1

Disparities in Immigrant Latino Children’s Health and

Healthcare: How We Can Level the Playing Field

Glenn Flores, MD Professor and Director, Division of General PediatricsUT Southwestern & Children’s Medical Center Dallas

2Overview:3 Goals of Today’s Presentation

Goal 1: share findings of latest national research on language spoken at home and disparities in medical and oral health, access to care, and use of services in immigrant Latino children

Goal 2: present results of study demonstrating successful elimination of racial/ethnic disparity for immigrant Latino children

Goal 3: propose priorities for research and policy action for immigrant Latino children which any young investigator can pursue

3

The Language Spoken at Home and Disparities in Medical and

Oral Health, Access to Care, and Use of Services in US Children

Publication: Pediatrics 2008; 121;e1703-e1714.

4

Background 55.8 million Americans (20%) speak a language other than

English at home 24.4 million Americans (9%) limited in English proficiency >10 million school-age children (20%) speak

a language other than English at home Number has tripled since 1979

But very little known about whether childrenin non-English primary language households experience medical and oral health disparities Vast majority of whom are immigrants

5

Study Aim

To identify disparities for children whose primary language spoken at home not English, in: Medical and oral health Access to health and dental care Use of health and dental services

6Methods: Data Source- National Survey of Childhood Health (NSCH)

Telephone survey in 2003-2004 of national random sample (in all 50 states and D.C.) of households with children 0-17 years old

Oversampled households with African-Americanand Latino children

Parent or guardian most responsible for child’s healthcare interviewed in English or Spanish (N=6035)

102,353 interviews completed Interview completion rate = 55% Adjustments made for non-response and non-coverage of

household without telephones Estimates based on sampling weights generalize to entire

non-institutionalized population of US children0-17 years old

7

Methods: Study Variables Disparities in medical and oral health and healthcare

examined for children in non-English primary language households, compared with children in English primary language households

Variables examined included Medical and oral health

General health status by parental report Prevalence of specific chronic conditions

Access to health and dental care Use of health and dental services

8

Methods: Statistical Analysis Multivariable analyses performed to adjust for

Child’s age Medical and dental insurance coverage Family income Race/ethnicity Number of children and adults in household Parental employment Parental educational attainment

9Selected Characteristics: 0-17 Year-Old US Children in 2003-2004 (NSCH)

Characteristic Non-English English P

Mean child age (±SE) 7.7 (±.03) 8.8 (±.11) <.001

Race/ethnicity

Latino

Asian/Pacific Islander

White

African-American

Native American

Multiracial

87%

7%

5%

2%

0.3%

0.2%

8%

1%

70%

16%

0.5%

4%

<.001

>3 children in household 22% 13% <.001

No adult in household with high school diploma 37% 14% <.001

Full-time employed adult in household 83% 91% <.001

Income <poverty threshold 42% 13% <.001

10Primary Language at Home and Medical and Oral Health: US Children

Characteristic

Non-

English English P

Health not excellent/very good 43% 12% <.001

Teeth condition not

excellent/very good 62% 27% <.001

Overweight or at risk for

overweight (BMI ≥85%) 48% 39% <.001

On prescription medications 11% 22% <.001

ADHD 1% 8% <.001

11Primary Language at Home and Access Barriers to Medical Care: US Children

Access Barrier Non-English English P

Health insurance coverage

None

Public

Private

27%

47%

24%

6%

25%

69%

<.001

Sporadic health insurance in past year 20% 10% <.001

No usual source of medical care 38% 13% <.001

Unmet medical care needs due to

Cost

No insurance

Health plan problem

43%

59%

8%

26%

39%

17%

.02

.01

.001

Any problem getting specialist care 40% 22% <.001

12Primary Language at Home and Access Barriers to Dental Care: US Children

Dental Access Barrier

Non-

English English P

Did not receive all needed routine

preventive dental care* 7% 3% <.001

Unmet preventive dental care needs due to

Health plan problem

Didn’t know where to go for treatment

Dentist didn’t know how to provide care

20%

4%

2%

8%

9%

5%

<.001

.03

.15

*If made routine preventive dental care visit in past year; only for children > 12 months old

13Primary Language at Home and Use of Medical & Dental Services: US Children

Service Use Issue

Non-

English English P

No medical visit in past year 27% 12% <.001

At least 1 ED visit in past year 16% 19% . 02

No dental visit in past year* 34% 21% <.001

No routine preventive dental visit

in past year† 14% 6% <.001

Didn’t get prescription for

needed medication 2.5% 3.2% .05*Only for children >12 months old †Among those who have ever made dental visits

14Multivariate Analyses: Disparities in Medical & Oral Health of US Children

Measure

Odds Ratio* (95% CI)

