10
Access to and Quality of Health Care

José J. Escarce and Kanika Kapur

The health of a population is influenced by both its social and its economic circumstances and the health care services it receives. As discussed in other chapters of this report, on average the socioeconomic status of Hispanics in the United States is considerably lower than that of non-Hispanic whites. Hispanics also face a variety of barriers to receiving health care services of high quality. Some of these barriers result from their low socioeconomic status; others are due to several specific features of the Hispanic population.

The low average socioeconomic status of Hispanics, compared with non-Hispanic whites, is reflected in their family income, educational attainment, occupational characteristics, and asset accumulation. In 1999, for example, 23 percent of Hispanics lived in poverty, compared with 8 percent of non-Hispanic whites, and 56 percent of Hispanic adults age 25 or older had a high school diploma, compared with 88 percent of non-Hispanic white adults. Hispanics are much more likely than whites to work in agriculture, construction, domestic and food services, and other low-wage occupations. Conversely, they are less likely than whites to work in managerial, professional, technical, sales, or administrative support positions.

The low average income and educational attainment of Hispanics are obstacles to receiving timely and appropriate health care. Low-income people are less able to afford the out-of-pocket costs of care, even if they have health insurance coverage. Low education may impair people’s ability to navigate the complex health care delivery system, communicate with health care providers, and understand providers’ instructions. In addition,



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Hispanics and the Future of America 10 Access to and Quality of Health Care José J. Escarce and Kanika Kapur The health of a population is influenced by both its social and its economic circumstances and the health care services it receives. As discussed in other chapters of this report, on average the socioeconomic status of Hispanics in the United States is considerably lower than that of non-Hispanic whites. Hispanics also face a variety of barriers to receiving health care services of high quality. Some of these barriers result from their low socioeconomic status; others are due to several specific features of the Hispanic population. The low average socioeconomic status of Hispanics, compared with non-Hispanic whites, is reflected in their family income, educational attainment, occupational characteristics, and asset accumulation. In 1999, for example, 23 percent of Hispanics lived in poverty, compared with 8 percent of non-Hispanic whites, and 56 percent of Hispanic adults age 25 or older had a high school diploma, compared with 88 percent of non-Hispanic white adults. Hispanics are much more likely than whites to work in agriculture, construction, domestic and food services, and other low-wage occupations. Conversely, they are less likely than whites to work in managerial, professional, technical, sales, or administrative support positions. The low average income and educational attainment of Hispanics are obstacles to receiving timely and appropriate health care. Low-income people are less able to afford the out-of-pocket costs of care, even if they have health insurance coverage. Low education may impair people’s ability to navigate the complex health care delivery system, communicate with health care providers, and understand providers’ instructions. In addition,

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Hispanics and the Future of America Hispanics’ low incomes and occupational characteristics are associated with low rates of health insurance coverage. Lacking health insurance makes the costs of health care services prohibitive for many people and is the most important barrier to adequate health care access. Specific features of the Hispanic population that affect their access to health care include degree of acculturation, language, and immigration status. More than two-fifths of Hispanics in the United States are foreign-born, and many are recent immigrants who retain their cultural beliefs and behaviors regarding health and health care. Most foreign-born Hispanics primarily speak Spanish, and fewer than one-fourth report speaking English very well. In 2000, only 28 percent of foreign-born Hispanics were naturalized citizens, a rate lower than the rates of naturalization for other immigrant groups. Among Hispanics who are not citizens, a sizable number are undocumented immigrants. These features of the Hispanic population have both direct effects on reducing access to health care and indirect effects through their association with lower rates of health insurance coverage. The jobs available to recent and undocumented immigrants who lack proficiency in English are unlikely to provide health insurance as a benefit of employment. Furthermore, under recent legislation, recent immigrants and noncitizens may receive fewer benefits than earlier immigrants and citizens from public health insurance programs. In this chapter, we review the evidence on access to health care for Hispanics and on the quality of health care that they receive. We provide a summary of the existing research and also present new data from recent national surveys. To provide a context for interpreting the data, our tabulations compare Hispanics with non-Hispanic whites and non-Hispanic blacks. We also focus on specific features that are of particular importance to Hispanics, including national origin, length of time in the United States, language, and citizenship, and we assess how these features are associated with access to and quality of health care. Our analyses of national-origin groups are constrained by data availability. Thus, of necessity, most of the analyses focus on Hispanics of Mexican, Puerto Rican, and Cuban origin, in addition to a residual category of “other” Hispanics. ACCESS TO HEALTH CARE Access to health care refers to the degree to which people are able to obtain appropriate care from the health care system in a timely manner. Researchers who study access to care often distinguish between “potential access,” which refers to the presence or absence of financial and nonfinancial barriers to obtaining appropriate and timely care, and “realized access,” which refers to the quantity of health care actually received.

