Addressing health care needs of Colorado immigrants using a community power building approach

Abstract

Objective

To assess and address through policy change the health‐care needs of immigrant populations in Colorado.

Data Sources

Primary data were collected in two Colorado communities from June 2019 through December 2020.

Study Design

This work utilized a mixed‐method, community power building approach to determine and meet health‐care needs of immigrants, a marginalized population of mixed documentation status. Findings were then used to inform Emergency Medicaid (EM) expansion in Colorado.

Data Collection

In‐depth interviews were conducted in Spanish, English, and Somali with 47 immigrants in rural Morgan County in June–September 2019; findings were presented to the community for feedback in January–February 2020. In March–December 2020, 330 interviews were conducted in Spanish and English with 208 unique individuals in Morgan and Pueblo Counties by local community grassroots leaders via four rounds of a novel phone tree outreach method. Interviewees were identified through snowball sampling and direct outreach among individuals seeking immediate relief (i.e., food assistance).

Principal Findings

Interviewees reported numerous barriers to health‐care access, including discrimination and limited service hours and transportation options. Data also revealed a clear health insurance coverage gap among undocumented immigrants. These data were then presented to Colorado's Department of Health‐Care Policy and Financing, ultimately contributing to securing EM expansion to this population to include COVID treatment, including respiratory therapies and outpatient follow‐up appointments. Data‐informed continued implementation advocacy to ensure the effectiveness of EM program expansion.

Conclusions

Immigrants are particularly marginalized by the health‐care system. Rapid data collection grounded in a community power‐building approach produced data that directly informed state policy and an increased power base. This approach enables direct connection to immediate “downstream” needs in communities while simultaneously building collective systemic “upstream” analysis and capacity of community members and laying pathways to translation and implementation of research into policy.

What is known on this topic

• Immigrants, particularly non‐citizens or those without legal status, experience significant barriers to access to health care.

• This population is often difficult to access through conventional research methods.

What this study adds

• Barriers to health care among rural immigrants include lack of insurance, high and additional costs of services, lack of timely access to services, long wait times, lack of transportation, and limited service hours.

• Changes to the health‐care system that would improve the experience of rural immigrants include more affordable insurance options; additional health‐care facilities and providers, including specialists; better trained and/or bilingual staff; and improved information about the disease, payment options, and access.

• Engaging immigrant populations using a community power building model is an effective method of identifying and addressing social and structural barriers to health care and building a power base for a community organization; in Colorado, it led to improved access to insurance through Emergency Medicaid and improved access to COVID‐related information.

1. INTRODUCTION

Nearly 44 million people living in the United States, or 13.5% of the total population, are immigrants. ¹ Overall, immigrants tend to be healthier than comparable groups born in this country. ² However, the immigrant health advantage does not pertain to all immigrants groups ³ and does not persist as immigrants spend more time in the United States. ⁴ Over time, the health of immigrants often erodes as a result of a cumulative disadvantage and systemic oppression. ⁴ , ⁵ The already vulnerable condition that many immigrants experience is augmented by the lack of systematic and timely access to quality health care. ⁵ , ⁶ , ⁷ For those living in rural and/or underserved areas, these challenges can be exacerbated by even more fragmented health care and social systems and greater deficiencies in the local workforces.

Immigrants, particularly noncitizens or those without legal status, consistently have more limited access to health care compared to US‐born populations. ⁸ , ⁹ , ¹⁰ , ¹¹ They are also generally less satisfied with their health‐care services and more likely to feel discrimination in health‐care settings. This is particularly true of immigrants of color and those with limited English proficiency. ⁸ , ¹² , ¹³ Emerging work shows that during the COVID‐19 pandemic, this inequitable access to quality health care and coverage led to misinformation and hesitation to seek care, likely exacerbating community transmission and delaying access to medical care. ¹⁴

