WW-07565     2000  

Improving Health Care Access
for Minnesota's Growing Latino Community

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MICHAEL J. DAVIDOFF, ELLIE ULRICH, PAUL CARRIZALES, AND LYNN A. BLEWETT

A collaboration between Chicanos Latinos Unidos En Servicio (CLUES), Westside Health Center (La Clinica), Hispanic Advocacy and Community Empowerment through Research (HACER), the Minnesota Department of Health, and the University of Minnesota School of Public Health.

MinnesotaCare has been a successful policy tool to increase access to health insurance for the uninsured, yet it is not as successful in meeting the unique needs of immigrant communities. This paper presents specific policy recommendations designed to increase access to health care for Latinos in Minnesota and describes the successful collaborative community-based research effort that was used to develop these recommendations.

Michael J. Davidoff is a student at the University of Minnesota School of Public Health.

Ellie Ulrich, MPH, is an alumnus of the School of Public Health and is currently a Health Program Analyst for the City of Minneapolis, Department of Health and Family Support.

Paul Carrizales is the Executive Director of the Hispanic Advocacy and Community Empowerment through Research (HACER).

Lynn A. Blewett, Ph.D., is an Assistant Professor at the University of Minnesota School of Public Health.

Introduction

As we enter the twenty-first century, the population of Minnesota is changing. It is estimated that by 2025, one-fifth of Minnesotans will be of Asian, African-American, American Indian, or Hispanic origin, as compared to 8.4 percent in 1995. (Minnesota Planning State Demographic Center, 1998; Minnesota Department of Health and the Urban Coalition, 1997). Of all racial/ethnic groups in Minnesota, the Latino population is growing the fastest. As shown in Figure 1, Minnesota Planning predicts that the Hispanic-origin population will grow almost 250 percent between 1995 and 2025, compared to an 8 percent increase in the white population and just over 100 percent growth in the African-American and Asian/Pacific Islander populations. If the estimates are correct, Minnesotas Latino population will grow from just under 132,300 today to 296,400 in 2025. Figure 2 and Figure 3 show that, while two-thirds of Minnesota's Latino population resides in the seven county metro area, as of 1998 six non-metro counties had Latino populations numbering greater than 1,500 (U.S. Bureau of the Census, 1998).

Figure 1. Between 1995 amd 2025. the Latino population will grow faster than any other population in Minnesota. (Source: Minnesota Planning, 1998)

These changing demographics provide a richness of diversity and cultural life, but also present new challenges to existing health and social service providers. Health care is one of the areas where we continue to see increasing disparities in terms of access to needed care and public health services. (Minnesota Department of Health, Office of Minority Health and The Urban Coalition, 1997). These health disparities in turn lead to poor health status, which directly impacts the resiliency of communities. While a large proportion of these health disparities exist in the inner city neighborhoods of Minneapolis and St. Paul, they are increasingly spreading to rural areas. Meat packing, food processing, and other light industrial plants have been attracting Latinos to small rural towns in an attempt to restore faltering farm economies. Although Latinos are a rich source of labor for these and other low-wage positions, low-wage jobs are often associated with either no or limited health insurance benefits. This combination of low-wage jobs and underinsurance, and the dynamics of a changing ethnic landscape, creates new challenges for policymakers interested in designing policies to meet basic human needs (Minnesota Planning State Demographic Center, 1998).

Figure 2. Estimated distribution of Minnesota's Latino population by country, 1997. (Source: Minnesota Planning, 1998)

Figure 3. 1997 Estimate of Latinos as percent of total county population. (Source: Minnesota Planning, 1998)

The proportion of Minnesota's Latino population that has health insurance receives that coverage through a heterogeneous mix of either private employer-sponsored insurance or publicly-subsidized programs. Some employers in low-wage industries offer health insurance; however, the burdens of premium sharing, sign-up waiting periods, coinsurance, and deductibles often prevent Latinos from accessing this coverage. While employer plans often fall short of meeting the needs of Latinos, public programs also have several limitations. The primary approach to increasing access to public health insurance for Minnesota's working poor has been the MinnesotaCare program. Yet despite MinnesotaCare's success and the high levels of Latino employment, the number of uninsured Latinos is six times the state average (30 percent compared to 5.2 percent). The key reasons Latinos do not sign up for public programs are that they lack comprehensible information about the plans, they do not know where to sign up, and they are often unsure of eligibility requirements. Additionally, many Latinos have a historical fear and distrust of the U.S. government and government public programs, and often live in areas that lack health services sensitive to their needs.

