Health Care Access for Latino Patients

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Health Care Access for Latino Patients

• Olveen Carrasquillo, MD, MPH
• Director, Columbia Center for the Health of Urban
  Minorities

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Outline

• Variable Specification
• Latino Health Paradox
• Latino Uninsured
• The Solution
• CHUM Access to Care Research
• CHUM Advocacy

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Variable Specification WHAT IS A Hispanic /
LATINO????
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Hispanic Population in the US 32 million in
2000, 41 million in 2004

• Newer groups
• Dominicans 2.2
• Salvadoreans 1.9
• Columbians 1.3

• The Big 3
• Mexicans 59
• Puerto Ricans 9.6
• Cubans 3.5

???Spaniards 5
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Latinos in New York City

• 2.2 Million (27 of NYC pop)
• Bronx 48 Latinos (650,000)
• 49 PR, 21 Dom
• Manhattan 27 Latinos (420,000)
• 29 PR, 32 Dom
• Brooklyn 20 Latinos (490,000)
• 44 PR, 14 Dom, 12 Mex
• Queens 25 Latinos (555,000)
• 20 PR, 13 DR, 11 Columbian, 10 Peruvian

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Citizenship Status
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What is Access to Care

• What is it?
• Does it Matter?

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Dictionary Access to Care

• An individual's ability to obtain appropriate
  health care services. Barriers to access can be
  financial (insufficient monetary resources),
  geographic (distance to providers),
  organizational (lack of available providers) and
  sociological (e.g., discrimination, language
  barriers).
• Efforts to improve access often focus on
  providing/ improving health coverage.

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Andersons Behavioral Model of Access

• Predisposing Factors ethnicity, education income
• Need for health care health status, attitudes,
  perceptions
• Enabling characteristics health insurance,
  geography, providers

J Health Soc Behav 199536(1)1-10
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Eisenberg Model of Access to Quality Health Care
Source Eisenberg J. JAMA 20002842100-07
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Bierman Model

• Primary Access- barriers getting to system
• insurance, cost,
• Secondary Access- barriers within system
• Appointments, hours, access to specialists
• Tertiary Access- provider meeting patient needs
• Language, culture, provider skills

J Ambulatory Case Management 199821(3) 17-26
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Inwood and Washington Heights compared to40
other NYC neighborhoods
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Access to Care (table)
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Access to Care

• Many Inwood and Washington Heights residents have
  poor access to medical care
• about 20,000 people report no current health care
  coverage
• 34,000 people did not get needed medical care in
  the past year
• and 68,000 people do not have a personal doctor.

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Factors That Influence Health Status
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• Health of Latinos

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Diabetes Prevalence- diagnosed/undiagnosed

• Even after adjust weight, SES, Hispanics 2-3
  times more likely have DM

Luchsinger J. Diabetes in Health Issues in
the Latino Community, 2001
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The Latino Paradox
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Age Adjusted Death Rates
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Latino paradox

• Many studies link poverty to poor health
• Latinos are poorer than African Americans but
  have lower overall mortality rates, death from
  cancer and heart disease, infant mortality than
  AAs/ whites
• But--acculturation leads to poorer health outcomes

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Latino paradox

• What causes the paradox? Theories
• Healthy immigrant salmon hypotheses
• Strong social/family networks
• Low tobacco and ETOH use especially in women
• Religiosity
• Traditional healing practices
• Traditional diet
• ? Lack of Health care

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How US compares to DR
WHO World Health Report ,2004
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Health Care Access for Latino Patients

• Olveen Carrasquillo, MD, MPH
• Director, Columbia Center for the Health of Urban
  Minorities

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Summary 1

• Despite the rest of my talk showing access
  barriers. Latinos overall health is not that bad

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45.8 MillionUninsured (15.7)
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New York City 2003
NYC 21 Uninsured 1.6 million 60 of uninsured
in NYS live in NYC
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Is Health Insurance Important??

