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Access to Health Care for Adult Latino
Immigrants:
Are Lack of Health Care Coverage and
Discrimination Barriers to Accessing Care?
Claire Olivier and Hana Tylova-SteinPH212C: Migration and Health, 2012
Today’s Outline
1. Andersen’s Behavioral Model of Access to Health Care
2. Is Lack of Health Care Coverage a Barrier to Accessing Care?
3. Is Discrimination a Barrier to Accessing Care?
1. Andersen’s Behavioral Model of Access to Health
Care
Health care access and utilization can be explained as a function of 3 indicators:
Predisposing characteristics – individuals' predisposition to access and use services
Enabling resources – factors that enable or impede access to and use of services
Need variables – individuals' need for services
Predisposing Characteristics
Demographic factors include age and gender.
Social structure includes ethnicity, culture, education, social networks, and occupational status that determine individuals’ status in the community and their ability to cope with problems.
Health beliefs “about health and health services that might influence subsequent perceptions of need and use of health services.”
Source: Andersen, 1995
Enabling Resources
Community resources include availability and ease of access to health personnel and health care facilities, and regular sources of care.
Personal resources include health insurance, income, and immigration status.
Source: Andersen, 1995
Need Variables
Include:General healthSeverity of symptomsLevel of functioningExperience of symptoms Perception of needing help
Source: Andersen, 1995
Equitable vs. Inequitable Access
Source: Andersen, 1995
Focus of Today’s Presentation
We will focus on enabling resources that impede health care access and utilization:
Lack of health care coverage
Discrimination
2. Is Lack of Health Care Coverage a Barrier to
Accessing Care Among Low-
Income Latino Adults?
Health Care Coverage: Outline
Review of literature on health care coverage and the lack of coverage as a barrier to care
Available health care coverage for low-income immigrant adults TodayUnder Health Care Reform
Policy implications
Final thoughts
Rates of Health Insurance Coverage
Latino adults have the lowest rates of health insurance coverage among all ethnic groups.The uninsured rate is 43.1% among Hispanic adults
(28.8% for native-born and 56.4% for foreign-born), compared to 15.6% for White, 26.8% for Black, and 19.4% for Asian adults.
Mexican immigrants have lower rates of health insurance coverage than other immigrant and white U.S.-born populations (Figure 1).
Source: Pew Hispanic Center, 2010; CONAPO, 2010
Figure 1: Immigrant Population (from Mexico and Other regions) and White U.S.-Born Population without Medical Health Insurance in the United States, 2007
Factors Associated with Health Care Coverage
Among undocumented Mexican immigrant adults, living in a residence with fewer other adults, linguistic acculturation, higher levels of formal income, social support, and poor health were associated with health insurance coverage.
Having health insurance coverage was one of the variables associated with access to a regular health care provider.
Source: Nandi et al., 2008
Barriers to Health Care Coverage
Lack of employer-sponsored insurance (ESI)
Immigration status
Other factors such as:Low English proficiencyHigh cost of health care coverage
Lack of ESI: A Barrier to Health Coverage
Noncitizens are the least likely to have employer-sponsored insurance, followed by naturalized citizens and the U.S.-born.
Mexican immigrants tend to engage primarily in poorly paid occupations that do not provide ESI. 85% of newly arrived and 70% of long-term
Mexican workers are concentrated in unskilled service occupations, manufacturing, and construction.
Source: Derose et al., 2009; CONAPO, 2010
Immigration Status: A Barrier to Health Coverage and Care
Immigration status affects immigrants’ ability to obtain public health care coverage designed for low-income families.
The lack of health insurance is a common reason for limited access and use of health care services for prevention, diagnosis, and treatment.
Source: Derose et al., 2009; CONAPO, 2010
Immigration Status: A Barrier to Obtaining Coverage and
Care Cont.
Immigrants, especially noncitizens and the undocumented, are less likely to have health insurance and regular sources of care, and to use services than the U.S. born populations.
The non-naturalized Mexican population with low incomes displays the lowest rates of health insurance coverage when compared to other immigrant populations (Figure 2).
Source: Derose et al., 2009; CONAPO, 2010
Figure 2: Immigrant Population (from Mexico and Other Regions) with Medical Insurance by Citizenship Status in the United States, 2007
Other Barriers to Health Coverage
The main barriers to obtaining health care coverage:
Undocumented status in the US, low English proficiency, and inability to navigate the health care system among low-income, newly arrived Hispanic immigrant adults.
High cost of health insurance, lack of required documents, and confusion about eligibility among those who lived in the US for several years.
