On a blustery January morning, Leslie Bachurski is at Northern Area Multi Service’s offices in Sharpsburg. Bachurski, a health care navigator, is at the resettlement agency to help non-English speaking refugees enroll in health insurance plans.
Her first client of the day is Birkha Tamang, a 42-year-old Bhutanese refugee who has been in the United States for 16 months with his wife and kids. He’s the only one in his family with a job — and the only one without health care coverage.
Using a Nepali interpreter, Tamang shares paystubs with Bachurski. After discussion and calculations, Bachurski estimates that Tamang earns just a little too much.
"Sadly, since we don’t have medical assistance expansion here, we’d be looking at the rates at full cost, so an insurance plan is likely going to cost him $200 and up," she told the interpreter, who takes a long pause before telling the hopeful-looking Tamang the deflating news.
The first few months of a refugee’s life in the U.S. are filled with new experiences. And with doctor’s visits. All that initial care is covered by medical assistance. But when that coverage ends, refugees may still have outstanding health issues and no way to pay for them.
Gov. Tom Corbett isn’t expanding Medicaid in Pennsylvania this year. It’s estimated that there are more than 600,000 people who could benefit from the Medicaid expansion, but for people like Tamang who face a disappointing reality, even the cheapest insurance plan would still cost him too much.
He has rent, gas and electric bills to pay for, as well as the costs of supporting a family of four. And in addition to those bills, there are other things he would like as well. He needs a phone to be able to call home, but that means his wife at home needs a phone, too. Right now, they can only afford one.
Tamang leaves and the next appointment, a young Bhutanese couple, enters the office Bachurski's using. They, too, fail to qualify for a subsidy, and they don’t commit to a plan, either. They leave with pamphlets for free health care clinics in the area.
Navigators say many refugees fall in this gap. Already uninsured, without Medicaid expansion, they will stay uninsured. Some won’t be penalized, while others will just pay the penalty.
New Home, New Struggles
Mira Chhetri knows all too well the perils of being uninsured. Chhetri came to the U.S. with her husband a couple years ago. The 23-year-old spent most of her life in refugee camps in Nepal.
In her first few months here, she had ovarian cysts removed. The procedure was expensive, but like all of her health care needs at the time, it was covered by federal refugee medical assistance.
All refugees have health care coverage for the first eight months they are in the U.S. But when the eight months are over, if they don’t qualify for Medicaid or disability or have a job that provides them health care, they are at a loss.
"After 8 months they are like any poor American, low-income American," said Leslie Aizenman, who runs Refugee Services at Jewish Family and Children’s Services, one of the four local agencies tasked with acclimating new refugees to Pittsburgh.
After their medical assistance ended, Chhetri and her husband were uninsured. They both made just above minimum — too much to qualify for Medicaid. Chhetri still had pending surgeries.
"I know I already have cysts in my ovary, and that’s why I have pain. I know that," she said.
According to Aizenman, during those first eight months, problems can be diagnosed and treatment can be started.
"A lot of these people were without health care their entire lives or certainly in the refugee camps, and not all of their health needs have been met in the last 8 months," she said.
The State Department issues guidelines for what the resettlement agencies have to provide refugees. But when it comes to health care, Aizenman said it’s open to interpretation.
"As regarding medical care there are three sentences about what we must do for newly arriving refugees," she said.
What they have to do is ensure they get an entry physical in the first 30 days, and they have to address acute medical issues.
In Pennsylvania, before 2009, there wasn’t even a standardized physical exam. Physicians generally just checked for tuberculosis and parasites and sexually transmitted diseases. They also made sure that refugees got immunizations.
But in 2009, the Pennsylvania Department of Health looked at what other states were doing and created a standardized screening exam. Pennsylvania’s was modeled on Minnesota’s. In the last two years, a mental health component has been added.
Even with mental health questions on the questionnaire, however, newly arrived refugees may answer questions the way they believe caseworkers or doctors want them to answer them. That means that caseworkers may not identify mental health problems until it is too late for the refugees to begin treatment under their initial health coverage.
Serious problems will eventually present themselves, said Barbara Murock, who works for Allegheny County’s Department of Human Services.
"We find that frequently refugees will be here in the beginning, and they might not exhibit any symptoms," she said. "But I always say when they exhale around after six months after they are settled in, that’s when the behavioral health symptoms might start becoming apparent with people."
By then, they are at the end of their health coverage.
Even With Care, It's Just Not Enough
In 2010, the Squirrel Hill Health Center entered into agreement with the state Department of Health and started serving larger numbers of refugees.
On a recent January morning, Alla Puchinsky was in her cramped office at one of the resettlement agencies, Jewish Family and Children’s Services. Puchinsky came to Pittsburgh as a refugee from Russia in the early '90s. Now she is a refugee case manager.
One of her biggest challenges, she said, is helping refugees after their health benefits end.
"It’s a huge problem after 8 months," she said.
On this particular morning, she’s helping out a young family who has been here from Iraq for four days.
She’s preparing to bring the family to the Squirrel Hill Health Center for their first physical.
Doctors at the center say that when refugees come with scant medical history and not much prior health care, it takes a while to diagnosis people. It also takes a lot of case management to get them on a health care regiment, which then becomes more complicated when they are uninsured.
In Mira Chhetri’s case, in the last couple years, she and her husband have moved in and out of jobs, obtaining and losing health insurance along the way.
Along with her outstanding physical pain, in February, while she was uninsured, she attempted suicide. She spent a few days at Western Psychiatric Institute and Clinic. Then, she received a bill for more than $8,000 in care.
"Again, I’m depressed, like how can I pay this much money," she said.
Chhetri’s employment caseworker at Northern Area Multi-Service Area found a University of Pittsburgh Medical Center program that forgave all but $2,000. The rest Chhetri is paying in an installment plan — still costly for her on a low-income salary.
Since Mira Chhetri’s hospitalization, both she and her husband have jobs that provide them health insurance. Even so, she says the co-pays for doctor’s visits and specialty services such as MRIs are too high for the care she needs, especially now that she’s paying back hospital bills, her travel loan to the state department and the rest of her other bills.
She’s been putting off visits and exams because she knows she will have to address her physical pain. And when her doctors call to check in, she just tells them she is OK.
"I lied to my doctor," she said, "because I don’t have enough money."
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This project results from the Reporting On Health Collaborative, which involves 90.5 WESA, Mundo Hispánico in Atlanta, New America Media in California and New York, Radio Bilingüe in Oakland, Univision Los Angeles (KMEX 34); Univision Arizona (KTVW 33), and ReportingonHealth.org. The Collaborative is an initiative of The California Endowment Health Journalism Fellowships at the University of Southern California’s Annenberg School for Communication and Journalism.
Read more from the Living in the Shadows project.