Health Care Access for Latino Patients Olveen Carrasquillo, MD, MPH Director, Columbia Center for the Health of Urban Minorities
Health Care Access for Latino Patients
Olveen Carrasquillo, MD, MPH
Director, Columbia Center for the Health of Urban Minorities
Outline
• Variable Specification
• Latino Health Paradox
• Latino Uninsured
• “The Solution”
• CHUM Access to Care Research
• CHUM Advocacy
Hispanic Population in the US: 32 million in 2000, 41 million in 2004
The Big 3
Mexicans 59%
Puerto Ricans 9.6%
Cubans 3.5%
Newer groups
Dominicans 2.2%
Salvadoreans 1.9%
Columbians 1.3%
???Spaniards 5%
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
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.
Anderson’s 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 1995;36(1):1-10
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 1998;21(3); 17-26
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.
10%
88%
20%
4%
20%
4%
50%
4%
0%
25%
50%
75%
100%
Determinants Expenditures
BehaviorsGeneticsEnviromentAccess to Care
Factors That Influence Health Status
Diabetes Prevalence- diagnosed/undiagnosed
• Even after adjust weight, SES, Hispanics 2-3 times more likely have DM
Whites 12%
Blacks 19%
Mexicans 24%
Puerto Ricans 26%
Cubans 16%
Luchsinger J. “Diabetes” in Health Issues in theLatino Community, 2001
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
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
How US compares to DR
Life Expectancy Health Expenditures
USA 77 yrs $ 5,635
13% GDP
Dom Rep 68 yrs $353
6.1% GDP
WHO World Health Report ,2004
Health Care Access for Latino Patients
Olveen Carrasquillo, MD, MPH
Director, Columbia Center for the Health of Urban Minorities
Summary #1
• Despite the rest of my talk showing access barriers…. Latino’s overall health is not that bad
New York City: 2003
County % Uninsured
Bronx 24%
Brooklyn 24%
Manhattan 15%
Queens 25%
Staten Island 15%
Upstate 11%
NYC 21% Uninsured= 1.6 million60% of uninsured in NYS live in NYC
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
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
Racial and Ethnic Disparities inHealth Insurance Coverage :2004
11%
20% 19%
33%
0%
10%
20%
30%
40%
NHW's Blacks Asians Hispanics
Source: US Bureau of the Census
Change in # Uninsured (1,000)
1992 2004Hispanics 8,441 13,678Blacks 6,567 7,186NHWs 21,719 21,983
Source: Harell & Carrasquillo JAMA 2003 289;9:1167
NHWs: No longer a majority of the uninsured:
Trends in composition of uninsured population1987
NHWS 58%
Blacks 19%
Hispanics 19%
Asians 3%
2004
NHWS 48%
Blacks 16%
Hispanics 30%
Asians 5%
Source: Current Population Surveys
Latino Uninsured
36%
18% 19%
26%
33%
0%
5%
10%
15%
20%
25%
30%
35%
40%
Mexicans PR Cuban Dominican Other
% U
nins
ure
dLATINO UNINSURED
Source: Analysis of March 2002CPS Data
16%
28%
53%
32%
0%
20%
40%
60%
Puerto Ricans Dominicans Mexicans Other Hisp
% U
nins
ured
NYS: Insurance coverage by Hisp. Sub-group
N= 925,000 650,000 300,000 800,000
Insurance DataCoverage by Immigrant Type
43%
18%13%
0%
20%
40%
60%
Not US Citizens Became US Citizens US Born
# Uninsured 8.9 million 2.3 million 32.3 million
Immigrants accounted for 26% of uninsured in US
Insurance Coverage among immigrants by length of time in US
48%
41%39%
25%28% 28%
20%
12%
0%
20%
40%
60%
< 5 yrs 5-10 yrs 10-15 yrs > 15 yrs
% U
nins
ured
Not US CitBecame US Cit
10%
18%
23%
14%
22%
36%
55%
26%
0%
20%
40%
60%
NHWs Blacks Hispanic Asians
% u
nins
ured
US citizens
Non-citizens
Racial/ethnic disparities in insurance coverage by citizenship status
10%
16%
25%
15%
20%
59%
30%
48%
0%
20%
40%
60%
80%
NHWs PRs Mexicans Cubans Other
% U
nins
ured
US citizens
Non-citizens
Insurance coverage among Hispanic sub-groups by citizenship status
Source: March 2001CPS
Country % Unins. Country % Unins. Mexico 53% Vietnam 23% Guatemala 52% China 21% El Salvador 48% India 16% Haiti 33% Philippines 12% Dom Rep 32% Germany 12% Korea 25% Italy 9% Cuba 24% England 9%
21%18% 17% 18%
42%
36%34%
44%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Bronx Manhattan Brooklyn Queens
% U
nin
sure
d
Citizens
Non cit
New York City
Source: Analysis of March 2003CPS Data
Health Coverage in NYC% of Uninsured Children in Immigrant Families
All 11%
Citizen children 8%
Non- citizen children
28%
Source: LANYC Immigrant Survey/ Urban Inst.
Health Coverage in NYC% of Uninsured Adults
Naturalized
Citizens
21%
Permanent residents
41%
Refugees /Assylees
41%
Undocumented 79%
Source: LANYC Immigrant Survey/ Urban Inst.
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 1998;21(3); 17-26
The Latino Uninsured:Failure of the Private Sector
Hispanics
Blacks
NHW Employer Provided1 43% 54% 70% Government Insurance 26% 31% 24% Medicaid2 18% 21% 7%
Source: Analysis of March 2002CPS Data
HispSub-Group
% with Employer Insurance
% With Gov.
