North Carolina immigrants report language, discrimination as barriers to health care
North Carolina’s immigrant residents face challenges such as language barriers, complex eligibility rules and discriminatory treatment when interacting with government agencies and that’s leaving many people excluded from social assistance programs, according to a new study by the Washington, D.C.-based Urban Institute and UNC-Chapel Hill.
About one in 12 North Carolina residents are immigrants. In Mecklenburg County, that number rises to nearly one in six people.
Their experiences with the health care system and government agencies, like the Department of Health and Human Services, can vary widely depending on their background and their location.
Urban Institute senior fellow Hamutal Bernstein led a statewide assessment of how well immigrant residents can access safety net programs, like SNAP and Medicaid.
Nearly half of the state’s non-citizen immigrants lack health insurance, compared to about 9% of U.S.-born citizens. They are also insured at a lower rate than immigrant residents nationwide.
“We saw a real variation in resources across counties,” Bernstein said. They found program administration and policy interpretation varied by county.
The report notes that North Carolina is one of 10 states that operates programs like SNAP and Medicaid through a decentralized system. That means county governments, rather than statewide agencies, run the programs.
“If there are ways that there can be more sharing of knowledge, resources and information across counties — or if the state Health and Human Services agencies could facilitate collaboration across counties or sharing of resources across counties — that could be helpful,” Bernstein said.
Researchers interviewed 42 North Carolina stakeholders from divisions like DHHS. They also conducted focus groups in four counties with residents who spoke either Spanish, Swahili or Hmong. They found language access was a challenge for all three groups, but especially for non-Spanish-speaking immigrants.
“One of the things that we were struck by was speaking to stakeholders, including HHS agencies, but honestly, across the board, just not knowing what the language needs are beyond Spanish,” she said. “You cannot assume that if you provide it in Spanish you're covering the language access needs of the diverse immigrant population.”
In Mecklenburg County, for example, almost 40% of immigrant adults with limited English proficiency speak a language other than Spanish. The most spoken languages by North Carolina immigrants are Spanish, Chinese, Vietnamese, French and Arabic.
Researchers conducted four focus groups with members of immigrant families. This included two sessions in Spanish, one in Swahili and one in Hmong.
More than half of immigrants in North Carolina speak Spanish, and about 40% of the state’s immigrant residents were born in Latin America. This is also a diverse group, with many people coming from families with mixed immigration statuses.
“Their major barriers in accessing safety net programs included concerns of past or changing immigration policies, documentation requirements, and lack of interpreters and Spanish-speaking staff at HHS offices,” the report says.
Bernstein noted that Spanish-speaking participants felt increased fear in counties where sheriffs have partnered with federal Immigration and Customs Enforcement.
Spanish speakers also commented on discrimination, which was a concern among all three language groups.
“They reported the need to set aside an entire day to visit the office, arrive early, and wait for several hours before being served,” the report says.
“Two participants connected the lack of Spanish-speaking staff to poor treatment and discrimination. Another said that she felt the color of her skin was a barrier to receiving good service at the office.”
The participants in this study group were all newly arrived refugees from the Democratic Republic of the Congo. They had lived in the United States between two months and four years. Bernstein explained that their situation varies from that of many other immigrant groups.
“Refugees are specifically provided assistance to enroll for safety net programs when they are resettled,” Bernstein explained. “They get assistance early on in their arrival, but they may drop off and face barriers to staying enrolled.”
They also experienced language access challenges.
“None had ever seen any written materials in Swahili at their county HHS agency. They reported receiving all correspondence from HHS in English and Spanish only, even when their HHS caseworkers knew they did not speak these languages,” the study says.
“They also reported a lack of use of professional interpretation services when calling the HHS office and confusion in finding and navigating government buildings because of the language barrier.”
Hmong families represent a more established immigrant group in North Carolina. Many fled Southeast Asia after the Vietnam War, and Hmong families in North Carolina often span three generations, the report notes.
Many of the focus group participants were second-generation Hmong who help their parents navigate the health system. Some were concerned about how living in multi-generational households could affect income eligibility requirements. Many had also taken on the role of interpreter.
“Participants reported a lack of translated materials in Hmong, saying that they provide interpretation for their parents when interacting with county HHS offices,” the study says. “The majority tried to assist their parents through the process by translating information and completing forms on their behalf. But they lacked full Hmong fluency and were concerned that they would inadvertently misinterpret information shared by their parents.”
The study found children in North Carolina with an immigrant parent were more likely to live in a low-income household. Statewide, more than a quarter of children from families with a low income had at least one immigrant parent. In Mecklenburg County, they make up almost half of that population.
Bernstein says that sends a message about the importance of investing in immigrant families: “If you want to help children and low-income families, you need to have the understanding that reaching immigrant families is important.”
The Urban Institute has released an interactive data tool that provides county-level data on North Carolina immigrant communities and health insurance rates.