Alex Sherman, Seve Gaskin

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Alex Sherman discusses the make-up of Student Health Action Coalition (SHAC) and their medical and dental clinics. Sherman discusses the demographics that these clinics serve, what services their patients usually require, and what services SHAC can offer them. Sherman elaborates on specific services, particularly the Amigas en Salud community outreach program, a program which promotes community participation and the prescription medicine dispensary, and he later introduces Seve Gaskin’s program, Get Covered Carolina. Gaskin goes into further detail on the Get Covered Carolina program, detailing how the organization operates in the Chapel Hill area, inquiring as to whether people are insured. Later, Gaskin explains the relationship between Get Covered Carolina and SHAC, and how SHAC’s clinics provide the perfect arena for Get Covered Carolina to operate. Gaskin and Sherman believe that nearly a hundred percent of patients using SHAC clinics are uninsured. Consequently, Get Covered Carolina tries to ensure everyone who walks in, and in this way they are able to identify non-citizens, as they are the only people who do not pursue Medicaid applications.



Danny: Ok. Hello my name is Danny Hogenkamp and I am interviewing Seve Gaskin and Alex Sherman in the Health Sciences Library of UNC Health Sciences Library Room 228. The date is April 15, 2014 and today I am here to interview these two young gentleman on the Affordable Care Act and how it effects undocumented workers, specifically there wonderful work with the student organization SHAC, which is an acronym for Student Health Action Coalition. Ok. So, so I am going to ask questions and whoever wants to take it will just put this (the mic) in front of them and bring it towards you so the sound quality is higher. And, all right. Thank you for coming here today and speaking with me and I guess my first question is can you guys just give me a brief history of SHAC, why it started, and yea?
Alex: All right, I am Alex Sherman. This past year I served as the overall director of the organization. So there is a myriad, a number of different projects going on within SHAC, and my job is to sort of oversee those and make sure that they are all going in the right direction, according to plan. And, so as part of this, I am probably one of the most familiar people with the organization and where SHAC came from. And, the line that we typically tell people and the one that is easiest to comprehend is that SHAC started in ninety sixty seven with mostly just the medical clinic as a group of medical volunteers volunteering both in the local neighborhood around here and in the Durham area. Basically started in the back of a barber shop as part of the civil rights movement and so ever since its foundation it’s been an open-door policy at SHAC. If you come to SHAC looking for medical care you will receive medical care no questions asked. And, we still try and hold true to that even with the medical clinic nowadays. So through out the years its grown, added in students from different disciplines— nursing, pharmacy, public health, social work. Literally, the whole shebang. They are all there now. It has expanded into a dental clinic as well, as lot of these community initiatives. And so our real three missions are to mostly make sure that one, we are providing quality patient care. Two, we are interacting with the community and making sure we can create sustainable initiatives for that community. And, three, and that we are really the source of a student learning environment and that we make sure to get enough students volunteers. And, mixing all those three is pretty much one of the trickier things we have to do.
Danny: Nice. Yea. Ok. So My next question is could you, I guess I will probably direct this again to Alex, could you describe SHAC’s overall current structure. I saw online the clinic, the dental and medical, and then you have a lot of outreach? I mean I guess either of you could take that.
Alex: So that is an excellent question. That’s actually one of the biggest questions we have about SHAC, and so for posterity’s sake I will answer that right now if someone ever goes looking for this. So, future, the leadership structure is as follows. As I just mentioned, the organization has grown over the years and its, we try and keep one central face to everything that is going on and so I am the director of what would be considered the board of directors, which we would call the coordinating council, which consists of a number of staff positions that consist of the day to day operations like finance and development as well as a number of student representative seats from each health professional school that interacts with SHAC-- and, so that sort of serves as the legislative and executive directorship of SHAC on that level. And, within that there committees you could say are responsible for overseeing the medical clinic and the dental clinic as well as these community initiatives, some of which include the Get Covered Carolina, which is most relevant to what this conversation is about.
Danny: Ok. Awesome. So I guess. All right. So this project is focused on the undocumented Latino community as you may have guessed. I guess just as an overview, what is SHAC’s relationship with the undocumented community in the Chapel Hill area?
Alex: Seve, do you want to talk about that one first?
Seve: So, my name is Seve Gaskin. I am the project manager for the Get Covered Carolina Initiative with SHAC. I have also served on the medical clinic operations committee and I am one of the public health coordinators for the medical clinic as well. So specifically inside of the medical clinic, we definitely have a lot of patients who probably would fall into the undocumented category and we do provide them assistance without any consideration of where they come from—if they are a citizen, legal permanent resident, what have you. So long as they come into our clinic, and they have an appointment, generally, we will treat them. We also try and take walk-ins as well. So we do try and maintain a relationship with the undocumented community mainly because we know that there are only a few safety net clinics within this area that could serve these people besides the emergency rooms.
