Language Attributes and Older Adults:
Implications for Medicare Policy
Ninez Ponce, PhD,MPP1,2; Leighton Ku, PhD4; William Cunningham, MD, MPH1,3
1UCLA
2UCLA
3UCLA
Department of Health Services
Center for Health Policy Research
Division of General Internal Medicine
4Center
for Budget and Policy Priorities
June 2004
Academy Health Annual Research Meeting – San Diego, CA
www.healthpolicy.ucla.edu
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Background
Å 2000 Census reveal that a large number of seniors — about 2.3
million or almost 7 percent of persons 65 or older — do not
speak English
Å Immigrants to the U.S. are likely to face numerous challenges –
including language barriers – that affect their health status and
care
Å Most research concerning health disparities related to limited
English proficiency (LEP) or immigration status have focused on
low-income children and families and, therefore, on Medicaid
policies
Å This study investigates whether such disparities also occur
among older adults—a majority who are covered by Medicare
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Research Objective
Å We investigate if and to what extent there are disparate patterns
by language attributes in self-reported general and emotional
health, having a usual source of care, seeing a doctor over the
past year, and experiencing delays in obtaining care among older
adults
Å We focus on California—a state that leads the nation as the home
to nearly 40% who speak a language other than English at home
(Census 2000)
3
Understanding the correlates of obesity and physical inactivity
among a diverse population of Latino adults will aid in
developing targeted interventions to reduce obesity, increase
physical activity, and reduce risk for diabetes
3
Funders
National Institute for Aging; P.I. Carol Mangione;
Pilot Grant to N. Ponce; Mentor W.Cunningham
P.I. Leighton Ku; Co-PIs ER Brown, N.Ponce
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Study Design
Å Data Source
™ 2001 California Health Interview Survey (CHIS 2001)
¾ Random-digit dial (RDD) telephone survey, providing a representative sample
of the state’s non-institutionalized population
¾ Conducted in English, Spanish, Mandarin, Cantonese, Vietnamese, Korean and
Khmer
Å Sample
™ 10,994 adults age 65 and over
Å Analyses
™ Descriptive analyses of health status and access to care measures by
language attributes
™ Logistic regression models weighted to the 2000 Census to examine the
association of language attributes to several health status and health access
measures
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Dependent Variables
Å Health Status
™ Self-reported general health
“In general, would you say your health is excellent, very good, good, fair, or poor?”
™ Self-reported emotional health
“Did you feel downhearted and sad (all of the time, most of the time, some of the
time, a little of the time or not at all)?”
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Dependent Variables
Å Health Care Access
™ Having at least one doctor visit in the past 12 months
“During the past 12 months, how many times have you seen a medical doctor?”
™ Having a usual source of care
“Is there a place that you usually go to when you are sick or need advice about
your health?”
™ Delaying medical care
“During the past 12 months, did you delay or not get any other medical care you felt
you needed—such as seeing a doctor, a specialist or other health
professional?”
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Regression Analyses: Independent Variables
Å Main Independent Variable:
™ Language Ability
¾ LEP – individual speaks English “not well or not at all”
¾ Bilingual – individual speaks a language other than English at home but
reported speaking English “well or very well”.
¾ English only – individual speaks only English
Å Other Independent Variables:
™ Socioeconomic/Demographic - Race/Ethnicity, Years lived in the U.S., Health
insurance status, Gender, Cohabitation structure, Age, Area of residence,
Education, Household Income (as % of FPL),
™ Health Status - Number of chronic conditions
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Sample Characteristics, Adults Age 65+
Race/Ethnicity
LEP
(n=551)
Bilingual English only
(n=1285)
(n=9154)
Total
(n=10,994)
Latino
41.3
22.0
1.2
6.5
Asian
46.0
22.8
2.6
7.9
Black
0.1
2.1
6.5
5.9
American Indian/Alaska Native
0.0
0.3
0.4
0.3
Other single race/multiracial
2.8
7.3
1.9
2.3
White
9.7
45.5
87.3
77.1
Source: 2001 California Health Interview Survey
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Sample Characteristics, Adults Age 65+, Cont’d
Insurance Status
LEP
(n=551)
Bilingual English only
(n=1285)
(n=9154)
Total
(n=10,994)
Uninsured
4.1
0.2
0.2
0.6
Private only
8.9
4.6
4.0
4.6
Medicare only
8.9
10.2
5.7
6.7
Medicare plus Medicaid
58.9
22.8
14.4
20.1
Medicare plus private
19.1
62.2
75.7
68.0
Source: 2001 California Health Interview Survey
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The sample was predominately female, between the ages of 65 and 74,
urban dwelling, lived with others, with at least one chronic condition
Substantial numbers of LEP (n=551) and bilingual speakers (n=1285)
LEP speakers had fewer HS grads, greater proportions in poverty and
more noncitizens than bilingual and English only speakers
Adequate representation of Latinos (n=560) and Asians (n=489)
However, population proportions, are less than 15% of the total age 65+ population
compared to 32% (Latino) and 11% (Asian) of California’s overall population
Very few elderly lived in the U.S. less than ten years (n=45)
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Unadjusted Rates, Adults Age 65+
Sample Size
Unadjusted Rates (%)†
Dependent Variable
LEP/Bilingual/English Only
LEP
Bilingual
English
Only
All
Elderly
Health Status
Reported fair or poor
health status1,2
327 / 340 / 2441
60.2
26.5
26.3
28.7
57 / 54 / 305
10.5
4.5
3.2
3.9
505 / 1204 / 8628
92.3
93.5
94.6
94.2
510 / 1242 / 8891
94.1
96.6
97.5
97.1
29 / 69 / 487
7.3
4.7
5.1
5.3
Felt sad all or most of
the time1,2,3
Health Access
Saw a doctor in the
past 12 months1
Have a usual source
of care1,2
Delayed care1,2
† Weighted to Census 2000 estimates of California’s 65 and older population.