Future health policy solutions should be responsive to the unique characteristics, traditions, and needs of each immigrant community. One-size-fits-all designs simply do not work. We have learned through our preliminary research that any effort to reduce the number of uninsured Latinos must consider alternative and complementary approaches to existing programs as a necessary component to increasing access to affordable coverage. This paper addresses the health care needs of Latinos and also presents a community-based research model that can be used to gather information on other immigrant groups in an effort to develop relevant policy solutions. We will present an integrative model for designing policy solutions with immigrant populations, discuss key results from ongoing research collaborations, and make specific policy recommendations based on our findings.

Policy Model Approach

When studying variables such as health care access in different cultures, it is important to recognize that the process of gathering information impacts the quality of the data. We have heard numerous reports from the Latino community about researchers that rush into communities, probe for information, and produce reports that yield little or no change for the participants of the study. When researchers do not take the time to understand the Latino culture, there is evidence that study participants will report false or incomplete information.

To gain a better understanding of the Latino community while utilizing the resources of the School of Public Health, we established a collaborative research initiative called the Latino Health Care Access Project (LHCAP). An advisory committee was set up to guide the research and included representatives from Chicanos Latinos Unidos En Servicio (CLUES), Westside Health Center (La Clinica), Hispanic Advocacy and Community Empowerment through Research (HACER), the Minnesota Department of Health, and the University of Minnesota School of Public Health. The initial work included a literature review, nineteen key actor interviews with leaders in the Latino community, and six focus groups (four in rural Minnesota) conducted in Spanish. The results of this multi-faceted approach provided a greater awareness of existing public health data on Minnesota's Latino community and reinforced the need for more comprehensive data collection. The following section highlights our key findings.

Access to Health Care

Access to needed health care services was the most important health issue affecting Latinos in Minnesota. Barriers to access included: lack of insurance, the high cost of care, lack of services in Spanish, and lack of providers sensitive to Latino traditions. Repeatedly, we heard about the need for appropriate health care as a key issue. That is, even when Latinos were able to see a health care provider, many do not feel that they receive the care they need because of language and cultural barriers.

Some of these barriers result from a lack of understanding of the health care system in the United States. The concept of deductibles and coinsurance were found to be confusing, especially for new immigrants. Before coming to the United States, some Chicano participants told us that their preconceived notion of health care in the United States was that it would be far superior to the health care they received in Mexico. The inherent difficulty in maneuvering through the health care system was an obvious source of frustration, and this discomfort led to a feeling of distrust and dissatisfaction toward the medical community. In the words of one uninsured woman: "People do not go to the clinics because all they do is give you a white pill and charge you two hundred dollars."

Health Status and Public Health Issues

Chronic diseases, and in particular, diabetes, obesity, hypertension, and HIV/AIDS, are significant health concerns for the Latino community. We also heard concerns about poverty and crowded, dirty, living conditions as major public health issues affecting some Latinos in rural Minnesota. In addition, we found a significant lack of preventive and general health care that may lead many Latinos to seek care only when a condition has reached the crisis point. Lack of preventive health care utilization was attributed to both access and knowledge barriers. Specific examples of preventive health care services underutilized by Latinos in Minnesota included immunizations, preventive care for children, AIDS/ STD prevention, and breast and cervical cancer screening.

While most of the focus group participants said their communities were very young, some participants expressed concern for the elderly. One man told us that the elderly "can't walk, can't bathe themselves, can't go to the bathroom, and can't change their clothes." He believed health care provided to elderly Latinos was inadequate. In addition, one woman expressed concern about the health of her aunt, a ninety year-old woman without legal papers. Specifically the woman said "she [the aunt] doesn't have any insurance, and there are times when she gets really sick because she has diabetes."

