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National Research Council (US) Panel on Hispanics in the United States; Tienda M, Mitchell F, editors. Hispanics and the Future of America. Washington (DC): National Academies Press (US); 2006.

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Hispanics and the Future of America.

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10Access to and Quality of Health Care

and .

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, 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.

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 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.

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 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 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.

TABLE 10-1. Health Insurance Coverage, by Age Category and National Origin .

TABLE 10-1

Health Insurance Coverage, by Age Category and National Origin .

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 10-2. Health Insurance Coverage for Working-Age Adults, by Nativity, Years in United States, and Citizenship .

TABLE 10-2

Health Insurance Coverage for Working-Age Adults, by Nativity, Years in United States, and Citizenship .

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 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.

TABLE 10-3. Health Insurance Coverage for Working-Age Adults, by Language Preference .

TABLE 10-3

Health Insurance Coverage for Working-Age Adults, by Language Preference .

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 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 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 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.

TABLE 10-4. Usual Source of Care, by Age Category and National Origin .

TABLE 10-4

Usual Source of Care, by Age Category and National Origin .

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.

TABLE 10-5. Usual Source of Care for Working-Age Adults, by Nativity, Years in United States, and Citizenship .

TABLE 10-5

Usual Source of Care for Working-Age Adults, by Nativity, Years in United States, and Citizenship .

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 Ricans who prefer English are more likely than those who prefer Spanish to have a physician's office as their usual source.

TABLE 10-6. Usual Source of Care for Working-Age Adults, by Language Preference .

TABLE 10-6

Usual Source of Care for Working-Age Adults, by Language Preference .

Other Barriers

An important structural barrier to health care access faced by many Hispanic patients is distance to medical care providers, in general, coupled with low availability of Hispanic health care professionals, in particular. In California, communities with a high proportion of Hispanic residents are four times more likely than communities with a high proportion of non-Hispanic whites to have a shortage of physicians, irrespective of income level (Komaromy et al., 1996). The low number of Hispanic physicians undoubtedly contributes to these geographic patterns, as Hispanic physicians are much more likely than other physicians to locate in Hispanic communities.

The low number of Hispanic physicians also exacerbates the effects on patients of geographic physician shortages. Hispanic physicians are more likely than other physicians to care for Hispanic patients, even after accounting for the demographic composition of the community (Komaromy et al., 1996). Hispanics perceive that Hispanic physicians provide care of higher quality than do other physicians (Saha, Komaromy, Koepsell, and Bindman, 1999), and they tend to seek care from Hispanic physicians because of personal preference and language, irrespective of location and socioeconomic factors (Gray and Stoddard, 1997; Saha, Taggart, Komarony, and Bindman, 2000). For example, Saha et al. (2000) found that more than two-fifths of Hispanic patients considered the physician's ability to speak Spanish when choosing a physician.

Cultural differences between patients and health care providers may create barriers to access as well. According to Betancourt, Green, and Carrillo (2002), cultural differences encompass patients' ability to recognize symptoms of diseases, thresholds for seeking care, expectations of care, and the ability to understand prescribed treatments, all of which are likely to affect Hispanic patients' patterns of seeking care as well as providers' responses to their Hispanic patients.

Barriers to obtaining appropriate and timely health care may arise from the behavior of providers. There is considerable evidence that many well-meaning people who are not overtly biased hold unconscious negative racial attitudes and stereotypes (e.g., Dovidio, Brigham, Johnson, and Gaertner, 1996). There is also evidence that health care providers are influenced in their clinical decisions by patients' race and ethnicity. Although most of this research pertains to blacks, studies based on patient reports suggest that these provider attitudes and behaviors may influence the care that Hispanics receive as well.

Lillie-Blanton and colleagues (2000) analyzed data from interviews with a nationally representative sample of U.S. adults. They found that 30 percent of Hispanics believe racism, defined as people being treated worse than others because of their race or ethnicity, is a “major problem” in health care, compared with 16 percent of non-Hispanic whites. In addition, more than one-half of Hispanics thought the health care system treats people unfairly based on their race or ethnicity, and nearly three-fourths thought it treats people unfairly based on how well they speak English. More than one-half of Hispanics thought Hispanics received lower quality of care than whites. Perhaps most significant, 36 percent of Hispanics, compared with 15 percent of whites, reported that they, a family member, or a friend had been treated unfairly by the medical care system because of their race or ethnicity. And 13 percent of Hispanics, compared with 1 percent of whites, reported personally experiencing unfair treatment.

These barriers to health care access may have profound effects on Hispanic patients' decisions to seek care. For example, parents of low-income Hispanic children report that low affordability, language problems, transportation problems, long waiting times in the office, poor communication with providers, and lack of cultural understanding by clinic staff are obstacles to access that occasionally caused them not to bring their children in for care (Flores, Abreu, Olivar, and Kastner, 1998). Language barriers, in particular, may cause Spanish speakers not to seek needed care.

Health Care Utilization

In this section, we review the status of Hispanics with regard to their utilization of health care services. We discuss the use of prenatal care and preventive health care services, rates of ambulatory visits and hospitalizations, and medical care expenditures.

