The Patient Protection and Affordable Care Act offers many benefits and protections to consumers of health care services.1 Coverage, however, is limited to U.S. citizens and foreign-born individuals with certain immigration status.2 Some immigrant consumers cannot take advantage of the Act’s benefits due to language, culture, and other barriers. Worse, unscrupulous agents may use these barriers to scam naive immigrant consumers. Here I discuss some of the health care scams found in immigrant communities—specifically how the Act may affect immigrant consumers as it relates to deceptive practices.
Immigrant Consumers in the United States
The United States is often referred to as a “nation of immigrants.”3 Currently about 40 million foreign-born individuals are in residence.4 One in eight Americans, and one in six American workers, are foreign-born.5 Immigrants are a large and significant subset of our population.
Origin and Diversity
Today’s immigrants come from all over the world and are very diverse. Recent U.S. immigration has been dominated by individuals from Latin America and Asia.6 Of the total foreign-born population, 53 percent originate from Latin America, and 29 percent from Asia.7 Latinos have become the largest minority group.8 Asian Americans are the fastest growing racial group.9 And 12 percent of foreign-born individuals originate from Europe, and 4 percent from Africa.10
Although the Affordable Care Act is expected to result in many consumer protections and benefits, it presents many opportunities for scams on immigrant consumers.
There is great diversity within each continent of origin. For example, Korean-born immigrants and Indian-born immigrants are both categorized as “Asian” despite significant differences in culture, language, and physical appearance. This diversity makes for both richness and difficulty in working with immigrant consumers.
Immigrants have varying status. They enter and reside in the United States through multiple channels. Ultimately some are given the opportunity to naturalize and become U.S. citizens. However, currently only 45 percent of total foreign-born residents are naturalized U.S. citizens.11 Because they are either unable or unwilling to become U.S. citizens, a majority of foreign-born individuals hold another form of immigrant legal status (e.g., legal permanent resident, refugee, asylee) or no authorized legal status at all.12 In fact, as of 2012, an estimated 11.7 million foreign-born residents were unauthorized and did not have legal status to reside and work in the United States.13 Because noncitizens have fewer legal rights than their U.S. citizen counterparts, a majority of immigrants live under greater scrutiny or hidden in the shadows of our informal economy.14 Confusion and fear related to immigration status contribute to the difficulty of reaching out to immigrant consumers.15
Confusion and fear related to immigration status contribute to the difficulty of reaching out to immigrant consumers.
Many immigrant consumers are not fully assimilated and operate outside the mainstream. They have greater affinity to languages and cultures from their countries of origin. This is because 63 percent of the foreign-born population entered the United States after 1990.16 Not surprisingly, 50.9 percent of foreign-born individuals speak English less than “very well,” and 84.6 percent speak a language other than English in their homes.17 Immigrants obtain information differently from English-speaking mainstream audiences. Of Hispanic immigrants, 31 percent report that they get news exclusively in Spanish.18 Asian-language media are also growing.19 Immigrants use media differently. For example, Latino immigrants face a digital divide, evidenced by their lower computer and Internet usage.20 Language, culture, and technology present barriers for many immigrants—barriers to receiving vital information for avoiding and reporting fraud.
Overall the foreign-born have lower educational attainment and household income compared to their native-born counterparts. The foreign-born population has lower rates of educational attainment at virtually every level.21 In fact, 31.3 percent of foreign-born individuals do not have a high school diploma.22 This is nearly three times the rate of nonattainment by the native-born population (10.6 percent).23 The foreign-born population lags behind the native-born population in household income. The average household income of the foreign-born ($47,420) is $5,000 lower than that of their native-born counterparts ($52,428).24 Lower levels of education and income put immigrants at a higher risk of becoming victims of consumer fraud.
