[Senate Hearing 107-701]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 107-701
 
HISPANIC HEALTH: PROBLEMS WITH COVERAGE, ACCESS, AND HEALTH DISPARITIES
=======================================================================

                                HEARING

                               BEFORE THE

                     SUBCOMMITTEE ON PUBLIC HEALTH

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

 EXAMINING HISPANIC HEALTH PROBLEMS, FOCUSING ON COVERAGE, ACCESS, AND 
                           HEALTH DISPARITIES

                               __________

                           SEPTEMBER 23, 2002

                               __________

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                                Pensions










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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio

           J. Michael Myers, Staff Director and Chief Counsel

             Townsend Lange McNitt, Minority Staff Director

                                 ______

                     Subcommittee on Public Health

                      EDWARD M. KENNEDY, Chairman

TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        JUDD GREGG, New Hampshire
JAMES M. JEFFORDS, Vermont           MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico            TIM HUTCHINSON, Arkansas
PAUL D. WELLSTONE, Minnesota         PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     CHRISTOPHER S. BOND, Missouri

                      David Nexon, Staff Director

                 Dean A. Rosen, Minority Staff Director

                                  (ii)






                            C O N T E N T S

                               __________

                               STATEMENTS

                       MONDAY, SEPTEMBER 23, 2002

                                                                   Page
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico.     1
Rodriguez, Hon. Ciro, a U.S. Representative from the State of 
  Texas..........................................................     3
Beato, Cristina, M.D., Deputy Assistant Secretary For Health, 
  U.S. Department of Health and Human Services, Washington, DC; 
  Francisco Cigarroa, M.D., President, University of Texas Health 
  Science Center at San Antonio, TX; Glenn Flores, M.D., Chair, 
  Latino Consortium of the American Academy of Pediatrics Center 
  For Child Health Research; Director, Community Outcomes, and 
  Associaate Director, Center For the Advancement of Urban 
  Children, Department of Pediatrics, Medical College of 
  Wisconsin, Milwaukee, WI; Dan Reyna, Director, Border Health 
  Office, New Mexico Department of Health, Las Cruces, NM; and 
  Elena Rios, M.D., President, National Hispanic Medical 
  Association, Washington, DC....................................     9

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Francisco G. Cigarroa, M.D...................................    33
    Glenn Flores, M.D............................................    36
    Ciro D. Rodriguez............................................    41
    Cristina Beato, M.D..........................................    48
    Dan Reyna....................................................    59
    Elena Rios, M.D..............................................    74

                                 (iii)

  


HISPANIC HEALTH: PROBLEMS WITH COVERAGE, ACCESS, AND HEALTH DISPARITIES

                              ----------                              


                       MONDAY, SEPTEMBER 23, 2002

                              U. S. Senate,
                     Subcommittee on Public Health,
of the Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:00 p.m., in 
room SD-430, Dirksen Senate Office Building, Senator Bingaman 
(chairman of the subcommittee) presiding.
    Present: Senator Bingaman.

                 Opening Statement of Senator Bingaman

    Senator Bingaman. We will go ahead and start the hearing. 
Thank you all for coming today. Our hearing today is focussed 
on the health of the Hispanic population in the United States. 
The figures that all of us are generally aware of are shocking. 
Over a third or 35 percent of Hispanic adults lack health 
insurance. Despite the passage of the Children's Health 
Insurance Program, 27 percent of Latino children remain 
uninsured. That compares to 9 percent of white children, 18 
percent of black children, 17 percent of Asian-Pacific Islander 
children.
    In the case of poor children who are largely eligible for 
Medicaid and SCHIP, 1.1 million poor Latino children are 
uninsured, compared again with 806,000 white, 704,000 black and 
95,000 Asian poor uninsured children.
    The Centers for Disease Control and Prevention keeps 
figures on morbidity and mortality rates and again those are 
very adverse to the Hispanic community. For example, age-
adjusted mortality rates for diabetes are over 50 percent 
higher among Hispanic persons than with non-Hispanics. HIV 
infection rates are over three times those for non-Hispanics. 
Tuberculosis rates among Latin children are 13 times as high as 
in the white population.
    This hearing will raise particular attention to the 
problems that we face along the U.S.-Mexico border where we 
have 11 million people, five of the seven poorest metropolitan 
statistical areas in the country. If the region were a State 
the border would rank number one in the number of uninsured, it 
would rank last in terms of per capital income, and first in 
the number of diseases.
    The purpose of today's hearing is to get an updated 
assessment of the status of Hispanic health in the country, 
begin to put forth an agenda that can take the next steps in 
addressing these profound disparities in health that should be 
viewed as unacceptable in our society.
    Representative Rodriguez, who is the new chair of the 
Congressional Hispanic Caucus, he and I have worked together in 
an effort to respond to the challenges before us with regard to 
coverage and access and health disparities and as a result, 
we've put together a legislative initiative we are introducing 
today entitled ``The Hispanic Health Improvement Act of 2002.'' 
While that legislation puts forth several initiatives to 
address what are disproportionately Hispanic problems, it needs 
to be noted that each section of the bill, including those to 
reduce the number of uninsured and to improve access to care, 
would substantially improve the overall health of our entire 
Nation, regardless of their race or ethnicity.
    Let me just begin by introducing Representative Rodriguez. 
He is our first witness to testify about the legislation and 
the issues that he believes call on us to pass this 
legislation. It is a pleasure for me to work with him jointly 
on this effort and we appreciate him coming over for this 
testimony today. Why do you not go right ahead, Congressman?
    Before we begin I have a statement from Senator Clinton.
    [The prepared statement of Senator Clinton follows:]

                 Prepared Statement of Senator Clinton

    I am pleased that my colleague on this committee, Senator 
Bingaman, and Representative Ciro Rodriguez have worked to 
bring a much-needed spotlight to the important issue of 
healthcare disparities among our nation's Hispanic population. 
In fact, I believe that this issue deserves floodlights, given 
that minority health barriers are a significant burden for 
millions of Americans of color today.
    In New York, the healthcare hurdles are truly disappointing 
and the lack of access to healthcare must be addressed. For 
example, nearly 30 percent of Latinos in New York were 
uninsured from 1999-2000, and nationwide, there are currently 
1.1 million uninsured Hispanic children in the U.S., compared 
to 806,000 uninsured white children or 703,000 uninsured black 
children.
    The prevalence of health disparities speaks to a complex, 
multi-layered problem with many causes, including a need for 
education on part of healthcare providers, a need for greater 
awareness among patients, discriminatory actions, and 
inaccessible or unaffordable healthcare options. The public 
health risks that result from unchecked illnesses are far 
costlier and more troubling than education programs, outreach 
initiatives, or cultural training in healthcare facilities or 
universities. Perhaps the costliest, most intolerable expense 
is an expanding number of unhealthy, Hispanic families and 
children.
    In my home state of New York, Latino constituents face 
multiple challenges on a daily basis. We have heard often from 
community health workers who stress the importance of 
recognizing the unique health struggles that the heterogeneous 
Latino population experiences from neighborhood to 
neighborhood, community to community, whether Puerto Rican, 
Mexican, Dominican, or Columbian. While some communities may 
battle asthma, another may battle diabetes. In Buffalo for 
example, Hispanics are likely to stiffer from asthma because of 
the region's extreme weather and the prevalence of older homes, 
whereas in New York City, though Hispanics make up 24 percent 
of the city's population, Hispanics also account for 31 percent 
of all the city's reported AIDS cases.
    However, if we look closely enough, common barriers emerge 
as well. Many Hispanics experience language barriers, which can 
compromise the quality of their care. Cultural barriers in 
certain communities have engendered mistrust of healthcare 
providers. Worse still, some may feel a lack of entitlement to 
visit a physician in their time of need. Even if these 
obstacles were removed, without health insurance coverage, 
families will never access high-quality, affordable, accessible 
health care. Currently. Hispanics represent a
    disproportionate percentage, one-quarter. of the 44 million 
Americans who are uninsured. If these conditions continue, a 
growing number of Hispanics will continue to be without 
medications or professional assistance.
    While the numbers may project a grim outlook, Senator 
Bingaman and Representative Rodriguez have certainly taken a 
strong step toward a creating brighter, more productive future 
for the Hispanic population in this nation by meeting their 
healthcare needs. It is certainly time for steps to improve 
bilingual services, educational and outreach field programs, 
and training the next, truly diverse generation of physicians 
and nurses.
    I firmly believe that this gap in care must be addressed 
immediately. I am committed to addressing this disparity as 
well as educating patients and healthcare professionals about 
this injustice in our healthcare system.

STATEMENT OF HON. CIRO RODRIGUEZ, A REPRESENTATIVE IN CONGRESS 
 FROM THE STATE OF TEXAS, AND CHAIRMAN, CONGRESSIONAL HISPANIC 
                             CAUCUS