Findings regarding immigrants' health care are very consistent: they report lower rates of having a usual source of health care, insurance coverage, and good quality of care. ⁸ , ⁹ , ¹⁰ , ¹¹ However, there is still much to learn regarding variation among immigrant subgroups. Other factors that impede regular access to health care should also be explored further. Qualitative studies show that transportation issues, doctors' time availability, concerns related to the medical interpretation, and perceived discrimination attributed to language, race/ethnicity, or insurance status are important factors preventing immigrants from using health care. ¹⁵ , ¹⁶ Structural racism is also increasingly recognized as a potential impediment to care and a mediator of immigrants' health outcomes. ¹⁷ There is similarly much to learn regarding immigrants' health‐care access and experiences in relationship to the place of residence policy environments and safety net local capacities. ⁸ , ¹³ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ Addressing the health‐care needs of immigrants is challenging because of the heterogeneity of this group interacting with unique contexts, which are shaped by federal, state, and local policies, as well as specific health‐care system characteristics. ⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹

Available literature provides recommendations to guide interventions addressing barriers to health care for immigrants. ¹⁰ These include advocacy for health‐care policy change, as well as nonhealth‐care policies that are also necessary to decrease barriers to health care (e.g., interventions to allow undocumented immigrants access to driver's licenses or fair immigration reform that includes a path to citizenship). ⁶ , ¹⁹ , ²⁰ Other recommendations include improved enforcement of existing health‐care laws and existing labor laws and protection of immigrant workers' right to organize ⁶ , ¹⁵ ; providing insurance options through the state to undocumented immigrants and/or full insurance benefits to employees regardless of their status ⁸ , ²⁰ , ²¹ , ²² , ²³ ; increasing the capacity of safety net providers to serve the population and receive reimbursement for additional services, like medical interpretation or referral to social services ⁷ , ⁸ , ¹⁸ , ²³ ; and providing immigrants linguistically appropriate information on how to navigate the health‐care system and on rights afforded to undocumented immigrants. ⁸ , ²²

Within the health‐care system, eliminating health‐care inequities in quality of care for immigrants will require an examination of the institutional policies and practices that limit immigrants' rights, resources, and sense of security. ⁶ Understanding the many sources of health‐care disparities for immigrants within the health system can guide quality improvement interventions to eliminate these disparities. These goals can only be accomplished through multilevel quality improvement strategies that engage health‐care organizations, patients, providers, and communities. ¹³ Putting immigrant communities at the center of change efforts by elevating their lived experiences, expertise, and leadership through collaboration and participation is necessary not only to understand their needs better but also to identify and build on their strengths. ²⁴ Participatory and collaborative planning of research and interventions can increase the relevance, effectiveness, and sustainability of interventions by tailoring strategies and programs to the needs and realities of specific immigrant communities and local health systems. ⁶ , ¹⁸

Such participation and collaboration are highly consonant with a community power‐building model, which serves as the foundation of this study. Community organizing is based on the belief that our world is based on relationships between people, organizations, and institutions, and that these relationships reflect a massive power differential that leads to systemic oppression. ²⁵ This power differential is created and reinforced by laws, policies, and practices, which community power‐building organizations aim to change in order to realize more equitable institutions. ²⁶ Community organizing theory posits that non‐traditional power is generated through organized people, organized ideas, and organized money. ²⁶ Power building is defined as “the set of strategies used by communities most impacted by structural inequity to develop, sustain and grow an organized base of people who act together through democratic structures to set agendas, shift public discourse, influence who makes decisions and cultivate ongoing relationships of mutual accountability with decision‐makers that change systems and advance health equity.” ²⁵ As such, this approach relies on building a broad base of organized people aligned around common values, priorities, and demands that will become a significant voice of change. Importantly, successful power‐building organizations have the unique ability to build deep relationships with a constituency of historically marginalized or underrepresented community members. To be most successful in advancing structural and policy changes, these relationships need to be “independent (meaning the constituency can spring into action without a donor giving the organization resources to activate it), committed (meaning the constituency is loyal to the organization and to each other), and flexible (meaning the constituency will shift with the organization even as the political choices and terrain shift).” ²⁷

Notably, this community power‐building approach differs from typical processes that are dominant in both research and health system transformation efforts. ²⁸ , ²⁹ Typically, even in projects with the best community engagement structures, institutions hold power over community members because they are responsible for collecting data from community members, analyzing that data, and designing interventions based on what the data and community say. ³⁰ The result of this arrangement is often token‐level engagement and interventions that might not align closely with the affected population's most pressing needs. A community power building approach flips this power dynamic by building power in the community first and engaging research, political, and health‐care systems from that place of power to effect change.