Danny: Yea. And just kind of quickly, one thing that came into my mind is I saw on your website, that you guys have moved to Electronic Medical Records over the past, what is it, year? Two years?
Alex: I would say probably three or four years, yea.
Danny: Ok. So I wanted, does your transition to the Electronic Medical Records affect the no questions asked policy as far as patients coming in?
Seve: So in the terms of the EMR system within the medical-- some of the questions that we usually ask patients, on their intake, generally consist of name, birthday, address, phone number, email address, and then we will ask them some demographic information like income levels, and preferred language, socioeconomic status, educational attainment, and things like that. So we do ask some questions, and mainly that is for us in terms of fundraising purposes. We can kind of analyze which demographics we have served in the medical clinic over the past couple of years. But, with that said, we don’t ask any questions about citizenship status or anything like that.
Danny: So with your EMRs, you’re not pulling records from hospital records? Do you have access to like UNC’s files?
Alex: So, a number of our students and the attending physicians who work there could access the records if they have any questions about the patients in that regard. We generally don’t ever access those. And SHAC itself doesn’t link to those records at all?
Danny: And why, why is that?
Alex: One, we never found it really to be necessary, I think would be number one reason. There is plenty of demand to get treatment from that, from us, in a very actute type setting. We don’t really do to much on-going or chronic care. So, a lot of all the questions we have can be addressed just in that initial visit that we have and if we do need to refer somebody than we sort of take the extra step afterwards.
Danny: Going off that. Focusing on the acute care, what type of acute visits do you get most often?
Alex: Ok, so that is an excellent question. Hold on one second and I can tell you exactly what those would be.
Danny: I was very impressed on the website, for the record, how well you guys keep your data.
Alex: Thank you. Well for the record, thank you Andrew Morgan for that who is a PhD -MdH student. And so, I am taking a look real quick to see the types of visits. And so, for the most part the types of complaints we get we don’t categorize them specifically by diagnosis code, or ICD9 code but we do generally lump them into some of the big categories. You will see that they generally coincide with conditions in the general health population, and a little more towards what you would see in an acute care clinic. So we do see a significant percentage of patients with high blood pressure, a number of patients with diabetes, previously diagnosed and even some un-diagnosed that we catch, but as well a majority tend to be some dermatological complaints as well. We have the run of the gambit really. People with GI complaints, feel like, and a number of complaints just related to sexual health or access to social services.
Danny: So people don’t ever come to you with like broken bones? Or?
Alex: Not in the past few years that I could recall, yea. So, we try to have a pretty good network of places that we can refer to. And, we will generally see the people, as you mentioned, that sort of fall outside the big gap of care. There is definitely acuity of patient that we see at SHAC. We generally see the lower acuity patient, the less severe, and the patient with less severe complaints. If their complaints sort of reach a certain threshold, there is a number of places we can call pretty much immediately that would take them right there.
Danny: So, do they, does the community know that if they have a more serious problem that you guys are not where they should be going. Or do they tend to know that you are this great free resource, come to you, and then let you refer them?
Alex: I would say it would definitely be the latter. We don’t, I wouldn’t say that patients with say a broken leg or something like that would say come to SHAC first.
Danny: So, it’s sort of self-referral.
Alex: Yea, it is self-referral. We do zero advertising whatsoever.
Danny: Ok. And so where do you refer them?
Alex: So there is two places, and Seve can now probably even add more places. But the two main places that we refer to are either UNC Family Medicine or to Piedmont Health Services which are the federally qualified healthcare centers in the area. There are definitely some concerns about referring undocumented patients to either source or how much information they require because they are both federally funded to some degree.
Danny: Ok. So, UNC Family Health and Piedmont Health Services. If you had an undocumented that you needed to refer, where would you be more apt to send them?
Alex: Some of that depends. You can tell me if I am wrong as well.
Seve: So, from my experience, serving on the operations side, we have referred probably more patients to Piedmont Health Services than UNC Family Medicine, mainly just because transportation and access factors. Our clinic, the medical clinic, operates out of Piedmont Health Care’s Carrboro clinic so we found that it is very easy for people to just go back to that same location as opposed to trying to get to UNC family medicine.
Danny: Yea. Have you guys ever had a problem where you referred someone to the hospital or even Piedmont and then they have been reported? Has that ever come up or would you guys be aware if that happened?