    Mr. Rodriguez. Thank you, Mr. Chairman. Let me first of all 
take this opportunity to thank you for the invitation for this 
historic hearing on Hispanic health. I am currently serving as 
the first vice chair of the Congressional Hispanic Caucus and 
chairman of the Task Force on Health and looking forward to 
becoming the chairman of the caucus. So I want to thank you 
personally for allowing us to come before you and I do feel 
that this is a historical hearing in terms of the fact that we 
have an opportunity to talk about health care as I impacts 
Latinos throughout this country.
    In my own district, which stretches from San Antonio to the 
Mexican border, over 60 percent of my constituency is Hispanic. 
One of my border counties, which is Starr County, is about 98 
percent Hispanic and Starr County unfortunately is also the 
poorest county in the Nation. It has over 44 percent that live 
in poverty.
    It is truly an honor to be here with you, Senator, and I 
have enjoyed working with you and look forward to continuing to 
work with you. I would like to extend special thanks to also 
Senator Kennedy and yourself and your staff for their hard work 
that has brought us to this day.
    In addition, I would like to recognize the witnesses in the 
next panel, especially of our own hometown, Dr. Francisco 
Cigarroa of the University of Texas Health Science Center at 
San Antonio. I have worked with Dr. Cigarroa on a variety of 
issues and consider him a leader in health care at both the 
local and national levels. Dr. Cigarroa is the first Hispanic 
to ever be president of an institution regarding health, so we 
are real pleased to have him there in San Antonio.
    As you also know, September 15 marks the beginning of 
Hispanic Heritage Month. The many events of this month mean 
little if we cannot have some positive change, and that is with 
regard to policies, so I want to thank you for bringing up the 
legislation as it deals with health during this particular 
month.
    Today's hearing represents an important part of that whole 
equation and our celebrations of Hispanic Heritage Month but I 
commend the subcommittee for the desire to learn more about 
what I consider to be a national emergency, the status of 
Hispanic health.
    I will focus on what I believe are the three most critical 
and comprehensive areas of need. First, we need to dramatically 
expand health care coverage for the growing Hispanic 
population. Second, we need to improve access to services for 
Hispanics in areas of particular need, such as diabetes, AIDS 
and border health, including mental health. Third, we need to 
build a health profession system that will reduce health 
disparities in the long run through improving training 
opportunities, as well as educational opportunities.
    On improving coverage, the 2000 Census revealed what many 
of us already knew, and that is that the Hispanic community has 
grown by leaps and bounds over the past decades. Hispanics are 
now the fastest growing community in the United States, making 
13 percent of the U.S. population, yet Hispanics make up 23 
percent of the uninsured population. Nearly 37 percent of 
Hispanics under the age of 64 are uninsured. Sadly enough, 31 
percent of the Hispanic children are uninsured.
    Research shows that about 87 percent of the uninsured 
Hispanics come from working families. These are families that 
are working hard trying to make ends meet and yet find 
themselves uninsured. Additionally, only 43 percent have 
employer-based coverage compared to 73 percent of Anglos. Close 
to 60 percent of Hispanic families have annual incomes less 
than 200 percent of the Federal poverty rate. Access to 
affordable, quality health care is challenging. This includes 
economic challenges, language barriers, cultural differences, 
citizenship status. Even location plays a key role and we know 
that it is a direct relationship to health disparities.
    A recent report of the National Institutes of Medicine 
outlined four areas that contribute to the health disparities. 
One of these areas is the language barrier. The second is the 
inadequate health coverage; the third, health care provider 
biases, as well as the fourth, which is the lack of minority 
physicians. In addition, the report showed that even when 
controlling for factors such as access to care, racial and 
ethnic health disparities still exist.
    This report documents what health care advocates have been 
talking about for years. There is a level of unequal treatment 
for racial and ethnic minorities in health care systems. We 
need to target public health changes to reverse these trends in 
both the short term and the long-term. I believe we can do so 
by greatly expanding insurance and other coverages, by also 
addressing specific diseases that disproportionately impact 
Hispanic communities, and also by making institutional changes 
in our health professions and training so that more doctors 
become sensitive to the particular needs of the Hispanic 
community.
    The Hispanic population encounters many of the diseases at 
rates that are far beyond their numbers in the population. We 
need to improve access to affordable treatment in these 
specific areas if we are serious about addressing the needs of 
Hispanic health. I have included greater detail in the written 
testimony but I would like to be able to mention a few of the 
items that disproportionately hit and these diseases, such as 
diabetes, HIV/AIDS, and along the border with Mexico, Hispanics 
also encounter unusual high levels of infectious diseases, such 
as tuberculosis and hepatitis.
    About approximately 10.2 percent of all Hispanic Americans 
have diabetes. For those that are 50 and over, about 30 percent 
have diabetes. Worse yet, Type 2 diabetes is spreading among 
Hispanic youth. According to the Centers for Disease Control, 
Hispanics account for 18 percent of the cumulative AIDS cases 
and 20 percent of the total AIDS cases among women and 23 
percent of the total AIDS cases among children. In 1999, 
Senator, approximately 19 percent of the new AIDS cases were 
among Hispanics.
    Hepatitis A also, which is mainly spread through unclean 
food and water migration, is two or three times more prevalent 
along the border than in the U.S. as a whole. We still have the 
need for infrastructure development when it comes to potable 
water. We still have people we call the water haulers that are 
hauling water in buckets and they still need those services. 
And I am not talking about the other side of the border; I am 
talking about on the U.S. side.
    One-third of the new TB cases also in this country are in 
the border States. While the challenge seems daunting, I am 
confident that we have resources and the passion to change 
those outcomes.
    This past August we helped organize the first National 
Hispanic Health Leadership Summit in San Antonio, TX. Dr. 
Richard Carmona, the new U.S. Surgeon General, delivered a 
striking keynote address on the need for ensuring that all 
sectors of society have access to health care services. We were 
joined also by a selected group of over 150 health experts 
nominated from across the country by partners that also helped 
to participate in this conference. Participants navigated 
through a series of facilitated workshops to build consensus on 
program and policies that can be delivered and enhanced to 
improve the quality of health care delivery to Hispanics in the 
United States for the next 5 years.
    This leadership summit was sponsored by the National 
Hispanic Medical Association with the Congressional Hispanic 
Caucus serving as an honorary chair. Dr. Elena Rios, president 
of the National Hispanic Medical Association, should be 
commended for her leadership and her hard work in making the 
summit a success. I am sure she will share some of her thoughts 
on the leadership summit during her testimony.
    However, I want to highlight some of the recommendations 
that came from the eight workshops that were done. The 
recommendations included increasing outreach and enrollment in 
Federal programs by creating State initiatives for community-
based outreach programs, not only for AIDS but also in the area 
of SCHIP and Medicaid enrollment and high uninsured 
populations. Second, infusing cultural competencies into 
medical literacy and medical error debate. Third, building 
workforce capacity to deliver quality health services, 
including interpreters and promotoras. Third, creating a 
Federal clearinghouse for health information and a regular 
report on the status of Hispanic health in this country. And 
finally, building community-based Hispanic research, just to 
name a few.
    A report is going to be put together and the 
recommendations are going to be laid out and we look forward to 
continuing to work with you but I am pleased that the Hispanic 
Health Improvement Act, of which you are the main author and I 
want to thank you, Senator, incorporates a lot of the concerns 
that were raised during that summit, and that is why I have 
taken the time to mention that summit, because it took people 
from throughout the country to address those issues.
    Congressional action is needed to address the needs of the 
Hispanic community so Senator, I want to thank you for 
introducing the legislation entitled ``The Hispanic Health 
Improvement Act of 2002.'' I will also introduce the companion 
bill tomorrow in the House, since it turns out that we are not 
in session today. This landmark legislation, as you well know, 
is based on the previous Hispanic Health Care Act that we had 
introduced in the 106th Congress and on existing legislation 
that you yourself have had and you have championed in the 
Senate.
    In addition, we have taken some of the Federal 
recommendations from the Hispanic Health Leadership Summit and 
incorporated them into what I consider to be one of the most 
comprehensive bills aimed at improving Hispanic health in the 
United States. The legislation offers a variety of different 
strategies for expanding health care coverage. It helps to 
improve access and affordability and helps to reduce health 
disparities. While I consider each provision in our bill to be 
important, I am just going to highlight some of the important 
things that I think are urgent ones.
    In order to address the lack of health care and coverage, 
the legislation provides $33 billion between fiscal year 2003 
and 2010 for the expansion of the successful State Children's 
Health Insurance Program or SCHIP, to cover the uninsured low 
income pregnant women and parents.
    In addition, it provides States the option to enroll legal 
immigrant pregnant women and children in Medicaid and SCHIP. 
The Congressional Hispanic Caucus considers the expansion of 
Medicaid and SCHIP eligibility to those that are here legally 
critical legislation as a priority, so we want to thank you in 
those efforts.
    Second, the title also deals with access and affordability. 
Our bill requires an annual report to Congress on how Federal 
programs are responding to improving the health status of 
Hispanic individuals with respect to diabetes, cancer, asthma, 
HIV infection, AIDS, substance abuse, and mental health. The 
legislation provides $100 million targeted to diabetes 
prevention, education, and school-based programs and screening 
activities in the Hispanic community.
    Similarly, the bill also provides for targeted funding for 
programs aimed at prevention of suicide among Hispanic young 
ladies. We found some alarming data and research that shows 
that Latina young ladies are committing suicide at alarming 
rates and so I want to thank you for including that in your 
legislation.
    Targeted grants also will be available for funds also to 
provide support for promotoras, improving the health of women 
and families in medically underserved areas, such as the 
border.
    The third title focuses on the reduction of health care 
disparities by addressing the lack of providers who provide for 
the culturally competent and linguistically appropriate care. 
The bill also provides for increasing funding for the HRSA's 
health professions diversity programs. And, as you well know, 
the president's 2003 budget proposal eliminates virtually all 
the funding for these important programs that are drastically 
needed in our community and throughout our country.
    In addition to promoting diversity, these programs support 
the training of health professionals in the fields experiencing 
shortages, such as pharmacy, dentistry, allied health, as well 
as nursing, and promoting access to health care services in 
medically underserved communities. The Hispanic Caucus 
considered increased funding for these programs a high 
priority. As the Hispanic community continues to grow, the 
implementation of these provisions will take on an even greater 
importance.
    Mr. Chairman and members of the subcommittee, I ask for 
your support of the Hispanic Health Improvement Act and I want 
to thank you for your leadership in this area.
    And I just want to close by indicating the importance of 
the cultural relevancy. When I first heard testimony and we 
allowed individuals to come before us in the year 2000, we had 
a lady who basically testified that she had been told, and she 
testified in Spanish and indicated to us that she had been told 
that she was positive, positiva, when it came to AIDS and she 
understood that as being positive, that everything was okay. 
And when she had a baby, her baby contracted AIDS, not knowing 
full well that she had AIDS. She had misunderstood her doctor 
when she was told that she did have it. So by indicating that 
she was positive, positiva, for AIDS, that was interpreted as 
being positive, so everything was okay, versus the other.
    So when we hear stories like that of what continues to 
occur, it only emphasizes the need for us to continue to reach 
out, the need for us to continue to provide the education that 
is needed and the interpretation that is required and 
especially when we are dealing in cases of mental health and 
psychiatric help where those interpretations even become more 
critical.
    Mr. Chairman, thank you for your leadership. I look forward 
to continue working with you and I really do appreciate your 
hard work in this area. Your staff has done a tremendous job 
and I want to thank you for being there for us and for all 
Americans. Thank you.
    Senator Bingaman. Well, thank you very much, Congressman 
Rodriguez. I think your leadership is absolutely essential for 
us to succeed with this legislation, so we very much appreciate 
it.
    Let me also just acknowledge Bruce Leslie, who used to be 
in the House, on the staff there, and has been working here 
with me in the Senate now for some time. He, of course, is from 
the border, as well, and understands these issues very well, as 
well as understanding the way the Congress functions.
    So we are anxious to move ahead and I will not pose a 
series of questions to you at this point. I think it is clear 
to both you and me what the real questions are here. We have 
five very distinguished witnesses on the next panel and I am 
looking forward to hearing what they can contribute to this 
effort.
    But again thank you very much and we will continue to work 
with you in the remaining weeks of this session and then into 
the next Congress, as well.
    Mr. Rodriguez. Looking forward to working with you, 
Senator. Thank you very much.
    [The prepared statement of Mr. Rodriguez may be found in 
additional material.]
    Senator Bingaman. Why do we not go ahead with the second 
panel and let me ask all five witnesses to come forward. Dr. 
Cristina Beato, Dr. Francisco Cigarroa, Dr. Glenn Flores, Dan 
Reyna, and Dr. Elena Rios.
    Let me give a little more complete introduction for each of 
these witnesses before they begin their testimony. First let me 
welcome Dr. Cristina Beato, who is the Deputy Assistant 
Secretary for Health. I am happy to add that she comes from my 
home State of New Mexico, which we are very proud of, and 
served as the chief medical officer at the University of New 
Mexico Health Sciences Center.
    Next to her, Dr. Cigarroa, Dr. Francisco Cigarroa, who is 
the president of the University of Texas Health Sciences Center 
at San Antonio. Congressman Rodriguez referred to Dr. Cigarroa. 
He is the Nation's first Hispanic president of a medical school 
and a renowned pediatrician and transplant surgeon. We very 
much appreciate you being here.
    Dr. Glenn Flores has recently published an outstanding 
report as lead author of the Latino Consortium of the American 
Academy of Pediatrics Center for Child Health Research in the 
Journal of the American Medical Association or JAMA entitled 
``The Health of Latino Children,'' so we very much appreciate 
you being here.
    Dan Reyna, who is the head of the Border Health Office for 
the New Mexico Department of Health and has initiated a number 
of outstanding and successful projects in the southern part of 
our State with far too few resources, I would point out, but 
has done a wonderful job in spite of that. He is also past 
president of the U.S.-Mexico Border Health Association.
    And our final witness is Dr. Elena Rios. She is the 
president of the National Hispanic Medical Association and 
chief executive officer of the Hispanic-Serving Health 
Professionals Schools, Inc. Thank you very much for being here.
    Why do we not just go right across and we will hear from 
all of you? If you could summarize your testimony, that would 
be most appreciated. We will include the complete statement 
that you have submitted in the record but if you could make the 
main points that you think we should be aware of and then I 
will have a few questions.
    Dr. Beato, go ahead.

 STATEMENTS OF DR. CRISTINA BEATO, DEPUTY ASSISTANT SECRETARY 
   FOR HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
WASHINGTON, DC.; DR. FRANCISCO CIGARROA, PRESIDENT, UNIVERSITY 
 OF TEXAS HEALTH SCIENCE CENTER AT SAN ANTONIO, TX; DR. GLENN 
  FLORES, CHAIR, LATINO CONSORTIUM OF THE AMERICAN ACADEMY OF 
    PEDIATRICS CENTER FOR CHILD HEALTH RESEARCH; DIRECTOR, 
  COMMUNITY OUTCOMES, AND ASSOCIATE DIRECTOR, CENTER FOR THE 
   ADVANCEMENT OF URBAN CHILDREN, DEPARTMENT OF PEDIATRICS, 
    MEDICAL COLLEGE OF WISCONSIN, MILWAUKEE, WI; DAN REYNA, 
   DIRECTOR, BORDER HEALTH OFFICE, NEW MEXICO DEPARTMENT OF 
HEALTH, LAS CRUCES, NM; AND DR. ELENA RIOS, PRESIDENT, NATIONAL 
         HISPANIC MEDICAL ASSOCIATION, WASHINGTON, DC.