Prenatal Care

Early and continuous prenatal care is thought to promote good health outcomes for both mothers and infants. Although the effects of prenatal care are difficult to measure, it is widely believed that early prenatal care fosters healthier pregnancies by enabling health care providers to identify and treat maternal conditions and behaviors that can adversely affect the initial stages of fetal development, provide medical advice, and assess the risk of a poor pregnancy outcome (Giachello, 2001). Prenatal care may also provide an entry point to the health care system, especially for women who do not have a usual source of care. Women who begin prenatal care after the first trimester of pregnancy or who have no prenatal care receive less preventive care and education and have a higher risk of undetected complications.

Historically, Hispanic women have been less likely than non-Hispanic white women to receive early prenatal care. For example, in both 1980 and 1990, 60 percent of Hispanic women received prenatal care beginning in the first trimester, compared with more than 80 percent of white women (National Center for Health Statistics, 2003). However, the gap between Hispanic and white women has been shrinking in recent years. In 1995, 71 percent of Hispanic women began prenatal care in their first trimester, compared with 87 percent of white women; in 2001, the proportions who began prenatal care in the first trimester were 76 percent and 89 percent, respectively. As shown in Table 10-7, Hispanic women and non-Hispanic black women have similar rates of receiving early prenatal care.

TABLE 10-7. Receipt of Prenatal Care for Live Births, By National Origin .

TABLE 10-7

Receipt of Prenatal Care for Live Births, By National Origin .

As with most other access indicators, aggregate data mask important differences in prenatal care across Hispanic groups defined by national origin. Hispanics of Mexican origin have long had the lowest rate of prenatal care, whereas the rate for Cubans has often exceeded that for non-Hispanic whites. Puerto Rican and Hispanics of other Central or South American origin fare better than Mexicans but worse than whites.

Other studies have found that Hispanic mothers born in the United States are more likely than foreign-born Hispanic mothers to receive prenatal care in the first trimester (Giachello, 2001). However, the difference—76 versus 73 percent in 1999—is very small, especially when compared with the effect of nativity on health insurance coverage and usual source of care.

Lack of health insurance coverage may make prenatal care unaffordable for many Hispanic women. Additional barriers are likely to include language and cultural incompatibility between women and their prenatal care providers, lack of understanding or knowledge of prenatal care, and fear of the effect of seeking care on immigrant status.

Thus the narrowing of disparities in prenatal care between Hispanics and whites during the 1990s is noteworthy, especially in light of the high proportion of Hispanics who lack health insurance. Many analysts believe that recent expansions in Medicaid eligibility have enabled more low-income women, including Hispanic women, to access prenatal care (e.g., Morbidity and Mortality Weekly Report, 2000; Ray, Mitchell, and Piper, 1997). Others, however, underscore a persistent gap in prenatal care between women with private and with public insurance coverage (Braveman, Bennettt, Lewis, Egerter, and Showstack, 1993).

Preventive Services

The goal of preventive health care services is to reduce morbidity and mortality through the prevention or detection of disease. For the last decade and a half, the United States Preventive Services Task Force has assessed the available evidence on the effectiveness of preventive health care services and issued recommendations regarding their use. Recommended preventive services for children include immunizations against a wide and growing array of infectious diseases. Recommended preventive services for adults vary by age, but generally include screening tests for certain cancers as well as selected immunizations.

Hispanics are less likely than non-Hispanic whites to receive recommended preventive services, although, as with prenatal care, the gap between Hispanics and whites has narrowed in recent years. By contrast, Hispanics are more likely than non-Hispanic blacks to receive certain preventive services. For example, in 1995, 68 percent of Hispanic children 19 to 35 months of age had received the recommended doses of diphtheria and tetanus toxoids and pertussis vaccine, oral poliovirus vaccine, measles vaccine and haemophilus influenzae Type B vaccine, compared with 76 percent of white children and 70 percent of black children (National Center for Health Statistics, 2003). By 2001, the proportions were 77, 79, and 71 percent, respectively. In 2001, Hispanic and white children had similar rates of hepatitis B and varicella vaccines (National Center for Health Statistics, 2003), whereas Hispanics had higher rates than blacks. A likely explanation for the shrinking gap in childhood vaccination rates is the Vaccines for Children program, which was created in 1994 and provides vaccines free of charge to eligible children, including uninsured children (Centers for Disease Control and Prevention, 2004).

In contrast to children, Hispanic seniors continue to lag non-Hispanic white seniors in the receipt of age-appropriate vaccinations (National Center for Health Statistics, 2003). For example, in 1999–2001, only 31 percent of Hispanic adults age 65 and older reported ever receiving a pneumococcal vaccine, compared with 56 percent of white seniors and 32 percent of black seniors. And 55 percent of Hispanic seniors reported receiving a flu shot during the preceding 12 months, compared with 67 percent of whites and 47 percent of blacks.

Working-age Hispanic women lag both non-Hispanic white and non-Hispanic black women in the rates of mammography and pap smears (National Center for Health Statistics, 2003). In 2000, only 54 percent of Hispanic women 40 to 49 years old and 66 percent of Hispanic women 50 to 64 years old reported receiving a mammogram within the previous two years, compared with 67 and 81 percent of white women in these age groups, respectively, and 61 percent and 78 percent of black women. Mexican women had the lowest mammography rates (61 percent for women 40 to 64 years old), while Cubans had the highest rates (80 percent). In addition, 79 percent of Hispanic women 18 to 49 years old and 76 percent of Hispanic women 50 to 64 years old reported receiving a pap smear within the previous three years, compared with 87 and 85 percent of white women in these age groups, respectively, and 89 and 84 percent of black women. Sambamoorthi and McAlpine (2003) found that socioeconomic status and health insurance coverage explain the disparities between working-age Hispanic and white women in their rates of pap smears and mammograms. Interestingly, Hispanic, white, and black women who were 65 years and older reported similar rates of mammography and pap smears, suggesting an important role for Medicare coverage.

