Bettigole gave three examples of patients from her practice, people who were eligible for insurance before the ACA was passed, but who encountered barriers as they tried to obtain that insurance: A Portuguese-speaking man applied for Medicaid after a devastating assault requiring surgery. He was given application materials in Spanish. He obtained coverage only because of the social worker who accompanied him to the office. A young mother failed to obtain coverage for her children because she could not read the Medicaid application; they went without care. An African-American woman in her 50s refused to apply for Medicaid because she was so humiliated by her treatment at the local Department of Public Welfare office. She too goes without care.
These scenarios illustrate just a few of the challenges that will need to be addressed as coverage expansion is implemented, Bettigole said. In many cases, the literacy level in materials is too high for many patients. While some states have set a literacy level of sixth grade or lower for materials, she noted that many of her patients do not read at that level, or do not read at all. There is inadequate access to translated materials and interpreters. Many patients do not have access to computers or do not have basic computer skills. The new requirements for proof of citizenship using original documents is also a barrier to enrollment for many people. Families of mixed immigration status often fear applying for Medicaid coverage. And lastly, attitudinal barriers and health literacy among frontline medical staff are also issues.
The ACA does present many opportunities to address some of these issues. For example, the literacy level of materials that are used in the exchanges can be regulated, and interpretation and translation requirements can be integrated as these materials are created. TV and radio can be used to reach low literacy populations and those without computer access. It is also important to engage groups already in the community that are trusted by vulnerable populations, to help bridge the divide.
With regard to Medicaid coverage expansion, Bettigole said that states should be allowed to relax the requirements for documented proof of citizenship. This would help facilitate other application methods like Internet and phone applications. Financial incentives for increasing enrollment of vulnerable populations are also needed. There is funding for community assistance programs and ombudsman programs in the exchange funding, and the availability of this assistance needs to be advertised on TV and radio, in multiple languages, so people know where to go for help when literacy and language requirements are not met.