Alex: I doubt, I doubt, we would be aware of that if that happened for the most part if that happened.
Seve: The previous medical clinic co-director, RJ, yea, he has been working on trying to follow up on people that we refer to a better degree. So it used to be in the past that we kind of just referred patients off to Piedmont Health and then we wouldn’t know. But, I think he has been trying to follow up more so I don’t think we have had any instance of that happening but that is not to say that it has not happened.
Alex: And the way that works now versus the way it worked in the past is formerly we used paper charts and we would refer people and they would sort of disappear into the ether. We could call them and the phone number may or may not work. But now, with the medical record, we may see whether or not they have gotten the appointment at least with Family Medicine or Piedmont. All that does is really extend the time we are aware that they are looking for that appointment for a little while. It doesn’t necessarily even, I don’t know if we would even hear if what exactly happened? And they got deported.
Danny: Yea, so I mean, I guess from my interview just briefly, the people, they need to go the emergency room. They go, they are stabilized. And, if a doctor is worried about their life and needs to pull out past medical records and they go searching in the database. That is where the red flag goes up and then ICE would just be at the door the next morning before they are discharged.
Alex: Oh jeeze.
Danny: Yea, it’s a pretty rough process. Anyway, yea I see you guys are more of an acute, primary care, which is good because that is definitely in demand. So do you keep a demographic count of whom you serve?
Alex: We do, mostly as Seve mentioned mostly for our own internal funding purposes and for quality of care.
Danny: Ok cool. Can you share that? Or is that possible?
Alex: Let me see what we got. So I can definitely get back to you with some more information. We try not to put too much data on this that is publicly available and that is publicly available and that is the thing I am looking at right now. I will say, what I can talk to you about that I have data right now is for the general age distribution and sort of the zip codes of patients that we see and then I can comment sort of off the top of my head on demographic. And so for the age demographic what we are seeing is sort of the younger to middle aged adults, somewhere in the about like 25- early 40’s. And as far as zip codes, the vast majorities are from, I would say 80% are within the Orange County, Chatham, and Alamance type area. And Seve can confirm that as well. And now, from my memory, and Seve you can correct me on this one as well. Since we, on our intake form our demographics form the accuracy of what people put down for their demographic information, I wouldn’t say that is something that probably they put down all that often.
Danny: Why is that do you think?
Alex: Well, probably due to the large number of undocumented people we do serve.
Danny: Do you think they fear if they put Latino that they will immediately be tagged as probably undocumented?
Alex: I would say. Well, I don’t want to put words in other people’s mouths.
Danny: Just guessing, just guessing.
Alex: I would imagine if you were a person who was here undocumented, you would, and having to go get medical care, you would be worried. If you had ever gotten care from the ER in the past, or you had heard of friends in your population that happened to I would be cautious of what I wrote regardless of where I went.
Seve: I will just comment on that. So in terms of the Get Covered Carolina Project, when we do, when we have counseled people that kind of qualify, that would classify themselves as the Hispanic/Latino population, sometimes they are very hesitant to enter their information into and actually there was a kind of concern that we had voiced to the Center of Medicaid and Medicare services that we were responsible for.
Danny: Even if they are documented?
Seve: Right. Even if they are documented. But, especially if they are undocumented. And, we found that most of the undocumented people know that there will not be much help available to them through But, what CMS actually did was during the application process, there is this nice little blurb that says “any information you provide to the website will only be used for the purposes of getting your health insurance coverage”. So CMS is not allowed to share that information with the Department of Homeland Security for example. Which, I think was comforting for some of the people who got to that step. But, I think there is still a stigma around entering my social security number if I have one, or if my name and my address, how many people are in my household etc., etc.
Danny: So, they are, if they are documented why would they have any fear of entering their information.
Seve: I don’t know. I think there is just kind of a hesitation in terms of the federal government. I think a lot of people are scared of the federal government for a lack of a better word. But I am not entirely sure why there would be hesitation if they were documented. I think that there are also some people who might be, like we have assisted some people who have had their parents or guardians be undocumented, but the children are documented. But their have been some instances where theoretically the government could have figured out that the parent or guardians are undocumented by the kid’s information. But like I said the federal website does not allow that.
Danny: In those cases the kids would be covered by CHIP?
Seve: Correct. Presumably if the household falls between a certain income ranges legally or if they have a green card, they would be covered by CHIP or Medicaid.
Danny: What about the kids who are here illegally? Well what about if the parents are illegal but if the kids are born in the United States obviously they are American citizens?