Health Care Insurance Coverage
Of the foreign-born population, 72.1 percent are between the ages of 25 and 64 (80.4 percent are between 18 and 64).25 Although healthy working-age individuals are often sought for enrollment by health insurance companies, many immigrants do not have any insurance coverage. According to 2012 U.S. census estimates, 33.5 percent of foreign-born individuals had no health insurance coverage.26 The percentage of uninsured is as high as 48.2 percent for foreign-born individuals from Latin America.27 By comparison, only 12.3 percent of native-born individuals had no health insurance coverage.28 Immigrants are a large subset with a significant number of potential and desired health insurance consumers.
Health Care Options
Relatively new, complicated, and controversial, the Affordable Care Act attempts to reform our broken health care system. Among other ways, reform entails Medicaid expansion to cover low-income individuals in states opting for such expansion.29 Reform subsidizes health insurance for low-income individuals who do not qualify for Medicaid.30 Reform established marketplace exchanges where consumers can purchase health insurance at competitive rates.31 And reform penalizes covered consumers who fail to obtain health care insurance.32 Through subsidies and penalties, reform sets out to get every American covered with some form of basic health care insurance.33 The Affordable Care Act is now nearly fully in effect. Millions have enrolled and have health insurance for the first time. However, coverage under the Act is not universal and excludes many immigrants. Some implementation problems have affected immigrant enrollment.
Coverage and Immigration Status
Coverage under the Affordable Care Act is limited to U.S. citizens and lawfully present residents.34 Covered immigrants are generally eligible for subsidies and may be penalized for nonparticipation.35 The 11.7 million unauthorized immigrants are not covered and not eligible for subsidies or subject to penalties.36
The Affordable Care Act does nothing to improve health care options for unauthorized immigrants. Since all health insurance companies now participate in exchanges, unauthorized immigrants have a harder time finding affordable health insurance plans. Essentially they are locked out of personally purchasing affordable private health insurance. Unauthorized immigrants are still not eligible to participate in federal public health care or other safety net programs.37 And since unauthorized immigrants are not legally allowed to work in the United States, their employers do not likely give them health insurance. Unauthorized immigrants rely almost exclusively on emergency rooms and local clinics for their health care needs.38 The Affordable Care Act has minimal benefits for unauthorized immigrants.
The Affordable Care Act may not improve health care even for some authorized immigrants. A combination of legal status and length of residency determines whether a low-income foreign-born individual qualifies for federal public benefits programs.39 Even with subsidies, some very low-income immigrants cannot afford health insurance. And, because of immigration and residency requirements, they do not qualify for federal benefits either.40 Some low-income authorized immigrants are not any better off than their unauthorized counterparts.
Immigrants are especially susceptible to health care scams due to language, culture, and other barriers.
Overall the Affordable Care Act is expected to help millions of both native-born and foreign-born Americans obtain health care. However, since the Act covers only certain immigrants and does not expand public benefits eligibility to immigrants of varying status, many foreign-born individuals are still left without any health care coverage.
As of its deadline of March 31, 2014, the government exceeded its enrollment goals for the Affordable Care Act. Some 7.1 million people signed up.41 The government owes its success in part to its active outreach and multiple enrollment options. A consumer had the option to sign up in person, by phone, by mail, or online. Furthermore, enrollment services were advertised regularly and in multiple foreign languages.
