By Pippa Fung PHOENIX – My grandmother moved to the U.S. from India because health concerns had left her unable to live alone. When she moved in with my family, who lives in New Mexico, she was in the process of getting a green card. But with this in-between immigration status, she had trouble finding an insurance plan that would accept her, and she was not eligible for Medicare. In 2020, Brookings reported that 30 million people in America were uninsured, with about half of them being people of color. In addition, according to the Commonwealth Fund, around half of all undocumented adults in the U.S. were uninsured in 2024. Poverty, geographical inequalities and immigration status are foundational factors in creating healthcare insurance disparities, and they often disproportionately affect people of color. Though government programs such as Medicaid and other insurance regulations help to make sure that healthcare is more affordable, it can still be difficult for all people to have access to medical treatment. This is especially significant in Arizona, which has diverse racial and ethnic demographics as well as a large immigrant population. Cheryl Curell, an independent insurance agent who helped my grandmother find a coverage plan, said that, in her experience, rural communities faced the most challenges with gaining access to health care insurance. She recounted helping an elderly woman in Steins, New Mexico, who had a telephone, though she never went on social media or online. Curell instead heard about this woman through word of mouth and helped her set up a Medicare health insurance plan, which the woman had never done before. For areas like these, where it is more difficult for insurance agents to reach out to people, community centers and hospitals often have to take this role. Curell mentioned places such as Tuscon’s El Rio Community Health Center, where medical professionals can get certified to help patients find coverage plans. Marcus Johnson, the deputy director of Community Engagement and Regulatory Affairs for Arizona’s Medicaid program, said that geographic challenges affect both health care workers as well as patients. “If you're in one of those rural or frontier areas and you don't have a hospital nearby or regular source of care nearby, it means that often you're finding time to take away from work in order to drive for far distances in order to get the care that you might need,” he explained. Johnson said that this issue also impacts certain racial demographics more than others, particularly in Native American and African American communities. A 2022 KFF report said that nonelderly American Indian, Alaska Native and Hispanic people had the highest rates of uninsurance out of all other ethnic groups. Arizona Medicaid, which is called the Arizona Health Care Cost Containment System, has American Indian programs dedicated to this cause. “It really intends to make sure that American Indians can get Medicaid coverage,” Johnson said of these programs. “It is accompanied by certain payment models that invest significantly in healthcare providers and healthcare facilities that are specifically focused on, often rural populations and American Indian populations, and that kind of infusion of funding from the state and the federal government helps to build new facilities or renovate existing facilities.” Non-government programs such as Native Health in Phoenix also offer health care services to Native American patients, providing for a wide range of medical needs with a “culturally sensitive” approach. Racial divides pervade health care insurance and access in immigrant communities as well. “The number one thing is they just don't know that the programs are available, or they don't know how to find out about them, or how to enroll in them, or what the criteria is,” Curell explained. Furthermore, immigrants can file for Medicaid and Medicare, but only after they have been a qualified non-citizen and permanent resident for five years. This prevented my grandmother, for instance, from getting government aid for her own medical treatments. Curell said that, because of reasons like these, immigrants often only get medical care if something like an injury happens to them first. However, going to a hospital without insurance coverage is expensive, and takes a toll on medical centers. “The most expensive way to get health care is to go to the emergency room, but that's their only choice, so they go to the emergency room,” Curell explained. “It puts a big strain on the hospitals, because the hospitals cannot deny people for care in the United States. They have to be seen and treated, but there's nobody to pay the bill, so the hospitals end up carrying the bag.” But since somebody has to pay for treatments, Curell continued, it then tends to fall on insurance prices, which rise to meet these needs. With complicated issues like this one, a plethora of programs to choose between and not enough education on health insurance, Curell said that the biggest difficulty with health care insurance – for both immigrants and other patients – is that it is a “challenging system to work with.” While Curell tries to reach people through social media, community outreach events and volunteering opportunities, she acknowledged that it is hard to find everyone who has a need. “I'm just one person,” she said. “We could use help.” Government aid, and programs such as Johnson’s, aim to do so. As far as Arizona’s Medicaid program, Johnson said that “the state Legislature appropriated additional funding for rural hospitals, and so we have certain programs that do go to critical access hospitals for additional funding.” Critical access hospitals are medical centers in Arizona which are designated by the state and federal government. They often lack funding and are in rural areas, leaving them more susceptible to challenges with providing adequate health care. Johnson also mentioned federal programs such as the Children’s Health Insurance Program, coverage for maternal and postpartum health, and other ways in which the government has been able to expand their reach of health insurance aid. Curell added that the federal government has even grown health insurance coverage for immigrants and people under the Deferred Action for Childhood Arrival program. “Until recently, the DACA recipients were not eligible for healthcare, which is absolutely heartbreaking to me,” she said. A new law under the Biden administration ruled that, as of Nov. 1, immigrants in the DACA program can file for insurance under the Affordable Care Act – a decision that Curell is very thankful for. Beyond state and federal aid for health care insurance, the government has also created ways to ensure that private companies are following the law. Sterling Gavette is the life and health oversight manager for the Arizona Department of Insurance and Financial Institutions. His job is to make sure that insurance companies are in line with government requirements and legislation. “Our role is kind of limited when it comes to promoting access, but what we’ll certainly do is make sure that those policies that they purchase – whether it be Affordable Care Act policy, or Obamacare, through the marketplace or an agent – those documents, those policies, are all in compliance and they’re not discriminatory,” he said. The Department, he explained, values consistency and aims to make sure that the insurance benefits patients are promised and mandated to have are actually provided. This approach can look different for different states, as some create their own insurance marketplaces and people might either be on a private or federally provided insurance plan. Still, Gavette aims to enforce the law and ensure that insurance plans are compliant with it. And yet, Johnson said that all of this is not enough to solve the root issue of disparities in access to health care. Arizona Medicaid has had to start “thinking not just about traditional medical insurance, but also thinking about what are the other kinds of basic needs that our members need to have met in order to set them up for success, in order to bring them closer to good health,” he explained. One of the needs they have been focusing on most is housing. “Maybe there's something that we as a Medicaid agency can do to coordinate housing, or at least pay for housing for certain members,” Johnson offered. This has come to fruition with the Housing and Health Opportunities program. For people who have trouble accessing or paying for health care for geographical reasons, Johnson added that Arizona Medicaid has also begun providing transportation and growing their telehealth services. In the end, though poverty, geographical differences and immigration status have led to racial divides in health care insurance, Curell has remained passionate about her work to overcome challenges like this and to help people like my grandmother. “I would like to see everybody have access to healthcare,” she concluded.