Seve: Right, than it still applies. The kids would still qualify for Medicaid or CHIP.
Danny: Well, what about if the kids were born in Mexico but travelled across with the parents?
Seve: Then, if the kids were here legally, then they would still qualify for Medicaid or Chip. But, if they do not have a legal immigration status than they would not, in North Carolina.
Danny: So, in North Carolina there could be kids who, you know, can be brought across when they are two or three, and they are not covered by CHIP?
Seve: Absolutely.
Danny: Oh wow. Ok. And, all right. So, my other question just technically on how CHIP works. If a family has parents that came across illegally, kids were born in the United States, are American citizens, they are eligible for CHIP, get CHIP, but does CHIP extend to when they are 26, like as if the kids were on their parents plan? But since the parents are illegal they don’t have a plan?
Seve: CHIP has interesting rules. So it does not extend to til 26. I believe CHIP extends until you are 18, unless you are still in school, in which case you can stay on the program until you are 21. But besides that, after 21 you are kind of on your own is what we find.
Danny: Alright. So going back to SHAC, I saw you guys have a Latina Wellness Initiative.
Alex: Yea. We do.
Danny: Ok. Can I just get a quick overview of that?
Alex: Sweet. Everyone is getting a shout-out here. So that program was created last year by one of our physical therapy students, Sarah van der Horst who has poured both of her heart and soul into that project because it probably takes more times out of her life than I think even clinic operates. So, once a week as far as I know last she told me, is, she has about an hour and a half to two hour session with a number of Latina women in the communtiy. The first hour is usually some sort of Zumba class or some sort of group exercise and the second hour is some sort of workshop about where to get healthy food, bridge that gap, or even self-defense or our social work students will come in and provide them with some resources about where they can get care and stuff like that.
Danny: So, that Latina Wellness Initiative is attacking what root health problem?
Alex: Access would probably be one of the largest, access to healthcare for that population. And, access to, even, athletic activities, things like that. A lot of the women in that program, Sara mentioned, generally spend the days either sort of household maids or cleaners or things like that. They work very back-breaking jobs. It’s just, trying to make sure I don’t misrepresent anything she told me, but she said they probably work 10 – 12 hour days and a lot of the information that they would get is just really not available to them in the times that they are working, the schedules that they work. And so, the times she offers are usually, like late on weekends or late weeknights or, there is evidence to show that, specifically the Latina women in the population have higher rates of obesity and diabetes and things like that and so its, we are sort of trying to address those, that as well.
Danny: And yea. And also, possibly put kids in…
Alex: Yea. So that was actually one of her biggest concerns with that program. She knew that a lot of these women would be bringing these children and we actually had a long discussion about what child care would look like if they brought their children their. Specifically just from a legal standpoint of how to set up a small childcare program but I think she has managed that pretty well. I agree though, a lot of that information trickles down to the entire family. They also have the Veggie-Van come by and actually bring fresh produce there.
Danny: Oh wow. Is any of this charged or is this just free?
Alex: I don’t think the patients, the participants, participants is a better word. I don’t think the participants are charged anything.
Danny: Even for like the food?
Alex: I don’t think so. I think it is all funded by donations and grants that she has found for the program as well as a little bit from SHAC to start her up. But she is fairly self sustainable at this point. She is a great example of one of the things that I think SHAC can do in the future and keep…
Danny: So you would consider her what branch of your organization?
Alex: Outreach is what we would call it. So, outreach would consist of the Get Covered Carolina Project, the Latina Wellness Initiative, which I should clarify is now called Amigas en Salud. So, yea, she just decided to change that.
Danny: So this is just for women?
Alex: Yea, just Latina women.
Seve: But, we also have had some success with reaching out to the Hispanic community, the Hispanic and Latino populations with the Get Covered Carolina Project as well. So a couple of weeks back, me and some of my other Certified Application Counselors were in Burlington counseling patients on how they could get Affordable Care Act insurance at a place called, Centra la Communidad. And, that was referred to us by Piedmont Health Services actually and our Certified Application Counselors over there. Today I received an email about living healthy classes for the Hispanic and Latina populations at UNC Family Medicine Actually. And so that is something that we will be referring SHAC medical clinic patients too, if they see fit. And, my understanding of that program is that it is just kind of a health and wellness initiative for members of that demographic, free of cost. And, their will I guess, just go over what the options are for people that identify with one of those communities.