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Hispanics and the Future of America Barriers to Access Hispanics face a variety of financial and nonfinancial barriers to obtaining appropriate and timely health care. Degree of acculturation, language, and immigration status all directly affect access to care. Recent arrivals to the United States are more likely to be isolated from mainstream U.S. society and to be unfamiliar with the U.S. health care system, a situation that may interfere with obtaining appropriate and timely care (Wells, Golding, Hough, Burnam, and Karno, 1989). Limited proficiency in English affects Hispanics’ ability to seek and obtain health care and reduces access to health information in the media (Ruiz, Marks, and Richardson, 1992). In addition, communication is central to the process of health care delivery and has profound effects on patient–provider relationships and on the health care people receive. Studies have found that language barriers between providers and patients may result in excessive ordering of medical tests, lack of understanding of medication side effects and provider instructions, decreased use of primary care, increased use of the emergency department, and inadequate follow-up (David and Rhee, 1998; Morales, Cunningham, Brown, Liu, and Hays, 1999; Timmins, 2002). The unique sociopolitical status of undocumented immigrants poses considerable barriers to health care access as well. Two key barriers to health care access are not having health insurance coverage and not having a usual source of care. Health insurance reduces the out-of-pocket costs of health care and has been shown to be the single most important predictor of utilization. Without health insurance coverage, many people find health care unaffordable and forgo care even when they think they need it. Having a usual source of care reduces nonfinancial barriers to obtaining care, facilitates access to health care services, and increases the frequency of contacts with health care providers. In particular, having a usual source of care provides a locus of entry into the complex health care delivery system when care is needed and serves as the link to more specialized types of care (Lewin-Epstein, 1991). Compared with people who lack a usual source of care, people with a usual source are less likely to have difficulty obtaining care or to go without needed care. Hispanics rank poorly on both barriers to access, as we review below. Health Insurance Historically, lack of health insurance coverage has been a major problem for Hispanics, who are substantially more likely to be uninsured than non-Hispanic whites. For example, in 2004, 36 percent of Hispanics under age 65 lacked health insurance coverage, compared with 15 percent of whites (Rhoades, 2005). Rates of being uninsured vary across Hispanic

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Hispanics and the Future of America subgroups defined by national origin; for instance, Mexicans and Central and South Americans have higher uninsured rates than Puerto Ricans or Cubans (Carrasquillo, Orav, Brennan, and Burstin, 2000; Hoffman and Pohl, 2000). Other studies have found that uninsured rates are higher for foreign-born compared with U.S.-born Hispanics and for noncitizens compared with citizens (e.g., Carrasquillo et al., 2000). Uninsured rates are especially high among undocumented immigrants; Berk, Schur, Chavez, and Frankel (2000) estimated that between 68 and 84 percent of undocumented immigrants in southern California are uninsured. The causes of low health insurance coverage among Hispanics are multiple and complex. Hispanics are much less likely than non-Hispanic whites to receive health insurance as a benefit from an employer, which is the most common source of health insurance coverage for working-age adults and their children in the United States. Using the 1996 Medical Expenditure Panel Survey (MEPS), Monheit and Vistnes (2000) found that 42 percent of non-elderly Hispanics had employer-provided insurance, compared with 71 percent of nonelderly whites. Among workers, rates of employer-provided insurance coverage were 48 and 77 percent for Hispanic and white males, respectively, and 61 and 80 percent for Hispanic and white women. Hispanic male and female workers were less likely than their white counterparts to be offered health insurance by their employers (56 versus 81 percent or males and 62 versus 75 percent for females). This is consistent with other data showing that Hispanics are less likely than whites to work for an employer that offers health insurance to some employees, and they are less likely than whites to be eligible to participate if they work for such an employer (Quinn, 2000). Moreover, only 76 percent of Hispanic males who were offered insurance took it up, compared with 85 percent of white males. Take-up rates were about three-fourths for both Hispanic and white women. Monheit and Vistnes (2000) also used multivariate regression analysis and decomposition techniques to examine the causes of low rates of employer-provided insurance among Hispanics. About three-fifths of the 29 percentage-point gap in insurance coverage between Hispanic and white male workers was explained by differences in the characteristics of workers and their employers, including poverty status, wages, education, and firm size. The remaining two-fifths of the coverage gap was explained by differences between Hispanics and whites in the relationship between worker and employer characteristics and insurance coverage. Thus, Hispanic males in poor, low-income, or middle-income households; those earning low wages; and those in firms with fewer than 25 workers were less likely than their white peers to have employer-provided insurance. Interestingly, nearly all the insurance coverage gap which Hispanic female workers experienced was explained by worker and employer characteristics.