We performed two-sample tests of proportions comparing unadjusted rates. Comparisons at p ≤ 0.05
are designated as: (1) LEP ≠ English only, (2) LEP ≠ Bilingual, (3) Bilingual ≠ English only
Source: 2001 California Health Interview Survey
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Summary of Bivariate Analysis
Å Compared to those who speak English only, LEP individuals had:
™ Higher % in poorer general and emotional health and who had delayed care
™ Lower % who had an annual doctor visit and who had a usual source of care
Å Compared to those who were bilingual, LEP individuals had:
™ Higher % with poorer health status and access
™ Equivalent % who had at least one doctor visit
Å Compared to English only speakers, bilingual speakers had:
™ Similar % with poorer health status and less access to care
™ Higher % in poorer emotional health
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Adjusted Relative Risks, Adults Age 65+
LEP vs. English Only†
Baseline
Rate (%)
Adjusted
Relative
Risk††
Reported fair or poor
health status
15.6
Felt sad all or most of
the time
Dependent Variable
Bilingual vs. English Only†
95% CI
Baseline
Rate (%)
Adjusted
Relative
Risk††
95% CI
1.89
1.44, 2.43*
18.9
0.93
0.78, 1.10
3.6
2.41
1.36, 4.14*
3.9
1.50
1.07, 2.08*
86.0
0.96
0.83, 1.06
85.4
1.00
0.93, 1.04
Health Status
Health Access
Saw a doctor in the
past 12 months
Have a usual source of
care
90.3
0.81
0.60, 0.96*
89.2
0.97
0.90, 1.02
Delayed care
15.1
1.98
1.25, 2.90*
14.4
1.20
0.88, 1.61
* p ≤ 0.05; † Weighted to Census 2000 estimates of California’s 65 and older population; ††Adjusted
for race/ethnicity, insurance status, gender, living arrangement, family income as % FPL, length of
residency in the U.S., education, age, urban vs. rural, and number of chronic conditions.
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Source: 2001 California Health Interview Survey
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Summary of Multivariate Analysis – Health Status
Å Fair/Poor Health Status
™ RR for LEP seniors was nearly twice that of English only speakers
Å Emotional Health, feeling sad all or most of the time
™ RR for LEP seniors was more than twice that of English only speakers
™ Higher RR for bilingual speakers than for English only speakers
Å Usual Source of Care
™ LEP individuals were less likely to have a USOC than English only
speakers
Å Delays in Care
™ LEP individuals were twice as likely to delay care as compared to English
only speakers
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Conclusions
Among older adults, LEP individuals were more likely to report
worse general and emotional health and worse access to care
than English only speaking individuals.
™ With the exception of our emotional health measure, bilingual
speakers and English only speakers were very similar across all
health status and access measures
™ Compared to English only speaking individuals, the barriers to
care are clearly faced by LEP individuals, but not by bilingual
individuals who are English proficient
™ However, bilingual older adults are at increased risk of reporting
feeling sad all or most of the time as compared to English only
speakers, although their increased risk is lower than LEP
individuals
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Study Limitations
California may not be generalizable to the the rest of the U.S.
The CHIS 2001 telephone administration systematically excluded
households without telephones--which may more likely be lowerincome and/or LEP
CHIS 2001 was conducted in Spanish and several Asian languages so
monolingual speakers of other non-English languages may not have
been represented in the survey
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Policy Implications
Å Policy discussions about increasing the availability of
interpretation services has primarily focused on problems
occurring among the Medicaid and the uninsured populations
Å This paper demonstrates that language barriers should also be of
concern to those who establish policies for Medicare
Å In light of the demographic trends of growth in the immigrant and
the older adult populations, these problems will become more
common in the coming years
Å Federal civil rights policies already establish the rights of LEP
patients to interpretation services, but Medicare policy regarding
the availability of and payment for language services ought to
come into concordance
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