Danny: And do you think? Have you thought at all about a community, I guess the exercises in the Zumba classes; those are great ways to bring these people together and to form some type of community. But one of the biggest things prevalent in Hispanic Health research is just like this depression and loneliness of these undocumented workers that move here, especially amongst women who are kind of isolated to the home by traditional, kind of outdated cultural values. So have you guys at all thought about addressing, I guess you guys are very good about comprehensive health, but even more of a comprehensive health, like a social?
Alex: Yes (laughing). To the extent that Sara brought that up in what she addresses now in Latina Wellness or I guess now Amigas en Salud Initiative, the participants aren’t random each week. It is very much like a cohort of participants. I think they are in there for like 8 –12 weeks for the entire program. So that’s one of the sort of the initial things that got us thinking about what you were just talking about. We do try and get out there and find ways to interact with the community and what we have been focusing on in the past year is just figuring out a way for our organization to do that in a way that is more sustainable. And that is pretty much one of the words that is hardest for us to do each year is to create projects that actually last from year to year with such high volunteer turnover.
Danny: So that is one of my questions. The high volunteer turnover, but where do you guys getting your funding from?
Alex: So, funding, luckily the directors 5-10 years ago thought about this and had a big donation drive, found a lot of grants, and we tend to put a lot of the money that we receive in donations back into an endowement that is run for us, and most of our operating budget is actually completely covered by that endowement for the medical clinic and a lot of our smaller initiatives, and so any grants or anything like that that we receive usually go to fund new startup initiatives. And, then we will seek out funding to see how we can maybe even fund that internally or fund that with outside resources.
Danny: Ok. So what was your guys’ budget, your operating budget?
Alex: So, I can speak to the medical clinic off the top of my head, actually I can speak to the endowment. Generally we get about, the budget for the entire operations minus some things going on in the medical clinic is about $25,000 per year.
Danny: Ok. So where are those costs coming from? Because obviously the service is free right?
Alex: Yea.
Danny: Because they are all volunteers, even your doctor. And so.
Alex: I wish you had talked to me on Friday. I will be getting the updated balance sheet and can send you that. But, I can tell you generally where it goes to. The majority goes to the medical clinic and the dental clinics just for operation and use of space. The medical clinic, so the dental clinic runs out Tarson Hall right here in the dental school building, but they are looking to move to an individual location. They do pay for a security guard which is required by UNC to keep the building open late at night.
Danny: That stinks.
Alex: Yea. It does. But sometimes better safe than sorry. And the medical clinic operates out of the Carrborro facility of Piedmont Health Services. And, we have an agreement with them, which we pay them a very small amount thanks to them. Thanks Eugene. For dry goods and using their space as well, and that is a small amount of the fee, as well as paying for laboratory testing, individual supplies that volunteers need. That is probably about 2/3 of the cost, the medical and dental clinic and the other third probably could go to these community initiatives, just funding for startup costs and to keep them running.
Danny: And I saw something on the website about prescription medicines.
Alex: Sure.
Danny: Ok. So how do you guys do those?
Alex: Ok, so we are luckily saved from a lot of high budget items from being more of an acute care clinic where most of the medications are priced fairly low. And, luckily I am a pharmacy student, so I can speak to some of this, I have been fairly involved in the process of setting this up. The way that our medication fund is funded is from a large grant from the American Colleges of Clinical Pharmacy a few years back for $15,000 for a pharmacy, slash dispensary for the medical clinic. And, so they generally spend around two to three thousand dollars a year on medicines for the medical clinic which, as far as free clinics go in the nation, and as far as student run free clinics go, is not a lot. But most other free clinics don’t use the same kind of acute care model or have sort of a more dedicated funding source. So we manage with about two to three thousand dollars a year.
Danny: And how many people, what percentage of patients do you think getting access to prescriptions?
Alex: Um, I would say easily over 50% and probably closer to 75%, if not more.
Danny: And what are the most common forms of medicine issued?
Alex: So, the biggest thing we will see is blood pressure medication. Just your various different classes of blood-pressure medication, which is just generic.
Danny: And what do you think that is from? Just unhealthy eating? Or inactivity?
Alex: The same reason that everyone in the population has high blood pressure, which is obviously all of the above.
Seve: That is more an environmental thing. I think there are a lot of environmental factors that go into high blood pressure, hypertension, etc.
Alex: Yea, some of the dermatological complaints that we do a good amount, as we mentioned they are some of the largest things we see. And, you have to account that we are only open one day a week. And so you…
Danny: What day?