Recent data show that only 18 percent of Hispanics 50 years old and older receive colon cancer screening, compared with 28 percent of whites. Only 58 percent of Hispanic smokers receive smoking cessation counseling, compared with 82 percent of white smokers. Using MEPS, Stewart and Silverstein (2002) found that Hispanics were less likely than whites and blacks to have a blood pressure or cholesterol screening, although the differences in rates were explained by differences in health insurance coverage and socioeconomic status.

Visits and Hospitalizations

The available evidence suggests that the barriers to access faced by Hispanics result in lower use of health care. Most studies have found fewer ambulatory visits among Hispanics than among non-Hispanic whites, even controlling for demographic and socioeconomic factors, health status, and type of health insurance (e.g., Fiscella, Franks, Doescher, and Saver, 2002; Guendelman and Wagner, 2000; Weinick, Jacobs, Stone, Ortega, and Burstin, 2004). These studies have also documented differences across Hispanic subgroups defined by national origin. For example, Weinick et al. (2004) found that Hispanics of Puerto Rican or Cuban origin were more likely than those of Mexican or Central American origin to have had a visit during the preceding year. Other studies have found lower utilization among Hispanics who speak Spanish, compared with English speakers, and among those who are less acculturated (e.g., Fiscella et al., 2002; Solis, Marks, Garcia, and Shelton, 1990; Weinick et al., 2004). In fact, using data from the Community Tracking Survey, Fiscella et al. (2002) found a sizable difference between Spanish-speaking Hispanics and whites in physician visits and mental health visits, but no difference between English-speaking Hispanics and whites. However, using MEPS data, Weinick et al. (2004) found differences in ambulatory visit rates between Hispanics and whites regardless of language. The difference in findings between these two studies may reflect their use of different data sources; although both surveys are national in scope, MEPS is the only one that is nationally representative. Physician visit rates are much lower for undocumented Hispanic immigrants than for their legal counterparts (Berk et al., 2000). Studies of hospitalization rates have yielded mixed results, with some studies finding similar rates for Hispanics and whites and others finding lower rates for Hispanics (e.g., Berk et al., 2000; Freiman, 1998; Weinick et al., 2004).

We used data from the 1996–2000 MEPS to assess current patterns of utilization for Hispanics, non-Hispanic whites, and non-Hispanic blacks. Table 10-8 presents descriptive data on ambulatory visits to physicians and to nonphysician providers. Hispanic children are much less likely than white children to have a physician visit during the year, and they have fewer visits on average. Similarly, working-age Hispanics are less likely than whites to have a physician visit and have fewer visits. However, Hispanic children have more physician visits than black children, and working-age Hispanics have similar physician visit rates as their black counterparts. There is no difference between Hispanic and white seniors in their rates of physician visits.

TABLE 10-8. Visit and Hospitalization Rates, by Age Category and National Origin .

TABLE 10-8

Visit and Hospitalization Rates, by Age Category and National Origin .

In contrast to the findings for physician visits, Hispanics in all age groups have fewer visits than whites to nonphysician providers, and the rates of visits to nonphysician providers for Hispanic children and working-age adults are less than half the rates for whites. Rates of visits to nonphysician providers are similar for Hispanics and blacks. Use of inpatient hospital care is similar for Hispanics, whites, and blacks.

Table 10-8 also demonstrates important differences in utilization across Hispanic groups defined by national origin. Puerto Rican children and working-age adults and Cuban working-age adults have higher rates of ambulatory visits than Mexicans do. In fact, the average number of physician visits by Puerto Rican and Cuban working-age adults equals or exceeds the corresponding figures for non-Hispanic whites, although fewer Puerto Ricans and Cubans than whites have a visit to a physician during the year.

Additional tabulations found that nativity, time since arrival in the United States, and citizenship are all associated with the rate of ambulatory visits among working-age Hispanic adults. Thus, 48 percent of foreign-born Hispanics have a physician visit during the year, compared with 57 percent of the U.S.-born, and 12 percent of foreign-born Hispanics have a visit to a nonphysician provider, compared with 21 percent of the U.S.-born. Foreign-born Hispanics average 2.4 physician visits annually, compared with 2.7 visits for the U.S.-born. Among the foreign-born, Hispanics who have been in the United States less than five years and noncitizens have much lower rates of ambulatory visits, respectively, than Hispanics who have been in the United States longer than five years and naturalized citizens. These patterns are also found in Hispanic groups defined by national origin, with the exception of Puerto Ricans.

Working-age Hispanic adults who prefer English have more ambulatory visits to physicians and to nonphysician providers than those who prefer Spanish. Specifically, 58 percent of English speakers had a physician visit during the year, compared with 46 percent of Spanish speakers. The average numbers of annual visits were 2.8 and 2.4, respectively.