The work described here is the result of a collaborative research partnership led by the Center for Health Progress (CHP), a statewide organization in Colorado. CHP is a community power‐building organization that advances structural and policy changes with a number of communities across the state to improve health equity by understanding its root causes and concentrating resources where needs are greatest. CHP works with community members who are directly impacted by health inequities, including immigrants, people of color, rural Coloradans, and people living in poverty. CHP has community organizers on the ground in Fort Morgan, a rural community on the Eastern Plains, and in Pueblo, a small urban center in Southern Colorado.

The objective of this study was to assess and address the health‐care needs of Coloradan immigrant populations, using a community power building approach rooted in these constituencies. The research questions guiding our work were: (1) What are the health‐care needs of immigrant populations in Colorado communities, and how are these shaped and impeded by social and structural factors? (2) Can approaching data collection and engagement through a community power building approach serve as an effective method to identify and address social and structural barriers to health care?

2. METHODS

Our research sought to determine the health‐care needs of the immigrant population in Colorado, using Morgan County (MC) and Pueblo, CO, as representative immigrant communities in the state. These communities have large populations of the immigrant subpopulations most common in Colorado, including immigrants born in Mexico, Central America, and East Africa, with the exception of immigrants born in Asia. ³¹ Fort Morgan, the MC county seat, is a rural town (pop. 11,000) that has a majority population of people of color, with a large Latinx immigrant community, and more recently arrived refugees from African countries. Pueblo is a larger community (pop. 113,000) with a majority Latinx‐ and Indigenous‐identified population and a significant influx of new Latinx immigrants. Many of the immigrants in both communities are undocumented and/or from families of mixed‐documentation status, making them particularly difficult to access through typical recruitment efforts. These communities were chosen because of the existence of strong, immigrant CHP constituencies in both communities, as well as CHP's long‐standing commitment and community power building work in both locations.

To conduct this work, we utilized a mixed‐methods, community power building approach that centered on the leadership of CHP's constituencies. The study was approved by the Migrant Clinicians Network Institutional Review Board. The phases of data collection and their relevant characteristics are presented in Table 1. The first stage of data collection occurred in June through September 2019, prior to the onset of the COVID‐19 pandemic. During this period, we interviewed 47 members of the Latinx and Somali immigrant population in MC. A semi‐structured interview guide was used to facilitate each interview, which explored interviewees' health‐care access needs and barriers, experiences receiving health care, and aspects of health care needing improvement. All interviews were conducted in person and on location by MC CHP‐affiliated community leaders trained in qualitative methods and were conducted in interviewees' language of preference (English, Somali, or Spanish). Interviewees received $20 as a financial incentive for participation. Each interview lasted approximately 45–60 min. All were digitally recorded and transcribed verbatim; Somali and Spanish language recordings were transcribed in their original language and then translated to English prior to analysis.

TABLE 1.