However, there are problems. Many immigrants remain unaware of their obligations under a relatively new and complex law, particularly since the Affordable Care Act varies coverage with immigration status. Language and culture pose barriers to enrollment. For example, although enrollment services are available in multiple languages, they are not available in all languages and are not always provided effectively.42 Low educational attainment and computer literacy disadvantage many immigrants; many just do not have the reading skills or computer literacy to sign up on their own. And immigration status is a factor. Many immigrants belong to mixed-status households where some but not all household members qualify for coverage.43 Their status can add to the confusion on how families should enroll. Not surprisingly, immigrants lag behind in health insurance enrollment.44
Health Care Scams
Immigrants are especially susceptible to health care scams due to language, culture, and other barriers. Here are some of the health care scams that have been seen and that we expect to see in the immigrant community, especially in the context of the Affordable Care Act. While the Act does not necessarily increase or decrease fraud, scammers now likely use the confusion around the Act to defraud people.45
The Affordable Care Act is a new tool for affinity fraud, that is, scammers target members of an identifiable class or association (e.g., race, age, religion, social group). Scammers are often trusted by their victims because the scammers are also, or pretend to be, members of their victims’ class. Where cultural barriers can impede transfer of information, insider knowledge of a culture can expedite a transfer. Scammers with inside knowledge of an immigrant community can more easily convince immigrant consumers of false information and ultimately defraud them. Scammers may attempt to get immigrant consumers to purchase nonexistent services and subpar products or try to collect on products that they never sold. Indeed, there are already reports of fake websites selling fraudulent health insurance plans and scammers trying to peddle worthless insurance cards to consumers.46
Affinity fraud may be used to perpetrate identity theft. Enrollment under the Affordable Care Act requires submission of very sensitive and personal information, such as name, address, date of birth, and social security number. Scammers can use such information to open up fraudulent financial accounts or falsely assume an identity for other deceptive purposes.47 To perpetrate identity fraud, scammers may contact consumers under false pretenses. Scammers may offer free assistance or pretend to be an authority figure to elicit private personal information. For example, pretending to be from the U.S. Department of Health and Human Services or the Department of Homeland Security, they may cold-call immigrants to mine for personal data. Scammers may pretend that they need such sensitive information because of the Affordable Care Act. Naive consumers may unwittingly or fearfully give out their personal information and become victims of identity theft.
Notarios’ Unlicensed Practice of Law
Along the lines of affinity fraud, notarios may take advantage of immigrant consumers trying to purchase health insurance. Notarios in the United States often engage in the unlicensed practice of law within immigrant communities.48 They advertise a range of services—document translation, letter writing, tax preparation, and immigration assistance. Often their only qualification is that they speak some English and the language of their client victims. Many low-income immigrants turn to notarios because they are sometimes the only affordable alternative to expensive legal services from a licensed attorney. But even the most scrupulous notarios are not qualified, and malpractice is not uncommon. Unscrupulous notarios have been known to defraud their clients of money and, worse, leave their clients with dire legal consequences.49 Notarios may begin to offer their services to assist immigrant consumers in purchasing health insurance plans. If the past is any indication, notarios may even charge exorbitant fees to naive consumers for services that are actually free under the Affordable Care Act.50
Many uninsured low-income immigrants are increasingly turning to the unregulated medical sector for their primary care needs.
Unregulated Medical Care and Unlicensed Practice of Medicine
Many immigrant consumers continue to face danger associated with obtaining health care services from an unregulated industry. Uninsured immigrants combine regulated and unregulated medical services to meet their primary care needs. Since the Affordable Care Act does not cover unauthorized immigrants, this trend will likely continue.
Local and nonprofit clinics are the best, and sometimes the only, option for uninsured low-income immigrants seeking basic medical services. Most clinics offer free or low-cost primary care to low-income individuals, regardless of immigration status. Such clinics are often under state or federal oversight, and their quality of care is monitored. Due to such clinics’ limited resources and services, clinics are not a viable option for uninsured immigrants.
Many uninsured low-income immigrants are increasingly turning to the unregulated medical sector for their primary care needs. Growing numbers of “bodega clinicas” are appearing in largely immigrant neighborhoods.51 Despite their moniker, most bodega clinicas are not actually licensed clinics. Rather, they are unregulated private doctor’s offices operating on a cash-business model. While these bodega clinicas can be a valuable service to low-income uninsured immigrants, the level of care and service is largely unknown. With little regulation and no oversight, medical malpractice and other deceptive practices can easily escape detection.