Finally, we used multivariate logistic regression analysis to examine differences in the probability of having a physician visit, having a nonphysician visit, and having an inpatient stay between working-age Hispanics and non-Hispanic whites by national origin, by nativity, and by language preference, controlling for age, sex, income, education, marital status, health insurance coverage, and health status (measured using self-rated general health and chronic conditions). We found that, other things being equal, Hispanics in all national-origin groups are significantly less likely than whites to have a physician or nonphysician visit (P < .001). Hispanics of Mexican origin are less likely than whites to use inpatient hospital care (P < .001), but the other national-origin groups are hospitalized at rates similar to whites. We also found that foreign-born Hispanics are significantly less likely than their U.S.-born peers to have a physician visit (P < .05) or nonphysician visit (P < .001), and that Spanish-speaking Hispanics are less likely than English speakers to have a nonphysician visit (P < .001). Interestingly, both U.S.-born Hispanics and English-speaking Hispanics are less likely than whites to have a physician or nonphysician visit (P < .001), indicating that even the most advantaged Hispanics have lower use than whites, other things being equal.

Medical Care Expenditures

Analyses of medical care expenditures are useful because expenditures capture both quantitative and qualitative aspects of health care utilization. There are few studies of differences in medical care expenditures between Hispanics and non-Hispanic whites. Using data from the 1987 National Medical Expenditure Survey, Freiman (1998) found lower expenditures for Hispanics than whites even controlling for demographic and socioeconomic factors, health status, and health insurance coverage. By contrast, using data from MEPS, Escarce and Kapur (2003) found that Hispanic and white seniors had similar total expenditures for medical care. However, public sources of payment accounted for a much larger share of total expenditures for Hispanic seniors than for white seniors. Specifically, 82 percent of total medical care expenditures for Hispanic seniors were from Medicare or Medicaid, compared with 65 percent for white seniors. The differences in the distribution of payment sources between Hispanics and whites were nearly fully explained by differences in socioeconomic status and dual eligibility for Medicaid.

Table 10-9 presents descriptive data for Hispanics, non-Hispanic whites, and non-Hispanic blacks on total medical expenditures and expenditures for prescription drugs, obtained from the 1996–2000 MEPS. Hispanic children and working-age adults are less likely than whites to incur medical expenditures during the year, and their average expenditures are considerably lower. By contrast, Hispanic children are slightly more likely than black children to incur medical expenditures, and their average expenditures are higher. Hispanic children and working-age adults also have much lower expenditures than whites for prescription drugs, whereas Hispanic children have higher prescription drug expenditures than black children. Notably, Hispanic, white, and black seniors have similar total medical care expenditures and prescription drug expenditures.

TABLE 10-9. Total Medical Care Expenditures and Prescription Drug Expenditures, by Age Category, and National Origin .

TABLE 10-9

Total Medical Care Expenditures and Prescription Drug Expenditures, by Age Category, and National Origin .

As in previous comparisons, there are differences in medical care expenditures across Hispanic groups defined by national origin. In particular, working-age adults of Puerto Rican origin have much higher average total expenditures and expenditures for prescription drugs than Mexicans do.

Additional analyses found that nativity, time since arrival in the United States, and citizenship are associated with the level of medical care expenditures. As anticipated, foreign-born, working-age Hispanics have lower total expenditures and lower expenditures for prescription drugs than Hispanics born in the United States. In addition, among the foreign-born, those who arrived in the United States less than five years ago have much lower expenditures than those who have been in the United States longer than five years. Expenditures for noncitizens, on average, are less than half as large as expenditures for naturalized citizens.

Working-age Hispanics who prefer Spanish have lower total expenditures and expenditures for prescription drugs than do Hispanics who prefer English. Only 57 percent of working-age Hispanics who prefer Spanish incur medical care expenditures during the year, and only 44 percent have expenditures on prescription drugs. By comparison, 69 percent of working-age Hispanics who prefer English incur medical care expenditures, and 53 percent spend on prescription drugs.

As in the preceding section, we used multivariate logistic regression analysis to assess differences in the probability of incurring medical expenditures and incurring prescription drug expenditures between working-age Hispanics and non-Hispanic whites by national origin, by nativity, and by language preference, controlling for other factors than can affect the use of health care. We found that, other things being equal, Hispanics in all national-origin groups are significantly less likely than whites to incur medical or prescription drug expenditures (P < .001). In addition, foreign-born Hispanics are significantly less likely than U.S.-born Hispanics to incur expenditures (P < .001), and Spanish speakers are less likely than English speakers to do so (P < .001). Notably, both U.S.-born Hispanics and English-speaking Hispanics are less likely than whites to incur medical or prescription drug expenditures (P < .001), other things being equal.

QUALITY OF HEALTH CARE

According to the Institute of Medicine (1990), quality of health care consists of the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” Receiving high quality of care is an important component of maintaining the health of any population.

Quality of health care can be evaluated on the basis of structure, process, or outcome (Donabedian, 1980). Structure refers to the characteristics and attributes of health care providers. Process refers to the components of the encounters between providers and patients, although the emphasis is usually on technical components of care, such as the appropriateness of the services provided and the technical skill with which the services are performed. Outcome refers to the effects of care on patients' health, such as amelioration of symptoms or reduction in morbidity or in the probability of death (Blumenthal, 1996; Brook, McGlynn, and Cleary, 1996).

In practice, many researchers on the quality of health care agree that the measurement of technical quality should depend much more on process data than on health outcomes (Brook et al., 1996). Process data are more sensitive indicators of quality than outcomes, because poor outcomes do not necessarily follow errors in processes of care. Moreover, some poor outcomes are very rare, or they may lag poor process by many years. The development of process measures of quality of care has improved dramatically in recent years (Brook et al., 1996).