Alex: Wednesday nights one day a week. And so patients that make appointments and do not show up are generally patients that have issues that resolve within one or two days. And so a patient will call with a fever or something and we will say, we will make an appointment but you should go see your doctor, and generally it will have resolved by the time of their appointment. The complaints that we see, we will see dermatological complaints, some sort of infection or fungus for the most part, and we have a lot of drugs formulated to treat that and so one of the issues of that is even access to care is a main reason that these patients go so long without getting these issues treated because they don’t have the time, or they don’t have the resources to go get that looked at.
Danny: And just for the record, in the people you treat, you assume that almost 100% of them are uninsured?
Alex: Yea, I would assume that, yea.
Seve: Well, thanks to get covered Carolina, (laughing), not a hundred percent, but yea its definitely…
Alex: When they come in the door it is one hundred percent. Maybe when they leave, Seve has insured them.
Danny: Ok. Nice. So you have the aspect of when someone comes through the door you find out whether or not they are eligible for healthcare? And what percentage of people do you think that walk through the doors of SHAC end up being eligible for healthcare?
Seve: That’s a great question. And so, that’s a very good question (laughing), and so in the Get Covered Carolina project we have staff in various facilities since October. So we have been working out of the SHAC medical clinic, the SHAC dental clinic, the Chapel Hill Public Library. We have been working out of a facility in Durham and them some other kinds of enrollment drives in Burlington. And so what we have found is that most of the people that come into our doors at the medical clinic, and to a lesser extent in the dental clinic, will fall into the Medicaid Gap, not be eligible for that financial assistance on the market place nor will they be eligible for North Carolina’s Medicaid program, as it currently stands. We have had a lot of success at the Chapel Hill Public Library in fact, enrolling people in Marketplace plans who have received financial assistance and a lot of succcess for the people enrolling in Durham, but a large majority of the people who come into the medical clinic and dental clinics fall into that gap, not only because they are undocumented, but mainly because of the income restraints they face.
Alex: I just wanted to make one comment on that. And so SHAC, another place we get a small amount of funding is from the North Carolina Association of Free Clinics, a ground of I want to say around 80-90 free clinics in the state of North Carolina who generally do what free clinics do. We are also in the same boat together. And, they just had their annual conference about a week ago, and one of the discussions was titled, “How is the Affordable Care Act affecting your patient population?”, are you going to see less patients? And just unanimously, anyone who is involved in free clinics is saying “No, we are seeing more patients. All of our patients are falling in the medical gap”.
Danny: More patients?
Alex: Yea, more patients. There is no, there is infinite demand for our services, the Affordable Care Act has caused us to see if not more, at least the same. It has made zero effect on, just the volume.
Danny: And is that due to Medicaid refusal and undocumented immigrants not being covered?
Seve: From the Get Covered Carolina standpoint, that is mainly the Medicaid problem, the lack of expansion in North Carolina. But, a lot of our patients we see would have qualified if they were in a state like Kentucky or West Virginia or New York or California. But, since North Carolina chose not to go forward with this, a lot of them don’t qualify because of income constraints, but, second to that I would say would be the immigration statuses.
Danny: Yup. Ok. So going back to something we discussed earlier with Get Covered Carolina. When an undocumented person walks in to SHAC on Wednseday night and you try and sign them up for Get Covered Carolina, how does that conversation go if that person ends up being undocumented?
Seve: That is a great question. So usually what happens is that every week we have a schedule of patients that will come into the medical clinic, and so my other project manager, Vic Goshi, and I will typically on Monday evenings call all of the patients on the schedule, and so typicall what will say is that, “Hey this is why were calling, this is a new service offered by the Federal Government”, things like that. And, if the consumers are receptive to that, if they do want those services, we will say, “Ok. These are the things that you need to bring”. And so, some of the things that you need to bring are income information, usually on a W2 or on any of your tax forms, social security numbers for everyone who is applying for health insurance coverage, and also if you are not a US citizens you need your green card or whatever other eligible immigration statuses. So, we tell that to consumers before that, before the medical clinic, and we find that people who may not have social security cards, or greencards, or passports, or things like that will decline our service. So, I don’t want to presume that they are undocumented, but in some instances that may be the case.
Danny: So it’s that phone call where you tell them what to bring, that is where it triggers the “Oh. That’s not me”?
Seve: Right. And then we also have posters up, kind of in the medical clinic waiting room, which says “you need to be a US citizen or have elligible US immigration status to receive financial assitance or qualify for Medicaid.
Danny: Do you guys, if someone, so it becomes clear to y’all who is not trying to sign up for healthcare?
Seve:To an extent.
Danny: Because you are offering the free service and if they dont bring the stuff in, you know like, they are probably not elligible. They know it themselves, either because of immigration status or finances. So, do you have resources at SHAC for people without healthcare? Do you advise people without healthcare?
