Abstract
Introduction:
We describe awareness of Medicaid expansion to undocumented and recent immigrants among Mexican-origin Latino/as in Oregon (called Healthier Oregon/Oregón Mas Saludable).
Methods:
Cross-sectional survey in collaboration with the Mexican Consulate. We describe awareness of the program, knowledge about eligibility, and experiences with enrollment.
Results:
Among 447 respondents, less than half (41.2%) were aware of the program.
Conclusion:
Continued outreach is needed to ensure all potential beneficiaries are aware of Healthier Oregon/Oregón Mas Saludable.
Health Equity Implications:
Understanding the experiences and meeting the information needs of immigrant populations is necessary to improve health equity.
Introduction
Health equity—understood as the elimination of unfair and avoidable differences in health and health care access that are rooted in social, economic, and political disadvantage 1 —is undermined when immigration and insurance policies explicitly exclude certain groups on the basis of legal status. Achieving health equity requires the dismantling of structural barriers to health care access and utilization for marginalized populations. 1 However, undocumented and recent (<5 years) immigrants are explicitly excluded from federal public insurance for low-income individuals, known as Medicaid, as well as subsidized private insurance exchanges under the Affordable Care Act. 2 In addition, the “public charge,” a set of rules that outlines a list of federal public benefits and defines immigrants who accessed these benefits as likely to become an economic burden, excludes targeted populations and likely produces a chilling effect. 3 Drawing on a structural racism framework, 4 we situate these exclusions within a history of racism and xenophobia that has constructed Mexican-origin and other Latino immigrants as less deserving of public benefits, shaping both eligibility rules and the information environments in which they learn about coverage.
In recent years, six states (California, Colorado, Illinois, New York, Oregon, and Washington) have opted to use state funds to expand Medicaid benefits to recent and undocumented immigrants. 5 In Oregon, the state-funded Medicaid expansion to immigrants not otherwise eligible for federal Medicaid is known as Healthier Oregon/Oregón Mas Saludable. In 2018, Oregon first covered children, then extended coverage to young (19–25 years old) and older (55 years and older) adults in 2022. 6 In July 2023, coverage was extended to all ages and expanded eligibility to an estimated additional 55,000 adult immigrants, with the goal of improving health equity across the state. 6 The Oregon Health Authority has been conducting outreach, both disseminating materials in English and Spanish and by partnering with local community-based organizations to do outreach to encourage program enrollment since the program’s inception; early data show that individuals who gained access to care through Healthier Oregon felt they had a better understanding, and their access to health care improved. 7 However, we have no data about awareness of the program in the general immigrant community; evidence available to date about Healthier Oregon comes from those who have successfully enrolled and accessed health care. About 95,000 individuals have been enrolled since program inception in 2018. However, utilization is lower than traditional Medicaid and suggests that people either are not aware they have benefits or have not used them. 8
In Oregon, Latinos make up 15% of the population; 9 9% of the population are U.S.-born Latinos, and the remainder are immigrants, with the majority from Mexico. 10 The purpose of this study is to identify if Mexican-origin Latino/as in Oregon are aware of the Healthier Oregon/Oregón Mas Saludable program and whether they understand eligibility or experience barriers to enrollment. We also describe sources of information about Healthier Oregon/Oregón Mas Saludable. In doing so, we assess whether and how this state-level expansion begins to address structural inequities in access to health coverage.
Methods
Participants and Data Collection
We conducted a cross-sectional survey study in collaboration with the Mexican Consulate in Portland, Oregon. Between September 2023 and May 2024, we recruited a convenience sample of participants who were over the age of 18, resided in Oregon, and self-identified as Latino/as. Potential participants were approached while waiting to be seen in the Consulate lobby or at off-site Consular events. The Consulate provides passports, birth certificates, and other administrative services for Mexicans and Mexican Americans residing in Oregon and Southwest Washington. Our first-generation bi-cultural, bilingual research team of undergraduate students explained the purpose of the study to everyone in the lobby and asked individuals if they would be willing to participate. We provided interested individuals with an information sheet with study details. Participants were able to have any questions answered, and those who provided oral informed consent completed the self-administered survey in their preferred language (Spanish or English). If some participants needed help (due to vision impairment or for other reasons), the research team helped them take the survey. The surveys were completed on paper and then entered into a secure REDCap (Research Electronic Data Capture) electronic database.
Measures
Our survey consisted of 19 items, including sociodemographic questions used in our prior research: 11 survey language and location, gender, age, residence in the Portland metropolitan area, years in the United States, marital status, education level, whether they had a regular income source, English proficiency, language spoken at home, general health status, and health insurance status. Our primary outcome was awareness of the Healthier Oregon/Oregón Mas Saludable program (yes or no). We also asked where they had heard of the program, whether they knew about their eligibility for the program, whether they knew how to enroll in the program, whether they had tried to enroll, the difficulty of the enrollment process, and any barriers experienced with enrollment. We based some questions on the 2016 California Health Interview Survey, 12 which asks about California’s Medicaid expansion to immigrants, and developed the rest. We developed the survey in English, and our bilingual team translated it into Spanish. We worked with a public health expert in Mexico and with the staff of the Mexican consulate to ensure that the wording in Spanish was accurate and understandable.
Analysis
We compared participant sociodemographic characteristics by whether or not they had heard of the Healthier Oregon/Oregón Mas Saludable program using Pearson chi-squared or Fisher’s exact tests and graphically compared the percentage of the sample that had and had not heard of the program. Among those who had heard of the program, we tabulated where they had heard of it, whether they knew if they qualified, and whether they knew how to enroll. We then stratified those who had heard of the program by whether they had tried to enroll themselves or another person. For those who had tried to enroll, we tabulated how easy the enrollment process was for them; for those who had not enrolled, we tabulated their barriers to attempting enrollment. This study was approved by the Oregon Health & Science University IRB.