    Dr. Beato. Thank you, Senator. Good afternoon. I am 
Cristina Beato. I am Deputy Assistant Secretary for Health and 
I want to thank you, Senator Bingaman and the other members of 
the Subcommittee on Public Health, for the invitation to 
testify at this important hearing on the health care needs of 
our Hispanic population. In my testimony today I will primarily 
focus on the efforts of President George Bush and Secretary 
Tommy Thompson to eliminate those health disparities that 
disproportionately affect Hispanic Americans.
    The department recognizes that Hispanics are 
disproportionately affected by certain health conditions, such 
as heart diseases, breast cancer, unintentional injuries, 
diabetes, and HIV/AIDS. Additionally, Health and Human Services 
notes that Hispanics are also the largest group without any 
health insurance coverage.
    Under the leadership of Secretary Thompson, the department 
has made elimination of racial and ethnic disparities a health 
priority. Departmental efforts focus on six major areas where 
minorities, including Hispanic Americans, experience serious 
disparities in health access and outcomes: diabetes, heart 
disease, stroke, cancer, infant mortality, child and adult 
immunizations, and HIV/AIDS.
    Health and Human Services continues to support a vigorous, 
broad-based public health response to HIV/AIDS that include 
extensive research, prevention initiatives, and efforts to 
expand access to quality health care and services for those who 
need them. We are also working to address disproportionate 
impact of HIV/AIDS on racial and ethnic minorities. African-
Americans and Hispanics account for more than half of our 
Nation's AIDS cases although they only represent 25 percent of 
our population. Department funds will continue to be used for 
expanded treatment, services, and community-based prevention 
activities HRSA Ryan White Care and Treatment Programs, 
minority HIV/AIDS and Office of Minority Health RC expanded 
technical assistance program for HIV.
    Prevention of diabetes is primary in our department. The 
National Diabetes Education Program, a joint program sponsored 
by CDC and NIH, has reached 3.6 million Hispanics to date, with 
public service ads, media broadcasts, print media, including 
the Hispanic/Latino Campaign called ``Mas que Comida es Vida,'' 
meaning ``More than Food; It's Life.'' It focuses on Hispanics 
who have diabetes or who are at high risk to develop that 
disease and this effort is slated to continue for the fiscal 
year 2003.
    Health and Human Services also started ``Take Time to Care 
About Diabetes,'' another bilingual campaign to make more women 
aware of the dangers of diabetes. ``Cuide Su Corazon'' is one 
more campaign aimed at Hispanic Americans to help them 
understand the need to control all aspects of diabetes and to 
help prevent heart disease.
    Through the Racial and Ethnic Adult Disparities in 
Immunization Initiative, known as READII, HHS will continue the 
two-year demonstration projects in five sites to improve 
influenza and pneumococcal vaccination rates both in African-
American and Hispanic communities. San Antonio, TX, a 
predominantly Mexican-American community, is one of the 
selected sites and the efforts in Chicago, IL also target a 
significant Hispanic population. We know that immunization 
rates for adult Hispanics are at least 43 percent lower than 
those of their non-Hispanic white counterparts. Over the 2 
years, the READII project sites will collaborate with 
stakeholders to develop and implement a community-based plan 
utilizing existing and innovative approaches.
    Our department has developed a bilingual booklet to provide 
information to Spanish-speaking parents whose children may be 
eligible for health insurance benefits through the State 
Children's Health Insurance Program or SCHIP program and 
Medicaid. The State agencies and others involved in SCHIP and 
Medicaid programs are encouraged to use the booklet to assist 
our Spanish-speaking residents to learn about the availability 
of free and low-cost health insurance programs for children in 
low-income families through their State's SCHIP program.
    Secretary Thompson recently launched Healthfinder Espanol, 
a Spanish-language Web site that helps consumers track down 
reliable health information quickly and easily on the Internet 
on our Web site. By providing essential resources in Spanish, 
Health and Human Services is creating a gateway for Spanish-
speaking people to learn about preventing and treating illness 
and developing a healthy lifestyle.
    Healthfinder Espanol brings together in one easy-to-use 
site Spanish language health information on over 300 topics 
from 70 government agencies and nonprofit organizations, 
including the health issues of the greatest concern to those of 
Hispanic heritage. The site offers both a Spanish text search 
and a list of topics in Spanish that can be browsed.
    MEDLINEplus, the National Library of Medicine's consumer-
friendly health Web site, is also now in Spanish. The 
department is using tools at its disposal to increase health 
education and awareness to Americans across the country. 
MEDLINEplus en Espanol is one more step to ensuring that 
Hispanic Americans have real-time access to the important 
health information that they need.
    Vital to us are Community Health Centers. Health and Human 
Services continues to support increased funding for the 
Community Health Centers, which play a vital role in treating 
and serving the health care of Hispanics. Last month Secretary 
Thompson announced $30 million in grants to create 70 new and 
expanded health centers. This is a vehicle to extend health 
care service for people without health insurance. For fiscal 
year 2003 our department proposes to increase its funding of 
Community Health Centers to a level of $1.5 billion, a $114 
million increase above the current year's appropriation and 
$290 million above the funding level of the last 2 years. This 
funding will add 1,200 new and expanded health center sites 
over a five-year period and increase the number of patients 
treated from 11 million to 16 million.
    In terms of bilingual and bicultural services, Health and 
Human Services continues to support principal demonstration 
grants through the Office of Minority Health's Bilingual/
Bicultural Service programs in communities to improve Minority 
Health Grant Programs. Both of these programs support the 
development of strategies geared at eliminating health care 
access barriers, improving the coordination of integrated 
community-based screening, outreach, and other enabling 
services of the Spanish-speaking individuals.
    The U.S.-Border Health Commission, created in July of 2000 
by joint action of the United States and the Mexican 
governments, exemplifies our department's commitment to a 
binational framework. The goals for the Commission are as 
follows: to create ``Healthy Borders 2010'' objectives and 
health indicators pertinent to the region; to provide 
international leadership; and to optimize the health and 
quality of life along the U.S.-Mexico border. Secretary 
Thompson, who co-chairs the commission with the Mexican 
Minister of Health, has made border health a priority for our 
department.
    A Healthy Border 2010 program was recently launched by the 
BCH to promote and improve the health of people living on the 
United States-Mexico border region. The two major objectives of 
this program are to increase and improve the quality and the 
years of healthy life and to eliminate health disparities. A 
Border Commission office now operates out of El Paso, TX and 
funding is provided to support the BCH objectives.
    Recently, Secretary Thompson and the Mexican Minister of 
Health signed a cooperative agreement to enhance the safety of 
food supplies in both of our countries and to reduce the 
incidence of food-borne illnesses on both sides of the border 
through improved inspections. Other projects that address 
health issues along the U.S.-Mexico border include HRSA's HIV 
Border Health Initiative and the HRSA and NIH Salud para su 
Corazon, a project to reduce heart disease, and HRSA's 
Workforce Diversity Border Initiative, ``Building a Workforce 
for a Health Border.''
    Like Congressman Rodriguez said, Health and Human Services 
Centers for Medicare and Medicaid Services funds researchers, 
including Hispanic researchers, to conduct research on access, 
utilization, quality of service, and activities related to 
health screening, prevention, and education of Hispanic 
Medicare and Medicaid beneficiaries.
    The National Center on Minority Health and Health 
Disparities at NIH is authorized to promote minority health and 
to lead, coordinate, support and assess the NIH effort to 
reduce and eliminate health disparities. Addressing the health 
research needs of Hispanics is a key activity of this center.
    Promoting NIH minority health disparities research and 
health disparity career opportunities for minorities is a major 
goal of NCMDH. Since fiscal year 2001, NCMDH has operated two 
loan repayment programs--the Loan Repayment Program for Health 
Disparities Research and the Extramural Clinical Research Loan 
Repayment Program for individuals from disadvantaged 
backgrounds. There is outreach to Hispanic health professionals 
and researchers for participation in these two pipeline 
programs.
    Grants administered by the Centers of Excellence in HHS's 
Health Resources and Services Administration assist health 
professions schools to support programs of excellence in health 
profession education of minority individuals in allopathic and 
osteopathic medicine, dentistry and pharmacy, graduate programs 
in behavioral or mental health, including clinical counseling 
psychology, clinical social work, marriage and family therapy. 
The Centers of Excellence strengthen the national capacity to 
train students from minority groups that are underrepresented 
in these health professions and build a more diverse health 
care force. HRSA currently supports 11 Hispanic Centers of 
Excellence.
    In August of 2001 Secretary Thompson launched the Health 
Insurance Flexibility and Accountability waiver initiative to 
encourage States to expand access to health care coverage for 
low-income individuals through Medicaid and State Children's or 
the SCHIP demonstrations. This initiative gives the governors 
more tools and flexibility to coordinate State Medicaid and 
SCHIP programs and offers a simpler application for States that 
commit to reducing the number of people without health 
insurance. Thousands of Hispanic Americans living now in 
California, New Mexico and Arizona, among other States, now 
enjoy the ability to expand health insurance benefits as a 
result of waivers granted to their States under the secretary's 
initiative.
    President Bush also has health insurance tax credits 
because the absence of health insurance coverage for some 40 
million Americans, including many that are Hispanic Americans, 
is a problem calling for an immediate solution. The president 
in his 2003 budget sets forth a package of solutions including, 
most importantly, a proposal for the use of tax credits to 
offset the cost of obtaining health insurance. This proposal 
has received broad bipartisan support. If enacted, it can lead 
to a significant reduction in the uninsured population and, at 
the same time, lead to improvements in the market for 
individually purchased health insurance, greater choice and 
flexibility for individuals for determining the coverage that 
best fits their needs, and improving quality and price of 
health care provided not just to Hispanic Americans but to all 
Americans.
    In closing, I have provided a snapshot of some of the 
president's and the secretary's activities that focus on 
eliminating health disparities that disproportionately affect 
Hispanic Americans. Our department is making progress but we 
know that more can be done and we will continue to do more in 
order to lessen the social and economic burden of not improving 
the health status of Hispanic Americans.
    Again, Senator, I thank you for the opportunity to testify 
before you today. Thank you.
    Senator Bingaman. Thank you very much.
    [The prepared statement of Dr. Beato may be found in 
additional material.]
    Senator Bingaman. Dr. Cigarroa, why do you not go right 
ahead?
    Dr. Cigarroa. Senator Bingaman, I thank you very much for 
inviting me to speak and testify before this important 
subcommittee but I would also like to give my appreciation to 
Congressman Ciro Rodriguez, who has really been a tremendous 
leader in addressing health disparities and health challenges 
in South Texas.
    Senator Bingaman. Congressman Rodriguez, why do you not 
move up here beside me? There is no reason to be clear down at 
the end. I did not even see you sitting there. Please come over 
here. We have plenty of room right up here at the front.
    Go right ahead, Doctor.
    Dr. Cigarroa. Sorry, Ciro.
    Well, what I would like to do is discuss this testimony the 
subject of Hispanics and the health professions. I have given 
written testimony so I would like to just summarize this in 
about five minutes.
    The University of Texas Health Science Center is the 
academic health center responsible for the vast South Texas 
border region, which comprises more than 4 million people, 
almost 25 percent of the land mass of the State of Texas. Our 
Health Science Center has five schools but in addition to that, 
it has a regional academic health center which resides right on 
the U.S.-Mexico border region.
    We have been responsible for educating more than 15,000 
health professionals since the inception of the Health Science 
Center in San Antonio and many of those health professionals 
have chosen to practice in communities which are largely 
Hispanic. There is no doubt that our role is extremely 
important to South Texas because many of these regions in South 
Texas are among the most medically underserved. And Congressman 
Rodriguez actually cited Starr County, which is probably the 
most medically underserved region in this Nation.
    We also have clinicians and scientists whose great interest 
is really addressing diseases that affect the border 
population, predominantly diabetes and infectious diseases.
    I would like to touch upon some of the challenges we face 
in South Texas as we address the issues of Hispanic health. One 
of the greatest challenges, and I do not believe anybody here 
will disagree on this, is that the shortage of Hispanics in the 
health professions is among our greatest challenges. If we want 
to improve the health care of the Hispanic population, then it 
is essential that we educate more Hispanic health care 
professionals. And if we want to educate more Hispanic health 
care professionals, then we must provide more role models for 
the Hispanic population in South Texas and along the U.S.-
Mexico border region.
    So it is important that we provide these mentors and send 
these young students encouraging messages at an early age. I 
have been truly fortunate because my father, my grandfather and 
my uncle were practicing physicians in South Texas and I 
remember very clearly just about 25 years ago traveling with my 
uncle around the surrounding communities of South Texas because 