Insurance
% Uninsured
Mexicans 41% 23% 36%
PR 47% 38% 18%
Cuban
Dominican
47%
38%
34%
41%
19%
26%
Health insurance among Latino Sub-Groups
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
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 2003;22(2);139-153
• Lower offer rates are due to types of jobs they hold– Monheit and Vistenes
Summary # 2
• Lack of insurance is the major access barrier for Latinos
• Immigrants worst off
• Due to lack of employer coverage
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
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
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• MSA’s- leaves sickest costliest in traditional
insurance pools
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
An expansion of this magnitude would increasehealth spending’s share of gross domestic product (GDP) by less than one percentage point, from 14.1 percent of GDP to 14.5–14.9 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 spenton 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 areassured that everyone will be insured.
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
Racial/ Ethnic Disparities in Care at NY Presbyterian Hospital
• No health insurance call 1-800- Harlem Hosp
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 won’t 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
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
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 didn’t you say so….
• Dr. __ can see him next week
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
What is CHUM’s Access Core Doing About it?
• Research!!!!– In UK when there is a problem money is given
to solve it…In US When there is a problem $$$ is given to study it, study it and study it again
1993 1995 1997 1999 2000 2002 2003 CIb
NHWs 11.9 11.5 12.0 11.0 9.6 10.7 11.1 0.2
Latinos 31.6 33.3 34.2 33.4 32.9 32.4 32.7 0.7
Sub-Group.
Mexican 34.1 36.4 36.9 36.1 36.2 35.0 36.0 0.9
PR 17.9 17.6 20.2 16.5 16.7 17.9 16.3 1.9
Cuban 21.8 19.7 17.2 20.0 19.4 21.2 22.5 3.3
Domin. 33.4 34.1 34.1 32.7 26.9 29.7 25.6 4.3
Other 32.2 34.8 36.7 32.4 31.9 32.9 32.6 1.8
Immig
US born 22.7 24.8 25.4 23.6 22.6 21.9 20.9 0.8
Nat Cit. 26.5 25.8 27.2 24.7 25.4 25.9 24.8 2.2
Non-cit 50.0 52.0 55.9 54.9 55.9 55.5 58.6 1.4
Ten Year Trends In Health Insurance Coverage Among Latinos
Barring immigrants from government insurance:Initiatives 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 < 5 years get no federal money for
Medicaid, states can do what they want with their own money
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
Figure 1.
1.1 million Immigrant children less than 5 years in US
540,000 have insurance 460,000 uninsured children 150,000 310,000 possibly legally admitted undocumented and uninsured 80,000 230,000 not eligible for meet income eligibility Medicaid/CHIP guidelines for Medicaid/CHIP Due to income 110,000 110,000 Qualify based on state policy live in state where Medicaid Regarding CHIP/ Medicaid and or CHIP not available to newly To newly arrived immigrant arrived immigrant children
children, but not enrolled
110,000 (se 20,000) kidsWould gain coverage (sens 100-140,000)
AJPH 2003:93:1680-2
Results
• 1.1 million children in US < 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 2003:93:1680-2
Figure 2
.
4.0 million Immigrant adults less than 5 years in US
2.0 million have insurance 2.0 milllion uninsured 560,000 1.44 million 1.1 million possibly legally admitted do not have Medicaid/ undocumented and uninsured CHIP eligible children
100,0000 50.000
do not meet 250,0000 as adults meet Medicaid/ CHIP Medicaid income
guideliines newly eligible guidelines
90,000 100,000
have kids who already receive have recently arrived non-citizen kids or are already eligible to receive who meet Medicaid/ CHIP criteria Medicaid .CHIP
250,000 (se 40,000) adults
Would gain coverage
(sens 200-310,000)
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
NYC Health Security Act
Health Insurance and Expenditures Among Low-Wage Workers in
New York CityColumbia Center for the Health of Urban
MinoritiesAccess to Care Core: Working Paper #1
Sherry Glied, PhDBisundev Mahato, A.B.
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.
•
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.
Figure 1
50%
70%
90%
Pap Mammo Pap Mammo Pap Mammo Pap Mammo
All females age 18-70 Have Insurance Have source of care Adj. Percent
< 10 Yrs > 10Yrs US born
Prev Med 2004:39:943-50
More results
• Uninsured recent immigrants were less likely than US born to have Pap smears (60% [SE 7%] versus 79% (SE 2%)
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 Control’s Early Detection Programs could also help narrow disparities
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.
All Women Latina Women Only
Pap Smear
MammographyPap Smear
Mammography
UnadjustN=11,673 N=4,421
N=2,261
N=553
US-Born87 79 82 73
Naturalized 82a 73 a 84c 74c
Non-Citizen 71b 58 b 70b 52a
Model 1d
N=11,141 N=4,112N=2,15
9N=503
US-Born87 78 83 72
Naturalized 81b 75c 82c 75c
Non-Citizen 72 b 64 b 70b 58c
All Women Latina Women Only
Pap Smear
MammographyPap Smear
Mammography
Model 2e
N=11,103 N=4,098 N=2,151 N=501
US-Born87 78 81 70
Naturalized 81b 76c 81c 73c
Non-Citizen 76b 71c 73b 67c
Model 3f
N=2,151 N=501
US-Born78 66
Naturalized 81c 73c
Non-Citizen 77 c 72 c
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
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
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
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
What are P&S Students doing
• CoSMO -Free clinic for uninsured
• CHUM cannot help???
• Medical Director sponsorship on curriculum on working with uninsured populations
Main Points
• Latino Paradox
• It’s Health Insurance Stupid!!
• We need National Health Insurance
• There is more to it than just insurance
• There is some role for researchers in Advocacy
E-mail:[email protected]@columbia.edu