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.