he was the only general surgeon in these communities. That was 
only 25 years ago and we have done a lot to improve that but it 
is still extremely medically underserved.
    Also firsthand I realized the importance of being sensitive 
to cultural competencies and also the importance of being able 
to be bilingual in such an area.
    So really it was these topics that I was actually addressed 
with at home, growing up in this environment, that really set 
the stage for myself. It set the stage to develop high goals, 
to leave Laredo, among one of the poorest public school systems 
in the United States, but to have the courage to become 
educated and among one of the greatest educational centers in 
our Nation and among some of the greatest residencies in our 
Nation. And it was these experiences that gave me the great 
desire to return to South Texas and contribute to the education 
of health care professionals along the U.S.-Mexico border 
region.
    There is no doubt in my mind that if it was not for these 
important mentors that I had growing up in South Texas, I would 
not have become a pediatric surgeon; I would not have become a 
transplant surgeon; I would not have returned to South Texas. 
But it was these global experiences that I had that also gave 
me the courage to become the president of an academic health 
center.
    I know firsthand that there are many young, bright, capable 
students that have not had the privilege that I have had to be 
able to discuss health and the health professions around their 
dinner table. So I personally recognize the importance of 
stimulating the scientific interests of students long before 
they reach undergraduate or graduate school.
    So at the Health Science Center we place a great emphasis 
on these pipeline issues. One of our most successful programs 
is the Med/Ed program, which I believe should be replicated in 
cities around this Nation. This is a program which introduces 
young students from South Texas to the health professions by 
introducing them at a very early age to physicians, to clinics, 
to our own Health Science Center in San Antonio, and through 
that means hopefully providing that stimulating experience that 
inspires youngsters to enter the health professions and also to 
build big dreams.
    As the students who have participated in the Med/Ed program 
begin to graduate from college and enter the health 
professional training, we are seeing successes. Since 1997 more 
than 750 high school students have been a part of this program 
and now the first class is beginning to graduate and more than 
75 of these students are entering the health professions and 
many of these students will again practice in South Texas.
    We are also very proud that through Med/Ed we have actually 
established three Hispanic Centers of Excellence at the Health 
Science Center--one in the medical school, one in the dental 
school, and one in the school of nursing. There is no doubt 
that we have a commitment to providing role models and that 
commitment was demonstrated this past June when we established 
the Regional Academic Health Center in Harlingen, TX. That 
opening ceremony of the Regional Academic Health Center, at 
which 48 of our medical students are educated right along the 
U.S.-Mexico border region, in that 1 day we nearly doubled the 
number of Mexican-American physicians who serve as faculty at 
academic health centers in this Nation. Again the importance of 
establishing mentors and individuals which the younger 
generation can aspire to become.
    We are proud of these interventions we provide at the 
Health Science Center but we also know that the number of 
Hispanics who graduate from college is unacceptably low and 
this statistic is worse the closer you get along the U.S.-
Mexico border region.
    As the demographics change in our Nation, if we do not 
change, these two divergent trends--a rising Hispanic 
population and a small number of Hispanic college and 
postcollege graduates--then we are on a collision course. 
Unless we reverse the college and postcollege success rate of 
underrepresented minorities, the future and the health of our 
Nation are in jeopardy.
    Our major challenge in reversing these statistics, of 
course, is funding. Our past funding has allowed us to 
implement many of these wonderful programs which I have 
commented upon but in fiscal year 2003 we face the possibility 
not only of a funding shortfall but possibly even a virtual 
elimination of the current level of funding for Title VII 
health professional training programs. Now to discontinue this 
funding now would be to discontinue our progress now, which 
would take us a step away from the goal that we want to 
achieve.
    Now there exist many more issues that are critical to 
Hispanic health. Those are paucities of nursing and allied 
health professionals along this border region. There is also a 
severe shortage of these professionals in our Nation, but it 
certainly worse in Hispanic areas. And there also exist 
diseases, as Congressman Rodriguez has stated, such as 
diabetes, multidrug-resistant tuberculosis, that affect this 
border region so significantly. So we also not only need to 
encourage students to enter the health professions but we also 
need to encourage students to enter the field of biomedical 
science.
    I, too, Congressman Rodriguez, agree with the report issued 
by the Institutes of Medicine that calls for the government to 
recognize and reward academic health centers that actively 
recruit and support well trained faculty and students who are 
from underrepresented minority populations. If we fail to take 
steps to address the gap between the health of the majority 
population and the health of the Nation's rapidly growing 
minority population, then we are on a course leading to an 
unhealthier Nation. The bill, Senator Bingaman, that you are 
considering contains much that would be of great assistance as 
we continue to progress toward many of the goals that the 
Health Science Center and many other academic health centers 
are making.
    In Texas we know all too clearly that diseases care nothing 
about borders. Just as there are rivers of commerce, there are 
rivers of infectious diseases and though they may start at the 
border, they are eventually seen all the way to our northern 
border which we share with Canada.
    I personally applaud you, sir, for the concern that you 
have for the situations that we face along the U.S.-Mexico 
border, situations which if left unchecked, will have a major 
impact on the State of Texas and on our Nation. So I thank you, 
sir, for the opportunity to present this testimony to this 
important and distinguished subcommittee and certainly a more 
formal statement is made in my formal testimony.
    Senator Bingaman. Thank you very much for that excellent 
testimony.
    [The prepared statement of Dr. Cigarroa may be found in 
additional material.]
    Senator Bingaman. Dr. Flores, we are glad to have you here.
    Dr. Flores. Thank you very much, Senator. I chair the 
Latino Consortium of the American Academy of Pediatrics Center 
for Child Health Research. I am a pediatrician who has cared 
for disadvantaged children for over 10 years, a researcher who 
studies how to improve the health of America's children, and a 
faculty member at the Medical College of Wisconsin. I am 
pleased and honored to be here today.
    I am going to talk about kids. I will discuss the 
demographic surge in our Nation's Latino children, highlight 
urgent priorities and unanswered questions in Latino children's 
health, and show why the Hispanic Health Improvement Act or 
HHIA would improve the lives of millions of American children. 
For extensive details and 113 references on what I will discuss 
today, I refer you to my written testimony and an article of 
ours published in the Journal of American Medical Association 
in July 2002.
    Latinos are now the largest minority group of children in 
the United States, numbering 12 million and comprising 17 
percent of the population under 18 years of age. In California 
Latinos surpassed whites as the largest racial and ethnic group 
of children in 2000 and by 2010 half of California's children 
will be Latino. Latinos are one of the youngest and fastest 
growing groups in our Nation. Despite this dramatic population 
growth, Latino children continue to experience a 
disproportionate burden of illness, injuries, impaired access 
to health care, and health disparities.
    Here is a true story. Maria was a three-year-old Latino 
girl brought to the emergency room because of severe stomach 
pain. Maria's mother spoke no English and no medical 
interpreter was available. A pediatrician examined Maria and 
discharged her with a diagnosis of colic. An hour later Maria's 
parents brought her back to the emergency room because her pain 
had worsened. The same pediatrician examined her and Maria's 
mother found the physician to be quite angry. Maria's father 
was upset because no interpreter was available and he felt 
Maria was treated poorly because his family was Latino. The 
pediatrician sent Maria home again.
    Several hours later Maria and her family returned to the 
emergency room. Maria's condition had deteriorated and was not 
quite serious. The pediatrician hospitalized Maria immediately. 
In the operating room Maria was found to have a perforated 
appendix and peritonitis. Maria was hospitalized for 30 days 
because of complications, including two infections of her 
surgical incisions. Maria had no health insurance.
    The issues faced by Maria and her family typify those 
confronting millions of U.S. Latino children and their 
families. Maria's family spoke no English. 44 million Americans 
speak a language other than English at home and 19 million are 
limited in English proficiency, or LEP. Latino parents cite 
language barriers as the single greatest obstacle to health 
care access for their children but medical interpreters 
frequently are not called when needed, inadequately trained, or 
simply not available at all. Only a few States provide third-
party reimbursement for medical interpreters and only one-
fourth of hospitals actually train their interpreters.
    The HHIA would provide Medicare and Medicaid reimbursement 
for hospital interpreters and fund identification and training 
of bilingual health professionals. All third-party payers 
should reimburse for medical interpreters because we can either 
pay a little now for high quality medical care for all children 
or pay a lot more later when preventable medical errors, 
hospitalizations, lawsuits and deaths result because no 
interpreters were available.
    The Office of Management and Budget estimates that 
providing adequate language services to all LEP Americans would 
cost $4.04 per visit, a 0.5 percent annual increase in national 
health care expenditures. Medical Spanish classes should be 
mandatory in medical schools in States with large Latino 
populations and health care institutions should require that 
all medical interpreters undergo fluency testing and proper 
training.
    Maria had no health insurance coverage for her 30-day 
hospital stay. Latinos are far more likely to be uninsured at 
25 percent than any other group of U.S. children. In 
comparison, 7 percent of white and 14 percent of African-
American children are uninsured. SCHIP efforts to enroll Latino 
children have largely been unsuccessful. Only 26 percent of 
parents of uninsured children ever obtain information about 
Medicaid enrollment and 46 percent of Spanish-speaking parents 
are unsuccessful at enrolling their uninsured children in 
Medicaid because materials are unavailable in Spanish. 
Additional research is needed on effective interventions for 
insuring uninsured Latino children and the HHIA would be a 
giant step forward because it would provide grants to promote 
innovative outreach and enrollment.
    Maria's story emphasizes the importance of culturally 
competent health care. Failure to consider cultural issues in 
health care can result in dissatisfaction, medical errors, 
inadequate pain management, fewer prescriptions, and use of 
harmful remedies, but cultural competency training is still not 
an integral part of educating health professionals, with only 8 
percent of U.S. medical schools offering separate courses on 
cultural issues and only 26 percent teaching about Latino 
cultural issues. Cultural competency training should be 
mandatory in health profession schools and continuing 
professional education. The HHIA would enhance provision of 
culturally competent health care by creating a national center 
for cultural competency responsible for providing educational 
materials and programmatic assistance.
    The physician that cared for Maria was not Latino. Latinos 
are underrepresented in all health professions. Although 17 
percent of children are Latino, only 3 percent of medical 
school faculty, 5 percent of pediatricians, 3 percent of 
dentists and 2 percent of nurses are Latino. To match future 
population growth, our Nation would need twice as many Latino 
physicians but minority medical school enrollment recently 
fell. These trends are alarming because Latino communities are 
more likely to have physician shortages and Latino physicians 
significantly more often care for Latino and uninsured 
patients.
    We need programs targeting minority students interested in 
the health professions at an early age. The HHIA's Health 
Career Opportunity Program and Hispanic-Serving Health 
Professions Schools Grants are excellent examples.
    Latino children like Maria frequently receive a lower 
quality of health care. In children hospitalized for surgical 
correction of serious limb fractures, whites receive 
significantly higher doses of narcotic pain medications than 
Latinos. Other noteworthy health disparities for Latino 
children include the highest rates in U.S. children of 
tuberculosis, cavities, unintentional injuries, suicide in 
adolescent girls, obesity in boys, and asthma in Puerto Rican 
children. More research is needed on why health professionals 
treat minority children differently and effective interventions 
for eliminating health disparities. Mandatory medical school 
cultural competency courses examining health disparities are a 
critical first step.
    Because Latino children are frequently not included in 
medical research, we need mechanisms to ensure better 
recruitment. Federally funded research should always include 
methods to recruit and appropriately study diverse populations, 
including educating minorities about clinical trials, 
recruiting non-English speakers and immigrants, and collecting 
and analyzing data by race and ethnicity. The HHIA includes 
several important mechanisms for reducing health disparities 
for Latino children.
    In conclusion, one out of every six American children is 
Latino. It's time for our health policies, services, and 
research to address this dramatic demographic change, which can 
be accomplished by one, ensuring all children and families with 
limited English proficiency have access to trained medical 
interpreters reimbursed by third-party payers or bilingual 
health professionals; two, providing all children with health 
and dental insurance; three, requiring cultural competency 
training for health professionals; four, increasing the number 