Over the last decade and a half, there has been growing recognition that patients' opinions about their health care are also important indicators of quality (Blumenthal, 1996; Cleary and McNeil, 1988). Patients are in the best position to judge the nontechnical dimensions of their encounters with providers, including the quality of their interpersonal interactions and communication with providers, providers' ability to gain their trust, and the timeliness and responsiveness of the care they receive. Consequently, assessments of health care quality have increasingly incorporated patient reports of their experiences with health care and measures of their satisfaction with that care.

It is worth underscoring that the quality of interpersonal interactions between patients and providers and patient satisfaction with their care can affect the technical quality of care and health outcomes. For example, studies have found that satisfaction is associated with health care utilization, patient compliance with provider recommendations, and willingness to initiate malpractice litigation (Sherbourne, Hays, Ordway, DiMatteo, and Kravitz, 1992; Vaccarino, 1977; Zastowny, Roghmann, and Cafferata, 1989). In addition, dissatisfaction with care has been linked with switching providers and disenrollment from health plans, which can affect continuity of care (Marquis, Davies, and Ware, 1983; Newcomer, Preston, and Harrington, 1996).

Process of Care

Few studies have assessed process quality of care for Hispanic patients. Studies of quality of care for ischemic heart disease have generally suggested that Hispanics and non-Hispanic whites receive similar quality. For example, using data from the National Registry of Myocardial Infarction, Canto et al. (1998) found that Hispanics with a heart attack were as likely as whites to receive thrombolytic therapy, coronary angiography, and revascularization procedures. Similarly, Leape, Hilborne, Bell, Kamberg, and Brook (1999) analyzed data from 13 hospitals in New York City and found that, among patients in whom revascularization was clinically necessary, Hispanics were as likely as whites to receive revascularization procedures. In contrast, Hannan et al. (1999) found that Hispanics in New York state were less likely than whites to receive appropriate revascularization procedures even controlling for type of health insurance. Most likely, the divergent findings of these studies reflect geographic differences in patterns of care as well as variations in methods across the studies. Controlling for severity of disease and insurance status, Shapiro et al. (1999) found that Hispanics were less likely than whites to receive appropriate drug therapy for human immunodeficiency virus infection.

Several recent studies have compared process quality of care for Hispanic and white Medicare beneficiaries enrolled in Medicare managed care plans (e.g., McBean, Huang, Virnig, Lurie, and Musgrave, 2003; Virnig et al., 2002, 2004). These studies found worse quality for Hispanics on certain important indicators, such as cholesterol management after a cardiovascular event, control of blood sugar in diabetes, and rates of follow-up after a hospitalization for mental illness. Quality was similar for other indicators, however, including administration of beta blockers after a heart attack, preventive care for diabetics, and control of high blood pressure.

Satisfaction with Care

Several studies have assessed Hispanics' experiences and satisfaction with health care. An early review of the literature on the relationship between patient characteristics and satisfaction with care found no relationship between race or ethnicity and satisfaction (Hall and Dornan, 1990). More recent studies, however, have found differences in both experiences of care and satisfaction by race and ethnicity. Morales et al. (1999) found that Hispanics are less satisfied than whites with communication with health care providers in medical group practices. Phillips, Mayer, and Aday (2000) found that Hispanics were twice as likely as whites to perceive that clinicians fail to provide needed information. Doty (2003b) found that one-third of Hispanics, compared with 16 percent of whites, reported having a problem understanding or communicating with their physicians. Furthermore, only 56 percent of Hispanics were very satisfied with their health care, compared with 65 percent of whites. In contrast, Morales and colleagues (2001) found no differences in global ratings of care between Hispanic and white adults enrolled in 53 commercial and 31 Medicaid managed care plans across the United States.

Not surprisingly, language seems to matter enormously in Hispanics' reports of their experiences with health care as well as in their global ratings 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 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 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 similar 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.

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 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.