Phases of data collection

Data collection focus and sample	Community leaders' involvement	Findings Dissemination
June–September 2019. Key informant interviews to explore health‐care access needs and barriers, experiences receiving health care, and aspects of health care in need of improvement (47 Latinx and Somali immigrants in Morgan County ‐MC)	Center for Health Progress (CHP)‐affiliated community leaders (Caracoles) were introduced to the project and agreed to its purpose and content of the interview guide Caracoles and CHP‐Community Organizers (COs) received human subjects and data collection training CHP‐COs coordinated data collection locally Caracoles conducted interviews	Researchers analyzed interview results Researchers presented findings in a community meeting to receive feedback (December 2019) CHP‐COs conducted presentations at house meetings hosted by Caracoles and other community members in January–February 2020, with the purpose of identifying priorities for action from baseline interview findings
March 25, 2020: Stay at home order was mandated in Colorado. House meetings were suspended, and CHP‐COs launched a phone tree effort to keep communications active with immigrants and ascertain their needs regarding COVID‐19
March–April 2020. Phone Tree Round 1. Identify urgent needs due to COVID (access to food, ability to pay rent, access to COVID testing). (MC = 39, PC =58).	For each phone tree round: CHP‐COs coordinated data collection locally CHP‐COs trained Caracoles on conducting the phone tree, and how to guide immigrants in need of resources (e.g., cash and rent assistance) Caracoles conducted phone tree calls to collect data, reaching out to members of their networks, as well as referrals, and established bidirectional communication with immigrants in their phone tree	For each phone tree round: Researchers analyzed data collected through the phone tree questionnaire and provided a summary to CHP‐COs in English and Spanish CHP‐COs shared results with Caracoles and CHP Policy team, which iteratively shared findings with the Colorado Medicaid agency Throughout the data collection process, Caracoles continued receiving leadership training, and topic‐specific training about public health measures to mitigate COVID, access to health services, and vaccination information, among other topics
April–June 2020. Phone Tree Round 2. Access to COVID information (mitigation, testing, and treatment); access to health insurance/treatment; and access to paid leave. (MC =15, PC = 34)
July–September 2020. Phone Tree Round 3. Feelings and concerns about the ongoing pandemic and how health systems can help; and Census 2020 participation. (MC = 26, PC = 65)
November–December 2020. Phone Tree Round 4. Affordability and accessibility of prescription medicines and contraception; housing concerns, access to professional licenses; and 2020 election participation. (MC =26, PC = 67)

Analysis occurred in an iterative and team‐based process involving established qualitative content methods and reflexive team analysis. ³² , ³³ Interview transcripts were independently read multiple times by two members of the study team in order to achieve immersion prior to code development. Codes were derived inductively, then independently applied by each analyst to 10% of the transcripts. Inter‐coder reliability was then assessed, disagreements were resolved through in‐depth discussion and negotiated consensus, and the remaining transcripts were each coded by one analyst using the final coding schema. ³⁴ Throughout the analytic process, team members met regularly to discuss emergent codes and themes and assess the preliminary results. ³⁵ The qualitative data software program ATLAS.ti v7.0 was used for data organization and management. Following analysis, the results were presented to community members in a series of “house meetings” for discussion.

The second stage of data collection occurred during the COVID‐19 pandemic (see Table 1). During this period, assessing immigrants' health‐care needs became even more urgent. When social distancing requirements necessitated a strategy shift, we utilized a phone tree outreach approach to keep communication active with immigrants and ascertain their needs regarding COVID‐19, health‐care access, and 2021 policies needed for an inclusive and equitable recovery in Colorado. From March through December 2020, primary data were collected from 330 immigrants in both MC and Pueblo through four rounds of a novel phone tree approach. Almost immediately after the pandemic began, CHP staff Community Organizers (COs) in these communities invited a group of 18 community leaders (Caracoles) with whom they had previously worked on organizing efforts into ongoing collaborative power building with CHP. As part of that work, each Caracol then reached out to up to 10 members of the immigrant community to interview by telephone (see Figure 1).

FIGURE 1.

Phone tree structure

Community participants were identified through various mechanisms, including formal snowball sampling and direct outreach among individuals who were seeking immediate relief like food assistance. Caracoles used a questionnaire specifically designed by CHP and the research team for each round of the phone tree. The questionnaires were available in English and Spanish; most participants chose to answer in Spanish. The questionnaires typically consisted of closed‐ended questions (yes/no or multiple‐choice responses). Rounds 1 and 3 also included several open‐ended questions with responses captured in writing by the Caracoles. Analysis proceeded as described above and was undertaken after each round.

3. RESULTS

3.1. Interview data from Morgan County

Demographic characteristics of the 47 MC interviewees are presented in Table 2. Self‐reported health status and care characteristics are presented in Table 3. The themes that emerged from these interviews are summarized in Table 4.

TABLE 2.