The latter case was not isolated. The belief was systemic among the focus groups that undocumented Latinos had few options for accessing health care services. Not only are undocumented individuals ineligible for insurance programs, but they are often turned away from health clinics if they are unable to pay. One man told us that "if you don't have legal papers, you don't get services. Either you pay cash or they don't help you."

Knowledge and Education

We found that lack of knowledge about health conditions, prevention, nutrition, and available services was a major health concern. Specifically, respondents identified lack of Spanish educational materials about asthma, diabetes, hypertension, and cancer prevention, as well as lack of knowledge about available services and programs as significant health concerns.

The availability of a federal, state, or local community social service resource was one of the main determinants of health care access and education. This was reflected by some of the drastic differences between health insurance status and access to services between rural towns. One federal resource that was associated with an increase in insurance enrollment and access to health care services was the Women, Infants and Dependent Children Food Supplement Program (WIC). When a resource is available to facilitate the process of involvement in public programs or access to needed health care information, the communities we talked with fared better. One woman from an area that lacked these resources captured this point when she said: "We just need to know (about available health services and insurance programs)...only certain people know."

Other Barriers Related to Public Health and Health Care Access

We also heard concerns about community discrimination. Many participants believed there was discrimination in the workplace. The general belief was that low-wage jobs prevented many Latinos from accessing adequate housing and health insurance. Even when employers offered health insurance, many cited difficulty in learning how to enroll, and believed plan deductibles and coinsurance were unjust and unreasonable (with respect to their wages). There was a general dissatisfaction with the meat and poultry packing industry, and participants believed that a disproportionate share of menial jobs go to Latinos.

Additionally, many participants believed that apartment managers treated them unfairly. A majority of participants was unsatisfied with the quality of housing available and believed there was a lack of affordable housing.

Policy Recommendations

The information collected from the key informant interviews correlated well with the results from the focus groups. Consistent with our community-based model approach to health care and public health research, all members of the Latino Access Project have analyzed these results, and have taken part in designing long and short range policy strategies to eliminate health disparities. Although our research has found multiple factors affecting access to health and public health services that need to be addressed, this final section of the paper will present initial recommendations that we believe are the most important in reducing health disparities in Minnesota's Latino population. The recommendations are grouped into the following areas: access to health insurance, provider and service delivery, and data and information collection.

Increase Access to Health Insurance

Our research shows that lack of health insurance is a function of many variables for Latino communities, including the high percentage of Latinos in low-wage jobs, and the limited availability of adequate health coverage. Our first recommendation is to better facilitate access to the health insurance market through an increase in private and public program participation.

Private Programs: Employer Health Insurance Offerings

Increase the percentage that would qualify an employer contribution as "employer subsidized" insurance for the purposes of MinnesotaCare eligibility from 50 to 60 percent. Current law states that if an employer offers health insurance coverage and contributes at least 50 percent towards its purchase, the individual is not eligible for MinnesotaCare even though she or he may be eligible based on income. Recent data from the Department of Health shows that the average employer contribution is actually 82 percent for individual coverage and 70 percent for family coverage. The threshold is clearly too low and individuals working in low-wage jobs are likely not able to afford insurance coverage. Raising the premium contribution threshold may help those individuals working in low-wage jobs have access to MinnesotaCare. This is not likely to introduce new "crowd out" or employers dropping contributions, as the average of 80 percent contribution has been relatively stable at this high contribution rate.

Require employer health insurance plans to notify employees when the waiting period for health insurance will expire. During focus groups with Latinos in rural Minnesota we heard stories about the interest in signing up for employer-sponsored plans. However, there seemed to be some confusion about waiting periods for eligibility, when people were eligible, and how they would know. This provision requires employers to notify employees in writing (multiple languages) when their eligibility period is up, gives direction on how to sign up, and presents clearly the individual costs of the employer-sponsored plan.