Source: Cristancho et al., 2008
Research Recommendations
Growing body of literature has examined barriers to obtaining health care coverage, as well as how lack of health coverage is a barrier to care.
However, more research focusing on differences among immigrant subgroups is necessary to understand the patterns for specific groups.
Federal/State Health Care Coverage Medi-Cal: California’s Medicaid
Local Initiatives to Improve Access to CareHealthy San Francisco
Health Care Reform
Coverage for Low-Income Immigrant
Adults Today and Under
Health Care Reform
Federal/State Health Coverage: Medicaid Program
Provides comprehensive health care services to certain low-income groups.
Operated jointly by federal and state governments, with federal government sharing the cost.
Administered by states that define eligibility within broad federal guidelines, determining type of benefits, amount, duration, and scope of service.
Source: Kaiser Commission, 2004; National Health Law Program, 2000
Medi-Cal: California’s Medicaid
As required of ALL states, California covers: Basic package of health care services: hospital
care, nursing home care, physician services, laboratory and x-ray services, family planning, health center and rural health center services, nurse midwife, and nurse practitioner services.
Comprehensive children’s health benefit package known as Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for children under age 21.
California also provides: drug prescriptions, vision, dental, mental health care and more.
Source: Anthem Blue Cross, 2011; National Health Law Program, 2000
Medi-Cal: Eligible Groups
Medi-Cal covers ALL mandatory and optional categorically needy groups, for example:
Low-income families with dependent children SSI recipients Infants born to Medicaid-eligible womenChildren 1-18 Pregnant women Poor persons who are aged, blind, and disabledLow-income persons who have been screened for
breast and/or cervical cancer
Source: National Health Law Program, 2000 & 2008
Is Immigration Status a Barrier to Obtaining
Medicaid?
YES It Is…
Federal government prevents states from using federal funds for Medicaid to cover:
Immigrants who are lawful residents who have not lived in the United States for more than 5 years.
Legal immigrants who have resided in the United States for more than five years who are PRUCOL.
Undocumented immigrants.
All legal and illegal immigrants are eligible for emergency Medicaid (if meeting other eligibility criteria), and for emergency room and stabilization.
Source: Kaiser Commission, 2004; National Health Law Program, 2000
California’s Response?
Since federal law does not prohibit states or localities from using their own funds to provide health insurance coverage to immigrants (legal or undocumented), California has used state-only funds to address this gap for low-income immigrants.
Who is Covered by Medi-Cal?
Low-income lawful immigrants regardless of their date of entry and PRUCOL immigrants qualify for full-scope Medi-Cal.
Low-income immigrants awaiting legal status, who live in California and plan to stay, qualify for emergency and some other Medi-Cal health services.
Source: Kaiser Commission, 2004; National Health Law Program, 2008
From Federal/State Health Coverage to Local Initiatives to
Improve Access to Care for Immigrants
San Francisco’s Effortsto Improve Access to Care
San Francisco enacted several policy measures to encourage provision of public services and benefits regardless of immigration status:San Francisco’s Sanctuary Policy, also called
“limited cooperation,” fights against discrimination based on immigration status.
Municipal ID Ordinance offers a municipal identification card to all city residents regardless of immigration status.
Healthy San Francisco Source: Marrow, 2011
Healthy San Francisco (HSF)
Provides universal health
care to all uninsured SF
resident adults (18-65) who do not qualify for other
forms of federal or state public insurance
HSF: Basic and Ongoing Medical Services
Provided regardless of immigration status, employment status, or pre-existing medical condition.
Include primary and specialty care, inpatient care, diagnostic services, mental health services, and prescription drugs.
Services are provided by 29 participating clinics and 5 local hospitals.
Source: Kaiser Commission, 2009
HSF: Funding
It is funded by city funds, some federal funds, and payments from employers.
Participation is free if residents’ incomes fall below the federal poverty line; otherwise clients pay quarterly participation cost and point-of-service fees based on their income (Figure 3).
Source: Kaiser Commission, 2009
Figure 3: HSF Participant Cost Sharing
Source: Kaiser Commission, 2009
Deserving to a Point: Unauthorized Immigrants in
San Francisco’s Universal Access Healthcare Model
Marrow interviewed 36 providers and staff from San Francisco’s public safety net to examine how such inclusive local policies work.
Universal Access Healthcare Model: Benefits
The SF’s inclusive policies:
Reinforce public safety-net providers’ “views of unauthorized immigrants as patients morally deserving of equal care.”
Help them translate these views into actual behaviors by providing them with financial resources.
