Health Care Access for Latino Patients

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Health Care Access for Latino Patients

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Title: Health Care Access for Latino Patients

1
Health Care Access for Latino Patients

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

2
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3
Outline

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

4
Variable Specification WHAT IS A Hispanic /
LATINO????
5
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
6
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?

10
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.

11
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
13
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.

17
Factors That Influence Health Status
18

Health of Latinos

19
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

28
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

29
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

31
Summary 1

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

32
45.8 MillionUninsured (15.7)
33
New York City 2003
NYC 21 Uninsured 1.6 million 60 of uninsured
in NYS live in NYC
34
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

35
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

36
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
39
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
41
Insurance DataCoverage by Immigrant Type
Uninsured 8.9 million 2.3 million
32.3 million
Immigrants accounted for 26 of uninsured in US
42
Insurance Coverage among immigrants by length of
time in US
43
Racial/ethnic disparities in insurance coverage
by citizenship status
44
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
47
Health Coverage in NYC of Uninsured Children in
Immigrant Families
Source LANYC Immigrant Survey/ Urban Inst.
48
Health Coverage in NYC of Uninsured Adults
Source LANYC Immigrant Survey/ Urban Inst.
49
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
50
The Latino UninsuredFailure of the Private
Sector
Source Analysis of March 2002CPS Data
51
Health insurance among Latino Sub-Groups
52
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

53
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

54
Summary 2

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

55
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

56
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

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

58
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

59
The SolutionProposal of the Physicians'
Working Group for Single-Payer National Health
Insurance
60
United States Health Insurance Actaka H.R. 676
aka Conyers Bill
61
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
62
How much does it cost to cover the uninsured???
Hadley J, Health Affairs 2003W3-250-265
63
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.
64
Aaron HJ NEJM 2003349801-803
65
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

66
Racial/ Ethnic Disparities in Care at NY
Presbyterian Hospital

No health insurance call 1-800- Harlem Hosp

67
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

68
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

69
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

70
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

71
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

72
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

74
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

75
110,000 (se 20,000) kids Would gain coverage
(sens 100-140,000)
AJPH 2003931680-2
76
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
77
250,000 (se 40,000) adults Would gain coverage
(sens 200-310,000)
78
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

79
Health Care Expenditures of Immigrants
AJPH 2005 951431-8
80
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.

81
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.

82
Does insurance make a difference for immigrants?
83
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.

84
Figure 1
Prev Med 200439943-50
85
More results

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

86
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

87
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.