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Hispanics and the Future of America Other analyses of employer-provided insurance have emphasized differences between Hispanics and whites in job characteristics (e.g., Schur and Feldman, 2001). Hispanics are more likely than whites to be employed in agriculture, construction, domestic and food services, and retail trade. Moreover, in these industries Hispanics are much less likely than whites to be in executive, administrative, or managerial occupations or in professional specialties. The industries and occupations in which Hispanics commonly work are less likely than others to offer health insurance as a benefit of employment. Hispanics also are more likely than whites to work in small firms, in seasonal occupations, and part-time, all of which are associated with a lower probability of being offered health insurance as a benefit of employment. Notably, Monheit and Vistnes (2000) found little effect of industry and occupation on employer-provided insurance in their multivariate analyses, although firm size remained an important factor. It is likely that the effects of industry and occupation were captured by such worker characteristics as wages, income, and education. A focus group study conducted by the Commonwealth Fund investigated the barriers to employer-provided insurance for Hispanic workers (Perry, Kannel, and Castillo, 2000). This study found that, for many Hispanics seeking a job, getting the job is the primary concern, and the second concern is salary. Most uninsured participants in the focus groups admitted not asking about health insurance when they applied for their jobs and reported that health insurance takes a back seat to basic needs such as food and rent. A few participants noted that Hispanic workers, especially those recently arrived in the United States, are unfamiliar with the system of employer-based health insurance and may not sign up for coverage. Other participants cited language barriers to obtaining information about health insurance options. Given the complex array of factors that affect employer-provided health insurance coverage, the considerable variation in rates of this coverage across subgroups of Hispanics is unsurprising. Differences in rates of employer-provided coverage have been documented by national origin, nativity, length of residence in the United States, and language (Schur and Feldman, 2001). Public health insurance programs for low-income people, such as Medicaid and the State Children’s Health Insurance Program (SCHIP), provide health insurance coverage to many low-income Hispanics. Nonetheless, these programs are not sufficient to close the health insurance gap between Hispanics and non-Hispanic whites. Many Hispanics—especially Mexicans and Cubans—live in states with restrictive eligibility rules for Medicaid and SCHIP, including Arizona, Florida, New Mexico, and Texas. By contrast, Puerto Ricans tend to live in New York and New Jersey, where Medicaid and SCHIP eligibility rules are less restrictive (Dubay, Haley, and

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Hispanics and the Future of America Kenney, 2002; Morales, Lara, Kington, Valdez, and Escarce, 2002). Also, the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA, the federal welfare reform law) barred legal immigrants who entered the United States after August 1996 from receiving federal Medicaid or SCHIP benefits for the first five years in the country, leaving it to the states to decide whether to cover the costs of these benefits without a federal contribution (Zimmerman and Tumlin, 1999). Only 15 states use state funds to cover new immigrants during their initial five-year period in the United States, and only 9 states provide full benefits to undocumented immigrants. Finally, several factors have recently conspired to inhibit Hispanics’ enrollment in public health insurance programs, even when they are eligible for benefits. This is especially the case for immigrants who are not naturalized citizens. The limits on new immigrants’ eligibility for Medicaid and the time limits on welfare benefits under PRWORA led to general confusion about Medicaid eligibility and affected Medicaid participation by many immigrants who entered the United States long before 1996. Under federal immigration law, people may be barred from entering the United States or moving from temporary to permanent resident status if the government determines that they may become “public charges.” In the mid-1990s, the Immigration and Naturalization Service (INS) and the California Medicaid program interpreted the public charge requirements of federal law as meaning that immigrants had to repay the value of Medicaid benefits received or place their residency status in jeopardy (Ku and Matani, 2001). Although in 1999 the INS clarified that Medicaid participation would not affect the determination of public charge status, the earlier interpretation led to a widespread belief that immigrants should avoid enrolling in Medicaid, even if they were eligible (Schlosberg and Wiley, 1998). Ku and Matani (2001) reported that Medicaid participation among low-income noncitizens fell and rates of uninsurance rose from 1995 to 1998. Similarly, Kaushal and Kaestner (2005) found a sizable increase in the proportion of uninsured among foreign-born, unmarried women and their children after PRWORA was implemented. Since PRWORA changed eligibility only for immigrants who entered the United States after 1996, observers attribute this decline in Medicaid participation to effects on immigrants who arrived before 1996 and were still eligible. Enrollment in SCHIP of U.S.-born children of immigrants appears to have been affected as well (Ku and Matani, 2001). Of note, PRWORA is unlikely to have affected Puerto Ricans, since they are U.S. citizens from birth whether they live on the island or the mainland. Uncertainty about Medicaid (and SCHIP) eligibility and the risks of enrolling in Medicaid were added to other long-standing barriers to participation in public health insurance programs, such as lack of information and language. Studies suggest that lack of awareness of eligibility for Medicaid