Source: Marrow, 2011
Universal Access Healthcare Model: Disadvantages
Formal barriers: Services offered are limited to those provided by
participating healthcare institutions.A range of specialty services is not covered.
Hidden bureaucratic barriers: Hospitals’ complicated registration process. Clinics’ overburdened phone lines.Fear of deportation resulting from the need to
submit proof of SF residency, low income, and a denial from Medi-Cal.
Source: Marrow, 2011
Looking Ahead: Health Care Reform
Coverage OptionsUnder the
Affordable Care Act (ACA)
Beginning in 2014:
Medicaid will expand to cover nearly all individuals with incomes up to 133% of poverty.
Individuals without access to affordable employer insurance will be able to buy insurance through new health insurance exchanges.
Those with incomes up to 400% of poverty will be eligible for tax credits to help pay for the coverage.
Source: Kaiser Commission, 2012
ACA: Immigrant Eligibility Restrictions
Source: Kaiser Commission, 2012
ACA: Impact on Latino Immigrants
It will increase access to preventative and primary care, and improve efforts to fight chronic disease.
However, it may negatively impact undocumented immigrants. With the flood of new immigrants with health care
coverage, it may be difficult for safety-net providers to keep their doors open for undocumented immigrants.
Policy Implications
Although state and local governments play a key role in expanding access to care for all immigrants, and the ACA will be the first step towards reducing disparities in access to health care coverage, barriers for certain immigrants will remain.
We need to encourage:Cooperation between all levels of government to ensure
adequate funding, and to reduce eligibility restrictions for Medicaid so as to offer universal health care.
Public-private initiatives and bi-national health insurance options that might help ensure better coverage of all immigrants.
Final Thoughts
Find out more on bSpace about federal, state, and local efforts to provide health care coverage to children from low-income families.
“Providing insurance coverage to all immigrants would no doubt reduce access disparities, but given that a number of studies still found reduced use of services for noncitizens and persons with limited English proficiency even after adjusting for insurance status, other barriers associated with being an immigrant remain.”
Source: Derose et al., 2009
Be back in 5-7minutes please
3. Discrimination As a Barrier to Accessing Health Care: Outline
I. Literature Review Exploring Discrimination as an Impacting Factor in Accessing Health Care for Immigrants
II. Summary
III. Limitations of Research Articles
IV. A Look at Health Care Providers
V. News Article Re: Healthcare Discrimination & Video Clip
VI. Recommendations for Research and Policy
VII. Questions
I. Literature Review Exploring Discrimination as an Impacting Factor
in Accessing Health Care for Immigrants
Questions that led research:
Is it a barrier to health care for immigrants?
How do immigrants experience discrimination?
Does legal status of immigrants matter?
Are there differences between urban and rural reports of discrimination?
Lit review includes research from various locations within the U.S. Focusing on Latino Adults
First Study• Access to and use of health services
among Mexican born undocumented immigrants living in New York City in 2004
• 431 immigrants interviewed, age 18+, 299 were men, 130 women
Source: Nandi et al., 2008
One set of questions looked at enabling factors, such as discrimination that could impede their use of health care services.
Participants were asked if they had ever been discriminated against, prevented from doing something, hassled, or made to feel inferior because of age, race, language, immigrant status, gender, sexual orientation, poverty, drug use, having been in jail or prison, religion, mental illness, physical illness or disability, or other reasons.
171 reported no discrimination (40.6%). Those experiencing discrimination experienced as:
Related to race (12.4%),
Related to language (25.2%),
Immigrant status (15.9)
Other forms of discrimination (5.59).
Access to Health Insurance
Access to a Regular Provider
Receipt of Care in an Emergency Dept
No Discrimination
40.6%13.0% 42.9% 13.0%
Race
12.4%9.6% 35.3% 9.8%
Language
25.2%7.6% 24.8% 11.5%
Status
15.9%7.6% 43.3% 16.9%
Other
16%16% 24% 20%
Second StudyCA study of immigrant perceptions of discrimination in health care
This study asks…
Whether foreign-born persons are more likely to report discrimination in healthcare than U.S.-born persons in the same race/ethnic group,
whether the immigration effect varies by race/ethnicity, and
whether the immigration effect is “explained” by socio-demographic factors.
Source: Lauderdale et al, 2008
The authors conducted a cross-sectional analysis of the 2003 California Health Interview Survey consisting of 42,044 adult respondents.
18+, average age was late 30’s to early 40’s
Approximately 50% male/female.
They did not inquire about immigration status, only if the person was foreign born.