of Latinos in health care professions; five, including more 
Latino children in medical research; and six, eliminating 
health disparities for Latino children.
    The Hispanic Health Improvement Act would address all of 
these issues and result in significant improvements in the 
health and well-being of the 12 million Latino children in 
America. Thank you.
    Senator Bingaman. Thank you very much for the excellent 
testimony.
    [The prepared statement of Dr. Flores may be found in 
additional material.]
    Senator Bingaman. Next is Dan Reyna, who, as I indicated 
before, is director of the Border Health Office for the New 
Mexico Department of Health in Las Cruces. Dan, please go right 
ahead.
    Mr. Reyna. Thank you, Senator Bingaman, Congressman 
Rodriguez. I appreciate the invitation to be with you today. I 
appreciate also the opportunity to share some thoughts with you 
today on the issues of Hispanic health as they affect this 
Nation and the Hispanic heartland of the Southwest, the U.S.-
Mexico border.
    The U.S.-Mexico border is my neighborhood. It is a complex 
binational, bilingual, multistate, multicultural, multieconomic 
10-State region that stretches nearly 2,000 miles horizontally 
with no less than five distinct vertical border regions that 
are more directly defined by those communities 100 kilometers 
on either side of the international border. The border is an 
area with multiple public health systems among the 10 States, 
local county jurisdictions and two Federal Governments. Today 
it is, as Congressman Rodriguez mentioned, most appropriate 
that the discussion of a new strategy for the improvement of 
the Nation's Hispanic health occurs during our celebration of 
Hispanic Heritage Month.
    The U.S.-Mexico border factors significantly in the overall 
Hispanic demographic picture, as is evident by the following 
and as mentioned by some of the presenters. Half of all 
Hispanics live in just two States--California and Texas. New 
Mexico has the highest percentage of Hispanics of any State, at 
42 percent, followed by California and Texas at 32. New Mexico 
led all States in the percentage of people aged five and up who 
spoke Spanish at home, followed by Texas at 27 and California 
at 26 percent.
    Targeting the health status improvement of the growing 
Hispanic population is both a public policy challenge and 
opportunity. It is a true opportunity to engage in a systems 
approach that can target long-term improvements in health 
status.
    As to health care coverage, the New Mexico Border Health 
Office has been a State partner with the Rural Health Office at 
the University of Arizona in Tucson since 1996 and the Health 
Resources and Services Administration's ``Border Vision 
Fronteriza'' Project. Although the project began as an 
initiative to develop model outreach projects, the focussed 
shifted in 1999 toward outreach and enrollment of children into 
Medicaid and SCHIP. The project for the current funding cycle 
referred to as BVF II was funded for 1 year from October 2001 
to September 2002.
    The BVF II project is unique in New Mexico such that I 
refer to it as an integrated program approach model. HRSA 
provided funds taken from at least three internal program 
sources, since there was no specific line item, to the 
University of Arizona who thereafter subcontracted to a 
community nonprofit organization in Las Cruces, NM to support 
the project in Dona Ana County, a border county just north of 
El Paso County, Texas. The role of the Border Health Office is 
to operate as the coordinating entity directing the activities 
of the 13 partner agencies.
    The BVF II project provides at least a half-time community 
health advisor or promotora, Spanish for promoter of health, to 
the primary partners, which includes a hospital outreach 
clinic, two community health centers, a State public health 
clinic, a behavioral health center, a juvenile criminal 
detention facility, and partial support to a primary school. A 
key ingredient to our partnership list is the active 
involvement of the local staff of the Income Support Division 
of the State Department of Human Services, the State Medicaid 
agency and the leadership of the local, surprisingly so, 
Immigration and Naturalization Service, INS, district office. 
The New Mexico project was to receive nearly $79,000 for this 
fiscal year but program cuts will limit us to only $60,000. It 
is probable that funding may not be provided after the end of 
this month, although we remain hopeful.
    The effectiveness of this model approach for outreach and 
enrollment of children is evident in the results. For the 
project period of January 1, 2000 to August 15, 2001, BVF I 
phase, the project in Dona Ana County achieved 549 percent of 
its target. This amounted to direct processing of no less than 
12 percent of all Medicaid and SCHIP enrollments in the county. 
For the project BVF II from October 2001 to September 2002, the 
project has to date, through August of this year, achieved 190 
percent of the target enrollments. The legislation as proposed 
will provide $50 million to improve outreach and enrollment of 
children into Medicaid/SCHIP.
    We are confident that the replication of the BVF-type 
programs throughout the county will ensure that no child misses 
an opportunity to access the appropriate health care services. 
Using promotoras as in the BVP model is cost-effective and 
appropriate in targeting the Hispanic populations in need. It 
is a model they recognize and accept. It has performed as 
advertised.
    As to access, an example of a similar integrated program 
approach is that of the development of the Healthy Gente 
initiative for the U.S.-Mexico border region. Healthy Gente--
Gente is the Spanish word for people--is a risk-population-
targeted and outcome-based health planning initiative 
established by the U.S. State Border Health Offices 
specifically designed to be compatible with the United States 
Healthy People 2010 program. The Healthy Gente program includes 
25 Healthy Gente objectives that relate directly to the 46 
national Mexican health indicators on the Mexican side.
    Progress in achieving the Healthy Gente objectives for the 
U.S. border region is a significant challenge when you consider 
that if the U.S. border region were a separate State it would 
rank last in access to health care, first in the highest rates 
of uninsured, second in deaths related to hepatitis, third in 
deaths related to diabetes, first in the number of cases of 
tuberculosis with 34 percent of all U.S. cases found in the 
four border States, first in children living in poverty and 
last in per capital income. Additionally, the average percent 
of uninsured for Hispanics in the four States of the border 
exceeds 34 percent, as mentioned earlier, slightly higher than 
the national uninsured rate for Hispanics at 32.
    Diabetes, Senator, is a major chronic disease confronting 
the Hispanic population. It is one of the leading causes of 
death on both sides of the U.S.-Mexico border.
    The Las Cruces Sun News editorial of September 17 described 
diabetes as the ``darkest cloud'' upon the review of the 
recently released report on the Status of U.S. Health by the 
Department of Health and Human Services. Diabetes, I contend, 
is essentially the center of gravity for the Hispanic 
population in the U.S. Prevention and control efforts require 
the maximum support at all levels. All available means and 
approaches focussed on early screening and diagnosis, including 
at the primary school age, require immediate attention.
    The U.S. Mexico border region is the unavoidable front line 
to many of the growing and emerging public health challenges. 
The funding of the border health initiatives at $200 million 
for fiscal year 2003 will allow the stakeholders to address the 
problems in their totality. Effective solutions require 
resources for prioritization and coordination and strengthening 
of joint efforts and sustainability.
    Adequate funding to the Border Health Commission--$10 
million for fiscal year 2003--will ensure strengthening its 
capacity to serve as a platform from which public health 
problems can be assessed, collective policy development 
coordinated and assurance of actions adequately evaluated. The 
U.S.-Mexico Border Health Commission is an appropriate venue to 
undertake these significant impact issues of Hispanic health 
for the border region, developing and supporting bold 
interventions by local and State partners in areas such as 
diabetes, substance abuse, and infectious diseases.
    The utility and appropriateness of the promotora model has 
been proven effective for the range of outreach and community 
support activities. The approach is compatible with all 
Hispanic populations. It is, as I have referred to it at times, 
the ``Mary Kay'' approach to community health. It has worked 
throughout the country and I ask that you support the requested 
funding of $5 million for fiscal year 2003 through 2005.
    As to health disparities, the emerging national 
demographics will bring additional challenges in meeting the 
health manpower capacities needed by the increasing minority 
populations. Latinos, African-Americans and Native Americans 
account for about 25 percent of the U.S. population yet they 
represent only about 6 percent of practicing physicians in the 
United States, according to the report, ``The Color of 
Medicine: Strategies for Increasing Diversity in the U.S. 
Physician Workforce.''
    A quick look at the data on the availability of Hispanic 
faculty in the health professions schools is no less than 
disturbing, as may be seen by the following institutional self-
reporting statistics on the percentage of Hispanic faculty. As 
to medical colleges, Hispanic faculty make up 3.33 percent of 
all faculty, as to colleges of nursing, 1.3 percent, as to 
social work, 4 percent, dental, 3 percent. We cannot engage in 
a systems approach to addressing the health problems of the 
Hispanic population if we cannot open the doors to the future 
and widen the hallways of opportunity for aspiring and 
qualified health professions students and faculty.
    It is no less a crisis for the next generation, considering 
the gestation time from high school graduation to medical 
practice, and surely much more to reach for a medical or dental 
school faculty position. It could take a half-century to reach 
10 percent in any one professional category, or possibly more. 
We should hope not.
    Senator, Congressman, I thank you for the opportunity to be 
with you today.
    Senator Bingaman. Thank you very much, Dan, for that 
excellent testimony.
    [The prepared statement of Mr. Reyna may be found in 
additional material.]
    Senator Bingaman. Dr. Rios, you are the final witness 
today. We are very pleased to have you here. Please go right 
ahead.
    Dr. Rios. Thank you very much, Senator and Congressman 
Rodriguez. I am very honored to be here.
    I just wanted to start out by saying I just flew in this 
morning from California where I was with the California Latino 
Medical Association, which is a group that I was actually 
president of before I came to Washington in 1993. And on Friday 
I was in San Diego with a sponsored conference, along with our 
partner national groups, the National Medical Association 
representing African-American doctors and the American 
Association of Indian Physicians representing Native American 
doctors. And in both meetings I think there is a lot of 
enthusiasm among the medical community for the support of 
activities such as this bill that really show potential for how 
the health system can improve American health for all 
Americans. And I just want to say that we are actively seeking 
support for this bill.
    The National Hispanic Medical Association represents 
licensed Hispanic physicians in the United States. The mission 
of NHMA is to improve the health of Hispanics. The Health-
Serving Health Professions Schools, Inc. represents 22 medical 
schools and three public health schools and the mission of this 
organization is also to develop Hispanic student and faculty 
and research capacity to improve Hispanic health.
    We all know Hispanics are now 14 percent of the U.S. 
population and by the year 2050 one out of every four Americans 
will be of Hispanic origin. In the case of Hispanic patients, 
as we have heard, we are challenged by the language needs, 
literacy levels, lower levels of poverty and education, 
citizenship status, strong cultural beliefs and attitudes, 
family group decision-making, poor awareness of public health 
programs or how to follow instructions that come with complex 
treatment regimens, prescription drug labels, referrals for 
specialty care or elaborate x-ray preps and exams.
    Our health system is the best in the world but in order to 
be proud of that system the Hispanic Health Improvement Act of 
2002 challenges the U.S. Senate to develop new strategies to 
improve the quality of health care delivery that responds to 
the needs of Hispanics.
    In August, as Congressman Rodriguez mentioned, NHMA was 
proud to co-sponsor, with the Congressional Hispanic Caucus and 
the Department of Health and Human Services, the National 
Hispanic Health Leadership Summit. Also partners included the 
EPA, the National Highway Traffic Safety Administration, the 
Robert Wood Johnson Foundation, California Endowment, Amgen, 
Aventis, PhRMA, GlaxoSmithKline, and several national Hispanic 
organizations. One hundred and fifty health providers from 
Hispanic communities around the country and our partner 
representatives put forward several recommendations to improve 
programs both at the Federal and State level and at the 
community level for our private sector community-based 
organizations and many of those recommendations overlap with 
issues addressed by this bill. We will have a report on those 
recommendations this fall and I am not going to address that 
here, just to say that we are very proud to see people on the 
same page.
    I would like to address proposed strategies that this bill 
addresses for the Department of Health and Human Services to 
continue to improve health programs and activities targeted to 
Hispanics.
    First of all, on access to care, I think we do know the 
major barrier to access is that two out of five Hispanics do 
not have insurance and this legislation addresses this barrier 
by creating grants for outreach and enrollment and increasing 
eligibility for both SCHIP and the Medicaid program and we 
applaud these efforts. However, we also believe that employers 
need incentives that increase their ability to provide 
insurance, since smaller employers who employ Hispanics cannot 
afford insurance benefits.
    We also applaud the special programs that would be targeted 
at families with limited English proficiency and we recommend 
that there be reimbursement for interpreters added to this 
legislation. Moreover, the U.S. Department of Health and Human 
Services, currently reviewing its guidance to the Nation on LEP 
services under Title VI and supported by the administration, 
should have a clear and firm guidance to direct to our health 
providers. It is critical that communication be enhanced 
between providers and patients and we are supportive of the 
Federal Government, representing the largest insurance programs 
in the Nation, taking the lead in this area. We recognize the 