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Hispanics and the Future of America and SCHIP is widespread among Hispanics. For example, fewer than half of the participants in the focus group study described earlier had heard of the SCHIP program in their state (Perry et al., 2000). Language barriers also hamper both initial and continuous enrollment in public insurance programs. Knowledge gaps and difficulties with the enrollment process have been identified as important causes of incomplete SCHIP uptake among all children (Kenney and Haley, 2001); these factors are likely to be even more important for Hispanic children. To complement our literature review, we used the 1997–2001 National Health Interview Surveys (NHIS) to examine recent patterns of health insurance coverage for Hispanics, non-Hispanic whites, and non-Hispanic blacks. As Table 10-1 shows, Hispanics in all age groups are much more likely than whites and blacks to be uninsured. Hispanics of Mexican origin have the highest uninsured rates, whereas the rates for Puerto Ricans and Cubans are only about half the rates for Mexicans. However, Puerto Ricans are much more likely than Cubans to rely on Medicaid or SCHIP as sources of health insurance coverage. As anticipated, nativity, time since arrival in the United States, and citizenship are associated with health insurance coverage (Table 10-2). Nearly one-half of foreign-born, working-age Hispanic adults are uninsured, compared with 27 percent of working-age Hispanic adults born in the United States. Furthermore, among the foreign-born the uninsured rate is much higher for those who have been in the United States less than five years and for noncitizens than for those who have been in the United States longer than five years and for naturalized citizens, respectively. Notably, the uninsured rate does not vary by nativity for Hispanics of Puerto Rican origin, a pattern that differs from that of the other national-origin groups and probably reflects the unique circumstances of Puerto Ricans regarding U.S. citizenship. Nativity is associated with health insurance coverage among Hispanic seniors, although the differences in uninsured rates by nativity are much smaller for seniors than for working-age adults, presumably as a result of the Medicare program. Overall, 9 percent of foreign-born Hispanic seniors are uninsured, compared with 2 percent of U.S.-born seniors. Table 10-3 shows the relationship between language preference, as assessed by the language of the survey, and health insurance coverage among Hispanic working-age adults. Overall, Hispanics who prefer Spanish are twice as likely as those who prefer English to be uninsured (57 versus 29 percent). This is due to much higher rates of employer-sponsored coverage for working-age adults who prefer English, combined with a minimal difference in Medicaid coverage by language preference. However, the pattern for Puerto Ricans again differs from that of the other national-origin groups. Puerto Rican working-age adults who prefer Spanish have a much higher

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Hispanics and the Future of America TABLE 10-1 Health Insurance Coverage, by Age Category and National Origin Age and National Origin Coverage Employer (%) Medicaid (%) Medicare (%) Other (%) Uninsured (%) Number All Hispanics Children 43 27 1 3 28 40,483 Working-age adults 48 8 2 3 40 62,170 Seniors 18 26 81 9 6 5,726 Mexican Children 41 26 1 2 32 26,677 Working-age adults 45 7 1 2 46 38,203 Seniors 17 24 80 10 7 3,047 Puerto Rican Children 43 41 1 4 12 3,474 Working-age adults 53 19 4 4 23 5,438 Seniors 18 30 85 8 3 562 Cuban Children 61 16 1 10 14 1,026 Working-age adults 59 5 3 11 24 2,957 Seniors 14 30 88 8 2 903 Other Hispanics Children 47 26 7 4 24 9,306 Working-age adults 50 7 2 4 38 15,572 Seniors 22 27 77 10 8 1,214 Non-Hispanic white Children 76 10 0 6 9 72,101 Working-age adults 75 3 3 7 14 185,580 Seniors 39 5 93 33 1 43,243 Non-Hispanic wlack Children 48 35 1 4 14 23,602 Working-age adults 58 12 4 5 24 40,667 Seniors 29 18 85 13 3 6,037 SOURCE: 1997–2001 NHIS. rate of Medicaid coverage than those who prefer English; as a result, the difference in uninsured rates by language preference is much smaller for Puerto Ricans than for the other groups. Usual Source of Care Not having a usual source of health care is another key barrier to health care access. A usual source of care is a health care provider where people usually go when they are sick or need advice about their health. Having a