Worse, some uninsured immigrants turn to unlicensed medical practitioners. Desperate for medical care, some uninsured immigrants seek services from individuals without any formal medical training or from practitioners who are not licensed to practice medicine in the United States. The Affordable Care Act does nothing to mitigate these risks for unauthorized immigrants and others unable to participate in its programs. Unable to afford health care, many immigrants continue to take great risks with their finances and health.52
Medical Debts and Unfair Debt Collection Practices
The Affordable Care Act does not alleviate immigrants’ medical debt problems. It still leaves many people unable to afford health care. Most unauthorized immigrants and many Medicaid-ineligible low-income immigrants will remain uninsured.
Uninsured low-income immigrants remain susceptible to bankruptcy, bad credit history, and unfair debt collection practices. Although hospitals are not allowed to refuse patients with emergency medical needs, patients are usually responsible for paying rendered medical services. Because medical treatments are very expensive, many uninsured immigrants are unable to pay and become indebted. People with significant debts risk ruining their credit history, further destabilizing their lives. Bankruptcy may be one of their few options.
Hospitals contract with collection agencies and attorneys to collect medical debts. Courtrooms are filled with such cases. Default and consent judgment are very common. Furthermore, these judgments often exceed the amount of the original debt because they include administrative fees such as court costs, interest rates, and attorney fees. These additional fees compound the difficulty of low-income individuals trying to pay back their debts. And while the Fair Debt Collection Practices Act protects consumers from unfair debt collection practices, violations are not uncommon.53
Immigrants are especially vulnerable as debtors. They often do not understand letters and documents sent to them in English. The court system is equally foreign to them. Cultural and language barriers prevent them from bargaining with creditors. And some unscrupulous debt collectors even illegally harass immigrant consumers with threats of jail or deportation. Because the Affordable Care Act leaves out a significant number of immigrants from its coverage, these practices will persist in immigrant communities.
Prevention and Remedies for Immigrant Victims of Health Care Scams
Although the Affordable Care Act is new, scams against immigrants are not. Scammers have already adapted their schemes to fit this new forum. But government agencies and nonprofit organizations are fighting back.
Outreach and Education
At the national level, AARP, the Centers for Medicare and Medicaid Services, the Federal Trade Commission (FTC), and others have released broad guidelines to help consumers protect themselves from fraud related to the Affordable Care Act.54 In fact, a consumer need look no farther than the Affordable Care Act’s own marketplace website to find information specifically related to fraud prevention.55 For those with limited English proficiency, similar official information is available in Spanish and other foreign languages.56
Although the Affordable Care Act is new, scams against immigrants are not. Scammers have already adapted their schemes to fit this new forum.
Local service providers and community organizers are reaching out and educating consumers at a more personal level. For example, navigators, in-person assistance personnel, and certified application counselors are locally based, certified professionals whose tasks, among others, are to inform consumers and dispel confusion around the Affordable Care Act.57 Often hosted by established local nonprofit entities, these certified professionals are quickly becoming trusted sources of information for local communities. Northern Virginia Family Service used its certified professionals to reach out to Latino, Korean, Vietnamese, and other immigrant communities. It did so by leveraging its connections with other trusted ethnic nonprofit entities and coordinating efforts among them. Fighting fire with fire, local knowledge, cultural understanding, and language abilities are often the best weapons to fight affinity fraud.
For the most part, Affordable Care Act fraud prevention efforts offer similar advice. First and foremost, all guidelines encourage consumers to stay aware and get their information from trusted sources. All point to the official marketplace website, HealthCare.gov, as the foremost trusted source of information. They encourage consumers to use HealthCare.gov to stay on top of basic information related to signing up, enrollment dates, telephone numbers, links to specific state exchanges, certified navigators, and other key information.58 Second, guidelines advise consumers to stay wary. Consumers are encouraged to probe and ask questions, especially consumers who receive unsolicited calls asking for money or personal information. Consumers should never pay, apart from monthly insurance premiums, for advice or enrollment. The FTC specifically warns against unsolicited calls from individuals holding themselves out to be insurance or government agents or offering Medicare cards and medical discount plans.59 These calls are almost certainly scams. And, third, as in any transaction, consumers should keep good records of their health care transactions. In the event of fraud, such information can be valuable to lawyers, law enforcement, and government agencies investigating the incident.
