mail that we still sometimes need help from the Community Health Worker. Our health is important to us and we don’t want to misunderstand anything or miss important appointments.” *Laura – migrant worker in dairy industry

Pedro and Laura share in common a desire for a better life than they left behind but each is unique. They have their own personal and familial histories, their own cultural health beliefs and experiences navigating health systems, and divergent work-family contexts: all of which influence their opinions, concerns and preferences as well as their needs and desired outcomes.

Each time a client or a parent of a client reaches out to us requesting assistance it is because they feel unable to independently navigate a health related need – usually connected to uncertainty and barriers accessing one or more aspects of a health and/or social services system in Vermont. Bridges to Health takes a person-centered approach seeking to understand each person’s unique story, the social and physical context in which they currently live and how that intersects with their current and ongoing needs and opportunities to access services towards a desired outcome. Frequently, after assessing and prioritizing needs to begin supporting an individual in a household that is new to us, we are connected to others in the household. We apply the same person-centered approach to each new client taking into account what we have learned over time about the household.

In the case of Pedro, he was a new arrival to Vermont. He had few social connections and no experience navigating health and social services in Vermont much less the United States. For him and his household, the initial primary concern was having enough good to eat while in between jobs. The Community Health Worker, aware of community resources accessible to him based on his current situation, connected him to the food shelf providing interpretation so he could fully understand how to utilize the resource. The personal introduction gave him and his household the knowledge and confidence necessary to begin accessing the service independently. Weeks later, when facing a health issue, his first barrier was awareness of what was available to him. Again the Community Health Worker, gathered information about his unique context and as an uninsured individual with limited English skills with an acute but not emergent health issue, connected him to the local free clinic. Pedro and Jorge both let the Community Health Worker know that they were struggling with getting a drivers license in Vermont. They had drivers licenses from their home countries but due to limited English skills needed an interpreter for the Vermont road test. Recognizing the relationships between economic success, access to health and health related needs (like food) and having a driver’s license, the Community Health Worker served as an interpreter and both successfully got their license. When Pedro’s partner, Maria, approached the Community Health Worker with breast pain, the Community Health Worker explained the options available. Maria decided she wanted to seek out care at the local free health clinic so the Community Health Worker helped her make an appointment and provided in-person interpretation to assist with new patient paperwork. When Maria was referred to the local hospital for a mammogram and was concerned about the cost, the Community Health Worker let her know about and helped her sign up for You First; a Department of Health Program, that covered the cost of the mammogram. Pedro, with his new Vermont driver’s license, was able to drive her to her appointments. The Community Health Worker helped communicate the results of the normal mammogram and next steps.

For Laura, she and her partner had become familiar with the health care system over the years and have increasingly become independent. When she initially reached out, she identified wanting help getting established with local care. The Community Health Worker collected information about where they had accessed care in the past and explained the local options including financial assistance options for uninsured members of the family. Laura and her partner, both uninsured, decided to get established at the Community Health Center where they could receive a discount while deciding to establish their insured daughter at a private practice. They requested help with the paperwork and the initial appointment. They expressed confidence and a desire to navigate services independently so the Community Health Worker steps in only to support in the areas where they struggle or to offer connections to any new programs. For ongoing needs, like prenatal care, the Community Health Worker reaches out routinely to see how the pregnancy is progressing, ensure Laura is attending the recommended schedule of appointments and to identify any new concerns or needs Laura has.

With both households our approach was similar; centered on the person and open to serving whomever in the household was facing barriers to services at any give time. We tailored our response to identified needs and barriers based on information gathered from the individuals and household and our knowledge of how to navigate services and programs they are eligible for that met the needs and priorities they have expressed. Each person was treated with dignity and respect, provided information about their options, asked about barriers to services, and supported in being as independent as possible while moving together towards desired health related outcomes.

Navigating Mountains of Paperwork

By Naomi Wolcott-MacCausland

“There are so many pieces of paper to fill out and questions to answer that I am not sure about going to the doctor.”

The volume and complexity of paperwork required to navigate the health care system is a barrier for many especially those with limited reading and writing skills; for those whose first language is not English and/or are unaccustomed to the bureaucracy embedded within the health care system, it can sometimes be the culminating reason that someone delays or even forgoes needed medical care. A young man with whom we have been in touch for the past three months faces myriad barriers in accessing health care services. He works long hours 7 days a week. He is paying off a large debt in Mexico while also sending money home to support his family’s daily living expenses. He does not have access to transportation. He can see the Canadian border from his window and lives in fear of being detained and deported. He has been struggling for months with acid reflux that is still causing daily discomfort after an unsuccessful six week trial of the over the counter medication omeprazole that we delivered to him under the recommendation of a volunteer health provider. Due to some troubling symptoms, the next step would likely be an endoscopy which requires a referral from a primary care provider. A Community Health Worker has offered to assist with coordinating the appointment, help fill out the new patient paperwork and sliding fee application to establish discounted care at a primary care provider and coordinate transportation with our trusted volunteers yet answering all the questions required of the new patient paperwork still feels daunting enough that it is a primary reason that he has yet to receive needed care.

The amount of paperwork that the Bridges to Health team helps migrant workers and their family members navigate is astounding. In the past 30 days:

  • We filled out 108 pages of paperwork for 18 individuals including 8 children who needed assistance to register at a health or dental clinics (average of 6 pages per clinic).
  • We filled out 40 pages of paperwork with 20 individuals who requested our assistance in applying for financial assistance at a hospital or health center.
  • We filled out 80 pages of health insurance enrollment paperwork with 10 families who had requested our assistance, collecting from them more than 40 pages of supporting documentation demonstrating their eligibility.
  • We filled out 40 pages of paperwork assisting two families apply for 3 Squares Vermont nutrition benefits.
  • Over a dozen clients requested assistance in understanding bills, patient surveys, and other health related paperwork that had arrived at their home.
  • One of the many families that we are supporting to navigate health insurance coverage received 49 pages of paperwork that they did not understand.