Seve: We do. Fortunately, we have been fortunate to work with UNC Healthcare, throughout this past enrollment period of October to March. And, typically when we are working with them through enrollment drives or enrollment sessions and we have patients or consumers who fall into that Medicaid Gap, UNC Hospital will usually steer them in the direction of UNC Charity Care. And so Charity Care is pretty much a line item on UNC Healthcare’s budget that allows for certain qualifying individuals to receive healthcare services kind of on a sliding scale similar to how FDHC is charged, but Charity Care does not take into consideration, to my knowledge, immigration statuses and things like that. So if we have someone that fell into the Medicaid gap for instance, in North Carolina, and we were working with UNC internal medicine, we would refer them to Charity Care, and then typically they would be eligible for Charity Care for a year. And then they are able to renew subsequently after that.
Danny: Based on income? If they still fall into the Medicaid Gap?
Seve: Right. The stipulation is that the consumers have to at least try and apply to the marketplace first, in order to be eligible for Charity Care. But, that is usually how things will play out. Unfortunately, we don’t have access to thos Charity Care applications in the SHAC medical or dental clinics or anywhere else, so if that ever happens in the medical clinic our hands are kind of tied. And so we will kind of, we will try to advise them, even on UNC Charity Care, but it is not something that we can do, inside of the medical clinic.
Danny: Seems like a good, next interview, the Charity Care people to try and follow this process of how they would go about finding help. So, ok, one last question and then you guys can kind of both finish with final thoughts if you want. There is a thing in Latino Health Literature, especially with the undocumented. It is called the Hispanic Health Paradox and it is kind of confusing because people who cross the border and live here, although seemingly unhealthier, they actually live longer. There is a higher, its not a mortality rate, higher expected years of life. So from your work in SHAC, do you have any isnite into this Hispanic Health Paradox that has so confused scholars?
Alex: (laughing), Seve?
Seve: I’m reading briefly about this.
Danny: Take your time.
Alex: Now I was just reading about mortality rates in general, and, for a class, and I know that childhood mortality tends to unfailry skew overall mortality down. And I don’t know if that is necessarily being taken into account with this, the Hispanic Health Paradox and healthy migrants in general, wherever they come from, I don’t really see the data that much as well. And that is essentially what happened in the Middle Ages, once people got past two or three, they would live to their sixties or seventies. People werent dying at 34 or 35, it was just a large portion of people dying down younger. I wouldn’t say that, I don’t know why a specific population would necessarily have that type of…
Danny: It’s just interesting because people would expect them to have, just much lower life expectancies because they get sick and like, what do they do?
Alex: Yea, I’d say the US population, even though its not homogenous, but, there is physiologically, there is not a massive difference between ethnic groups and races. It would seem like it would have to be something more population based effect. For instance, people migrating are generally healthier, than people who arent.
Danny: Yea, that is one of the things they talk about. They also talk about sick people leaving and affecting the statistics.
Alex: Oh, that is interesting because if you were to get medical care you know you wouldn’t be able to get it in the country you aren’t a citizent of.
Danny: Yea, and Hispanic have this weird thing where, it’s very sad, they get sick and they just kind of give up much quicker than Americans, and so a lot of them return to their home countries.
Alex: And does some of it, maybe some of it depends on the type of medical care as well. I know culture obviously plays a big part and there is, at least I know in smaller villages in rural Mexico for even like a herbalist, not a doctor, where they have special teas, and there are actually, there is medication in those, not medications but plants that current drugs are derived from that are medicinal and sort of serve as like a stop gap in terms of bad healthcare, and I know that is one thing that at least Spanish Speakers or people of Spanish speakers in the family are more considerate of in our medical clinics and so I don’t know, it’s an interesting question. Seve, I am trying to buy you time so..
Seve: I don’t have any extremely insiteful thoughts. My, I guess when I think about the Hispanic Health Paradox, I try and relate that to the health outcome of people who identify with the African-American or black community in the United States. So there have been some research studies that show that infant mortality rates in the United States are higher than for people in an African country, I can’t remember which one. And researchers associated that kind of with racism, and in fact these demographic people in the United States sort of deal with racism and that’s why a lot of stress factors that have to deal with infant mortality and low borthweight babies, so maybe, I don’t know how that would really relate to the Hispanic Health Paradox. One would think that maybe that would be stressful for some in the undocumented community to get sick and then have to try and find medical care that would not result in their deportation. But, I am not sure why that is?
Danny: What about the idea that if you know you don’t have healthcare, you would live in a way that would lead you to less sickness or injury?