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Hispanics and the Future of America TABLE 10-2 Health Insurance Coverage for Working-Age Adults, by Nativity, Years in United States, and Citizenship Nativity, Years in U.S., and Citizenship Coverage Employer (%) Medicaid/SCHIP (%) Medicare (%) Other (%) Uninsured (%) Number All Hispanics U.S.-born 60 9 2 4 27 24,625 Foreign-born 40 8 2 3 49 37,236 < 5 years in U.S. 19 5 0 2 74 4,611 > 5 years in U.S. 45 8 2 3 43 21,584 Noncitizen 31 6 1 2 61 19,591 Citizen 58 10 3 5 26 9,585 Mexican U.S.-born 60 8 2 4 28 16,041 Foreign-born 34 6 1 1 58 22,016 < 5 years in U.S. 16 3 0 1 80 2,933 > 5 years in U.S. 40 7 1 1 52 12,418 Noncitizen 28 6 1 1 65 13,412 Citizen 55 6 2 3 35 3,984 Puerto Rican U.S.-born 55 17 3 5 23 2,691 Foreign-born 51 21 6 4 22 2,708 < 5 years in U.S. 37 28 2 8 25 187 > 5 years in U.S. 54 21 6 4 20 1,736 Cuban U.S.-born 69 4 1 9 17 687 Foreign-born 55 6 3 12 26 2,248 < 5 years in U.S. 30 10 1 2 57 251 > 5 years in U.S. 58 5 4 13 22 1,404 Noncitizen 37 8 2 8 47 719 Citizen 67 4 5 14 13 989 Other Hispanics U.S.-born 62 8 2 4 25 5,206 Foreign-born 44 7 1 4 45 10,264 < 5 years in U.S. 21 3 0 5 71 1,240 > 5 years in U.S. 50 8 1 4 38 6,026 Noncitizen 35 7 1 3 55 5,399 Citizen 63 7 2 5 24 2,540 SOURCE: 1997–2001 NHIS. usual source of care reduces barriers to care that may arise from the difficulty and cost of searching for a health care provider. Familiarity with a particular provider may also make people more comfortable in seeking care, make it easier to make appointments at convenient times, and reduce

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Hispanics and the Future of America TABLE 10-3 Health Insurance Coverage for Working-Age Adults, by Language Preference Language Preference Coverage Employer (%) Medicaid/SCHIP (%) Medicare (%) Other (%) Uninsured (%) Number All Hispanics English 59 8 2 4 29 30,320 Spanish 31 10 2 2 57 23,660 Mexican English 59 6 2 3 31 17,382 Spanish 28 8 1 1 63 15,537 Puerto Rican English 57 16 4 5 21 3,770 Spanish 34 34 6 2 27 1,035 Cuban English 71 4 3 7 17 851 Spanish 49 6 3 14 29 1,726 Other Hispanics English 60 6 2 5 28 8,317 Spanish 32 10 1 2 55 5,362 SOURCE: 1997–2001 NHIS. uncertainty about the costs or other inconveniences involved in obtaining care. A usual source of care enhances continuity and provides the connection with more specialized forms of care. Not surprisingly, people with a usual source of care are more likely than those without a usual source to get care and less likely to have difficulty obtaining care or to go without receiving needed services. However, not all types of usual source of care are the same. Private physicians’ offices and health maintenance organizations are believed to represent the most appropriate settings for primary care, as they foster continuity of care and facilitate preventive care. By contrast, public clinics, hospital outpatient departments, and emergency departments are characterized by long waiting times, less satisfactory patient–physician relationships, and less continuity of care (Lewin-Epstein, 1991; Petchers and Milligan, 1988). Studies show that Hispanics are less likely than non-Hispanic whites to have a usual source of care (Hargraves, Cunningham, and Hughes, 2001), and more than one-third of immigrants lack a usual source. Furthermore, among Hispanics, Spanish speakers are less likely than English speakers to

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Hispanics and the Future of America have a usual source (Schur and Albers, 1996; Weinick and Krauss, 2000). Hispanics also are more likely than whites to rely on community or public clinics or hospital outpatient departments rather than physicians’ offices or health maintenance organizations as their usual source of care (Doty, 2003a; Lewin-Epstein, 1991). However, U.S.-born Hispanics are more likely than immigrants to have a physician’s office or a health maintenance organization as their usual source of care, and naturalized immigrants are nearly twice as likely as noncitizens to have these types of usual source (Ku and Matani, 2001). Table 10-4 presents data on usual source of care for Hispanics, non-Hispanic whites, and non-Hispanic blacks, obtained from the 1997–2001 NHIS. Overall, Hispanics in all age groups are more likely than whites and blacks to lack a usual source of care, and they are less likely to have a physician’s office as their usual source. As with health insurance coverage, the differences between Hispanics and whites are most pronounced for Hispanics of Mexican origin: 14 percent of Mexican children and 33 percent of Mexican working-age adults lack a usual source of care. By contrast, the proportions of Puerto Ricans and Cubans lacking a usual source of care are similar to or only slightly higher than the proportions of whites and blacks. The main difference between Puerto Ricans and Cubans is the type of usual source: Puerto Ricans are less likely than Cubans to use a physician’s office as their usual source of care, but more likely to use a clinic. Nativity, time since arrival in the United States, and citizenship are associated with having a usual source of care (Table 10-5). Foreign-born, working-age Hispanic adults are more likely than Hispanic adults born in the United States to lack a usual source of care. This pattern is also observed for every national-origin group except Puerto Ricans, for whom having a usual source of care is unrelated to nativity. Moreover, among foreign-born Hispanics those who arrived in the United States less than five years ago and those who are not citizens are twice as likely to lack a usual source as those who have been in the United States longer than five years and naturalized citizens, respectively. Nativity, time since arrival, and citizenship are also associated with having a physician’s office as the usual source of care. Only 20 percent of recent immigrants have a physician’s office as their usual source of care. Nativity is unassociated with having a usual source of care among Hispanic seniors. Finally, Table 10-6 shows the relationship between language preference and having a usual source of care. Overall, Hispanic working-age adults who prefer Spanish are nearly twice as likely to lack a usual source of care than those who prefer English. This pattern also holds for Mexicans, Cubans, and other Hispanics. For Puerto Ricans, by contrast, language preference is unassociated with having a usual source of care, although Puerto