Public Programs: MinnesotaCare Refinements

Establish presumptive eligibility for women and children for MinnesotaCare insurance coverage. Results from the Latino Health Care Access study, and a recent report by the Minnesota Department of Health on uncompensated care by health care providers, showed that lack of insurance is perpetuated by the difficulty in filling out forms as well as general lack of knowledge of programs and program eligibility. This not only increases the burden of uncompensated care in the health services industry, but also puts the health of many women and children in jeopardy. We suggest the implementation of retroactive coverage for women and children who present with a medical condition to any licensed health care provider. If the person presenting with the medical condition satisfies the requirements for MinnesotaCare coverage they would receive coverage benefits for that initial visit. To defray the added cost to the program, the person presenting with the medical condition would be responsible for a retrospective premium payment for the current month in which they presented.

Implement enrollment specialists to facilitate the insurance enrollment process. Results from focus groups showed that many people eligible for public insurance did not sign up for that insurance because they did not understand the process. Based on this evidence, the availability of a culturally competent enrollment specialist to streamline the enrollment process would be a beneficial outreach program to those eligible for public insurance. In addition to increasing the access to health care for these populations, the program would also decrease the amount of uncompensated care in Minnesota. The Department of Human Services should seek federal waivers to allow the use of certified enrollment specialists to enroll persons in MinnesotaCare. The DHS would also be required to develop training opportunities for non-English speakers and representatives of different cultures in Minnesota communities to become enrollment specialists.

Provider and Service Delivery

During the focus groups and interviews, we discovered that cultural understanding plays a unique role in Latinos' decisions to seek out health services. Just as continuing education is required to be aware of technical developments in professions, additional training is also necessary to foster good working relationships with the people a profession serves. Our second recommendation focuses on increasing the cultural competency of key professions that affect population health.

Establish a provider cultural competency continuing education program in collaboration with the continuing education infrastructure already in place at the University of Minnesota to promote the development of a profession-specific cultural competency program in the fields of medicine, public health, nursing, dentistry, education, and law.

Establish a cultural competency curriculum financing fund at the Minnesota Department of Health. These funds will be awarded to organizations that include cultural competency curricula in their training and development programs.

Data and Information Collection

A key component of forming policy to affect access to health care is the availability of accurate data. There is currently limited data available to understand or monitor access and health issues for immigrant populations and other communities of color. Key to development of good policy solutions is good baseline data. Minnesota has always been a leader in public health data collection. It is time to focus that expertise on populations that have largely been ignored. Our third recommendation focuses on increasing data collection for Minnesota's populations of color.

Develop an information and data collection strategy. Minnesota Department of Health, Health Economics Program in consultation with the Office of Minority Health, the Latino Health Care Access Advisory Committee, and the University of Minnesota, School of Public Health should develop an information and data collection strategy to establish baseline information on access to health insurance coverage and methods for periodic follow up to monitor change in health coverage over time for immigrant populations and other populations of color. The Department of Health should study available options and provide a report to the legislature outlining a strategy that discusses various options considered and the costs associated with each option.

The legislature should establish mandatory annual reporting of health utilization data on services provided to populations of color. Integral to a health care data collection strategy will be reporting utilization patterns by populations of color of hospitals and outpatient surgical centers. We propose amending the Health Care Cost Information Act of 1984 to require these institutions to include this information in their annual summary reports.

These policy recommendations are only a first step in eliminating health disparities in Minnesota's growing Latino population. We have targeted health insurance, provider services, and data collection because we believe these are the best combination of long and short range solutions to address these problems.

References

Minnesota Department of Health and the Urban Coalition. 1997. Populations of Color in Minnesota Health Status Report. Minnesota Department of Health, Office of Minority Health and the Urban Coalition, Saint Paul.

Minnesota Planning State Demographic Center. 1998. Faces of the Future: Minnesota Population Projections, 1995-2025. Minnesota Planning State Demographic Center: Saint Paul.

U. S. Bureau of the Census. 1998. 1998 County Population Estimates. Washington: U.S. GPO.

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