But many of those she’s enrolled are surprised and indignant when they go to the doctor and are asked to a pay a bill— perhaps a copayment. They insist they’ve already paid their monthly insurance premium.

“They call us and say, ‘it’s a scam’,” says Abouarabi, an insurance navigator for the Arab Community Center for Economic & Social Services (ACCESS), a nonprofit agency that specializes in helping the largest Arab-American population in any U.S. city.

That’s just one example of the confusion immigrants face as they try to navigate the U.S. health care system. Even after signing up for insurance through the Affordable Care Act, advocates find that explaining to clients that they will still have to pay out of their own pockets each time they go to the doctor or get lab tests requires more than translating words like “premium” and “deductible” for non-English speakers.

“This whole concept of insurance doesn’t exist in the Eastern world,” said Madiha Tariq, public health manager for ACCESS. “People are always confused about the health care system when they come to this country.”

Problems like this are arising all over the country where Latino, Asian and other immigrant populations face cultural as well as language barriers.

Non-citizens are three times more likely to be uninsured than U.S.-born residents, according to the Kaiser Commission on Medicaid and the Uninsured. As many as 10 million non-citizens living legally in the U.S. are expected to gain health insurance through the Affordable Care Act although it’s unclear how many have gained coverage so far.

Mandate Covers Legal Immigrants

Many of these immigrants are getting insurance because the just as it does for U.S. citizens and because it may be affordable for the first time. Like citizens, legal immigrants can use the law’s online exchanges to sign up for coverage and find out if they are eligible for government subsidies. They also face a tax penalty if they don’t sign up.

Immigrants who are not in the country legally, however, are barred from using the exchanges and aren’t required to have coverage.

ACCESS clients typically hail from places such as Yemen, Lebanon, Iraq, Bangladesh and Syria. Besides training navigators and helping clients enroll, the center offers primary care services, cancer screenings and various public health awareness workshops in the community.

Some of them are not easy to convince that they should enroll in health coverage.��

“Iraqis don’t believe in insurance,” said Hasanain Al Ani, a case manager at ACCESS and a refugee from Iraq, who says people from his country are accustomed to government-sponsored health care. “…They don’t know about it [health insurance] and they don’t want to know about it.”

Tariq said another challenge has been helping clients understand how access to doctors works in the U.S.

“In their country, the wait time depends on socioeconomic status … the lower the status, the longer the wait time,” she said.

Barra K., 27, who didn’t wish to be identified by her full name, came to Dearborn as a refugee from Baghdad in February and developed a severe sore throat. She was shocked at the prices for the medication, let alone what it costs to see the doctor as someone without health insurance.

“Here I have to pay $70 to see a doctor, but in Iraq I only have to pay $15 and do not have to wait as long,” she said.

She couldn’t afford the doctor or the medication so she had to wait the illness out. She does not qualify for full Medicaid services because she hasn’t been in the country for five years, but Michigan’s Medicaid program does give her access to some limited emergency services.

Cultural Issues Can Be Barrier To Care

But toughing it out is harder for people with chronic diseases, which are a big problem among ACCESS clients who suffer from diabetes, breast cancer, cardiovascular disease and, oftentimes among refugees, depression.

Cultural barriers also make it difficult to get some clients to come in for care.

“We have ladies who have never had a mammogram,” Tariq said. “Cancer is stigmatized in the Arab culture. [Women] were scared no one would marry their daughters if others found out they were diagnosed.”�� That’s because people worry the cancer is hereditary and can be passed down from mother to daughter.

To persuade women to come in for mammograms, Tariq said, ACCESS has an unmarked door that allows them to slip in and out of the testing area without being identified.�� ACCESS also distributes a special pamphlet for Arab American women, explaining the importance of mammograms and how to examine themselves. It also pairs women diagnosed with cancer with survivors who can help them navigate the system and give them support. Public health workshops have also helped get others to come in regularly for testing and physicals.

ACCESS also helps people with chronic illness navigate how to pay for their care.

“As a diabetic I was walking on eggshells,” said Najwa Dahdah, 48, as she talked about paying for the insulin she needed to manage her diabetes.

She had had insurance but after getting diagnosed with diabetes while she was pregnant with her third child in 2005, her premium skyrocketed from $400 a month to almost $900 a month. She canceled the policy and started paying for doctors’ appointments out of pocket. She clipped manufacturer coupons and constantly asked her doctors for insulin samples to help her manage her ailment.

But since signing up again under the health law, which prohibits charging higher premiums to those with health issues, Dadah and her husband receive $430 in subsidies toward their monthly insurance premium, while her children qualify for Medicaid, the federal-state insurance program for the poor.

The premium “is now $133 for both my husband and I through Blue Care Network,” Dahdah said. “It’s a blessing.”

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But LaVrene Norton is working to change that.��

Norton is founder and president of Action Pact, a national consulting firm. It specializes in helping retirement communities and nursing homes train staff and design their facilities to feel and be more like living at home. ��Since beginning work on the “household model” in 1984, Norton has helped design hundreds of these communities.