Characteristics of Morgan County interviewees

	Latin America (n = 34)	Africa (n = 13)	Total (n = 47)
Age in years (average)	40	36	39
Age in years at arrival to the US (average)	25	29	26
Male (%)	18%	54%	28%
Birthplace
Mexico	79%	0%	57%
Central America a	15%	0%	11%
Somalia	0%	69%	19%
Other African country b	0%	31%	9%
Did not respond	6%	0%	4%
Years living in US (average)	16	7	14
Years living in US (range)	(1–30)	(1–19)	(1–30)
Employed (%)	59%	85%	66%
Meatpacking plant	15%	73%	35%
Farm	10%	0%	6%
Construction	10%	0%	6%
Service (e.g., cleaning, nursing home)	35%	9%	26%
Office‐based	30%	18%	26%
Housing (%)
Owns house	21%	0%	16%
Rents house	12%	27%	16%
Rents apartment	15%	73%	30%
Owns mobile home	27%	0%	20%
Rents mobile home	18%	0%	14%
Employer housing	6%	0%	5%
Owns a car (%)	88%	92%	89%
Number of household members (average)	4	5	4
Number of household members (range)	(2–7)	(2–7)	(2–7)
Living with family (%)	97%	77%	91%
Education
Less than elementary	9%	8%	9%
Elementary	21%	8%	17%
Less than 12th	12%	33%	17%
High school	26%	33%	28%
More than HS	15%	8%	13%
College	18%	8%	15%

^a Four participants were born in Guatemala and 1 in El Salvador.

^b A few participants who identified as Somali were born in other African countries: Two were born in Kenya, one of them specified he was born in a refugee camp, one was born in Ethiopia, and one in South Africa.

TABLE 3.

Self‐reported health status and care characteristics of Morgan County interviewees

	Latin America (n = 34)	Africa (n = 13)	Total (n = 47)
Current health
Very good	3%	15%	6%
Good	56%	77%	62%
Fair	29%	8%	23%
Poor	12%	0%	9%
Migratory status affects access to health care
Yes	56%	0%	40%
No	38%	62%	45%
Sometimes	6%	8%	6%
No response	0%	31%	9%
Health insurance
Private	18%	77%	34%
Public	9%	15%	11%
Uninsured	74%	8%	55%
Health care provider a
Local FQHC	74%	77%	74%
Private clinic	15%	0%	11%
Local hospital	6%	38%	15%
Emergency department	6%	0%	4%
Employer based clinic	3%	8%	4%
Only dental care	3%	0%	2%

^a Participants mentioned more than one place; percentages add to more than 100%.

TABLE 4.

Themes from data collection and policy or regulatory changes realized

Themes from key informant interviews	Themes from phone tree data collection (rounds 2 and 3)	Policy or regulatory changes realized
Health‐care barriers Health‐care affordability Lack of insurance High costs of services Lack of affordability even with employer‐based insurance Additional costs, particularly when receiving services out of town (e.g., transportation, childcare, food) Health‐care experiences Lack of timely access to services Long waits in waiting and exam rooms Other barriers: lack of transportation, limited service hours Health‐care experiences as immigrants Being treated differently because they are uninsured or because staff are rude and racist Lack of access to interpretation services or distrust of accuracy of interpretation Feeling of not receiving complete information from health‐care staff Health‐care improvements needed Health‐care programs for immigrants Government has affordable insurance options for immigrants Employer ‐based programs are more affordable Health‐care structure Additional health‐care facilities; more doctors and staff More access to specialists in town (e.g., diagnostic services, dental, vision, mental health services) Health‐care processes Better trained staff Bilingual and/or Latinx doctors Receive more frequent and better information about the disease, prevention, and well‐being; and about payment options or other resources for the uninsured	Health‐care barriers Health‐care affordability Lack of insurance High costs of services Lack of affordability even with employer‐based insurance Health Information sources Variety of COVID information sources (e.g., TV news, social medical, friends) Health‐care system perceived as an ideal source to look for COVID or health‐related information Health‐care improvements during COVID emergency Access to health insurance More accessible and affordable health services More humane treatment and in‐person Immigrants have access to more and adequate information about the disease and how to access care	Health‐care improvements during COVID emergency Access to insurance through Emergency Medicaid State Medicaid agency issued a clarification about Emergency Medicaid policy for COVID‐related care to include coverage of COVID‐19 testing, evaluation, and treatment under EM, all low‐income individuals, regardless of immigration status, would have COVID‐19 services covered under EM. Increased community relevance of EM policy through a regular feedback loop with state leaders and CHP, leading to further rule clarifications over time. Access to more and adequate information CHP monitored the implementation of EM policy, developed educational materials for use by outreach workers, clinics, and immigrants to spread clear information about the EM changes. Community materials and EM information guide was developed for immigrants and their families in English and Spanish. A similar guide for health‐care providers was also developed.