Non-English vs. English

Health not excellent/very good 2.7 (2.3-3.1)

Teeth condition not excellent/very good 2.3 (2.0-2.7)

Overweight or at risk for

overweight (BMI ≥85%) NS

On prescription medications 0.6 (0.5-0.7)

ADHD 0.2 (0.1-0.2)

*Adjusted for age, health or dental insurance coverage, income, race/ethnicity, no. of children and adults in household, parental employment, and parental educational attainment

15Multivariate Analyses: Disparities in Access to Medical & Dental Care in US Children

Measure

Odds Ratio* (95% CI)

Non-English vs. English

Uninsured 3.5 (2.9-4.1)

Sporadically insured in past year† 1.9 (1.6-2.0)

No usual source of care 1.7 (1.4-1.9)

Unmet medical care needs due to

No one accepts child’s insurance

Dissatisfaction with doctor

4.8 (1.3-18.0)

10.3 (3.3-33.0)

Any problem getting specialist care 1.7 (1.2-2.3)

Unmet dental care needs 1.8 (1.2-2.7)

Unmet dental care needs due to

Dentist not knowing how to provide care 3.2 (1.2-8.5)*Adjusted for age, income, race/ethnicity, no. of children and adults in household, parental employment, and parental educational attainment; †Referent= those continuously insured

16Multivariate Analyses: Disparities in Use of Medical & Dental Services in US Children

Service Use Issue

Odds Ratio* (95% CI)

Non-English vs. English

No medical visit in past year 1.6 (1.4-1.9)

At least 1 ED visit in past year 0.7 (0.6-0.8)

No dental visit in past year 1.2 (1.01-1.4)

No routine preventive dental visit

in past year NS

Didn’t get prescription for

needed medication 0.7 (0.5, 0.95)*Adjusted for age, health or dental insurance coverage, income, race/ethnicity, no. of children and adults in household, parental employment, and parental educational attainment

17

Multivariate Analyses: Racial/Ethnic Disparities in US Children in Non-English Language Households

OR* (95% CI) vs. Whites

Health Status Measure Latino

Asian/Pacific Islander

Health not excellent/very good 3.1 (1.9-5.0) NS

Teeth condition not excellent/very good

2.2 (1.5-3.4) NS

Overweight or obese 2.1 (1.3-3.6) NS

Bone/muscle/joint problem 14.3 (3.2–63.9) NS*Adjusted for age, income, health or dental insurance (where applicable), no. of children and adults in household, parental employment, and parental educational attainment

18

Multivariate Analyses: Racial/Ethnic Disparities in US Children in Non-English Language Households

OR* (95% CI) vs. Whites

Access/Use of Services Measure Latino Asian/Pacific Islander

Uninsured 1.8 (1.1-3.0) NS

No usual source of care (USC) 3.0 (1.7-5.1) NS

USC never/only sometimes spends

enough time with child 2.1 (1.3–3.3) 3.1 (1.5–6.3)

Unmet dental care needs 4.4 (1.6-12.4) 12.9 (2.7-61.5)

Needed but did not get prescription

medication in previous 12 mo 8.6 (3.0–24.1) 5.6 (1.3–24.7)

Interpreter needed to speak with

doctors or nurses 3.4 (1.2-9.0) 0.04 (0.01-0.2)*Adjusted for age, income, health or dental insurance (where applicable), no. of children and adults in household, parental employment, and parental educational attainment

19

Conclusions Compared with children in English primary language

households, children in non-English primary language households experience multiple disparities in Medical and oral health Access to care Use of services

Among children in non-English primary language households, Latinos and Asian/Pacific Islanders experience several unique disparities,compared with whites

20

Conclusions Latino NEPL children have higher adjusted odds than white NEPL

children of Suboptimal health status and teeth condition Overweight and obesity Bone/joint/muscle problems Lack of medical insurance No usual source of care (USC) USC not spending enough time with child Needing but not getting prescription medications

One in four Latino NEPL children and their families require medical interpretation, equivalent to more than triple the odds of white NEPL children

21

Implications Reducing language barriers may be most effective

way to eliminate medical and dental disparities for children in non-English primary language households, such as by Providing all limited English proficient patients

and their families with trained interpreter services Increasing number of states reimbursing

for medical interpreter services,which currently includes only 13 (but not California)

22

The Successful Elimination of a Racial/Ethnic Disparity in

Immigrant Latino Children’s Healthcare:A Randomized Controlled Trial of the

Effectiveness of Community-BasedCase Managers In InsuringUninsured Latino Children

Funding: RWJF, AHRQ, CMS

Publication: Pediatrics 2005;116:1433-1441

                                    

23

Uninsured Children in US About 7.3 million US children (10%)

uninsured Children at greatest risk of being uninsured:

Latinos Poor Immigrants Non-citizens Citizen children of non-citizen parents

24Children’s HealthInsurance Program (CHIP)

Enacted by Congress in 1997 to expand insurance coverage for uninsured children

Targets uninsured children < 19 years old with family incomes < 200% of federal poverty level ineligible for Medicaid and not covered by private insurance

Matched block grant programthat allocates $39 billion over 10 years

Increases state coverage of uninsured children by Raising Medicaid income limit Creating new, non-Medicaid state insurance program Doing both

25CHIP & Medicaid Not Reducing Number of Uninsured Children

Since CHIP’s inception, number of uninsured US children has more or less remained unchanged

Some states cannot find enough eligible uninsured children to use all funds they’re entitled to

States used < 20% of $24 billionallocated by Congress for CHIP for first 5 years

CHIP money for given year remains available for 2 years, but some states have built up huge reserves because they’re not close to spending their Federal allotment

Congress already has taken back several states’unused CHIP funds to use for other purposes

26

CHIPRA On 2/4/09, President Obama signed into law Children’s

Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Adds $33 billion in federal funds for children’s

coverage over next 4 ½ years Aims to cover additional 4.1 million children by

2013 through Medicaid and CHIP Under CHIPRA, states will be able to

Strengthen existing programs Cover additional low-income, uninsured children Increase outreach and enrollment efforts through

grants and express-lane eligibility

27Research Issues:Insuring Uninsured Children

Although Medicaid and CHIP outreach and enrollment programs exist, few have been formally evaluated Prior to our study, there were no published

randomized controlled trials comparing effectiveness of various outreach/enrollment programs

Critical need for innovative, rigorously tested outreach and enrollment interventions

28Relevant Findings: Community-Based Studies of Uninsured Latino Children

Boston communities with highest proportions of Latinosand uninsured children

East Boston: 29% Latino, 37% of Latino children uninsured Jamaica Plain: 32% Latino, 27% of Latino children uninsured State of Massachusetts: 7% Latino, 5% of children uninsured

Focus groups of parents of uninsured children from East Boston and Jamaica Plain revealed many barriers to insuring uninsured children

Strict rules for pay stubs and identification Language barriers Not knowing how to apply Misconceptions about work, welfare and immigration rules System problems: excessive waits for decisions, misinformation

from representatives, loss of applications, and arbitrary suspension of insurance

Focus group parents universally agreed that case managers would be very useful, helpful alternative (Ambulatory Peds 2005;5:332-340)

29

Study Goal

Conduct randomized trial to evaluate whether community-based case managers more effective than traditional CHIP and Medicaid outreach/enrollment methods in insuring uninsured children

30

Methods

Design = randomized controlled trial Single blinded: outcomes monitored by

research assistant unaware of whether participant allocated to interventionor control group

Double blinding not possible, given that participants immediately aware ofassignment to case manager

31

Methods Uninsured children recruited at community sites and randomized to:

Trained case managers (intervention) Control group (no intervention)

Setting: supermarkets, bodegas, beauty salons, Laundromats, and churches in 2 Boston communities (East Bostonand Jamaica Plain) with highest proportions of

Uninsured children Latinos

Subjects in both groups Received participation incentives Contacted monthly by blinded research assistant to monitor

outcomes for 1 year

32

InterventionCase managers: trained bilingual Latina staff (from samecommunities as participants) who Provided information and assistance on eligibility for insurance programs Filled out and submitted child’s insurance application together with

parent Expedited final coverage decisions by early and frequent contact with

Medicaid and Children’s Medical Security Plan (CMSP = CHIP equivalent in Massachusetts that covers non-Medicaid eligible, including non-citizens)

Acted as family advocate by being liaison between Medicaid/CMSP and family

Sought to remedy situations where children inappropriately had coverage discontinued or deemed ineligible

33

Control Group Received traditional Medicaid and CHIP outreach

and enrollment, which in Massachusetts currently consist of Direct mailings, press releases, newspaper

inserts, health fairs, and door-to-door canvassing Special attempts to reach Latino communities,

such as Spanish radio spots Mini-grants to community organizations A toll-free telephone number for applying for

health benefits

34

Main Outcome Measures Proportion of children obtaining health

insurance Proportion of children with episodic

coverage (obtained but then lost insurance coverage)

Number of days from study enrollment to child obtaining coverage

Parental satisfaction with process of trying to obtain coverage for child

35Results: Enrollment, Randomization, and Follow-up

275 subjects enrolled and randomized N=139 randomized to community-based case

managers (intervention group) N=136 randomized to control group

N=18 lost to follow-up or withdrew prior to follow-up Participated in at least 1 follow-up visit:

97% (N=135) in intervention group,90% (N=122) of control group

Participated in final follow-up visit (12 months after study enrollment): 72% (N=97) of intervention group and 62% (N=76) of control group

36Results:Baseline Sociodemographics

Characteristic

Intervention (N = 139)

Control (N =136) P

Mean age of child (in years) 8.9 8.9 NS

Latino subgroup: Colombian

Salvadorian

Dominican

Other

42%

21%

19%

18%

35%

24%

18%

23%

NS

Single Parent Household 55% 57% NS

Median annual household income $13,200 $14,400 NS

Parent limited in English proficiency 91% 93% NS

Parent high school grad 52% 57% NS

Parent not US citizen 90% 89% NS

37Results: Obtaining Health Insurance Coverage

Significantly higher proportion of case management (intervention) group obtained health insurance vs. control group, at 96% vs. 57% (P < .0001)

Intervention group more than twice as likely to obtain insurance coverage as control group (Adjusted Relative Risk, 2.30; 95% CI, 1.87-2.81) and had approximately 8 times the odds of being insured (Adjusted Odds Ratio, 7.78; 95% CI, 5.20-11.64) After adjustment for child’s age,

annual combined family income,parental citizenship, parental employment, andstate policy changes in Medicaid/CHIP (temporary enrollment cap and premium increases)

38Proportion Insured by Siteand Group Assignment

5563

57

96*95*96*

0102030405060708090

100

East Boston Jamaica Plain TOTALSAMPLE

*P < .0001

% I

nsur

ed

InterventionControl

39

Adjusted Incidence Curve Marked

difference between groups in obtaining insurance coverage emerged at approximately 30 days and was sustained

Adjusted Cumulative Incidence Curve*

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

0 15 30 45 60 75 90 105 120 135 150 165 180 195 210 225 240 255 270 285 300 315 330 345 360

Time to Insurance (Days)

Perc

ent I

nsur

ed

INTERVENTION

CONTROL

40Coverage Continuity and Time Interval to Obtain Coverage

Variable Intervention Control P

Continuously insured 78% 30% <.0001

Sporadically insured 18% 27% <.0001

Continuously uninsured 4% 43% <.0001

Mean time to insurance-

days (± SD)87.5 (±68) 134.8 (±102) <.0001

41Parental Satisfaction: Process of Obtaining Insurance Coverage

125 2 1

29

4

80*

41*

13* 14*

0102030405060708090

*P < .0001

%

InterventionControl

42

Conclusions

Compared with traditional Medicaid/CHIPoutreach and enrollment, community-basedcase managers substantially more effective in Obtaining health insurance for

Latino children Obtaining insurance quicker Continuously insuring children Achieving high parental satisfaction

with process of obtaining insurance

43

Conclusions Community-based case management highly

effective in insuring uninsured children documented to be at greatest risk forcontinuing to lack insurance coverage Latinos Poor Immigrants

Findings suggest it’s possible to eliminate a racial/ethnic disparity, using an evidence-based, family-oriented, community-based approach

44

Policy Consequences of Study Privileged to present Congressional Research Briefing on this study on

Capitol Hill in 2005 Led to introduction of Community Health Workers Act (S 586; HR

1968), now in committee (HELP) in Senate Authorizes Secretary of Health and Human Services to award

grants to promote positive health behaviors for women and children, especially minority women and children in medically underserved communities

Permits funds to be used to support community health workers to educate and provide outreach regarding enrollment in health insurance

Led to CHIPRA legislation including community health workers as means of outreach/enrollment of uninsured children

45

ImplicationsCommunity-based case management Could be an effective means for reducing or eliminating racial/ethnic

disparities in insurance coverage Could potentially serve as potent economic revitalization force in

impoverished communities Employing community members (such as welfare-to-work

participants) as case managers might reduce unemployment and reinvest capital in community while reducingnumber of uninsured children

Could serve as national model for insuring uninsured children and adults, given

Rigorous evidence base provided by randomized trial Potential utility in spectrum of universal coverage options being

considered, from single-payer to mandatory purchasing with subsidies

46Proposed Priorities: Research and Policy Action for Immigrant Latino Children

Develop interventions to eliminate disparities in Medical and oral health Overweight and obesity Bone/joint/muscle problems

Eliminate disparities in insurance coverage through Interventions using community health workers Enhanced outreach/enrollment opportunities

afforded by CHIPRA Including immigrant children in future healthcare

reform initiatives

47Proposed Priorities: Research and Policy Action for Immigrant Latino Children

Ensure that every Latino child has Medical home Quality of care in their medical home Access to needed prescription medications

Provide all limited-English-proficient patients and their families with adequate language services Medicaid, CHIP, private insurers, and all third-

party payers should reimburse for language services across our nation (not just in 13 states)