With the inclusion of an updated definition of health literacy that addresses both personal and organizational health literacy Healthy People 2030 acknowledges the health care system’s responsibility to “equitably enable individuals to find, understand, and use information and services to inform health related decisions and actions for themselves and others.” Reflecting on the hours each week that Bridges to Health Community Health Workers spend helping clients slug through the paperwork, I am struck by how much time is required in the health insurance application, financial assistance application, and patient registration process – prerequisites in many cases for clients to even get the the point where they are receiving the needed health care services and health information to then be able to apply personal health literacy skills to “make informed health related decisions and actions for themselves.”

For migrant workers and their family members who face some of the same health barriers as the young man with acid reflux, navigating the complexities of the paperwork on top of those barriers is so overwhelming that they forgo health insurance, financial assistance, or nutrition benefits despite being eligible or access health care services for non-urgent conditions at an urgent care or emergency department where they will get care if they simply show up. Whenever possible, Community Health Workers address the paperwork barrier head on by making sure clients they are connected with know their options and have the assistance needed to thoroughly complete applications, compile required supporting documentation such as identity and income information, and understand related follow up paperwork.

Without the support of Community Health Workers to complete establishing care paperwork, would the 18 individuals have resorted to going to urgent care or the emergency department for health needs? Would the two families eligible for 3SquaresVT benefits have enough nutritious food to eat had the Community Health Worker not been able to help them navigate the 20 page application? How many thousands of dollars of health care services would individuals incur if they had not learned about eligibility and then received assistance in completing the health insurance applications? What would be the immediate and long term health impact on individuals due to delayed or forgone care for fear of health care costs that would otherwise be covered through insurance or financial assistance?

Working Towards Health Equity: One Person at a Time

By Naomi Wolcott-MacCausland

“We got another bill today. This time for $450 for an ultrasound.”

“I have not heard anything from the pediatrician [since we saw them in December] about a referral requested for a nutritionist for my son.”

“I got two envelopes in the mail today from health insurance. Twelve pages that I don’t understand”

“Can you help me make an appointment to replace my implant? It expires in April.”

” I don’t have anyone to bring me to my appointment because the taxi can’t bring me.”

“I can’t find my vaccination card and I need proof of it to show that I was vaccinated”

“Heard anything about the insurance yet?”

“I have gone to the ER and Urgent care several times. I am so frustrated and depressed about this because I cant get an answer about what is wrong with me. They tell me to go home and come back if I get worse. That is the problem, I shouldn’t be getting worse, I should be getting better.”

The above represent a small handful of reasons migrant workers and their family members communicated with Bridges to Health’s Community Health Worker team over the past few days. Just this week, we were in touch with more than 80 individuals. This included responding to a myriad of messages soliciting assistance and coordinating 31 appointments to ensure migrant workers and their children from across 10 counties could access health and social service appointments addressing a wide range of issues: hearing loss, HIV, post op from a hernia surgery, back pain, an overactive thyroid, congestion, rash, orthopedics, immunizations, lab work, yeast infection, pneumonia, stomach pain, and multiple appointments for WIC, eye concerns, oral health, prenatal care, and birth control. I am writing this while on hold with Vermont Health Connect, one of multiple holds in the last 90 minutes since I initiated the call on behalf of a Spanish speaking family who has been struggling since September to enroll their infant in a health insurance plan.

Migrant workers and their family members have long played a critical role in sustaining Vermont’s agricultural economy. For decades, Jamaican workers have supported seasonal agriculture and within the past two decades, dairy farms have come to rely heavily on migrant workers from Mexico and Central America. Increasingly, other seasonal and year-round businesses in Vermont are utilizing migrant workers to fill labor shortages in construction, landscaping, restaurants, and other hospitality roles. Over the past year, there has also been an increase in the number of Spanish speaking asylum-seeking families that have moved Vermont. Whether in Vermont seasonal or year round, most individuals we work with are migrating out of economic necessity and many are fleeing challenging situations in their home country. Migrant workers, often putting in 60-80 hours a week, have become a relied upon workforce sustaining a wide variety of businesses that are critical to Vermont’s agricultural landscape, tourism industry, and construction trades.

Regardless of where they live in Vermont or where they work, migrant workers and their family members face significant individual and systemic barriers to care and are disproportionately impacted by the workforce shortages within Vermont’s health and social systems, factors that when combined can severely limit timely access to care. Our team of Community Health Workers (CHWs) works hard every day against these barriers moving the needle on health equity to ensure that all living in Vermont have a more fair and just opportunity to “attain their full potential for health and well-being.“* Each day, as the many messages, calls, and emails come in from migrant workers and their family members, community based organizations, health entities, and volunteers, CHWs seek to understand the unique needs of each client, family and household serving as liaisons, cultural brokers, health educators, advocates, patient navigators, and interpreters between individuals and community-based organizations to promote health, reduce disparities, and improve service delivery.

As I think about the 80 plus individuals who reached out to us this week, I wonder what the health impact would be if we didn’t exist. Would the individual we brought to the hospital who ended up needing overnight treatment and observation for pneumonia have received the care he needed? Would the family who makes $10.50 an hour have received the assistance they needed applying for financial assistance or would they have to pay out of pocket – using earnings from 42 hours of work? Would the woman seeking an implant have ended up with an unwanted pregnancy? What would have happened to the woman in need of thyroid medication, the child needing a check up about her HIV treatment plan, and the young man with significant dental pain?

*World Health Organization Definition of Health Equity

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