Results
We recruited 520 participants. After excluding individuals residing outside of Oregon (n = 29) or missing outcome data (n = 44), our analytic sample was 447. Table 1 shows demographic information stratified by awareness of the Healthier Oregon/Oregón Mas Saludable program. The majority of the sample were individuals between the ages of 30–39 (26.2%) and 40–49 (22.8%). Most of the sample resided in the Portland Metro area (72.7%) and had lived in the United States for 11 years or more (58.2%). Our sample included more females (56.2%) than males (44%).
Sociodemographic Characteristics of Survey Respondents, by Knowledge about Healthier
Overall, 41.2% (n = 184) of our sample had heard of Healthier Oregon/Oregón Mas Saludable. (Fig. 1), and 58.8% (n = 263) had not. Among participants who had heard of the program (n = 184), the most common source of information was family, friends, and coworkers (45.1%, n = 83; Table 2). When asked about eligibility, (43.5%, n = 80) said they knew they qualified, and (57.6%, n = 106) stated they knew how to enroll themselves or another person. Among the n = 97 who had heard of the program and had tried to enroll themselves or another person (Fig. 2), most stated it was very easy (15.5%, n = 15) or easy (55.7%, n = 54). Common reasons for not enrolling were not having enough information and not qualifying (21.1% each).
Percent of respondents who had heard (left) or had not heard (right) of the Healthier Oregon Program at time of survey (n = 447).
Characteristics Related to Health and the Healthier Oregon Program, among Respondents Who Had Heard of the Healthier Oregon Program (n = 184)
More than one response may apply; does not sum to 100%.
Participant responses about ease of enrollment or reasons for not attempting enrollment based on whether they had previously attempted enrollment in the Healthier Oregon Program, among respondents who had heard of the program (n = 184).
Discussion
We present evidence about awareness of Medicaid expansion to undocumented immigrants, Healthier Oregon/Oregón Mas Saludable, among community-dwelling Mexican-origin Latinos in Oregon. We found that nearly 60% had not heard of the Healthier Oregon program before taking our survey, and the most common sources of information were family, friends, and coworkers.
Limited evidence from other states suggests similar findings. In California, among a sample of adults over 50 presenting to an emergency department, 60% (31/51) were unaware of the Medicaid expansion happening in their state. 13 Similarly, in a study that included counties from California, Illinois, and Ohio, people also demonstrated a lack of trust in government and a confusing enrollment system, especially for low-income and vulnerable populations, affecting access to Medicaid expansions. 14
Among participants who had tried enrolling themselves or a family member in Healthier Oregon/Oregón Mas Saludable approximately three-quarters stated it was easy or very easy. Participants who answered they had not tried to enroll themselves or another person most commonly cited not qualifying and not having enough information as the reason. Evidence from program beneficiaries suggests that language and concerns about immigration status or the public charge are also barriers. 7 Lack of trust and fear of deportation may increase under the new federal administration.
Limitations
The interpretation of the findings should take into consideration the following limitations. While our community-dwelling sample is a strength, participants recruited at the Mexican Consulate may not be generalizable to all Mexican-origin Latinos in Oregon. For example, our sample likely over-represents the Portland metro area, Mexican nationals, and those comfortable visiting the Consulate. All participants completed the survey in Spanish; our survey was not available in indigenous languages. We are unable to calculate a response rate due to data collection procedures, and those who participated in the survey may have different awareness levels than those who did not. Lastly, although we asked participants if they had heard of the Healthier Oregon/Oregón Mas Saludable program before taking the survey, it is possible that participants learned about the program through taking the survey, overestimating awareness of the program.
Health Equity Implications
The Healthier Oregon/Oregón Mas Saludable program was developed with the explicit objective of improving health equity in the state of Oregon. 6 However, our findings suggest that information about the program has not reached many within the marginalized populations it was designed to benefit. Continued outreach is needed to ensure all potential beneficiaries are aware of the program. Participants reported hearing about the program through friends, family, coworkers, their providers, and television. From this data, community organizations can develop trusted ways of sharing information that will reach these communities.
The recent increase in racially targeted immigration enforcement has generated an environment of fear and anxiety for immigrant communities, 15 creating additional barriers to health care utilization for both immigrants and their families.16,17 In order to realize the goal of improving health equity in this political environment, understanding the experiences and information needs of immigrant populations is key. Our results identify an important need for outreach to ensure that all potential beneficiaries are aware of the Healthier Oregon/Oregón Mas Saludable program.
Authors’ Contributions
N.L.-M.: Writing—original draft (lead), data curation (equal); E.B.: Methodology (lead), formal analysis (lead), writing—review and editing (equal); G.P.: Writing—review and editing (equal), data curation (equal); A.N.-B.: Writing—review and editing (equal), data curation (equal); B.G.D.: Conceptualization (lead), funding acquisition (lead), writing—original draft (supporting), writing—review and editing (equal).
Footnotes
Author Disclosure Statement
B.G.D. is a member of the Board of Directors of the Society of Family Planning (SFP) and the Editor-in-Chief of Contraception. She has received honorarium from American College of Obstetrics and Gynecology (ACOG) for committee work. All other authors have nothing to disclose.
Funding Information
This study was supported with funding through NIH BUILD EXITO Grant TL4GMI18965. U-RISE Grant Number IT34GMI41989-01.