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Hispanics and the Future of America of care. Weech-Maldonado and colleagues (2001) used the Consumer Assessment of Health Plans Survey (CAHPS) to evaluate parents’ assessments of their children’s care in 33 Medicaid managed care plans in 6 states. Hispanics who spoke Spanish reported worse experiences than whites with regard to timeliness of care, provider communication, staff helpfulness, and health plan service, whereas Hispanics who spoke English reported experiences similar to those of whites. In striking contrast to their reports of care, however, Hispanics who spoke Spanish gave higher global ratings to their physicians and to their health plans than both whites and English-speaking Hispanics. Weech-Maldonado and colleagues (2003) also used the CAHPS to evaluate adults’ assessments of their care in 156 Medicaid managed care plans in 14 states. They found a gradient in patients’ reports of their experiences with care according to English fluency. Thus Hispanics who spoke English reported slightly worse experiences than whites with regard to timeliness of care and staff helpfulness; Spanish-speaking Hispanics reported substantially worse experiences than whites with regard to timeliness of care, provider communication, and staff helpfulness; and the reports of bilingual Hispanics were intermediate. Similar to the earlier study of children, however, Hispanics—and especially those who spoke Spanish—gave higher global ratings to their physicians and health plans than whites did. Other smaller studies support a role for language as well. In a study of patients treated in medical group practices, Morales et al. (1999) found lower satisfaction with communication among Spanish-speaking Hispanics compared with English speakers. In a recent survey (Doty, 2003b), nearly half of Spanish speakers reported problems communicating with or understanding their physician. Carrasquillo et al. (1999) found that non-English-speaking patients were less satisfied than patients who spoke English with the care they received during visits to the emergency room. The importance of language is further underscored by the findings of recent studies of the effect of interpreters. Morales et al. (2003) used CAHPS to assess the impact of interpreters on parents’ experiences with their children’s care in the California SCHIP program. They found that Hispanics who needed interpreters but never or only sometimes had one reported worse experiences than patients who did not need interpreters with regard to provider and staff communication, access to care, and health plan service. However, Hispanics who needed interpreters and always had one reported as good or better experiences than patients who did not need interpreters. Other studies also show benefits of interpreters, although they are not nearly as favorable as the analysis of children in the California SCHIP program. For example, Baker, Hayes, and Fortier (1998) studied Hispanic

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Hispanics and the Future of America adults seen in a public hospital emergency department. They found that patients who communicated adequately with their provider without an interpreter gave higher ratings to interpersonal aspects of their care than patients who communicated through an interpreter. The latter patients, in turn, gave higher ratings than patients who communicated directly with the provider but said an interpreter should have been called. Using data from a primary care clinic, Rivadeneyra and colleagues (2000) found that providers more often ignored comments from Spanish-speaking patients who used an interpreter than from English speakers. In a study of Spanish-speaking patients seen in a primary care clinic at a public hospital, Fernandez et al. (2004) found that physicians’ fluency in Spanish was associated with more favorable patient ratings of interpersonal aspects of their care despite the availability of interpreter services. Taken together, the findings summarized in the preceding paragraphs confirm the primacy of language in patients’ experiences with health care. The studies suggest that Hispanics who speak Spanish report much worse experiences with care than whites do, whereas English-speaking Hispanics report similar or only slightly worse experiences than whites. Furthermore, access to interpreters improves the care experiences of Spanish speakers, although they still lag the experiences of patients who speak English well. An important caveat is that the major studies of the role of language—i.e., those based on the CAHPS—included only low-income patients eligible for Medicaid or SCHIP (Morales et al., 2003; Weech-Maldonado et al., 2001, 2003). The only large study that included commercially insured patients did not assess language preference or proficiency (Morales et al., 2001). Similarly, most of the studies of interpreters have used data from individual institutions and consequently may not be generalizable. The finding in several studies that Spanish-speaking Hispanics give higher global ratings than English speakers to their physicians and health plans despite reporting worse care experiences is counterintuitive. Researchers have suggested that reports of care experiences are less subjective than global ratings, and that the high global ratings given by Spanish speakers reflect their low expectations regarding their interactions with the health care system (e.g., Weech-Maldonado et al., 2001). This may be especially true for low-income Medicaid recipients and for recent immigrants whose prior experiences in their countries of origin are likely to have been in health care systems that provide markedly inferior care to the less privileged. An alternative explanation is that the high global ratings given to their physicians reflect a cultural disposition among Hispanics to be deferential to those who are presumed to be of higher status. This explanation is consistent with the particularly high global ratings given to physicians by Spanish speakers. Additional research on this issue is needed. The important role of interpreters in improving Hispanics’ experiences