The idea is that residents’ rooms are clustered around a common area, with a kitchen and living room. The size varies from four people in a private home to a bigger building with up to 20 people in “household” groups. Nursing assistants and caretakers help with the more traditional side of things, such as helping residents take their medicine and bathing. Norton says the household model is “the new nursing home” that helps focus on “person-centered care” and helps meet the wave of demand for more quality services from aging consumers.�� Five percent of people over age 65 in nursing home-type facilities – more than 1.3 million.

Norton recently spoke with KHN’s Marissa Evans. Her comments have been edited for space and clarity.

How does your design compare to a modern day senior home?

There is no comparison. A traditional nursing home is institutional. When you move in, you in a way lose your identity. You definitely lose your uniqueness. It’s not like the staff is at fault, it’s the way the system is set-up. It’s very different when you’re in an institutionalized nursing home which most nursing homes are. The thing you’ll hear people talk about is person-centered care and that [means] teaching staff to seek the residents’ suggestions on things more, do more at the residents’ timetable and attend to the residents’ needs and wishes more. But the truth is this system fights against all of those things.

What are the challenges you’ve seen with people wanting to build a household model?

There’s the need to get everybody involved without getting scared. If you say we’re going to do universal workers and all of the housekeepers are going to become CNAs [certified nursing assistants] and everybody in the kitchen is going to become CNAs and CNAs are going to do the cooking, it just freaks everybody out. We promote something that’s called a “versatile worker” instead of a “universal worker.” So we don’t expect everybody to become a CNA. We expect everybody to cross-train in something. From the CEO down, everybody cross-trains in something and that makes them more versatile.

Is this scaleable on the national level?

It is scaleable on a national level and I think it is going to be the new nursing home. My generation of people, and I’m 69 years old, who were born and raised and toughened up in the 60s are not going to tolerate bad service, shared rooms, a bath time that’s scheduled by somebody else. So the market is changing and we have to respond to that market. The neighborhood model is where you have a small group of staff, a very homey kitchen area, living room and dining room for each small group. I bet there are thousands out there already. So either neighborhoods or households so some of that or one of that, is going to be in that new building once it’s built and all buildings will be rebuilt or renovated overtime.��

You call it the “new nursing home.” Is this a movement?��

It’s a movement because people want it. First of all, all of us want a good life for our elders and we’re frustrated by the old nursing home way. We don’t want that. Every CNA and every nurse and every cook and every housekeeper in this country, every activities person, every social worker in this country who works in a traditional nursing home doesn’t want it for the residents they serve. They would so much rather have a good way for them to live. So you got that going for you. That’s the movement part of it. Then you’ve got the market.

Anybody who’s got a household model in their market area knows the pressure of having a decent place to showcase, to attract people to come to your home. Thirdly, you’ve got the customer. People my age, and 10 years older than me for that matter are not wanting the old way. They want to have a say in their life, they want to continue to contribute and give to others, they want to have a good daily life and when they look at this, and they’re much more consumer savvy, they’re not going to put up with the old way.

Is this a long-term solution?

More and more people are able to stay in their assisted-living environments. That goes for residential care as well. Residential care is a lesser life than assisted living and people are able to stay there and home care keeping people at home. So, really and truthfully, whether or not in the future there are licensed nursing homes or not, there will be some kind of homey household model of community living. That allows [residents] the quality of life of home, that gives them freedom and independence and being in charge of their own life and yet has services that they need. So that’s going to be the ideal world for the future. We’ll never go back to institutionalized, long hallways filled with tons of people and warehousing people again, that’s done. ��

Who doesn’t this model work for?

I can’t think of a population that this concept does not work for. You use a smaller configuration which allows more interpersonal relationships with the residents to tend to them individually whether they’re severely disabled physically, whether they’re mentally ill, have severe memory loss, severe dementia.

People say “Well what about someone who is really sick, it won’t work for them, will it?” Well, of course it will. If I’m in bed all day I’d much rather live in a homey little space where someone could wheel my bed up to the door or help me into a lounge chair and help me into the living room area and I could just be there, whether I could talk, whether I could even be sure of where I’m at, just being around the clatter of dishes in the kitchen, and the smell of coffee pouring or bread baking, of genuine laughter in the other room. If I’m really, really sick I’m going to love it so much better. The best place to die would be at home, and this is as close to home as possible.

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, which includes Regence Blue Cross Blue Shield,will offer training to providers��and additional benefits for policyholders: more than 2.2 million members in Cambia’s family of health plan companies in Oregon, Washington, Idaho and Utah.

Palliative care improves the quality of life by managing pain and other problems for people who have serious life-threatening medical conditions, such as cancer, heart and kidney failure. It differs from hospice care, especially because patients do not necessarily have less than six months to live.