REFERENCES

  1. Baker DW, Hayes R, Fortier JP. Interpreter use and satisfaction with interpersonal aspects of care for Spanish-speaking patients. Medical Care. 1998;36(10):1461–1470. [PubMed: 9794340]
  2. Berk ML, Schur CL, Chavez LR, Frankel M. Health care use among undocumented Latino immigrants. Health Affairs. 2000 July–August;19(4):51–64. [PubMed: 10916960]
  3. Betancourt JR, Green AR, Carrillo JE. Cultural competence in health care: Emerging frameworks and practical approaches. New York: Commonwealth Fund; Oct, 2002. [accessed May, 16 2004]. Available:http://www​.cmwf.org.
  4. Blumenthal D. Part 1: Quality of care—what is it? New England Journal of Medicine. 1996;335:891–894. [PubMed: 8778612]
  5. Braveman P, Bennett T, Lewis C, Egerter S, Showstack J. Access to prenatal care following major Medicaid eligibility expansions. Journal of the American Medical Association. 1993 March;269(10):1285–1289. [PubMed: 8437308]
  6. Brook RH, McGlynn EA, Cleary PD. Part 2: Measuring quality of care. New England Journal of Medicine. 1996;335:966–970. [PubMed: 8782507]
  7. Canto JG, Taylor HA Jr, Rogers WJ, Sanderson B, Hilbe J, Barron HV. Presenting characteristics, treatment patterns, and clinical outcomes of non-black minorities in the National Registry of Myocardial Infarction 2. American Journal of Cardiology. 1998;82(9):1013–1018. [PubMed: 9817473]
  8. Carrasquillo O, Carrasquillo AI, Shea S. Health insurance coverage of immigrants living in the United States: Differences by citizenship status and country of origin. American Journal of Public Health. 2000;90:917–923. [PMC free article: PMC1446276] [PubMed: 10846509]
  9. Carrasquillo O, Orav EJ, Brennan TA, Burstin H. Impact of language barriers on patient satisfaction in an emergency department. Journal of General Internal Medicine. 1999;14:82–87. [PubMed: 10051778]
  10. Centers for Disease Control and Prevention. National immunization program, vaccines for children program. 2004. [accessed May 22, 2004]. Available:http://www​.cdc.gov/nip/vfc/Default.htm.
  11. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of quality care. Inquiry. 1988;25:25–36. [PubMed: 2966123]
  12. David RA, Rhee M. The impact of language as a barrier to effective health care in an underserved urban Hispanic community. Mount Sinai Journal of Medicine. 1998;65(5–6):393–397. [PubMed: 9844369]
  13. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor, MI: Health Administration Press; 1980. Explorations in quality assessment and monitoring: Vol. 1.
  14. Doty M. Insurance, access, and quality of care among Hispanic populations: 2003 chartpack. New York: Commonwealth Fund; Oct, 2003a. [accessed May 04, 2004]. Available:http://www​.cmwf.org/publications​/publications_show​.htm?doc_id=221241.
  15. Doty M. Hispanic patients' double burden: Lack of health insurance and limited English. New York: Commonwealth Fund; Feb, 2003b.
  16. Dovidio JF, Brigham JC, Johnson BT, Gaertner SL. Stereotyping, prejudice, and discrimination: Another look. In: Macrae N, Stangor C, Hewstone M, editors. Stereotypes and stereotyping. New York: Guilford; 1996. pp. 276–319.
  17. Dubay L, Haley J, Kenney G. Children's eligibility for Medicaid and SCHIP: A view from 2000. Washington, DC: Urban Institute; 2002.
  18. Escarce JJ, Kapur K. Racial and ethnic differences in public and private medical care expenditures among aged Medicare beneficiaries. Milbank Quarterly. 2003;81:249–275. [PMC free article: PMC2690217] [PubMed: 12841050]
  19. Fernandez A, Schillinger D, Grumbach K, Rosenthal A, Stewart AI, Wang F, Perez-Stable EJ. Physician language ability and cultural competence: An exploratory study of communication with Spanish-speaking patients. Journal of General Internal Medicine. 2004;19(2):167–174. [PMC free article: PMC1492135] [PubMed: 15009796]
  20. Fiscella K, Franks P, Doescher MP, Saver BG. Disparities in health care by race, ethnicity, and language among the insured: Findings from a national sample. Medical Care. 2002;40:52–59. [PubMed: 11748426]
  21. Flores G, Abreu M, Olivar MA, Kastner B. Access barriers to health care for Latino children. Archives of Pediatric and Adolescent Medicine. 1998;152(11):1119–1125. [PubMed: 9811291]
  22. Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu M, Medina L, Hardt EJ. Errors in medical interpretation and their potential clinical consequences in pediatric encounters. Pediatrics. 2003;111:6–14. [PubMed: 12509547]
  23. Frieman MP. The demand for health care among racial/ethnic subpopulations. Health Services Research. 1998 October;33(4 Pt 1):867–890. [PMC free article: PMC1070291] [PubMed: 9776940]
  24. Giachello AL. The reproductive years: The health of Latinas. In: Aguirre-Molina M, Molina CW, Zambrana RE, editors. Health issues in the Latino community. San Francisco: Jossey-Bass; 2001. pp. 107–156.
  25. Gray B, Stoddard JJ. Patient-physician pairing: Does racial and ethnic congruity influence selection of a regular physician? Journal of Community Health. 1997 August;22(4):247–259. [PubMed: 9247848]
  26. Guendelman S, Wagner TH. Health services utilization among Latinos and white non-Latinos: Results from a national survey. Journal of Health Care for the Poor and Underserved. 2000 May;11(2):179–194. [PubMed: 10793514]
  27. Hall JA, Dornan MC. Patient sociodemographic characteristics as predictors of satisfaction with medical care: A meta-analysis. Social Science Medicine. 1990;30(7):811–818. [PubMed: 2138357]