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Hispanics and the Future of America with health care is noteworthy. According to a directive from the U.S. Department of Health and Human Services issued in August 2000, any entity receiving federal funds must offer and provide language assistance services to all patients with limited English proficiency at no cost, at all points of contact, and in a timely manner during all hours of operation. Interpretation by telephone is available throughout the United States via the AT&T language line, in which patient, provider, and interpreter communicate through a conference call. Interpreters are costly, however, and many providers are not in compliance with the directive. In fact, only about half of Hispanic patients who need an interpreter usually get one, and in most cases the interpreter is a staff person in the health care facility, a relative, or a friend and not a trained medical interpreter (Doty, 2003b). Studies have found that the type of interpreter affects patient satisfaction: patients generally prefer professional medical interpreters, including telephone interpreters, over ad hoc interpreters such as clinic staff, relatives, or friends (Hornberger et al., 1996; Lee, Batal, Maselli, and Kutner, 2002). Errors in interpretation may have clinical consequences (Flores et al., 2003). Most of the available evidence suggests that interpreters do not make the experiences of Spanish speakers equivalent to those of English speakers. Interpreters appear to facilitate technical aspects of care, but they may not fully compensate for the effect of language differences between patients and providers on interpersonal aspects of care. As discussed earlier, the quality of interpersonal interactions between patients and providers can affect the technical quality of care and health outcomes. CONCLUSION Our summary of the existing research and our analysis of recent data are consistent with the notion that Hispanics have lower access to health care than do non-Hispanic whites. Hispanics in all age groups are much less likely than whites to have health insurance coverage or a usual source of health care, and they face numerous other barriers to access as well. Unsurprisingly, Hispanics have lower rates of use of prenatal care and preventive services than whites, although for certain of these services the gap between Hispanics and whites has narrowed in recent years. Hispanic children and working-age adults also have fewer physician visits than their white counterparts, and Hispanics of all ages have fewer visits to nonphysician providers than whites. Hispanics and whites have similar hospitalization rates. However, Hispanic children and working-age adults have much lower total medical care expenditures and expenditures for prescription drugs than whites do. Notably, Hispanic and white seniors have simi-

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Hispanics and the Future of America lar rates of physician visits and similar medical care expenditures, probably as a consequence of the availability of Medicare coverage to most seniors and the generosity of federal thresholds for dual Medicaid eligibility. Aggregate data for all Hispanics mask large and important differences across Hispanic groups defined by national origin. In general, Hispanics of Mexican origin fare worse on indicators of access to health care than Puerto Ricans or Cubans, although Mexicans’ indicators often resemble those of other Hispanics (i.e., Hispanics from other countries in Central or South America). Thus, compared with Mexicans, Puerto Ricans and Cubans are more likely to have health insurance coverage and a usual source of health care, have more physician visits, and have higher expenditures for medical care. Nonetheless, there are noteworthy differences in access indicators between Puerto Ricans and Cubans. For instance, Puerto Rican children and working-age adults are much more likely than their Cuban counterparts to obtain health insurance through public insurance programs like Medicaid or SCHIP, and they are less likely than Cubans to have a physician’s office as their usual source of care. Nativity, time since arrival in the United States, immigration status, and language also play crucial roles in determining indicators of health care access. Foreign-born Hispanics consistently have much worse access indicators than Hispanics born in the United States, except in the case of Puerto Ricans, for whom nativity makes little difference. Among the foreign-born, moreover, Hispanics who arrived in the United States less than five years ago and noncitizens have worse access indicators than those who arrived more than five years ago and naturalized citizens, respectively. Similarly, Hispanics who speak only Spanish or who prefer Spanish generally have worse access indicators than those who speak English. Puerto Ricans are again the exception, as their indicators of health care access do not differ by language preference. Notably, socioeconomic status and health insurance coverage explain disparities between working-age Hispanic and white women in their rates of pap smears and mammograms. By contrast, our multivariate analyses suggest that differences in the probability of having a physician visit, having a nonphysician visit, and incurring medical expenditures between Hispanics and non-Hispanic whites, between foreign- and U.S.-born Hispanics, and between English- and Spanish-speaking Hispanics are not fully explained by socioeconomic status, health insurance, and health status. Thus, the effect of social class on access to care accounts for some, but not all, of the differences we reported by national origin, by nativity, and by language preference. Other barriers to access reviewed in this chapter, which are harder to measure and capture in quantitative analyses, are likely to affect the utilization of care by Hispanics.