Ideally a consumer would identify, avoid, and report suspected fraud before any harm occurs. If that does not happen, the FTC advises victims of fraud to contact their local, state, or federal law enforcement agency or the appropriate state department of insurance. The FTC itself is an excellent place to start, and complaints can be reported to it at 1-877-FTC-HELP or ftc.gov/complaint.60 While individual victims may not always get relief through the FTC, their complaints can be used to track scams and help avoid fraud.
Although the Affordable Care Act is expected to result in many consumer protections and benefits, it presents many opportunities for scams on immigrant consumers. Without universal coverage for immigrants of all status, millions of mostly unauthorized immigrants continue to have poor or no health coverage. They continue to seek medical care from underregulated or unregulated sources to the detriment of personal and public health. They face mounting medical debts and associated negative consequences such as poor credit history, bankruptcy, and unfair collection practices. Even for those who are covered by the Affordable Care Act, the relative novelty and complexity of the law confuse many consumers, particularly immigrant consumers, who are generally less informed due to language, culture, and other barriers. Scammers who recognize these deficiencies may use their own language and cultural skills to deceive and defraud immigrant consumers. Affinity fraud, notariofraud, and identity theft are nothing new. However, the new law offers a new venue for scammers to use old tricks. While the Affordable Care Act is creating great changes for health care consumers, scammers are accommodating their deceptive practices to fit this new landscape.
Daniel Seokhwan Choi
Neighborhood Legal Services Program (DC)
680 Rhode Island Ave. NE
Washington, DC 20002
1 See Patient Protection and Affordable Care Act, Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by Health Care and Education Reconciliation Act of 2010, Pub. L. No. 111-152, 124 Stat. 1029 (2010). Some of the benefits are discussed in Kathleen Sebelius, Affordable Care Act at 3: Consumer Protections, White House Blog (March 18, 2013).
3 See, e.g., John F. Kennedy, A Nation of Immigrants (1964).
6 This modern trend results in part from the Immigration and Nationality Act Amendments of 1965, which abolished national-origin quotas heavily favoring Europeans (Pub. L. No. 89-236 (1965), 79 Stat. 911 (1968)).
7 See U.S. Census Bureau, supra note 4.
8 Id. (Table DP05—ACS Demographic and Housing Estimates: 2010–2012 American Community Survey 3-Year Estimates).
10 See U.S. Census Bureau, supra note 4.
12 Although the term “unauthorized” is used here, the terms “undocumented” and “illegal” to describe immigrants are also common.
14 Unauthorized immigrants are subject to deportation. Even authorized immigrants may lose the right to reside in the United States if they fail to maintain their immigration paperwork or are convicted of a crime.
15 Many immigrants come from countries where law enforcement is corrupt or ineffective. This fear carries over to the United States where many immigrants, especially those who face possible deportation, are reluctant to interact with law enforcement.
16 See U.S. Census Bureau, supra note 4 (Table B05005—Year of Entry by Nativity and Citizenship Status in the United States: Universe: Population Born Outside the United States: 2010–2012 American Community Survey 3-Year Estimates).
17 U.S. Census Bureau, supra note 4.
19 Asian media outlets grew 1,115 percent between 1999 and 2010 in the United States (Nielsen, State of the Asian American Consumer: Growing Market, Growing Impact 8 (2012)).
20 While the digital divide between Latinos and whites is shrinking, foreign-born Latinos still make up a majority of Latinos who are not using computers and the Internet (see Mark Hugo Lopez et al., Pew Hispanic Center, Closing the Digital Divide: Latinos and Technology Adoption 9, 11 (March 7, 2013)).
21 More foreign-born residents have graduate degrees than their native-born counterparts. However, native-born residents have a higher percentage in every other category of educational attainment (see U.S. Census Bureau, supra note 4).