Overall, 24.8% of respondents were foreign-born, but foreign-born % ranged by race/ethnicity from 5.8% of African American/blacks, 64.5% Latinos, 79.2% of Asians.
Access to care was represented by health insurance and usual source of care
Results
Foreign born effect was not significant for blacks and native Americans nor was it statistically different from the foreign born effect for whites.
Among Asians and Latinos, foreign birth significantly increases reports of discrimination.
Better SES is only weakly protective for the foreign-born.
Third Study: Health Care Access, Use of Services, and Experiences Among Undocumented Mexicans and Other
Latinos
Utilized the 2003 California Health Interview Survey data
Compared access to health care, use of services, and health care experiences for Mexicans and other Latinos by citizenship and immigrant authorization status.
Study looked at Mexicans as one group, Other Latinos as the other group
Within those two groups compared status: U.S. born, Naturalized, Green Card, Undocumented.
Source: Ortega et al., 2007
Results
The undocumented immigrants in both groups (Mexicans and other Latinos) constituted the highest proportions of those having difficulty understanding their physicians during their last visit
AND
thinking that they would get better care if they were of a different race or ethnicity.
Fourth Study
Listening to Rural Hispanic Immigrants in the Midwest: A Community-Based Participatory Assessment of Major Barriers to Health Care Access and Use (2008)
Study with immigrants in Midwest, 3 rural communities in Illinois
Used focused small group discussion.
181 participants, 18+
Source: Cristancho et al., 2008
Main question: What are the main barriers you encounter when accessing and utilizing health care services in your community?
Discrimination was one of the issues consistently mentioned.
Medicaid Discrimination
“While taking my treatment for tuberculosis, I was advised to take contraceptive pills. Then, I got pregnant. The doctor never told me then that treatment for tuberculosis might make the contraceptive pills less effective, as was later explained to me. I was not prepared to get pregnant again because my husband didn’t have a good job and I needed to start working to help my family. . . .
I ended up feeling very sick during my pregnancy and I was told that there was a chance that my baby could be born with some malformations. I suffered a lot because I didn’t know what was going to happen. Thank God, my baby was born normal and healthy; however, I never got an apology from my doctor, so how can I trust him again? If I would have had good health insurance, this would have never happened.”
Lack of insurance attributed as a cause of discrimination and negligence, which could lead to more serious health problems that could’ve been prevented with effective care.
“In some clinics and health care centers, they make us Latinos wait too long. It is common to wait for two or three hours to get assistance and the situation is worse if you don’t have health insurance. It is evident that they prefer Americans . . . gringos go first regardless of how urgently we need a solution to our problems.”
Discrimination in form of judgment from medical interpreters.
Lack of available, quality medical interpretation
May need to rely on clerical staff for interpretation
Problematic due to:
Lack of reliable information
Knowing if information has been translated correctly
Privacy concerns
“ Medical interpreters are not fair. . . . They lack professional ethics. They just assist people with whom they have a good relationship. Medical interpreters are in charge of deciding who gets discounts and what type of discounts they get. If you don’t have a good relationship with them, they don’t give you any discount. Some people give them some presents like tamales and fruits in order to get better access to health care services and it works.”
II. Summary
Further research included an article that was itself a lit review examining immigrant, health care access, quality and cost.
Authors conducted a systematic search for post-1996 to 2008, population-based studies of immigrants and healthcare. Of the 1,559 articles identified, 67 met study criteria of which 77% examined access, 27% quality, and 6% cost.
Source: Derose et al., 2009
Foreign born more likely to report feeling discriminated against in health care, specifically those who are:
non white, noncitizens, and have limited English proficiency.
Health insurance status can impact reports of discrimination.
Source: Derose et al., 2009
Undocumented Latinos and those with a green card were more likely to feel that they would get better care in of a different race, than U.S. born Latinos.
Parents who do not speak English well or who have noncitizen children are more likely to report being discriminated against in seeking care for their children than parents who speak English.
Source: Derose et al., 2009
III. Limitations of Research Articles
Term discrimination is subjective
Possible that undocumented immigrants may underreport key areas of concern
Limited by self reported data
Types of sampling used (venue)
Limitation Cont.
Heterogeneity may make the experience of being an immigrant or nonwhite different in California than the rest of the country
Studies tended to focus on general access to health care versus specialty practices
Due to not wanting to raise fear re: deportation, researchers could be hesitant or unwilling to ask for legal status
IV. A Look at Health Care Providers
Class BrainstormPotential reasons providers discriminateHow do they discriminate?