Seve: You know in economics there is that theory, you know, of moral hazard, in the sense that if you do receive health insurance coverage than you are more likely to engage in risky behavior. And, there is some evidence of that, and that is actually an interesting theory you proposed. But, I would like to look at the numbers, but that is plausible.
Danny: Yea, I was just wondering. You guys obviously have much more firsthand experience and exposure than I do.
Alex: Do you know, how significant is the effect in terms of …
Danny: It’s just like a year, maybe, a year or two more on the life expectancy, but they don’t have healthcare so you would assume it would be far lower. Alright, so that is it for my questions, but interview protocol. A lot of people have very interesting things to share in the end, so I guess I will open it up to you two. Who wants to go first?
Seve: Yea, so I guess I will go first. So, in terms of the SHAC Get Covered Carolina Project, I think that we tried to reach out to the communities that we thought would be of need, and who would benefit the most from gaining acess to affordable and quality health insurance coverage. It is unfortunate that we are not able to sign up more people for North Carolina’s Medicaid program. I think that would benefit a lot of the consumers and patients that we see in the Students for Health Action Coalition. And, with that said, even with the way the Affordable Care Act was written there is really no provision for undocumented people to obtain health insurance coverage. So, the way it stands now, even if you are undocumented, you can go on and purchase a private plan for full cost. They, like I said, when you enter in your information they will not share it with the Department of Homeland Security, so if I was undocumented I could go buy a Blue Cross, Blue Shield plan for my family, the problem being …
Danny: How much would it cost? A private plan?
Seve: It depends on your age, it depends on your family size, it depends on whether you smoke or not. So, obviously costs may be prohibitve with that. That may be, pretty much, the only provision in the Affordable Care Act in which undocumented immigrants or people with inelligible immigration statuses can get health insurance coverage.
Danny: What about employers?
Seve: So employers, typically, presumably if you work for an employer who is going to offer you health insurance coverage they are going to either use the E-verify system or have some other mechanism to determin whether or not you were here illegaly. So I don’t think that would be an option for this demographic. Ok, um, and I guess that is it for my statement.
Alex: My statement, (laughing). Obviously I am very happy that Seve was here to talk about the Get Covered Carolina project because I think, more than anything we’ve done in the past year or so, we have focused so much on this specific population that this project is interested in, I am really curious to see where this whole healthcare paradigm pans out and I am curious to see what SHAC’s role will be in the next five years. Our status, we are more of a community organization that is registered with the school as a campus organization more so supported directly or funded durectly by any sort of UNC system. And, so that gives us a lot of freedom in terms of what questions we need to ask or how we have to treat people. I don’t see that changing at any point, for the duration of this organization. It’s sort of the crux of what we are trying to be. I do see a shift, in where we are going, in providing the direct medical care we are offering, you know obviously the medical and dental clinics, to really focus on the more preventive care of things, which after guessing the Hispanic Health Paradox I guess we don’t need to focus on the Hispanic aspect of things (laughing), but ok. But, I see us focusing more on the preventive care in general, but that gives us a lot more oppurtunities as an organization to do what you said earlier, to get out into the communtiy and seeing what the non-medical needs or the bariers to medical care are. Such as, social support groups and stuff like that. And, I think SHAC is well positioned to do that without creating the stigma of a larger federal type organization. The other comment I thought would be interesting, I had it in my head a moment ago and now I forgot it, oh yes, that while we do a lot of good in the community, it is very much a small sample size, because regardless of what we do, and I think Seve can speak to this, like if he staid, if he just decided to stay open, regardless of whatever situation he was in, people would just come constantly, and that is the situation with our medical clinic. People would just be coming through constantly. And that is what every other free clinic in the state of North Carolina says too. Nobody is trying to drum up business for free medical care. So, I think the best thing that can happen when talking about organizations like us is trying to get really into that conversation on a larger level, because we are a barometer of what is going on, a barometer of essentially how we can change things, without necessrily having to jump through a lot of the larger hoops. And, in the past few years that is basically what we have been trying to do. We don’t have a lot of the same restrictions that a lot of larger organizations would have, in terms of making changes and trying to fix models or things like that, and so we are trying to make strides in the way that we deliver health services and the way that we deliver healthcare. And, hopefully, in the next couple of years we can start to put out that information and share it with people to establish some best practices for maybe even student organizations, or free clinics, or community health organizations. But, hopefully to really have some solid data on what’s working and not working to hopefully change some larger issues.
Danny: Alright. Its been great, that was a great interview. You did well.
Alex: Thank you.
Seve:Thank you so much.