importance of this bill in moving this area along.
    We recognize the vision for the development of the 
reimbursement policy for LEP services for Medicaid program and 
SCHIP in this bill and also recognize that the bill for the 
reauthorization of community clinics introduced earlier this 
Congress also provides a provision for reimbursement. We hope 
that there could be a strategy, perhaps starting with a 
Congressional task force, linked to the future of Medicare, 
Medicaid and SCHIP on LEP services reimbursement and the 
evaluation of interventions to guide further policy-making.
    In terms of the U.S.-Mexico border, it has already been 
addressed. The U.S.-Mexico Border Health Commission is very key 
and has great potential to serve as a conduit for advancing 
many, many health programs if properly supported and funded. It 
is also critical that we investigate further research along the 
U.S.-Mexico border.
    In terms of disparities in health, it has already been 
mentioned, all of the different areas--diabetes, HIV/AIDS, 
cancer, mental health. I think we are especially aware of these 
new programs supported in this bill and would hope that it 
would include also the patient navigator system, the community 
health workers, and the Special Population Networks, such as 
Redes en Accion, that are models right now for targeting 
chronic disease interventions in the Hispanic communities.
    In terms of diversity in the health professions, the U.S. 
Federal Government has supported the national policy to recruit 
disadvantaged and minority students into the health professions 
since the 1960s. The literature has proven over and over again 
that the Federal Health Careers Opportunity Program has 
resulted in two to three times the number of graduates 
practicing in medically underserved areas and Hispanic and 
black physicians provide more care to their communities and to 
Medicaid and uninsured patients than nonminority doctors. 
Surely we can recognize these programs as successful.
    In addition, in this era of increasing health care costs, 
we must also consider that minority patients, who tend to be 
uninsured, will eventually create more costs in the system as 
they demonstrate chronic illnesses. Thus it is more effective 
for the health system to finance recruitment programs for 
future minority doctors who can provide targeted services. The 
consequences of not supporting minority health workforce 
development will be greater cost to the taxpayers of America, 
who would bear the brunt of shifting costs.
    But even three decades of Federal funding of HCOP have not 
resulted in enough Hispanics in the health workforce. We are 
only 5 percent of the total physicians, 3 percent of the total 
dentists, 2 percent of the total nurses, and there are many, 
many reasons why this is so. I think a major reason though is 
the limited support from the health system for academic skills-
building and admissions preparation services available in 
minority community schools in the grammar schools and in the 
high schools and the colleges. The Federal Government and, I 
believe, the private industry and private businesses need to 
get involved in supporting HCOP at the $40 million level that 
has been recommended in this bill.
    So, too, the Congress should support the Center of 
Excellence at the $40 million level, which is the HRSA program 
that not only continues the HCOP's recruitment, but adds 
curriculum development and research and minority faculty 
development that is so much needed for role models in our 
health professions.
    Last in terms of health professions, I have to say that the 
concept of having special grants to those schools that are 
designated as Hispanic-Serving Health Profession Schools is a 
unique opportunity for this country to recognize the importance 
of those schools with important track records of having 
Hispanic students and having Hispanic faculty, that have the 
potential to promote much more curriculum that is needed for 
the whole country to understand Hispanics.
    In terms of data collection and research, we strongly 
support this area and we need to have racial and ethnic 
identifiers and data collection and research in order to 
demonstrate trends and new knowledge for our program 
development and a more effective policy analysis and policy 
debate on what is needed to improve Hispanic health. And we 
have to recognize all of our Hispanic subgroups--Mexican, 
Puerto Rican, Cuban, Central and South American and other 
Hispanics.
    Data collection through community-based research is most 
important, as is being done by the Federal agencies now, as was 
mentioned earlier, CMS, also NIH, AHRQ, and CDC. We strongly 
support expanding the opportunities for research in these 
agencies and, for example, specific projects--the NIH has a new 
Export Program; NIH and HRSA have Centers of Excellence 
Programs; the AHRQ agency has the Exceed Program, which is the 
Excellence Center to Eliminate Racial Disparities in Health; 
CDC has REACH programs and I know that CMS has a special 
Hispanic Health Services Research Program.
    But really what is critically needed is that we start 
putting more funding into the development of more research and 
more researchers that are from the Hispanic community and that 
we link the academic centers with the communities and have real 
community-based research. That is something that this Nation 
really has not done in terms of Hispanic health. And not only 
that, but we need research institutes, publications, journals 
and clearinghouses so that we can have better use of the 
research that we should develop.
    Then the last area really is about cultural competence. It 
has already been mentioned, the important needs, so I am not 
going to go over that. I just think that what is critical now 
is that we start developing a sense of where to go and having 
clearinghouses on cultural competence, and that is really one 
of the major roles of the Office of Minority Health and why I 
think the Office of Minority Health was included in this bill. 
The Office of Minority Health at HHS and all of the agency's 
Offices of Minority Health would continue to coordinate the 
outstanding internal programs of the development, as well as 
linking to the constituents through all of their HHS regional 
offices.
    But I think that what is most important in this bill is the 
Center for Cultural Competence and Language is a new center 
that needs to be funded at the highest levels--I believe it is 
mentioned at $5 million in this bill--so that demonstration 
projects can be not only started and enhanced but that we can 
publish the results of those demonstration programs, evaluate 
the outcomes, and learn from the demonstration programs. And we 
recognize the opportunity here for the Office of Minority 
Health to promote leadership in this whole area of cultural 
competence.
    And last, I might add that leadership development is 
something that we sorely need in the Hispanic health care 
community. We believe that Hispanic leaders need to be promoted 
within Hispanic health programs. The Federal Government and the 
private sector need to have leaders who are from the Hispanic 
health care community to better educate others about the 
important needs that we discuss here today. Thank you very 
much.
    Senator Bingaman. Thank you very much. Thank you for the 
excellent testimony.
    [The prepared statement of Dr. Rios may be found in 
additional material.]
    Senator Bingaman. I think all of this testimony has been 
very good. Let me ask a few questions and then defer to 
Congressman Rodriguez for his questions.
    Dr. Beato, let me ask you a couple of questions first. We 
have a bill, S. 724, which we passed out of the Senate Finance 
Committee. This is a bill involving prenatal care for women and 
babies, to add pregnant women, to expand the SCHIP to cover 
pregnant women, and we passed that out in July.
    In April, April 12, Secretary Thompson wrote a letter to me 
in which he said the following. He said, ``Prenatal care for 
women and their babies is a crucial part of medical care. These 
services can be a vital life-long determinant of health. We 
should do everything we can to make sure this care is available 
for all pregnant women. It is one of the most important 
investments we can make for the long-term good health of our 
Nation.''
    ``As I testified recently at a hearing of the Health 
Subcommittee of the House Energy and Commerce Committee, I also 
support legislation to expand SCHIP to cover pregnant women.''
    We got that legislation passed out of our committee and we 
have been anxious to get a letter of support from the 
administration for the bill, S. 724. Could you get that done 
for us?
    Dr. Beato. Yes, sir, we will.
    Senator Bingaman. Thank you very much. That would be a big 
help.
    Border health. Secretary Thompson in October of 2001 
visited El Paso and Cuidad Juarez and committed at a meeting of 
the U.S. Border Health Commission that he would work to come up 
with an additional $25 million for health projects along the 
border. A week later Dr. Frank Cantu of the Health Services and 
Resources Administration reiterated that commitment at the 
University of Texas Health Sciences Center at San Antonio.
    Do you know the status of the effort to get that $25 
million?
    Dr. Beato. I do not, Senator, but we will check on that and 
follow up with your office.
    Senator Bingaman. If you could get back to us on that, that 
would be appreciated. I think that funding is certainly needed.
    Dr. Beato. Yes, sir.
    Senator Bingaman. Let me ask on the health professions, Dr. 
Cigarroa and various others have asked or have emphasized the 
importance of training more health professionals who are 
bilingual and who are from the Hispanic community.
    The administration's budget to us this year proposed major 
cuts--I think a 72 percent cut--in health professions funding. 
Also it proposed zeroing out funds for a number of the programs 
that we have discussed here today.
    Do you know what the administration's position is now on 
that? Have they changed their views on that? Would they support 
a higher level of funding than was asked for in the budget?
    Dr. Beato. What the administration proposed was indeed 
eliminating some of those HRSA diversity programs and shifting 
those funds to the National Health Services Corps program. What 
we found is that individuals that went to the National Health 
Service program in the Public Health Service tended to stay in 
those communities longer than individuals who went to the HRSA 
program.
    So what the administration did was sort of refocus from the 
HRSA to the National Health Service Corps. The funds were 
reshifted to National Health Service Corps. That is what we 
proposed, I think in April, when the president put forth that.
    Senator Bingaman. Obviously in my own view, I support the 
National Health Service Corps but I had not thought that the 
two were really trying to target the same need. My impression 
was that the funding which had been substantially cut was 
really for training of people in the health care professions 
and that that would be needed even if there were increased 
funding for the National Health Service Corps.
    Dr. Beato. What the administration proposed was increasing 
the scholarships in the National Health Service, so it would be 
also for training health care professionals, including allied 
health and dentistry.
    Senator Bingaman. I see. So you basically stand by the 
position that you took in the budget proposal as to where the 
funds ought to be put?
    Dr. Beato. That is correct.
    Senator Bingaman. Dr. Cigarroa, let me ask you about some 
of the figures that you cited and that several others have 
cited here about the need for training of health care 
professionals. All of the statistics for the number of 
Hispanics in these professions are dismal. I am particularly 
concerned when I see the figure on nursing because it would 
seem to me that the barriers to entry to that profession should 
be substantially less or are, just as a de facto matter; they 
are substantially less than the barriers to becoming a doctor. 
I mean you can become a nurse more easily, with less years of 
education than you are required to put in to become a doctor. 
It would seem that there would be a chance to do much better 
than the 1.3 percent was the figure that Dan Reyna said; 1.3 
percent of the nurses in our country are Hispanic.
    Do you have some insights you could give us as to how to 
solve that problem? Also, if you have any comments as to the 
importance of funding for training in this area.
    Dr. Cigarroa. There is no doubt about it that this is a 
significant problem. In fact, when I became president 2 years 
ago of the University of Texas Health Science Center, I was 
also equally as alarmed as you are in regards to the very low 
percentage of students enrolling into the nursing profession.
    What has happened, at least over the past 5 years, is that 
a significant number of faculty who serve as educators in our 
nursing schools have retired, so we had to actually put a lot 
of energy in recruiting and retaining faculty members in order 
to increase enrollment. We are making headway on that but I do 
believe that just like in the medical school professions, the 
individuals in the Hispanic population need more role models 
not only in medical school but also in the nursing schools. We 
have increased enrollment by about 33 percent in the past 3 
years but we just have a significant way to go.
    Now why is there such a discrepancy between--why do we have 
more Hispanics becoming physicians than nurses? I still have 
not put my finger on that but it requires a lot of significant 
effort on all our parts to try to solve that problem.
    Senator Bingaman. Dr. Flores, I do not know if any of the 
work you have done gets at this question of why we are doing so 
poorly at bringing Hispanics into these professions and with 
particular emphasis on nursing. Is that something you have 
looked at or not?
    Dr. Flores. I think the first place you have to start is 
with the fact that Latinos by far have the highest school drop-
out rate of any group--29 percent. Compare that to 13 percent 
for African-Americans and 7 percent for whites. So the first 
thing we have to do is keep Latinos in school.
    The next thing is if they are interested in health care, we 
need to encourage that. We need to have pipeline programs like 
HCOP and I share your concern in looking at the 2003 budget and 
the fact that we are going to completely zero out that program, 
and also that we are going to completely zero out another 
important program called the Minority Medical Program for 
faculty who are minority and want to stay in medicine.
    On top of that, we are going to have all the minority 
student scholarships. Then finally, the ultimate blow, as well, 
is we are going to cut AHRQ funding and, as Dr. Rios mentioned, 
HRQ supports these Exceed grants, the Excellence Centers to 
Eliminate Ethnic and Racial Disparities, and I sat on the study 
section for those projects and I was so impressed with how 
creative those were. I thought those were some of the first 
programs we were looking at that actually made a difference and 