Paved With Good Intentions: Public Health & Human Service Providers
Contributions to Racial Disparities in Health.
Providers may influence help seekers views of themselves and their relation to the world.
Providers may consciously or unconsciously re-enforce and reflect societal messages.
Non-Whites have been found to be at significantly higher risk for inadequate or no pain assessment or pain control than their White counterparts in a variety of situations, including emergency department treatment of long bone fractures,'" nonmalignant pain in a nursing home,'" treatments for cancer-related (in this case the study focused on doctors and nurses).
Source: van Ryn et al., 2003
African Americans and Latinos have been found to be less likely than Whites to receive guideline-adherent treatment and follow-up (which could affect their continued utilization).
Cardiac patients race and ethnicity and SES negatively influenced physicians ratings of their personality, education, intelligence, career demands and likely treatment adherence.
Source: van Ryn et al., 2003
Class Brainstorm Part II“There is substantial evidence that when people mentally assign individuals to a particular class or group, they unconsciously automatically assign the characteristics of that group to the individual in question, a process referred to as stereotype application…
it is both difficult and painful for many of us to accept the massive evidence that social categories automatically and unconsciously influence the way we perceive people and in turn, influence the way in which we interpret their behavior and behave towards them. However given that this type of strategy is common to all humans in all cultures and is more likely to be used in situations that tax cognitive resources (eg time pressure), the expectation that providers will be immune is unrealistic.”
Source: van Ryn et al., 2003
What do you think of this quote?
If you agree, what do you think providers at any level, clerical to doctors, etc., can do to address this concern?
Deserving to a point: San Francisco Providers’ PerspectivesDo health care providers support San Francisco’s inclusive policies? Source: Marrow, 2011
Interviews were conducted with 36 primary care providers and staff working in San Francisco’s public safety net between May and September 2009
Utilized combination of purposive and snowball sampling.
Included a range of providers, 54 respondents
Source: Marrow, 2011
Results
Variation existed among participants, yet could still be distinguished from general American public and conservative health care providers.
Inclusive policy sanctions providers who disagree city’s inclusive local policy context
Clerical worker: policy of treating everyone tempers providers’ fiscal resentment.
Health worker union: “undocumented immigrants shouldn’t be here,” but “kids should get help.”
Medical evaluation assistant: everyone who is sick has right to health, but not 100% supportive of undocumented immigrants having equal access
Sanctuary ordinance encourages providers to look beyond patients’ legal statuses.
Inclusive policy allows public providers to not worry about direct financial cost
V. News Article Re: Healthcare Discrimination & Video Clip
“Three immigrants with green cards in N.J. file health care discrimination lawsuit” June 29, 2010 Source: Diamant, 2010
Stated it is discriminating against them by removing them from state-subsidized health care due to their immigration status.
The lawsuit seeks to prevent the state Department of Human Services from instituting planned budget cuts that would remove the plaintiffs — and about 12,000 other non-citizens — from New Jersey FamilyCare, the state’s insurance plan for low-income families.
Source: Diamant, 2010
Two of the plaintiffs are from Ecuador, the third from Jamaica.
They have been legal permanent residents less than five years, meaning they will lose their FamilyCare benefits.
Family cannot afford health care without subsidies; Manual Guaman, a cook, is sole provider.
Source: Diamant, 2010
Sen. Joe Vitale (D-Middlesex), who opposed the FamilyCare cuts, said he supports the suit.
"These men and women work hard, play by the rules, and are on the path to citizenship that we have established and that they honor," said Vitale, a longtime proponent of FamilyCare. "To kick the overwhelming majority of them to the curb and deny proper health care upon which they have come to depend, is morally wrong and fiscally imprudent.“
Source: Diamant, 2010
Video Clip: http://www.nj.com/news/index.ssf/2010/06/three_immigrants_with_green_ca.html
VI. Recommendations for Research & Policy
Immigration status should be included in research re: discrimination in health care as it is a key predictor of perceived discrimination among Asians and Latinos.
Outreach efforts through sources such as trusted community-based organizations are important to decrease concerns regarding how enrollment in publicly funded insurance programs might affect residency and citizenship applications.
Source: Lauderdale et al., 2006; Derose et al., 2009
Policies to improve language services should require Medicaid to cover access to an interpreter in each state
Federal and/or state policies that focus specifically on immigrants in new destinations
Include discrimination training for medical interpreters, especially in rural areas.
Source: Derose et al., 2009; Cristancho et al., 2008
Thank you for your attention!
Any Questions ???
References
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