• Of all the determinants of access to care
  insurance is by far most important !!!!
• Less likely to have usual source of care
• More likely to have unmet health care needs
• More likely to rely on emergency room for care
• Less likely to have preventive health services-
  Pap smears, mammograms, immunizations
• Higher adjusted mortality rates
• Higher preventable hospitalization rates

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The IOM Disparities Report

• Charge Assess the extent of racial and ethnic
  differences in health care that are not otherwise
  attributable to known factors such as access to
  care (insurance /ability to pay)
• This is somewhat artificial as many access-
  related factors affect the quality and intensity
  of health services.
• These access-related factors are likely the most
  significant barriers to equitable care and must
  be addressed as an important first step to
  eliminating disparities

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Source US Bureau of the Census
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Change in Uninsured (1,000)
Source Harell Carrasquillo JAMA 2003 28991167
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NHWs No longer a majority of the
uninsuredTrends in composition of uninsured
population

• 1987
• NHWS 58
• Blacks 19
• Hispanics 19
• Asians 3

• 2004
• NHWS 48
• Blacks 16
• Hispanics 30
• Asians 5

Source Current Population Surveys
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LATINO UNINSURED
Source Analysis of March 2002CPS Data
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NYS Insurance coverage by Hisp. Sub-group
N 925,000 650,000
300,000 800,000
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Insurance DataCoverage by Immigrant Type
Uninsured 8.9 million 2.3 million
32.3 million
Immigrants accounted for 26 of uninsured in US
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Insurance Coverage among immigrants by length of
time in US
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Racial/ethnic disparities in insurance coverage
by citizenship status
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Insurance coverage among Hispanic sub-groups by
citizenship status
Source March 2001CPS
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New York City
Source Analysis of March 2003CPS Data
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Health Coverage in NYC of Uninsured Children in
Immigrant Families
Source LANYC Immigrant Survey/ Urban Inst.
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Health Coverage in NYC of Uninsured Adults
Source LANYC Immigrant Survey/ Urban Inst.
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Latino Advocacy

• Primary Access- barriers getting to system
• insurance, cost
• Secondary Access- barriers within system
• Appointments, hours, access to specialists
• Tertiary Access- provider meeting patient needs
• Language, culture, provider skills

J Ambulatory Case Management 199821(3) 17-26
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The Latino UninsuredFailure of the Private
Sector
Source Analysis of March 2002CPS Data
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Health insurance among Latino Sub-Groups
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Why the Uninsured Failure of the private sector

• 61 of Hispanics work for an employer who offers
  coverage vs 89 of NHWs
• Insurance take-up rate for Hispanics same as NHWs
  at 82
• Reasons for not having insurance among working
  Hispanics
• 75 not offered by employer
• 16 part time /do not qualify
• 8 premiums too expensive
• 1 did not feel insurance important
• Types of occupation
• lower-income occupations
• small businesses, service sector, agriculture

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Why the Uninsured Failure of the private sector

• 70 of difference in overall employer coverage
  rates between Hispanics and whites is
  attributable to offer rates
• Zuvekas et al, Health Affairs
  200322(2)139-153
• Lower offer rates are due to types of jobs they
  hold
• Monheit and Vistenes

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Summary 2

• Lack of insurance is the major access barrier for
  Latinos
• Immigrants worst off
• Due to lack of employer coverage

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Is private sector insurance a solution??

• Employer Coverage continues to decrease
• Medicaid enrollment is increasing
• tax rebates- amounts too small
• 2,000 rebate for 7,000 policy?? (Empire, HIP,
  Horizon
• Bare bones policy- 3600 (Horizon)
• 3,000 deductible, 20-50 off drugs
• small business pooling- may help higher income
  employees
• for 5,000 policy cost 2.50/hr
• Healthy NY Family Monthly Rates 580-660
• Small business demonstration project
• 255/month, only HHC providers in select sites

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Why Private Sector will continue to fail

• Private Sector unable to contain costs
• managed care did not contain costs
• Insurance premiums rising 15 annually
• Employers re-thinking their role in providing
  insurance
• Employee contributions increasing
• Defined Contribution Plans
• Make health consumers more price sensitive
• Heritage Foundation and HIAA both agree that for
  the poor/sick expansion of government insurance
  programs are needed (however feel that healthy
  and non-poor should be covered by private plans)
• Medicaid managed care- now run by non profits
• Medicare managed care- a failure

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• Is the Incremental Public Sector Reform a
  solution??? e.g. Medicaid / SCHIP
• SCHIP over 4 million children enrolled
• improves access to care
• Lack of awareness is problem but main obstacle is
  bureaucratic barriers- real and perceived
• Like Medicaid has the end welfare mentality
• temporary transient patchwork
• Nothing like employer insurance
• enrollment is not automatic
• dis-enrollment is guaranteed unless conditions
  are met
• in NY Child Health Plus 50 of children up for
  re-certification dis-enrolled
• Politically weak group will always be vulnerable

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Medical Consumerism

• Main problem in US health care system is cost/
  too much care
• Let consumers decide what they want and how much
  they want to pay for it
• Type and level of insurance coverage you have
  will depend on your income/ ability to buy it
• Employers increasing co-payments, Deductibles
• Will decrease use of un-necessary care
• Will equally decrease use of necessary care
• MSAs- leaves sickest costliest in traditional
  insurance pools