now with the budget cut, those will probably be the first 
programs to go.
    So I would say we have to restart that pipeline, not cut it 
off, and begin early on, as early as the Head Start programs, 
where we know that Latino kids, despite the fact that they have 
high rates of poverty, are less likely than African-American 
kids to enroll in Head Start and we also know that Latino kids 
are more likely to be left back as early as elementary school 
grades.
    So from early age on, we need to encourage bright, 
talented, enthusiastic Latino students to stay with school and 
to go on into health care professions, like several of the 
doctors here.
    Senator Bingaman. Let me ask Dan Reyna on the promotora 
program that you have talked about, how extensive is that? Do 
we have a lot of people who are employed in that capacity and 
doing that throughout our State or is it just in a few locales 
or how extensive is that program today?
    Mr. Reyna. Senator Bingaman, we are fortunate in New 
Mexico. We have a citizen legislature and they are very much 
involved in the community. One of the charges that we received 
in 1994 with some State funding was replicate the promotora 
programs in Southern New Mexico, in our border region.
    So we have done so. We have all our six border counties 
with a promotora program. There are a number of similar 
programs in Northern New Mexico but we have the southern 
portion completely covered. For instance, we have I would say 
FTE equivalent, we have only 10 in the south that we fund 
through the Border Health Office but the Department of Health 
also funds promotora programs from other sources. And because 
of the success of this community-based program, our last review 
of one county, Dona Ana, there were 98 promotoras, outreach 
workers, in that one county provided by different sources of 
funds and projects.
    We think that we can do much with little. They are people 
from the community, people that know their neighbors. One of 
the key elements of community outreach is trust. If you do not 
trust the person that is trying to help you, you are not going 
to listen; you are not going to be educated. That is the 
success that we have had.
    The success with the BVF project cannot be discounted. When 
you exceed your target that HRSA has set by 549 percent and we 
are wondering 2 weeks before the end of the month whether we 
are going to have any funding next month, I am curious as to 
how we look at those kinds of things.
    Senator Bingaman. I would agree. Of course, around here we 
do not know if anything is going to be funded next, is the 
reality of things.
    Dr. Rios, did you have any experience with the promotora 
program in the work you have been doing? Is that something that 
is a useful expenditure of Federal funds or is that need being 
met? What is your thought on that?
    Dr. Rios. I have had experience dealing with leaders who 
have started promotora programs. In fact, in Arizona along the 
border, one of the clinics there, they had the beginning of a 
large program.
    I used to be in the Office on Women's Health and we 
actually worked with quite a few different women's health 
groups and promotoras were used back in the early 1990s. I 
think it was just starting to gain awareness by the Federal 
Government and I think that it is very crucial in our 
communities to have community workers who can relate to the 
communities and, like Dan said, the issue of trust in our 
health system needs to be overcome in terms of the Latino 
patients for several different reasons that I will not go into.
    But I think the promotora program is a model that has been 
used successfully in other countries and has been successful in 
this country and I think the Federal Government would be wise 
to support it.
    Senator Bingaman. Thank you very much.
    Let me call on Congressman Rodriguez for any questions that 
he has.
    Mr. Rodriguez. Thank you, Senator.
    I want to hit on a couple of items on the area of AIDS. It 
seems like we have been making a great deal of inroads, yet 
when it comes to the Hispanic community, we are losing ground 
there. There is a great disparity between the 13 percent 
population that we have and the almost 18 percent of the cases 
that are out there. And I know that one of the issues that is 
brought up by the community is the fact that in other 
communities, such as the African-American, they have community-
based organizations and that ours, we have very few of them and 
there is a large number of communities that do not have any.
    I was wondering as to what ways would be some of the ways, 
not only in terms of community-based organizations, but other 
things that we could reach out or some of the programs that you 
might already be familiar with that we could look at providing 
resources. I just wanted to throw that out to the panel as a 
whole.
    Dr. Rios. I can answer from East Los Angeles, where I grew 
up. There is a large community health center, Federal community 
health center, the Ultimate Health Services Corporation that 
has their own AIDS clinic in the middle of East L.A. and I know 
that they have had speakers to testify here for the Congress in 
the past as a model community program. And I think that, you 
know, there are so many people in the whole Los Angeles County 
and this is only one major clinic and it is community-based and 
a lot of people know about it but you do not have clinics in 
every city, in every suburb in Los Angeles, for public 
awareness about the HIV/AIDS services.
    In New York and other cities I know that there are very, 
very targeted HIV/AIDS services for Latinos. They are 
culturally competent and very good services but there are very, 
very few. That is the major problem. And I think that some of 
the strategies to get at that would be the Ryan White funding 
out of HRSA and the programs at CDC that the leadership within 
the agencies and the leadership on the review committees and 
the actual community boards that help to disseminate the 
awareness of the needs for these programs, that they be in tune 
with the needs.
    And I know that the Latino--I was on as task force for CDC 
on the implementation of their five-year strategic plan and the 
Latino rates are rising tremendously and we are in for a big 
disaster in HIV/AIDS.
    Mr. Rodriguez. We are hearing also in that area that the 
community-based groups. as the grants go out, have a great deal 
of difficulty of competing, at least in our communities, and 
competing with the other communities in those resources. I do 
not know if you want to add to that.
    Dr. Beato. There are two things I would like to add. Two 
months ago we had the first--with the Office of HIV/AIDS, 
faith-based Initiatives, just for Latino faith-based leaders 
around the country, we had 27 of them, Puerto Rico included, 
and it is the first time that the department sat down with 
faith-based Latino leaders to bring up the issue of HIV/AIDS, 
to try to engage at the community level leaders in the Latino 
communities to make education, prevention and treatment options 
available to them through issues like the Ryan White Act.
    Also, the Office of Women's Health, the fastest rising 
percentage is now in Latinas in HIV/AIDS. It is a large concern 
for Latinas. Tailoring programs to go reach out with the women 
in women's groups through education, again in prevention and 
treatment options, especially in anything that has to do with 
prenatal. As the example that you brought up, there is no need 
if we have an HIV-positive woman that we do not start taking 
steps to ensure that that baby does not get treatment before it 
is born.
    So there are several programs but including faith-based 
communities and forming partnerships with existing State health 
departments and sort of expanding that, CDC is looking at some 
of those programs, as Dr. Rios has said, and expanding, 
tailoring more to Latino women right now.
    Mr. Reyna. Congressman, I can add a point. For a number of 
years now the New Mexico Border Epidemiology Center at New 
Mexico State University, a component office of the Border 
Health Office, has had a unique project on the Mexican side 
funded with initial moneys provided by the U.S. Mexico Border 
Health Association about four or 5 years ago. We call that 
project Espejo. One of the ways to work on the AIDS issue is to 
try to prevent it and we have focussed on the Mexican side with 
the sex workers, the prostitutes in Palomas, Chihuahua. It is a 
community of less than 20,000 and it has almost a three-digit 
number of sex workers every weeks.
    So we are working with the health system on the Mexican 
side as they work with their sex workers every weekend because 
the customers come from the U.S. And in the years that we have 
worked that project, we have had only one AIDS confirmed case 
of a sex worker on the Mexican side but we work on that side 
and because of that, there are no sources for funding for us to 
help the Mexican public health system that although 
prostitution is illegal in Mexico, the public health system 
still works to try to prevent issues and health problems with 
the sex workers.
    I was in Matamoros, Mexico this past summer and visiting 
one of the hospitals in Matamoros across from Brownsville, TX. 
We spoke about the Espejo project in New Mexico, Chihuahua and 
they were trying to begin a similar project in Matamoros with 
about 1,000 sex workers. Unfortunately, we heard the news that 
in 1 week they had five confirmed AIDS cases of sex workers. 
Those clients--clients that they use come from the U.S. because 
they are paid in dollars. We have to find ways where we can 
work with Federal funding on the Mexican side to work with our 
colleagues in Mexico to help them help themselves so that 
eventually it ends up helping us.
    Mr. Rodriguez. Let me ask you one other question. I think 
when we talk about health, one of the areas that is almost an 
afterthought is the area of mental health and esp with 
children. I know that the piece of legislation talks about 
looking at the suicide rates among Latinas but I was wondering 
if you want to make any comments in the area of mental health 
services because I know it is one of the areas that is lacking.
    A recent report also talked about the great number of 
disparities among children, Latino children, in terms of access 
even after they have been diagnosed, of not getting access to 
health. I just wanted to throw that out to the panel if there 
are any comments.
    Dr. Flores. There is actually now an accumulating body of 
research on exactly what you are talking about, where there is 
some disturbing disparities. For example, we know that Latino 
children are substantially less likely to be hospitalized for 
mental health conditions across the board, whether you talk 
about all of them or individual diagnoses, despite the fact 
that they are more likely to have these diagnoses, even 
compared to African-Americans, and we do not understand why 
that is.
    And for some reason, Puerto Rican children lead the pack in 
all U.S. ethnic and racial groups as far as chronic 
developmental disorders, which I also would put under that 
general grouping.
    I think it is a good example, as well, when we are talking 
about HIV. I think there is an intriguing cultural phenomenon 
going on that we do not have enough research on and it is 
something called the healthy immigrant effect. Basically there 
is now a larger body of research that grows each year that 
shows that first generation U.S. Latino children have several 
excellent health outcomes and indicators and that deteriorates 
with greater acculturation in each successive generation. This 
has been found to be true for adults, as well.
    So we always talk about cultural competency as a deficit 
issue in many events, like avoiding harmful folk remedies----
    Mr. Rodriguez. Can I get a clarification? You said that as 
they assimilate they get worse in terms of their health?
    Dr. Flores. Yes. Let me give you an example. First 
generation Latino kids are more likely to have--sorry. The less 
acculturation you have, in other words, the less American you 
are, the better your health outcomes, whether you are talking 
about rates of low birth weight. Your rates are lower and once 
you have been in the U.S. for one or more generations, they go 
up.
    We also know that there are higher immunization rates when 
you first come to the U.S. Those go right downhill the longer 
you have been in the country and the more generations.
    We also know that when you have less acculturation you have 
less depression, less suicidal ideation, less cigarette 
smoking, less illicit drug use and an older age of first sexual 
intercourse. Once you have been in the U.S., all those outcomes 
become adverse outcomes, and this is called the healthy 
immigrant effect where the epidemiologic paradox--we do not 
understand what that is but is fascinating because there is 
something protective that Latinos bring to this country and 
then it gets destroyed by generations, probably of poverty, in 
the U.S.
    So if we could do some more research and find out what it 
is that is protective and maybe use our own community resources 
and our values and whatever it is that is healthy to then 
promote good behaviors and avoid AIDS and avoid mental health 
problems, I think we could make some fantastic strides, but we 
need to understand that better and we need to do more research 
on this.
    Mr. Rodriguez. Finally I just wanted to make a comment and 
I would hope a message to the administration, as well as to all 
of us. That is that in the area of the importance of resources 
and opportunities in training for health careers, I know that 
last year, the previous year, we had brought in about 190,000 
people through those H1 visas. A lot of them were in health 
professions. I know that in Texas, I will quote you a figure, 
not necessarily the exact numbers but we certify about 1,200 
doctors who graduate and then certify 4,500. So we basically 
import them from other States and other countries.
    And nationally the figures are also that we are not 
producing the number of doctors that we should. My 
understanding is that we graduate between 12,000 and 15,000 and 
then bring in 3,000 to 5,000 from abroad. And with the problems 
after 9/11, a lot of that is going to stop. And at a point in 
time, you know, we are a brain drain on the rest of the world 
so that we need to begin to prepare and educate our own so that 
it is a real need for us to put some real resources in that 
area.
    And I would hope the administration looks at those numbers 
and the fact that we complain, Senator, we complain about the 
Mexican that comes over but we forget that we have been a brain 
drain on them in terms of bringing a lot of their doctors over. 
After they pay for their education on the other side, they come 
over here and become doctors and they have been a great asset 
to us but at some point we also need to begin to prepare our 
own.
    Thank you, Senator.
    Senator Bingaman. Thank you very much, all of you. I think 
it has been very useful testimony. I appreciate it and I think 
this will help us in our efforts to persuade our colleagues, 
both in the House and the Senate, to move ahead with this 
legislation. Thank you very much.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