More than half (57%) of participants identified health‐care costs as a barrier to accessing health care. In a separate question, 20% identified it as one of the most important of such barriers.

“Imagine, very stressed out, because in addition of being sick, you need to be thinking on how much you have to pay for the visit, the medication, otherwise you won't get it, in addition of being sick you get more stressed and get sicker.” (Latinx Immigrant)

Many (54%) participants reported at least one significant health‐care‐related cost beyond those for services, exams, and medications. For example, 43% of participants reported expenses related to having to travel out of town to receive care, including the cost of transportation, meals, and childcare. Even when travel out of town was not necessary, approximately 17% of participants still needed to pay for childcare in order to receive health services. A few participants (3%) also mentioned the cost of missing work to attend appointments. An additional 4% also explicitly noted that cost‐related concerns were made more difficult because of the inability to know in advance the final cost of services (e.g., consultations, exams, and medication), regardless of insurance status.

Many participants (49%) indicated that they received good treatment when receiving health services.

“Well they're very friendly, they've known me for quite some time and so we have built relationships, they even ask about my personal life and overall wellbeing.” (Somali Immigrant)

However, many (40%) also reported problems related to bad treatment from the health‐care system. Experiences of mistreatment varied. Participants mentioned racist and discriminatory staff members (26%); poor and limited translation services (16%); and the perceptions that they were not given adequate information (21%), were not fully seen as people (16%), were treated poorly in general (16%), and/or that staff gave preference to people with insurance (11%).

“… sometimes they discriminate against people because of their color, which has already happened to me … one of my daughters was discriminated against, because we went to a check‐up that was teeth. I asked for the price and they said it was very expensive, not knowing that my daughter has medical coverage, just because they look at her brown color.” (Latinx Immigrant)

Participants reported many ways in which the health‐care system could provide better services for immigrants. The first group of actions for improvements was related to the structure of the health‐care system. Participants reported the need of employing more doctors and staff so that the waiting times for appointments and in the waiting or exam room could be reduced (82%); the need for access to specialists located in closer geographic proximity (53%); and the need for more time with their providers (19%).

“Well, to have more doctors, or more … for example an X‐ray, or other types of exams, that we do not have, so we are not traveling further …” (Latinx Immigrant)

The second group of actions for improvement was related to processes. Participants reported that it would be helpful if the health‐care system communicated more frequently and provided better information not only about their condition, treatment, and medication during the visit (17%) but also about how to stay well and maintain their health (18%) and also about the variety of services offered and payment and insurance coverage options (32%).

“… [We want] someone informing the people about the options, where we can get medical assistance.” (Latinx Immigrant)

Approximately 82% of participants also reported the need for access to more affordable health‐care services and having access to insurance coverage.

“They should try and make health care more accessible since not everyone has the money to go see a doctor. If there were more discount services, or if the government did something about it.” (Latinx Immigrant)

“I just want the insurance policy changed; we have [employer's coverage] so we are not able to access a lot of services … it is up to the government since they decided how to make the insurance, they made Medicaid affordable so maybe they can do the same to company insurance.” (Somali Immigrant)

A final group of suggested actions for improvement related specifically to the treatment of immigrants within the health‐care system. Participants reported the need for more bilingual doctors and more interpreters at the site, including those speaking languages other than Spanish (70%); and the need to employ staff who treat everyone equally and do not treat immigrants like “second‐class citizens” (66%).

“In case of an emergency, I could go to the clinic instead of going to the hospital. They treat you better there, and they speak your language.” (Latinx Immigrant)

3.2. Phone tree data from Morgan and Pueblo Counties

We engaged in four rounds of phone tree data collection. The topics for each phone tree round and number of people reached in each locality are presented in Table 1. In total, we reached 208 unique immigrants in Morgan and Pueblo Counties (MC = 76, PC = 132) over 330 phone interviews.

