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 Pediatrics
UT Southwestern & Children’s Medical Center Dallas
Overview:
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
2
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 children
in 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
Methods: 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-American
and 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 children
0-17 years old
6
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
9
Selected Characteristics: 0-17 Year-Old
US Children in 2003-2004 (NSCH)
Characteristic
Mean child age (±SE)
Non-English
English
P
7.7 (±.03)
8.8
(±.11)
<.001
Race/ethnicity
Latino
Asian/Pacific Islander
White
African-American
Native American
Multiracial
<.001
87%
7%
5%
2%
0.3%
0.2%
8%
1%
70%
16%
0.5%
4%
>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
Primary Language at Home and
Medical and Oral Health: US Children
NonEnglish
43%
English
12%
P
<.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
Characteristic
Health not excellent/very good
10
11
Primary Language at Home and Access
Barriers to Medical Care: US Children
Access Barrier
Non-English
English
P
Health insurance coverage
None
Public
Private
<.001
27%
47%
24%
6%
25%
69%
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
12
Primary Language at Home and Access
Barriers to Dental Care: US Children
NonEnglish
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
Dental Access Barrier
*If made routine preventive dental care visit in past year; only for children > 12 months old
13
Primary Language at Home and Use of
Medical & Dental Services: US Children
NonEnglish
27%
English
12%
P
<.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
Service Use Issue
No medical visit in past year
*Only for children >12 months old
†Among those who have ever made dental visits
Multivariate Analyses: Disparities in
Medical & Oral Health of US Children
Measure
Health not excellent/very good
Teeth condition not excellent/very good
14
Odds Ratio* (95% CI)
Non-English vs. English
2.7 (2.3-3.1)
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
Multivariate 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
15
Multivariate Analyses: Disparities in Use of
Medical & Dental Services in US Children
Service Use Issue
No medical visit in past year
At least 1 ED visit in past year
No dental visit in past year
No routine preventive dental visit
in past year
Didn’t get prescription for
needed medication
Odds Ratio* (95% CI)
Non-English vs. English
1.6 (1.4-1.9)
0.7 (0.6-0.8)
1.2 (1.01-1.4)
NS
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
16
17
Multivariate Analyses: Racial/Ethnic Disparities in
US Children in Non-English Language Households
OR* (95% CI) vs. Whites
Health Status Measure
Health not excellent/very good
Teeth condition not
excellent/very good
Overweight or obese
Bone/muscle/joint problem
Latino
3.1 (1.9-5.0)
2.2 (1.5-3.4)
2.1 (1.3-3.6)
14.3 (3.2–63.9)
Asian/Pacific
Islander
NS
NS
NS
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)
3.4 (1.2-9.0)
0.04 (0.01-0.2)
Interpreter needed to speak with
doctors or nurses
*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
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
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-Based
Case Managers In Insuring
Uninsured 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
Children’s Health
Insurance Program (CHIP)
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24
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 program
that 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
CHIP & Medicaid Not Reducing
Number of Uninsured Children
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25
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 billion
allocated 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
Research 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
27
Relevant Findings: Community-Based
Studies of Uninsured Latino Children
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28
Boston communities with highest proportions of Latinos
and 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 intervention
or control group
 Double blinding not possible, given that
participants immediately aware of
assignment to case manager
31
Methods
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

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 Boston
and 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
Intervention
Case managers: trained bilingual Latina staff (from same
communities 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 nonMedicaid 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
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


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
Results: Enrollment,
Randomization, and Follow-up




35
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
Results:
Baseline Sociodemographics
Characteristic
Intervention Control
(N = 139)
(N =136)
36
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
$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
Median annual household income
Results: 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, and
state policy changes in Medicaid/CHIP (temporary
enrollment cap and premium increases)
37
% Insured
Proportion Insured by Site
and Group Assignment
100
90
80
70
60
50
40
30
20
10
0
96*
96*
95*
55
East Boston
38
63
57
Intervention
Control
Jamaica Plain
TOTAL
SAMPLE
*P < .0001
39
Adjusted Incidence Curve
Marked
difference
between
groups in
obtaining
insurance
coverage
emerged at
approximately
30 days and
was sustained
Adjusted Cumulative Incidence Curve*
100%
90%
80%
Percent Insured

70%
60%
INTERVENTION
50%
CONTROL
40%
30%
20%
10%
0%
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)
Coverage Continuity and Time
Interval to Obtain Coverage
Variable
40
Intervention
Control
P
Continuously insured
78%
30%
<.0001
Sporadically insured
18%
27%
<.0001
Continuously uninsured
4%
43%
<.0001
Mean time to insurancedays (± SD)
87.5 (±68)
134.8
(±102)
<.0001
90
80
70
60
50
40
30
20
10
0
41
80*
Intervention
Control
41*
29
1
as
tis
fie
d
Di
ss
at
isf
ie
Ve
r
y
d
2
Di
ss
ta
in
14*
13*
5 4
Un
ce
r
d
Sa
tis
fie
isf
ied
12
Sa
t
y
Ve
r
%
Parental Satisfaction: Process of
Obtaining Insurance Coverage
*P < .0001
42
Conclusions
Compared with traditional Medicaid/CHIP
outreach and enrollment, community-based
case 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 for
continuing 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
Implications
Community-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 reducing
number 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
Proposed 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
46
Proposed Priorities: Research and Policy
Action for Immigrant Latino Children


47
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 thirdparty payers should reimburse for language
services across our nation (not just in 13 states)