Mark Ganz, president and CEO of Cambia, said the company realized providers are focused on disease treatment but they “never stop to ask the patient and family ‘How do you want to live with this?'”

“Palliative care at its best is in partnership with curative care,” Ganz said. “It’s not after curative care when it no longer matters or no longer is working.”

The company is going to start paying for things not typically reimbursed by other insurance companies including home health aides and advanced care planning counseling. One of the larger initiatives is training physicians and caregivers in how to have appropriate conversations about end-of-life care.

Dr. Csaba Mera, chief medical officer at Cambia Health, ��said the goal is to develop a holistic, comprehensive integrated program: “It’s about making sure (the patient’s) wishes are clearly documented, they’re respected and that they’re implemented so it’s not a crisis if they do at some point end up in terminal care and decisions have to be made,” Mera said.

Dr. J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization, a Virginia-based nonprofit organization representing hospice and palliative care programs, said Cambia’s program could become a national model as more and more providers look to integrate palliative care into their facilities. He said the the education and training component of the program is particularly critical.

“We’re an aging population with the baby boomers. More people are going to need to start having these conversations and accessing these services,” Schumacher said. “These are hard conversations to have if you don’t have the training.”

Ganz said over the years insurance companies have taken to following the Centers for Medicare &��Medicaid Services’s guidelines in how they look at palliative care and Cambia’s new initiative is fueling “creative tension” in the industry in how to approach it.

“We’re striving to take palliative care to the patient as opposed to forcing the patient to come into rigid walls of institution that tell you how exactly they’re going to treat you,” Ganz said. “Our hope is that the rest of the health care industry will follow suit.”

The company anticipates that the program will be in effect by early next year

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But new data suggest the law is failing to fully deliver on its promise: A lot of parents didn’t buy dental coverage during the recent online enrollment period.�� That spells trouble, according to health experts.

By age 5, about 60 percent of U.S. children will have had cavities; 40 percent have them when they enter kindergarten, Children with tooth decay are more likely to have ear and sinus infections. The chance of developing other chronic problems like obesity, diabetes and even heart disease also increases.

Dr. Paul Reggiardo, chairman of the��American Academy��of Pediatric��Dentistry’s Council on Dental Benefit��Programs, says early dental problems can affect children’s learning, how they interact with other kids and their ability to eat.

“It starts having an impact much more than cavities,” he says.��

Many children get coverage through their parents’ employer-based health insurance or the government-funded Children’s Health Insurance Program and Medicaid, which serve low-income people. But the American Dental Association says there’s still a big gap: 10 million children aged 2 through 18 had no dental insurance in 2011.

The health law marketplaces that opened last year were designed to help people who don’t qualify for Medicaid and don’t have workplace coverage. Parents seeking pediatric dental insurance had two options: purchasing it as part of a family medical plan or as a separate, stand-alone policy.

Federal officials don’t yet know how many kids got dental coverage through a family medical plan in the first enrollment period, which formally ended March 31. But they have reported numbers for stand-alone dental plans sold through the federal website serving 36 states: Just 63,448 children received this coverage.

One reason is shopping for coverage is complicated and confusing – not at all like picking a toothbrush from a shelf, experts say. Perhaps more importantly, there’s no separate subsidy for buying dental coverage and no federal penalty for failing to buy it. Only three states – Kentucky, Nevada and Washington – require parents to buy a children’s dental plan.

In light of these problems, “Are we expanding dental access for kids?” asks Marko Vujicic, chief economist and vice president of the American Dental Association’s Health Policy Institute.

Only��26 percent of medical plans sold on the federal exchange included pediatric dental benefits, according to an ADA study. Parents often confronted difficult choices – the ideal medical plan for their family might not have dental care for the kids, for example. To get that coverage, they’d have to buy a stand-alone plan at an additional cost.

Stand-alone plans are sold as either high–option policies, which likely involve higher premiums but smaller out-of-pocket costs; or low-option plans, for which premium payments may be less expensive but enrollees may have more out-of-pocket costs. Both cover preventive care and services like fillings, sealants and medically necessary orthodontia, says Evelyn Ireland, executive director of the National Association of Dental Plans.

Prices for stand-alone plans vary not only by option but also where people live. Insurance markets are regional, not national, so costs and competition vary greatly. For the current year, a family in Cleveland County in southwestern North Carolina could pay as little as $33 a month for a low-option children’s dental plan while another family in Beaver County in southwest Utah could pay as little as $8 for the same level plan, according to a KHN analysis of premium data for the federal marketplace.

In Lenawee County, Mich., a high-option plan was $46 or more; in Miami-Dade County in Florida, that same level plan could be bought for as little as $16. In Davis County, Utah, a high-option plan cost at least $7.

Nationwide, the average price of a low-option plan in a county was $21 and the average for the high option plan was $27.

Open enrollment resumes Nov. 15, but insurers are already developing plans and prices that will be submitted to regulators in the months ahead.