29 Virtually all U.S. citizens under 65 with family income up to 133 percent of the federal poverty level now qualify for Medicaid in states that decide to expand the program. Childless adults and low-income parents used to be excluded from Medicaid coverage in most states (see Affordable Care Act § 2001 (codified as amended at 42 U.S.C. §§ 1396a, 1396b, 1396d, 1396r-1, 1396u-7); American Public Health Association, ACA Frequently Asked Questions (2014)).
31 Affordable Care Act § 1311 (codified at 42 U.S.C. § 18301). See HealthCare.gov, A One-Page Guide to the Health Insurance Marketplace (n.d.).
33 In trying to accomplish this goal, the Affordable Care Act takes into account individuals who have health care coverage through their employers, Medicare, Medicaid, and other health insurance programs. Those who already have health care coverage are exempt from coverage under the Affordable Care Act.
37 Unauthorized immigrants are not allowed to participate in many federal programs such as Medicaid (see National Immigration Law Center, A Quick Guide to Immigrant Eligibility for ACA and Key Federal Means-Tested Programs (Jan. 29, 2013)).
38 Hospitals must give emergency treatment to anyone who needs it regardless of legal status or ability to pay (Emergency Medical Treatment and Active Labor Act, 42 U.S.C. § 1395dd; see Phil Galewitz, Medicaid Helps Hospitals Pay for Illegal Immigrants’ Care, Kaiser Health News (Feb. 12, 2013)).
39 E.g., lawful permanent residents have a five-year waiting period before becoming eligible for Medicaid (see National Immigration Law Center, supra note 37).
40 See National Immigration Law Center, supra note 37.
41 Lindsay Holst, 7.1 Million Americans Have Enrolled in Private Health Coverage Under the Affordable Care Act, White House Blog (April 1, 2014).
42 E.g., the Spanish translation of the Affordable Care Act website was criticized for its poor translation (see Ezra Klein, Obamacare’s Spanish-Language Web Site Is “Written in Spanglish,” Washington Post (Jan. 13, 2014)).
44 See, e.g., Erica Pearson, New York City’s Immigrant Population Not Signing up for Health Insurance Under Obamacare: Advocates, New York Daily News (March 19, 2014).
45 The Council of Better Business Bureaus picked the scam around the Affordable Care Act as the “Scam of the Year” for 2013 (Council of Better Business Bureaus, Better Business Bureau Names “BBB Top Ten Scams of 2013” (Feb. 11, 2014)).
46 See Katy Steinmetz, The Latest Obamacare Worry: Scam Websites, Time, Nov. 14, 2013.
47 See Michael Ollove, The Rise of Medical Identity Theft, Stateline (Feb. 7, 2014).
48 In some Latin American countries, a notario is a special type of lawyer who holds public office.
49 Many immigrant clients of notarios have faced deportation due to the false promises and poor services of notarios.
50 Government-certified navigators help individuals enroll for free.
51 See Sarah Varney, As “Bodega Clinicas” Fill Void, Officials Are Torn on Embracing Them, Kaiser Health News, Jan. 12, 2013.
52 See, e.g., Tovin Lapan, State Launches Campaign to Combat Backroom Medical Clinics, Las Vegas Sun, April 12, 2012.
53 The Fair Debt Collection Practices Act, 15 U.S.C. §§ 1692–1692o, regulates debt collectors in hopes of eliminating abusive debt collection and promoting fair debt-collection practices.
54 E.g., Sid Kirchheimer, Beware of the Latest Health Law Cons, AARP (Sept. 9, 2013).
56 E.g., CuidadoDeSalud.gov, Protéjase de los Fraudes del Mercado (n.d.).
57 Navigators “provide outreach and education to raise awareness about the Marketplace, and refer consumers to health insurance ombudsman and consumer assistance programs when necessary” (Centers for Medicare and Medicaid Services, In-Person Assistance in the Health Insurance Marketplaces (n.d.)). In-person assistance personnel and certified application counselors play similar roles (id.).
59 See Federal Trade Commission, Suspect a Health Care Scam? Here’s What to Do (Sept. 2013).