  28. Hannan EL, van Ryn M, Burke L, Stone D, Kumar D, Arani D, Pierce W, Rafii S, Sanborn TA, Sharma S, Slater J, DeBuono BA. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Medical Care. 1999;37(1):68–77. [PubMed: 10413394]
  29. Hargraves JL, Cunningham PJ, Hughes RG. Racial and ethnic differences in access to medical care in managed care plans. Health Services Research. 2001;36(5):853–868. [PMC free article: PMC1089264] [PubMed: 11666107]
  30. Hornberger JC, Gibson CD, Wood W, Dequeldre C, Corso I, Palla B, Bloch DA. Eliminating language barriers for non-English-speaking patients. Medical Care. 1996;34:845–856. [PubMed: 8709665]
  31. Institute of Medicine. Medicare: a strategy for quality assurance. In: Lohr KN, editor. Committee to Design a Strategy for Quality Review and Assurance in Medicare. Washington, DC: National Academy Press; 1990.
  32. Kaushal N, Kaestner R. Welfare reform and health insurance of immigrants. Health Services Research. 2005;40(3):697–721. [PMC free article: PMC1361164] [PubMed: 15960687]
  33. Kenney G, Haley J. Why aren't more uninsured children enrolled in Medicaid or SCHIP? Washington, DC: Urban Institute; 2001. (Assessing the New Federalism, Policy Brief No. B-35.)
  34. Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, Bindman AB. The role of black and Hispanic physicians in providing health care for underserved populations. New England Journal of Medicine. 1996;334(20):1305–1310. [PubMed: 8609949]
  35. Ku L, Matani S. Left out: immigrants' access to health care and insurance. Health Affairs. 2001 January/February;20(1):247–256. [PubMed: 11194848]
  36. Leape LL, Hilborne LH, Bell R, Kamberg C, Brook RH. Underuse of cardiac procedures: do women, ethnic minorities, and the uninsured fail to receive needed revascularization? Annals of Internal Medicine. 1999;130(3):183–192. [PubMed: 10049196]
  37. Lee LJ, Batal HA, Maselli JH, Kutner JS. Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic. Journal of General Internal Medicine. 2002;17:641–645. [PMC free article: PMC1495083] [PubMed: 12213146]
  38. Lewin-Epstein N. Determinants of regular source of health care in black, Mexican, Puerto Rican, and non-Hispanic white populations. Medical Care. 1991;29(6):543–557. [PubMed: 2046408]
  39. Lillie-Blanton M, Brodie M, Rowland D, Altman D, McIntosh M. Race, ethnicity, and the health care system: Public perceptions and experiences. Medical Care Research and Review. 2000;57(Suppl 1):218–235. [PubMed: 11092164]
  40. Marquis MS, Davies AR, Ware JE. Patient satisfaction and change in medical care provider: A longitudinal study. Medical Care. 1983;21:821–829. [PubMed: 6888031]
  41. Marquis MS, Rogowski JA, Escarce JJ. Recent trends and geographic variation in the safety net. Medical Care. 2004;42(5):403–405. [PubMed: 15083100]
  42. McBean AM, Huang Z, Virnig BA, Lurie N, Musgrave D. Racial variation in the control of diabetes among elderly Medicare managed care beneficiaries. Diabetes Care. 2003;26:3250–3256. [PubMed: 14633810]
  43. Monheit AC, Vistnes JP. Race/ethnicity and health insurance status: 1987 and 1996. Medical Care Research and Review. 2000;57(Suppl 1):11–35. [PubMed: 11092156]
  44. Morales LS, Lara M, Kington RS, Valdez RO, Escarce JJ. Socioeconomic, cultural and behavioral factors effecting Hispanic health outcomes. Journal of Health Care for the Poor and Underserved. 2002;13(4):477–503. [PMC free article: PMC1781361] [PubMed: 12407964]
  45. Morales LS, Elliott MN, Weech-Maldonado R, Hays RD. The impact of interpreters on parents' experiences with ambulatory care for their children. Santa Monica, CA: RAND; 2003. RAND working paper. [PMC free article: PMC1634763] [PubMed: 16686075]
  46. Morales LS, Elliott MN, Weech-Maldonado R, Spritzer KL, Hays RD. Differences in CAHPS adult survey reports and ratings by race and ethnicity: An analysis of the national CAHPS benchmarking data 1.0. Health Services Research. 2001;36:595–617. [PMC free article: PMC1089244] [PubMed: 11482591]
  47. Morales LS, Cunningham WE, Brown JA, Liu H, Hays RD. Are Latinos less satisfied with communication by health care providers? Journal of General Internal Medicine. 1999;14:409–417. [PMC free article: PMC1496614] [PubMed: 10417598]
  48. Morbidity and Mortality Weekly Report. Entry into prenatal care—United States, 1989–1997. Morbidity and Mortality Weekly Report. 2000;49(18):393–398.
  49. National Center for Health Statistics. Health, United States, 2003. 2003. Washington, DC: U.S. Department of Health and Human Services; Sep,
  50. Newcomer R, Preston S, Harrington C. Health plan satisfaction and risk of disenrollment among social/HMO and fee-for-service recipients. Inquiry. 1996;33:144–154. [PubMed: 8675278]
  51. Perry M, Kannel S, Castillo E. Barriers to health coverage for Hispanic workers: Focus group findings. New York: Commonwealth Fund; Dec, 2000.
  52. Petchers MK, Milligan SE. Access to health care in a black urban elderly population. The Gerontologist. 1988;28(2):213–217. [PubMed: 3360364]
  53. Phillips KA, Mayer ML, Aday LA. Barriers to care among racial/ethnic groups under managed care. Health Affairs (Millwood). 2000;19(4):65–75. [PubMed: 10916961]
  54. Quinn K. Working without benefits: The health insurance crisis confronting Hispanic Americans. New York: Commonwealth Fund; Mar, 2000.
  55. Ray WA, Mitchel EF Jr, Piper JM. Effect of Medicaid expansions on preterm birth. American Journal of Preventive Medicine. 1997;13(4):292–297. [PubMed: 9236967]
