Transcript Health Care Access for Latino Patients

Health Care Access
for Latino Patients
Olveen Carrasquillo, MD, MPH
Director, Columbia Center for the
Health of Urban Minorities
Outline
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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
Citizenship Status
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
Eisenberg Model of Access to Quality Health Care
Source: Eisenberg J. JAMA 2000;284:2100-07
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 (table)
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.
Factors That Influence Health Status
100%
75%
4%
4%
4%
50%
50%
20%
25%
0%
88%
20%
10%
Determinants
Expenditures
Behaviors
Genetics
Enviroment
Access to Care
Health of Latinos
Diabetes Prevalencediagnosed/undiagnosed
Whites
12%
Blacks
19%
Mexicans
24%
Puerto Ricans
26%
Cubans
16%
• Even after adjust weight, SES,
Hispanics 2-3 times more likely have
DM
Luchsinger J. “Diabetes” in Health Issues in the
Latino Community, 2001
The Latino Paradox
Age Adjusted Death Rates
Male
Female
NHWs
1,022
710
Blacks
1,341
902
Hispanic
767
518
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
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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
45.8 Million
Uninsured
(15.7%)
New York City: 2003
County
% Uninsured
Bronx
24%
Brooklyn
24%
Manhattan
15%
Queens
25%
Staten Island
15%
Upstate
11%
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 !!!!
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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 in
Health Insurance Coverage :2004
40%
33%
30%
20%
19%
Blacks
Asians
20%
11%
10%
0%
NHW's
Hispanics
Source: US Bureau of the Census
Change in # Uninsured (1,000)
Hispanics
Blacks
NHWs
1992
8,441
6,567
21,719
Source: Harell & Carrasquillo JAMA 2003 289;9:1167
2004
13,678
7,186
21,983
NHWs: No longer a majority of the
uninsured:
Trends in composition of uninsured population
1987
2004
NHWS
58%
Blacks
19%
Hispanics 19%
Asians
3%
NHWS
48%
Blacks
16%
Hispanics 30%
Asians
5%
Source: Current Population Surveys
LATINO UNINSURED
Latino Uninsured
40%
36%
33%
35%
% Uninsured
30%
26%
25%
20%
18%
19%
PR
Cuban
15%
10%
5%
0%
Mexicans
Dominican
Other
Source: Analysis of March 2002CPS Data
NYS: Insurance coverage by Hisp. Sub-group
% Uninsured
60%
53%
40%
32%
28%
20%
16%
0%
Puerto Ricans
N= 925,000
Dominicans
Mexicans
Other Hisp
650,000
300,000
800,000
Insurance Data
Coverage by Immigrant Type
60%
43%
40%
18%
20%
13%
0%
Not US Citizens
# Uninsured 8.9 million
Became US Citizens
2.3 million
US Born
32.3 million
Immigrants accounted for 26% of uninsured in US
Insurance Coverage among immigrants
by length of time in US
60%
48%
% Uninsured
41%
40%
28%
39%
28%
25%
20%
20%
12%
0%
< 5 yrs
5-10 yrs
10-15 yrs
> 15 yrs
Not US Cit
Became US Cit
Racial/ethnic disparities in insurance
coverage by citizenship status
60%
55%
US citizens
Non-citizens
% uninsured
40%
36%
26%
23%
22%
18%
20%
14%
10%
0%
NHWs
Blacks
Hispanic
Asians
% Uninsured
80%
Insurance coverage among Hispanic subgroups by citizenship status
60%
US citizens
Non-citizens
59%
48%
40%
30%
25%
20%
20%
16%
15%
10%
0%
NHWs
PRs
Mexicans
Cubans
Other
Source: March 2001CPS
Country
Mexico
Guatemala
El Salvador
Haiti
Dom Rep
Korea
Cuba
% Unins.
53%
52%
48%
33%
32%
25%
24%
Country
Vietnam
China
India
Philippines
Germany
Italy
England
% Unins.