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The SolutionProposal of the Physicians'
Working Group for Single-Payer National Health
Insurance
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United States Health Insurance Actaka H.R. 676
aka Conyers Bill
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What is Covered under NHI

• primary care and prevention
• inpatient care
• outpatient care
• emergency care
• prescription drugs
• durable medical equipment

• long term care
• mental health services
• dental services
• substance abuse treatment services
• chiropractic services
• basic vision care and vision correction

Private insurers could provide coverage for items
not covered by NHI
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How much does it cost to cover the uninsured???
Hadley J, Health Affairs 2003W3-250-265
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An expansion of this magnitude would
increase health spendings share of gross
domestic product (GDP) by less than one
percentage point, from 14.1 percent of GDP to
14.514.9 percent. In spite of its large
absolute value, is much lower than the expected
average annual revenue loss of almost 170
billion from federal tax cuts enacted since
2001 Our analysis noted that a substantial
amount is already being spent on care received by
uninsured people. A potentially important
implication of a comprehensive rather than
incremental approach to covering all of the
uninsured is that the existing public money
already being used to pay for care received by
the uninsured will be very difficult to capture
or reallocate if insurance expansion is
piecemeal. Providers treating the uninsured will
be loath to relinquish their existing subsidies
unless they are assured that everyone will be
insured.
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Aaron HJ NEJM 2003349801-803
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Summary slide 3

• We need National Health Insurance!!!
• There is more to it than insurance
• Cultural competency
• Linguistic Issues
• Workforce diversity
• Health beliefs / attitudes
• Discrimination / Bias system and providers

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Racial/ Ethnic Disparities in Care at NY
Presbyterian Hospital

• No health insurance call 1-800- Harlem Hosp

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Case Report 1

• JS, 55 yr H F on routine mammo had suspicion for
  malignancy, biopsy - ca
• Breast clinic meets once per week, totally booked
  next week then holiday then totally booked can
  see her in one month one month wont really make
  a difference
• Private breast surgeon secretaries sorry do not
  take Medicaid, no way will they see her must go
  to clinic
• Befriend one Spanish secretary, beg, beg, allows
  me speak to surgeon agrees see her but must
  follow up in clinic
• Pt in OR 2 days later

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Case Report 2

• DC, 77yo F daughter prominent cardiologist
• Needs knee replacement, has Medicaid
• Clinic waits 1 month told take pain meds get PT,
  chart documents did not want surgery
• Get her to private ortho
• 1 I do nor care who is of her son or where she
  lives if she has Medicaid must go to clinic
• 2 I once saw a Medicaid patient as a personal
  favor, it was a one shot deal
• Clinic explained will be done by trainee and all
  surgical risks reviewed in extensive detail

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Case 3

• CHF fellowship program ends
• We think AIM patients are best served by being
  re-integrated back with the regular cardiology
  clinic (3 month wait for appt)
• He has Empire Blue
• Oh..Why didnt you say so.
• Dr. __ can see him next week

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Case 4

• 52 yo Male with sz none x 3 yrs now 2 sz past 2
  months with nl drug levels
• Seen 8/31
• EEG 10/26
• Neuro clinic 11/3
• MRI have to call

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What is CHUMs Access Core Doing About it?

• Research!!!!
• In UK when there is a problem money is given to
  solve itIn US When there is a problem is
  given to study it, study it and study it again

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Ten Year Trends In Health Insurance Coverage
Among Latinos
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Barring immigrants from government
insuranceInitiatives circa 1996/97

• 1996 Personal Responsibility Welfare Reform
• All public benefits barred for 5 years after
  entry
• SSI/ Food Stamps only for US citizens
• States could limit/bar all state public benefits
  to legal immigrants
• INS could get any info from any government
  agency
• 1997 BBA
• Restored many public benefits to legal immigrants
  
• Immigrants arriving before 1996 Medicaid state
  option, feds would contribute
• Immigrants in US lt 5 years get no federal money
  for Medicaid, states can do what they want with
  their own money

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Should we repeal the 5 year ban???