  56. Rhoades JA. The uninsured in America, 2004: Estimates for the U.S. civilian non-institutionalized population under age 65. Rockville, MD: Agency for Healthcare Research and Quality; 2005. [accessed January 2006]. Available:http://www​.meps.ahrq​.gov/papers/st83/stat83.pdf.
  57. Rivadeneyra R, Elderkin-Thompson V, Silver RC, Waitzkin H. Patient centeredness in medical encounters requiring an interpreter. American Journal of Medicine. 2000;108(6):470–474. [PubMed: 10781779]
  58. Ruiz MS, Marks G, Richardson JL. Language acculturation and screening practices of elderly Hispanic women: The role of exposure to health-related information from the media. Journal of Aging and Health. 1992;4(2):268–281. [PubMed: 10117874]
  59. Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Archives of Internal Medicine. 1999;159:997–1004. [PubMed: 10326942]
  60. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Affairs (Millwood). 2000;19(4):76–83. [PubMed: 10916962]
  61. Sambamoorthi U, McAlpine DD. Racial, ethnic, socioeconomic, and access disparities in the use of preventive services among women. Preventive Medicine. 2003;37(5):475–484. [PubMed: 14572431]
  62. Schlosberg C, Wiley B. The impact of INS public charge determinations on immigrant access to health care. Washington, DC: National Health Law Program and National Immigration Law Center; May, 1998. Available:http://www​.healthlaw​.org/pubs/19980522publiccharge.html.
  63. Schur CL, Albers LA. Language, sociodemographics, and health care use of Hispanic adults. Journal of Health Care for the Poor and Underserved. 1996;7(2):140–158. [PubMed: 8935388]
  64. Schur CL, Feldman J. Running in place: How job characteristics, immigrant status, and family structure keep Hispanics uninsured. Millwood, VA: Project HOPE Center for Health Affairs; May, 2001.
  65. Shapiro MF, Morton SC, McCaffrey DF, Senterfitt JW, Fleishman JA, Perlman JF, Athey LA, Keesey JW, Goldman DP, Berry SH, Bozzette SA. Variations in the care of HIV-infected adults in the United States: Results from the HIV Cost and Services Utilization Study. Journal of American Medical Association. 1999;281(24):2305–2315. [PubMed: 10386555]
  66. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz R. Antecedents of adherence to medical recommendations: Results from the Medical Outcomes Study. Journal of Behavioral Medicine. 1992;15:447–468. [PubMed: 1447757]
  67. Solis JM, Marks G, Garcia M, Shelton D. Acculturation, access to care, and use of preventive services by Hispanics: Findings from HHANES 1982–84. American Journal of Public Health. 1990 December;80(Suppl 1):1–9. [PMC free article: PMC1404523] [PubMed: 9187576]
  68. Stewart SH, Silverstein MD. Racial and ethnic disparity in blood pressure and cholesterol measurement. Journal of General Internal Medicine. 2002;17(6):405–411. [PMC free article: PMC1495057] [PubMed: 12133153]
  69. Timmins CL. The impact of language barriers on the health care of Latinos in the United States: A review of the literature and guidelines for practice. Journal of Midwifery and Women's Health. 2002;47:80–96. [PubMed: 12019990]
  70. U.S. Department of Health and Human Services, Office of Minority Health. National standards for culturally and linguistically appropriate services in health care. Washington, DC: Author; Mar, 2001.
  71. Vaccarino JM. Malpractice: The problem in perspective. Journal of the American Medical Association. 1977;238:861–863. [PubMed: 577973]
  72. Virnig B, Huang Z, Lurie N, Musgrave D, McBean A, Dowd B. Does Medicare managed care provide equal treatment for mental illness across races? Archives of General Psychiatry. 2004;61:2001–2005. [PubMed: 14757597]
  73. Virnig BA, Lurie N, Huang Z, Musgrave D, McBean A, Dowd B. Racial variation in quality of care among Medicare+Choice enrollees. Health Affairs. 2002;21(6):224–230. [PubMed: 12442860]
  74. Weech-Maldonado R, Morales LS, Spritzer K, Elliott MN, Hays RD. Racial and ethnic differences in parents' assessments of pediatric care in Medicaid managed care. Health Services Research. 2001;36:575–594. [PMC free article: PMC1089243] [PubMed: 11482590]
  75. Weech-Maldonado R, Morales LS, Elliott M, Spritzer K, Marshall G, Hays RD. Race/ethnicity, language, and patients' assessments of care in Medicaid managed care. Health Services Research. 2003;38:789–808. [PMC free article: PMC1360917] [PubMed: 12822913]
  76. Weinick RM, Krauss NA. Racial/ethnic differences in children's access to care. American Journal of Public Health. 2000;90(11):1771–1774. [PMC free article: PMC1446405] [PubMed: 11076248]
  77. Weinick RM, Jacobs EA, Stone LC, Ortega AN, Burstin H. Hispanic health care disparities: Challenging the myth of a monolithic Hispanic population. Medical Care. 2004;42:313–320. [PubMed: 15076807]
  78. Wells KB, Golding JM, Hough RL, Burnam MA, Karno M. Acculturation and the probability of use of health services by Mexican Americans. Health Services Research. 1989;24(2):237–257. [PMC free article: PMC1065562] [PubMed: 2732058]
  79. Zastowny TR, Roghmann KJ, Cafferata GL. Patient satisfactions and the use of health services. Medical Care. 1989;27:705–723. [PubMed: 2747303]
  80. Zimmermann W, Tumlin KC. Patchwork policies: State assistance for immigrants under welfare reform. Washington, DC: Urban Institute; 1999. (Assessing the New Federalism, Occasional Paper No. 24)
Copyright © 2006, National Academy of Sciences.
Bookshelf ID: NBK19910

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