Outline Variable Specification Latino Health Paradox Latino Uninsured “The Solution” CHUM Access to Care Research CHUM Advocacy
Variable Specification: WHAT IS A Hispanic / LATINO????
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
What is Access to Care What is it? Does it Matter?
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
Source: Eisenberg J. JAMA 2000;284:2100-07 Eisenberg Model of Access to Quality Health Care
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
Inwood and Washington Heights compared to 40 other NYC neighborhoods
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.
Diabetes Prevalence- diagnosed/undiagnosed Even after adjust weight, SES, Hispanics 2-3 times more likely have DM Whites12% Blacks19% Mexicans24% Puerto Ricans26% Cubans16% Luchsinger J. “Diabetes” in Health Issues in the Latino Community, 2001
Age Adjusted Death Rates MaleFemale NHWs1,022710 Blacks1,341902 Hispanic767518
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 ExpectancyHealth Expenditures USA77 yrs$ 5,635 13% GDP Dom Rep68 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 NYC 21% Uninsured= 1.6 million 60% 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
NHWs: No longer a majority of the uninsured: Trends 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
LATINO UNINSURED Source: Analysis of March 2002CPS Data
New York City Source: Analysis of March 2003CPS Data
Health Coverage in NYC % of Uninsured Children in Immigrant Families All11% Citizen children8% 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% Undocumented79% 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 Source: Analysis of March 2002CPS Data
Hisp Sub-Group % with Employer Insurance % With Gov. Insurance % Uninsured Mexicans41%23%36% PR47% 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
The Solution: Proposal of the Physicians' Working Group for Single- Payer National Health Insurance
United States Health Insurance Act aka H.R. 676 aka Conyer’s Bill
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
Hadley J, Health Affairs 2003;W3-250-265 How much does it cost to cover the uninsured???
An expansion of this magnitude would increase health 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 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.
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
1993199519971999200020022003CI b NHWs 11.911.512.011.09.610.711.10.2 Latinos 31.633.334.233.432.932.432.70.7 Sub- Group. Mexican 34.136.436.936.136.235.036.00.9 PR 17.917.620.216.516.717.916.31.9 Cuban 21.819.717.220.019.42220.127.116.11 Domin. 33.434.1 32.726.929.725.64.3 Other 32.234.836.732.431.932.932.61.8 Immig US born 22.724.825.423.622.621.920.90.8 Nat Cit. 26.525.827.224.725.425.924.82.2 Non-cit 50.052.055.954.955.955.558.61.4 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
110,000 (se 20,000) kids Would 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
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
Health Care Expenditures of Immigrants AJPH 2005; 95:1431-8
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.
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.
Does insurance make a difference for immigrants?
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.
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 WomenLatina Women Only Pap Smear Mammography Pap Smear Mammograp hy Unadjust N=11,673N=4,421 N=2,26 1 N=553 US-Born 87798273 Naturalize d 82 a 73 a 84 c 74 c Non- Citizen 71 b 58 b 70 b 52 a Model 1 d N=11,141N=4,112 N=2,15 9 N=503 US-Born 87788372 Naturalize d 81 b 75 c 82 c 75 c Non- Citizen 72 b 64 b 70 b 58 c
All WomenLatina Women Only Pap Smear Mammography Pap Smear Mammography Model 2 e N=11,103N=4,098N=2,151N=501 US-Born 87788170 Naturalize d 81 b 76 c 81 c 73 c Non- Citizen 76 b 71 c 73 b 67 c Model 3 f N=2,151N=501 US-Born 7866 Naturalize d 81 c 73 c Non- Citizen 77 c 72 c
What is CHUM Doing? Research!!!! Advocacy – Talks –More Talks –Photo -ops
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
What is CHUM Doing? Research!!!! Advocacy ? Any Real Progress
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