3.2.1. Phone tree round 1 (March–April 2020)

At the beginning of the COVID‐19 pandemic, immigrants who participated in the phone tree reported significant basic needs driven by complete loss of income or reduction of work hours (60% MC, 34% PC). Phone tree participants reported insufficient funds to cover rent (21% MC, 32% PC) and food insecurity (18% MC, 34% PC). Many respondents reported emotional (46% MC, 48% PC), financial (37% MC, 48% PC), and health impacts (17% MC, 5% PC), even when at the time none of the respondents had been sick themselves or their families with COVID‐19.

“My husband was deported in November and left me alone … Our financial status is not good because we all lost our job and I, as the head of the house, have to pay the rent, the bills, the food and we live day to day and now only I am here … I need my partner to help and we are undocumented, it's difficult sometimes we've had 2 or 3 jobs, but now although even if I wanted one, there isn't one really.”

3.2.2. Phone tree round 2 (April–June 2020)

Sixteen percent of phone tree participants had health insurance (20% MC, 15% PC). Those who did not have health insurance relied on the local Federally Qualified Health Center's (FQHC's) discount to receive health services. Participants also reported that other members in their household, usually their children, had Medicaid (53% MC, 38% PC). Even when some of them had employer‐based insurance, respondents reported concerns related to cost, whether because co‐pays or deductibles are very high or because their insurance did not cover all medications. 63% of MC and 51% of PC respondents did not feel confident about their ability to cover additional medical expenses.

Overall, 75% of phone tree participants (53% MC, 82% PC) reported that their health‐care system/doctor did not reach out to them to provide information regarding how to stay healthy during the pandemic. The main sources of information regarding COVID‐19 for participants in the two communities were TV news (80% MC, 59% PC) and social media (40% MC, 53% PC). Other mentions in order of importance were community organizations and Churches, friends and family, and their doctor or clinic.

Phone tree participants also reported who they would call if they needed more or specific information related to COVID‐19. Forty‐seven percent of participants in MC and 44% in PC responded they would call their clinic/health‐care system. Others would reach out to a community organization or their Church (40% MC, 21% PC). Other sources of information to reach out were family and friends (20% MC, 18% PC) and Internet and Social Media (13% MC, 9% PC).

Seven percent of phone tree participants reported access to paid family leave in MC and 9% in PC. The few community members who reported having access to paid family leave reported they had not used the benefit, and one indicated not to be sure how it worked.

3.2.3. Phone tree round 3 (July–September 2020)

Forty‐five percent of phone tree participants reported that their main concern about the pandemic was getting sick, particularly their children (28% MC, 53% PC). The second most frequent concern was losing their job (21% MC, 15% PC). Other concerns due to the pandemic were children's education, lack of medical insurance, lacking access to adequate information, being an undocumented immigrant, and the uncertainty and seemingly endless nature of the pandemic.

In Pueblo County, 22% of participants mentioned that having more information, whether about the disease itself or about mitigation measures, was the most important thing the health system could do to help with their concerns about COVID‐19. Seventeen percent reported that health systems could have more supplies, medications, or doctors and staff.

In MC, 19% responded that having access to insurance was the most important thing that health systems could do about COVID‐19. Other frequent responses were having medical services that were accessible and affordable (12%); and providing services that were more humane and personal (9%).

“As an undocumented immigrant I would say something that could help is if the health care system would come up with a form of insurance or payment that is not expensive for us to seek care as well.” (MC participant)

3.2.4. Phone tree round 4 (November–December 2020)

Phone tree participants overall (41%) reported that they were able to pay up to $50 dollars monthly to receive health‐care services. In MC, 23% of participants reported that they were able to pay up to $100 dollars monthly for health‐care services. Regarding prescription medication expenses, participants reported that they would be able to pay up to $50 dollars per month (23% MC, 56% PC). Additional data collected in this round are not reported here because they are not directly related to health care (e.g., participation in the 2020 election).

3.3. Application to state policy change

These data were then utilized to directly inform state policy change around current needs articulated by impacted communities. In March and April 2020, we confirmed through the phone tree data that lack of health insurance and fear over health‐care costs was a leading concern among immigrant communities in Colorado and a primary barrier to seeking health‐care services to manage or prevent COVID‐19. These data determined CHP's policy advocacy priorities and set in motion a campaign to find policy solutions to expand health insurance coverage for undocumented immigrants seeking COVID‐19 related care.