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Hispanics and the Future of America Much less information is available regarding the quality of health care for Hispanics than regarding access to care. The available evidence indicates that process quality of care is similar or slightly worse for Hispanics, although the number of studies is very limited. Moreover, these studies have not assessed the role of national origin, language, or other factors that are associated with access to care. More information is available regarding Hispanics’ experiences and satisfaction with care. These studies have found that Hispanics who speak only Spanish have worse experiences with health care than both whites and Hispanics who speak English. In fact, English speakers appear to have care experiences that are very similar to those of non-Hispanic whites. Furthermore, the use of interpreters improves the care experiences of Hispanics who speak Spanish, but even with interpreters the experiences of Spanish speakers lag those of English speakers. An intriguing finding of the research to date is that Spanish-speaking Hispanics give higher global ratings to their physicians and health plans than whites do, despite reporting worse experiences. This may be a manifestation of Spanish speakers’ low expectations of the health care delivery system, or it may reflect a cultural disposition to be deferential to health care professionals. The data summarized in this chapter raise a number of critical issues for public and private policy makers concerned about the well being of Hispanics in the United States, for health care providers, and for the health care system more generally. Continued immigration of Hispanics from Mexico and other countries in Central and South America, coupled with diffusion of these immigrants to new areas of the United States, will challenge our current approaches for providing health insurance coverage and health care to populations with low socioeconomic status. Given current trends in employer-sponsored health insurance, it seems inevitable that the number and proportion of uninsured Hispanics will grow rapidly in the next few years. The apparent success of Medicaid eligibility expansions in increasing low-income women’s use of prenatal care and of the Vaccines for Children program in reducing disparities in childhood vaccination rates demonstrates the potential of public programs and public–private partnerships to enhance uninsured people’s access to essential health care services. However, further large-scale expansions of federally subsidized programs, such as Medicaid and SCHIP, seem unlikely in this age of welfare reform and federal budget deficits. Progress in insuring more of the uninsured is likely to depend on state initiatives. Growth in the number of uninsured Hispanics, in turn, will place increasing stress on the so-called health care safety net. This loosely organized system for making health care available to uninsured people includes public clinics and hospitals, many teaching hospitals, and free and reduced-price

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Hispanics and the Future of America care provided by community physicians and hospitals. Many observers believe that the safety net has already been stretched thin by the growth of managed care and the increasing role of market forces in health care, and there is evidence that many health care providers have curtailed their provision of charity care. In a recent study, Marquis et al. (2004) found that the capacity of the safety net in different communities is strongly influenced by local economic conditions. Thus access to health care for uninsured Hispanics who must rely on safety net providers is likely to depend in large part on the strength of the economy in the communities where they live. This observation is especially salient for recent immigrants choosing new destinations in the United States. Finally, the growth and geographic dispersion of the Hispanic population will challenge health care delivery systems and providers unaccustomed to caring for diverse groups of patients. In recent years, the concept of cultural competence has been proposed as a key factor in reducing racial and ethnic disparities in access to and quality of health care. According to Betancourt et al. (2002), “cultural competence describes the ability of systems to provide care to patients with diverse values, beliefs, and behaviors, including tailoring delivery to meet patients’ social, cultural, and linguistic needs.” Despite the lack of empirical evidence linking cultural competence to improvements in care, experts in both the public and private sectors consider cultural competence a crucial element of strategies to reduce disparities in care. Interestingly, a recent study found that physicians’ self-rating of their cultural competence in caring for Spanish-speaking Hispanics with diabetes was associated with more favorable patient ratings of interpersonal aspects of care (Fernandez et al., 2004). The data presented in this chapter indicate that finding ways to overcome the barriers posed by language must be a key component of providing culturally competent care to Hispanics. In most studies, lack of English fluency emerges as an important access barrier even controlling for other demographic and socioeconomic factors. Language clearly exerts a powerful influence on patients’ experiences with care as well. In 2001, the Department of Health and Human Services issued a set of national standards for culturally and linguistically appropriate services in health care. Not surprisingly, the provision of information and services in patients’ preferred language, including patient access to qualified, professional interpreters, assumes a central role in several of the standards (U.S. Department of Health and Human Services, 2001). Policy makers must also develop effective approaches for increasing the number of Spanish-speaking health care providers.

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