23%
21%
16%
12%
12%
9%
9%
New York City
50%
45%
44%
42%
40%
36%
% Uninsured
35%
34%
30%
25%
Citizens
Non cit
21%
18%
20%
17%
18%
15%
10%
5%
0%
Bronx
Manhattan Brooklyn
Queens
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
Permanent
residents
21%
Refugees
/Assylees
41%
Undocumented
79%
41%
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
1
Employer Provided
Government Insurance
2
Medicaid
Hispanics
43%
Blacks
54%
NHW
70%
26%
18%
31%
21%
24%
7%
Source: Analysis of March 2002CPS Data
Health insurance among Latino Sub-Groups
Hisp
Sub-Group
% with Employer
Insurance
% With
Gov.
Insurance
% Uninsured
Mexicans
41%
23%
36%
PR
47%
38%
18%
Cuban
47%
34%
19%
Dominican
38%
41%
26%
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 SinglePayer 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
How much does it cost to cover the uninsured???
Hadley J, Health Affairs 2003;W3-250-265
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.
Aaron HJ NEJM 2003;349:801-803
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
Ten Year Trends In Health Insurance Coverage Among Latinos
1993
1995
1997
NHWs
11.9
11.5
12.0
Latinos
31.6
33.3
Mexican
34.1
PR
1999
2003
CIb
2000
2002
11.0
9.6
10.7
11.1
0.2
34.2
33.4
32.9
32.4
32.7
0.7
36.4
36.9
36.1
36.2
35.0
36.0
0.9
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
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
SubGroup.
Immig
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
110,000 (se 20,000) kids
Would gain coverage
(sens 100-140,000)
460,000 uninsured
children
150,000
possibly
undocumented
310,000
legally admitted
and uninsured
80,000
not eligible for
Medicaid/CHIP
Due to income
230,000
meet income eligibility
guidelines for Medicaid/CHIP
110,000
Qualify based on state policy
Regarding CHIP/ Medicaid
To newly arrived immigrant
children, but not enrolled
110,000
live in state where Medicaid
and or CHIP not available to newly
arrived immigrant children
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
250,000 (se 40,000) adults
.
4.0 million
Immigrant adults
less than 5 years in US
Would gain coverage
(sens 200-310,000)
2.0 million
have insurance
2.0 milllion uninsured
560,000
possibly
undocumented
1.44 million
legally admitted
and uninsured
1.1 million
do not have Medicaid/
CHIP eligible children
100,0000
do not meet
Medicaid/ CHIP
guideliines
90,000
have kids who already receive
or are already eligible to receive
Medicaid .CHIP
50.000
250,0000
as adults meet
Medicaid income
newly eligible
guidelines
100,000
have recently arrived non-citizen kids
who meet Medicaid/ CHIP criteria
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 lowwage 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.
Figure 1
< 10 Yrs
> 10Yrs
US born
90%
70%
50%
Pap Mammo
All f emales age 18-70
Pap Mammo
Have Insurance
Pap Mammo
Have source of care
Pap Mammo
Adj. Percent
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
Pap
Smear
Latina Women Only
Mammography
Pap
Smear
Mammograp
hy
N=11,673
N=4,421
N=2,26
1
N=553
87
79
82
73
Naturalize
d
82a
73 a
84c
74c
NonCitizen
71b
58 b
70b
52a
N=11,141
N=4,112
N=2,15
9
N=503
87
78
83
72
Naturalize
d
81b
75c
82c
75c
NonCitizen
72 b
64 b
70b
58c
Unadjust
US-Born
Model 1d
US-Born
All Women
Pap
Smear
Model 2e
Mammography
Latina Women Only
Pap
Smear
Mammography
N=11,103
N=4,098
N=2,151
N=501
87
78
81
70
Naturalize
d
81b
76c
81c
73c
NonCitizen
76b
71c
73b
67c
N=2,151
N=501
78
66
Naturalize
d
81c
73c
NonCitizen
77 c
72 c
US-Born
Model 3f
US-Born
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
E-mail:
[email protected]
[email protected]