Building on a previous policy analysis by CHP and partners, which resulted in expanded Emergency Medicaid for standard outpatient dialysis in 2019, and CHP's ongoing relationship building with the Colorado Governor's office and the Colorado Department of Health‐Care Policy and Financing (HCPF), the office which administers state Medicaid, CHP began communicating with a small coalition of organizations to collectively push HCPF to allow EM for COVID‐19 related hospital services. Beginning in March 2020, several states, including Pennsylvania, New York, Washington, and California,³⁶ issued Medicaid updates to include coverage of COVID‐19 testing, evaluation, and treatment under Emergency Medicaid. These updates meant that all low‐income individuals, regardless of immigration status, would have COVID‐19 services covered under EM. CHP then communicated with HCPF leadership numerous times, including providing technical analysis around EM, policy language from other states, and data from immigrants in MC and PC. In June 2020, HCPF issued a clarification about its EM policy for COVID‐related care. The agency stated that: (1) many symptoms and complications due to COVID‐19 might be considered emergency medical conditions and (2) that people eligible for EM can receive services to treat it, including other medically necessary interventions to treat the emergency medical condition to prevent emergent readmission to a hospital, including certain outpatient treatments after discharge as well.

After the EM rule clarification, CHP monitored the implementation of this policy in Colorado and developed educational materials for use by outreach workers, clinics, and immigrants to help spread clear information about the EM changes. Informed by data gathered through community outreach, CHP developed implementation questions for the state to answer (e.g., if a person is treated for COVID symptoms but tests negative). In October 2020, HCPF provided additional clarification about its EM policy, answering how EM is actually accessed in the community. Community materials were then updated with those clarifications. An EM information guide was developed for immigrants and their families in English and Spanish to share this information. A similar guide for health‐care providers was also developed.

4. DISCUSSION

Immigrants living in rural and/or underserved communities are particularly marginalized by the health‐care system, and those who are undocumented and/or from mixed‐documentation status families face additional barriers to access. In the face of a pandemic like COVID‐19, inequities in coverage and reach are further exacerbated, leaving the needs of this marginalized population difficult to determine or address. ¹⁴ Rapid data collection grounded in a community power‐building approach produced data that enabled the identification of health and social needs. Importantly, the embeddedness of this research in a community power building model also enabled immediate action and an increased base of independent, committed, and flexible power that helped realize policy change. The results of the data collection allowed COs to not only identify but also advocate for and address urgent needs.

The data resulting from this study underscore the significant health‐care needs of immigrant populations and highlight the urgency of response, particularly in the face of a population‐level emergency such as the COVID‐19 pandemic. In such public health emergencies, health inequities for marginalized populations are further exacerbated. The community power‐building approach that we used to engage and access community members demonstrates its effectiveness in (1) enabling direct connection to communities affected by potential policy changes, while simultaneously (2) building collective policy analysis and capacity of community members and (3) laying pathways to translation and implementation of research into policy. We believe that more top‐down policy advocacy organizations must make this shift due to the limitations in their approach and the continual passage of legislation that has unintended consequences due to being disconnected from the lived experiences of those most affected by the issues.

This study intentionally focused on two immigrant communities in Colorado in order to achieve both breadth and depth within our specified universe and to enact targeted, meaningful change. Rapid data collection and analysis were critical for a timely response to our research questions. We expect that this work will contribute to generalizable knowledge in at least two ways: (1) By facilitating insights about immigrants' health‐care needs, which can then be investigated in additional communities and populations, and (2) by providing evidence of the effectiveness of a community power building approach to address social and structural barriers to immigrants' health care. We hope that our research will facilitate the smart scaling of these methods and strategies to other states.

CONFLICTS OF INTEREST

We have no financial conflicts of interest to disclose.

Albright K, de Jesus Diaz Perez M, Trujillo T, Beascochea Y, Sammen J. Addressing health care needs of Colorado immigrants using a community power building approach. Health Serv Res. 2022;57(Suppl. 1):111‐121. doi: 10.1111/1475-6773.13933