Health Care Access for Latino Patients Olveen Carrasquillo

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

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

Health of Latinos

Diabetes Prevalence- diagnosed/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 • • 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 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

Source: US Bureau of the Census

Change in # Uninsured (1, 000) Source: Harell & Carrasquillo JAMA 2003 289; 9: 1167

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 Source: Analysis of March 2002 CPS Data

NYS: Insurance coverage by Hisp. Sub-group N= 925, 000 650, 000 300, 000 800, 000

Insurance Data Coverage by Immigrant Type # 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

Racial/ethnic disparities in insurance coverage by citizenship status

Insurance coverage among Hispanic subgroups by citizenship status Source: March 2001 CPS

New York City Source: Analysis of March 2003 CPS 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 Source: Analysis of March 2002 CPS Data

Health insurance among Latino Sub-Groups Hisp Sub-Group % with Employer % 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 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

How much does it cost to cover the uninsured? ? ? Hadley J, Health Affairs 2003; W 3 -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, allows me speak to surgeon agrees see her but must follow up in clinic • Pt in OR 2 days later

Case Report #2 • DC, 77 yo 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 2000 2002 2003 CIb 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. 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 32. 7 26. 9 29. 7 25. 6 4. 3 Other 32. 2 34. 8 36. 7 32. 4 31. 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. 5 58. 6 1. 4 Sub. Group. 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

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, Ph. D 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 1990 s. • 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 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 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 82 a 73 a 84 c 74 c Non. Citizen 71 b 58 b 70 b 52 a N=11, 141 N=4, 112 N=2, 15 9 N=503 87 78 83 72 Naturalize d 81 b 75 c 82 c 75 c Non. Citizen 72 b 64 b 70 b 58 c Unadjust US-Born Model 1 d US-Born

All Women Pap Smear Model 2 e Mammography Latina Women Only Pap Smear Mammography N=11, 103 N=4, 098 N=2, 151 N=501 87 78 81 70 Naturalize d 81 b 76 c 81 c 73 c Non. Citizen 76 b 71 c 73 b 67 c N=2, 151 N=501 78 66 Naturalize d 81 c 73 c Non. Citizen 77 c 72 c US-Born Model 3 f 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 • Co. SMO -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: nmp 1@columbia. edu oc 6@columbia. edu