• So how many kids are barred from Medicaid / SCHIP
• How many adults would be excluded from expansion
  programs

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110,000 (se 20,000) kids Would gain coverage
(sens 100-140,000)
AJPH 2003931680-2
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Results

• 1.1 million children in US lt 5 yrs
• 460,000 (38) uninsured
• 110,000 (se 20,000) of uninsured financially
  eligible for Medicaid/ CHIP live in state where
  do not qualify due to immigration status- after
  adjust for undocumented
• 110,000 uninsured, and qualify based on income
  and state of residence
• In states where they are income eligible 30
  private insurance, 25 government and 45
  uninsured

AJPH 2003931680-2
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250,000 (se 40,000) adults Would gain coverage
(sens 200-310,000)
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Conclusions

• Repealing the 5 yr rule as part of a CHIP
  expansions program would allow about 360,000
  adults and children to qualify for coverage
• Is that too big or too small
• Fear/misperception much greater impact than
  policies

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Health Care Expenditures of Immigrants
AJPH 2005 951431-8
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NYC Health Security Act

• Health Insurance and Expenditures Among Low-Wage
  Workers in
• New York City
• Columbia Center for the Health of Urban
  Minorities
• Access to Care Core Working Paper 1
• Sherry Glied, PhD
• Bisundev Mahato, A.B.

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Principal Findings

• Rates of uninsurance among low-wage workers are
  highest among Hispanics and Asians. Of
  particular concern, some 57 of Hispanic low-wage
  workers lack health insurance.
• Over 2/3 of uninsured low-wage workers are
  employed in the retail or service industries or
  in sales and service occupations in other
  industries.
• Job-based coverage for low-wage workers has
  eroded, falling over 1.5 percentage points in New
  York City just since the late 1990s.
• Taxpayers and providers in New York City pay an
  estimated 612 million each year for health care
  services provided to uninsured and publicly
  insured working New Yorkers and their families.
  Of this, 466 million is for low-wage workers and
  their families.

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Does insurance make a difference for immigrants?
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Specific Aim

• In this paper we examine the impact of lack
  of insurance and USC on cancer screening
  disparities between immigrants and US born women.

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Figure 1
Prev Med 200439943-50
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More results

• Uninsured recent immigrants were less likely than
  US born to have Pap smears (60 SE 7 versus
  79 (SE 2)

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Policy Implications

• While the short term outlook for universal
  coverage in this country remains bleak, more
  targeted initiatives are possible. For example
  repeal of the the immigrant provisions of the
  Personal Responsibility Work Opportunity enjoys
  some bi-partisan support in congress
• Targeting health insurance enrollment and
  retention outreach in these states to recent
  immigrants may also be an effective strategy to
  narrow disparities
• Culturally appropriate initiatives informing
  uninsured recent immigrants about available
  safety net providers and other programs that
  provide cancer screening for uninsured women such
  as the Center for Disease Controls Early
  Detection Programs could also help narrow
  disparities

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Objectives

• To describe differences in pap smear and
  mammography screening due to citizenship status
  using a nationally representative sample
• We hypothesized that after adjusting for
  potential confounders, foreign-born noncitizens
  would remain less likely to receive cancer
  screening than foreign-born citizens or U.S.-born
  individuals.
• We also examine if acculturation is related to
  screening among immigrant females after adjusting
  for other potential covariates.

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What is CHUM Doing?

• Research!!!!
• Advocacy
• Talks
• More Talks
• Photo -ops

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Status of NYC Health Care Security Act

• Olveen participated in Steps of City Hall Press
  Conference
• Legislation passed only for retail/ grocery /
  food industry
• Impact very limited
• Passed City Council 46-5
• Bloomberg will veto it

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Advocacy Strategies

• Increase awareness of NHI among Latino media
• Overcome Myth Latinos Do not Support NHI
• Advocacy by Minority Professional Organizations
  is doubtful
• Latinos for National Health Insurance
• Congressional Testimony
• CHCI, CBC

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Working with the Community Data that is locally
useful

• Latino Uninsured by Borough
• How many Dominicans are uninsured?
• How many Latino elders in NY lack supplementary
  coverage?
• Community Lectures!!!
• Dominican American Round table

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What is CHUM Doing?

• Research!!!!
• Advocacy
• ? Any Real Progress

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A little outside the box

• List of Sources of Care for uninsured
• Not screening services!!!!!
• Where and How
• Sources of Medications for the Uninsured
• Explicit institutional policies for uninsured
• Remind CBOs their opinions matter
• Web site for insurance qualification
• Navigators for Insurance Coverage

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What are PS Students doing

• CoSMO -Free clinic for uninsured
• CHUM cannot help???
• Medical Director sponsorship on curriculum on
  working with uninsured populations

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Main Points

• Latino Paradox
• Its Health Insurance Stupid!!
• We need National Health Insurance
• There is more to it than just insurance
• There is some role for researchers in Advocacy

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E-mail nmp1_at_columbia.edu oc6_at_columbia.edu