           Prepared Statement of Francisco G. Cigarroa, M.D.
    Good afternoon. Mr. Chairman, members of the Committee, I am Dr. 
Francisco Cigarroa, President of The University of Texas Health Science 
Center at San Antonio.
    I want to give you a brief overview of are region and the 
university I lead, so that as I discuss the importance of this issue, 
you will understand that it is not just a theoretical issue with me. It 
is at the very core of what we do every day.
    The UT Health Science Center at San Antonio is the medical center 
responsible for the vast South Texas/Border Region, which comprises 
more than 4 million people, and is one of the most rapidly growing 
areas of the nation. The Health Science Center has five schools, 
(Medical, Dental, Nursing, Allied Health Sciences and Graduate School 
of Biomedical Sciences.) We have educated more than 15,000 health 
professionals and are the center of the biosciences in San Antonio, the 
city's largest economic generator and one that has an annual impact of 
more than $8 billion on the area. We are also the source of 
internationally-recognized medical breakthroughs, major medical 
research, and extensive patient care. Each year, we also give more than 
$80 million in uncompensated health care to the medically indigent in 
our region.
    We also have extensions campuses throughout the region. Much of our 
focus is on the Hispanic population. In San Antonio, the Hispanic 
population is more than 50% and as you go further toward the Border, it 
is more than 90%. This is the most rapidly growing segment of our 
nation, and it is a true statement that we cannot have a healthy 
America unless we take the steps necessary to ensure a healthy Hispanic 
population. And we do just that. We are the only post-graduate 
institution in the nation to have earned the distinction of being the 
site of three Hispanic Centers of Excellence--in our Medical, Nursing 
and Dental schools. We are also the lead center for the United States/
Mexico Center of Excellence Consortium, an entity that includes major 
universities from California, Arizona, Texas, and, Senator Bingaman, 
your own state of New Mexico.
    I am also a pediatric transplant surgeon who is still doing surgery 
so that, even as Health Science Center President, I am never very far 
away from the front lines of medicine. It is an honor to be with you 
today and I am so pleased to have so many Congressional leaders 
gathered in support of this common cause today. Thank you all for being 
here and for the leadership you are providing on this most important 
issue.
       hispanics and the health professions: focus on the future.
    As president of the Health Science Center, I would like to talk to 
you about some of the challenges we face in South Texas as we address 
the issue of Hispanics and health, particularly Hispanics and the 
health professions. Increasing the number of Hispanics who enter the 
health professions is a critical element to improving the overall 
health care of the Hispanic population. And if we want to educate more 
Hispanic health care professionals, then we must begin by providing 
young Hispanics with encouraging role models and mentors in the health 
professions.
    It is so important that we provide these role models and send these 
positive encouraging messages at an early age. I am fortunate, because 
my father and grandfather were both physicians. I didn't have to seek 
out role models; they sat around my dinner table. That made it easy for 
me to set high goals for myself, and to go from the Laredo public 
schools to Yale, Harvard and Hopkins. My mentors were always available 
to me and it made all the difference in the world in my own career . . 
. from an early age, all the way to when I assumed the role as the 
first Hispanic in the nation to become the President of a major health 
and research university.
    But I am all too aware that so many young, bright, capable students 
do not have the privilege of discussing health careers around the 
dinner table. Far too many of our young people, who are just as bright 
as others, never even have the opportunity to consider a career in the 
biosciences. And that severe lack of professionals is taking a major 
toll on the health, the wellbeing, and, ultimately, even the economy of 
this vast region which is so reflective of the America of tomorrow. At 
the Health Science Center, we recognize the importance of stimulating 
the scientific interests of students long before they reach 
undergraduate or graduate school. We place a great deal of emphasis--
and resources--on the `pipeline'.
    I would like to describe a couple of our most successful programs, 
because they are easily replicable and because they have been so 
successful.
    One of our most successful programs--our Med/Ed program--should be 
replicated in cities around the country. This year-round program 
introduces young students from the Rio Grande Valley in Texas to the 
health professions by allowing them--at an early age--to visit labs, 
doctors' offices, and hospitals, and our Health Science Center, years 
before they will start their future careers. These young students, in 
high school and even in middle school, see our doctors, dentists, and 
nurses-and our students-in action. They get help with difficult science 
course work. They talk to students and see that many of our students 
are not that different from themselves. And they begin to build big 
dreams--many for the first time in their lives.
    As the students who participated in the Med/Ed program begin to 
graduate from college and enter health professions training, we are 
seeing success in the results of this program. Since 1997, a total of 
750 students have participated in our Med/Ed Program. Of the 1997 and 
1998 high school graduates who participated, we have a total of 78 
students who are entering the health professions. And because many of 
the other participants are still in college, we know that the number of 
students who enter the health professions will continue to grow.
    We are very proud of our Med/Ed program, and we are proud to be the 
only Health Science Center in the nation with three Hispanic Centers of 
Excellence on campus to support the needs and goals of our Hispanic 
students. As I mentioned, we hold this distinction in our Medical, 
Dental, and Nursing Schools. Through these Centers of Excellence, we 
provide support for our students through faculty mentors, pre-
matriculation programs, and tutoring opportunities. In addition, 
through the Hispanic Centers of Excellence, we are able to provide 
additional outreach programs to high school and college students. 
Through our partnership with a local undergraduate university, St. 
Mary's University, and the Health Careers Opportunity Program, we offer 
a six-week intensive summer academic enrichment and career preparation 
program. This program, like many others offered through the Centers of 
Excellence, immerses young students in the clinical setting and 
provides them with the unique and inspiring opportunity to shadow 
health professionals.
    Our Health Science Center's commitment to providing role models was 
shown again this past June when we opened the Medical Education 
Division of our Regional Academic Health Center in Harlingen. In that 
one day, we nearly doubled the entire national number of Mexican-
American physicians who serve as faculty physicians--and therefore as 
mentors--for medical students and the younger students of the 
community.
    We are very proud of the early intervention programs that we offer 
at the Health Science Center.
    But we also know that the number of Hispanics who graduate from 
college is unacceptably low. As the demographics in our nation change, 
if we don't change these two divergent trends--rising Hispanic 
population and small number of Hispanic college and post-college 
graduates, physicians and other health professionals--then we are on a 
collision course with disaster. Unless we reverse the college and post-
college success rate of under-represented minorities, the future and 
the health of our nation are in serious jeopardy.
    Our major challenge in reversing these statistics will be funding. 
Our past funding has allowed us to implement so many wonderful and 
successful programs. But now, for the Fiscal Year 2003, we face the 
possibility not only of a funding shortfall, but possibly even a 
virtual elimination of the current level of funding for all Title VII 
health professions training programs. To discontinue this funding now, 
to discontinue our progress now, would be to take a large step away 
from, rather than toward, our goal.
    As a nation, we must continue to provide positive role models and 
early intervention opportunities for our young people who are 
underrepresented in the health professions. We must continue to provide 
the resources to support these important programs. We must commit 
ourselves to improving the college and post-college success rate of 
under-represented minorities in order to provide a healthier, more 
prosperous future for all people.
    I have had some of my colleagues ask why we place such an emphasis 
on these early intervention programs when, after all, we are a post-
graduate institution. The answer is easy. Our vision for our region, 
our state and our country is a seamless transition of success: from 
elementary school, through high school, college and medical school.
    These pipeline programs are an integral part of the success and the 
future of our country, and I would be pleased to send additional 
information to anyone who would like to know more about these 
initiatives.
                            other challenges
    But there are many more issues that are critical to Hispanic 
health. We have a desperate shortage of nurses in this country, and the 
shortage is even more severe in the largely Hispanic areas. Even as 
President in my own medical school in San Antonio, I was called to do a 
transplant and was then told that we could not proceed with the 
operation because the hospital could not find sufficient nurses. As 
President, I had the authority to do whatever it took to save a life 
that day. How many surgeons have heard that same message: ``We don't 
have enough nurses for you to operate today'' and been unable to do 
anything about it.
    Our nursing school turned away more than 300 qualified students, a 
great many of them Hispanic, because we couldn't find enough faculty to 
keep the required one-to-eight ratio. Through some creative financial 
steps, I was able to increase our faculty and add many new students . . 
. but we need more resources, so that we can hire more faculty, so that 
we can educate more students. This is a high priority for the entire 
country.
         research breakthroughs: the key to a healthier future
    We are focusing our basic research on conditions most prevalent in 
this region, diseases that take a tremendous financial toll on our 
country. Diabetes: diseases related to aging, infectious diseases, 
multi-drug resistant tuberculoses, which is undergoing a terrible 
resurgence. We need programs that encourage students, and particularly 
Hispanic students, to enter the research field and complete their PhDs. 
An alarming twenty percent of our Mexican American population will 
develop adult-onset diabetes. That is a rate substantially higher than 
the non-Hispanic population. What follows are an array of diseases of 
the heart, eyes, circulatory system, neuropathy of all kinds. What this 
does to the quality of life is hard for us to imagine. What this does 
to our state and national budget is also hard to imagine. We have 
scientists who already have identified genes that are involved in 
diabetes. We believe we are close to the critical ``next steps'' that 
lead toward prevention. What an overwhelming difference that will make 
on this country, once we are successful in that search.
                        steps to ensure success
    I agree with the report issued by the Institute of Medicine that 
calls for the government to recognize and reward medical schools that 
actively recruit and support well-trained faculty and students who are 
from under-represented minority populations.
    We should do this because it is the smart thing to do. If we fail 
to take steps to address the gap between the health of the majority 
population and the health of the nation's rapidly growing minority 
populations, we are on a course leading to a collision. We are far too 
great a nation to allow this to happen.
    We know that it is futile to continue to do the same things, but 
expect different results. Well, as a nation, if we continue to treat 
issues of Hispanic health as we are doing now, we will indeed see the 
same results: lack of coverage, access and care. And those results are 
not sufficient to ensure a healthy America in the future.
    At The University of Texas Health Science Center at San Antonio, we 
are doing all that we can, and with great success, to ensure a 
healthier region. I am proud of our record of success, which also 
includes leveraging government resources with private philanthropy and 
we have also been very successful in that arena as well. We look 
forward to continuing our partnership with the government--federal as 
well as state--as we work together in this most worthy common cause of 
a healthier America, achieved by ensuring a healthier Hispanic 
population.
    The bill you are considering contains much that would be of such 
great assistance to us as we continue the progress we have already 
made. It addresses topics that we address every day: diabetes, 
addiction, issues of early care for pregnant women and children, 
pipeline issues, and funding for Border and Hispanic health concerns. 
In Texas, we know all too clearly that diseases care nothing about 
green cards. Germs respect no INS regulations. We truly must work with 
our neighbors to the South if we are to avoid a major influx if new 
conditions and diseases. It can be seen so clearly on a map. Just as 
there are `rivers of commerce' there are `rivers of infectious disease' 
and though they may start at the Border, they are eventually seen all 
the way to the northern Border that we share with Canada. We can and do 
work with Mexico on these, and other environmental-related diseases. I 
applaud all of you for the concern you have for the situations we face 
along the Border, situations which, if left unchecked, will have a 
major impact on every state in the nation.
    Thank you for the opportunity to present this testimony to this 
important and distinguished Senate Committee.
                Prepared Statement of Glenn Flores, M.D.
    The views presented are those of the author, and do not necessarily 
represent those of the American Academy of Pediatrics or Medical 
College of Wisconsin.
    Good afternoon, Mr. Chairman, and distinguished Members of the 
Committee. I appear before you as Chairman of the Latino Consortium of 
the American Academy of Pediatrics Center for Child Health Research. I 
am a pediatrician who has cared for disadvantaged children for over 10 
years, and Associate Professor of Pediatrics, Epidemiology and Health 
Policy at the Medical College of Wisconsin, where I am Director of 
Community Outcomes, and Associate Director of the Center for the 
Advancement of Urban Children in the Department of Pediatrics. I am a 
researcher with expertise on Latino children's health issues, access to 
health care, children's health disparities, and cultural and linguistic 
issues in health. Prior to coming to the Medical College of Wisconsin, 
I founded and was Co-Director of the Pediatric Latino Clinic at Boston 
Medical Center
    I am pleased and honored to be here today to discuss with you the 
important issue of the health of Latino children. I will talk about the 
dramatic demographic surge in our nation's Latino children, highlight 
the urgent priorities and unanswered questions in Latino children's 
health, and show why the Hispanic Health Improvement Act would 
substantially improve the lives of millions of American children. For 
further details and 113 references on these issues, I refer you to the 
article of ours published in the Journal of the American Medical 
Association (Flores G, et al. The health of Latino children: Urgent 
priorities, unanswered questions, and a research agenda.
    Latinos are now the largest minority group of children in the 
United States, numbering 12.3 million, and comprising 17% of the 
population less than 18 years of age. In California, Latinos surpassed 
whites as the state's largest racial/ethnic group of children in 2000, 
and by 2010, half of all California children will be Latino, 
outnumbering white children in the state by 1.9 million. The 2000 
Census documents that Latinos are one of the youngest and fastest 
growing groups in our nation. But despite this dramatic population 
growth, Latino children continue to experience a disproportionate 
burden of health risk factors, illness, injuries, impaired access to 
health care, and health disparities.
    I would like to share with you two stories about children that we 
recently cared for at the Pediatric Latino Clinic at Boston Medical 
Center (the names have been changed to protect confidentiality):
    Maria Fuentes was a 3-year-old Latino girl brought to the emergency 
room by her parents at midnight because of complaints of severe stomach 
pain. No medical interpreter was available in the emergency room, and 
because Maria's mother spoke no English, she was unable to adequately 
describe her daughter's condition. The emergency room pediatrician 
examined Maria, and discharged her with what Maria's mother understood 
to be a diagnosis of ``colic.'' One hour later, both parents brought 
Maria back to the emergency room, because her pain had worsened. The 
same pediatrician examined her, and Maria's mother found the physician 
to be quite angry. Maria's father was extremely upset because no 
interpreter was available, and he felt that Maria was treated poorly 
because his family was Latino. The pediatrician sent Maria home again, 
this time with a medication, the name of which the Maria's mother did 
not recall.
    Several hours later, Maria and her family returned to the emergency 
room. Maria's condition had deteriorated, and was now quite serious. 
The pediatrician hospitalized Maria immediately.
    In the operating room, Maria was found to have a perforated 
appendix and peritonitis, a serious infection of the lining of her 
abdomen due to her appendix bursting. Maria was hospitalized for 30 
days, because of complications including two infections of her surgical 
incisions. Maria had no health insurance.
    My second story is about a two-year-old Latino girl named Rosa 
Morales, whose parents brought her to the emergency room for right 
shoulder pain. X-rays revealed that Rosa had fractured her right 
collarbone. Rosa's mother spoke Spanish almost exclusively. When Rosa's 
mother was asked what happened, she responded, ``Se pego, se pego.'' 
The resident physician interpreted this to mean, ``She was hit.'' 
Rosa's mother then showed the nurse a discharge summary from a previous 
emergency room visit to another hospital two months prior to the first 
visit, when Rosa also was diagnosed with a right collarbone fracture 
after a fall from her bed.
    Child abuse was suspected by the emergency room staff, and the 
state Department of Social Services was contacted. A Department of 
Social Services caseworker came to evaluate Rosa and her 4-year-old 
brother, Jose. Without a Spanish interpreter, the caseworker spoke with 
Rosa's mother, and then asked her to sign over voluntary custody of 
Rosa and Jose. Rosa and Jose immediately were taken from their mother 
and placed in Department of Social Services custody.
    When the Spanish interpreter arrived, Rosa's mother was interviewed 
again, and she reported that Rosa had fallen from her tricycle and 
struck (``se pego'') her right shoulder. The primary care physician was 
contacted, and denied any history of abuse or neglect in the family, or 
having concerns. Rosa's mother regained custody of Rosa and Jose after 
48 hours.
    The issues faced by Rosa, Maria and their families typify those 
confronting millions of Latino children and their families in the 
United States. For example, neither Rosa nor Maria's family spoke 
English. About 45 million people in the US speak a language other than 
English at home, and about 19 million are limited in English 
proficiency, or LEP. Spanish is the language spoken by 26.7 million, or 
60%, of those who speak a language other than English at home, and 12.5 
million, or 64% of LEP Americans. Five percent of school aged US 
children (or about 2.4 million) are LEP, an 85% increase since 1979. 
Multiple studies demonstrate a wide range of adverse effects that LEP 
can have on health and use of health services, including impaired 
health status, a lower likelihood of having a usual source of medical 
care, lower rates of mammograms, pap smears, and other preventive 
services, non-adherence with medications, a greater likelihood of a 
diagnosis of more severe psychopathology and leaving the hospital 
against medical advice among psychiatric patients, a lower likelihood 
of being given a follow-up appointment after an emergency department 
visit, an increased risk of intubation among children with asthma, a 
greater risk of hospital admissions among adults, an increased risk of 
drug complications, longer medical visits, higher resource utilization 
for diagnostic testing, lower patient satisfaction, and impaired 
patient understanding of diagnoses, medications, and follow-up.
    Latino parents cite language barriers as the single greatest 
barrier to health care access for their children. But research 
documents that medical interpreters are frequently not called when 
needed, are inadequately trained, or are simply not available at all. 
In Maria's case, if an interpreter had been present when she initially 
presented to the emergency room, the nature and severity of the 
symptoms might have been recognized immediately. The outcome with an 
interpreter, indeed, could potentially have been prompt diagnosis of 
appendicitis, a routine short hospital stay for an appendectomy, and a 
satisfied family, in stark contrast with the costly, complicated 30-day 
hospital stay that actually occurred and left the family dissatisfied 
and embittered. A recent study of ours underscores that lack of 
adequately trained medical interpreters can result in increased medical 
errors. We found that an average of 19 interpreter errors of clinical 
consequence are made per pediatric encounter, with untrained 
interpreters, such as family members, making significantly more such 
errors than trained interpreters. In a case where a child was visiting 
his physician for an ear infection, an untrained interpreter 
incorrectly told a mother that an oral antibiotic should be placed in 
the child's ear, and in another case, a hospital interpreter told a 
mother to rub a steroid cream prescribed for an infant's facial rash 
over the infant's entire body.
    But only five states in the US currently provide third-party 
reimbursement for medical interpreter services, and less than one-
quarter of hospitals nationwide provide any training for medical 
interpreters. The HHIA would ensure many children and families with 
limited English proficiency would have access to health care without 
language barriers by providing for use of Medicare and Medicaid funds 
to pay for hospital interpreters. I would also suggest that all third-
party payers should reimburse for medical interpreters, because we can 
either pay a little now to provide high quality medical care to all 
children, or pay a lot more later when preventable medical errors, 
hospitalizations, lawsuits, and even deaths result in LEP patients 
because no interpreters were available. Indeed, a 2002 report to 
Congress by the Office of Management and Budget estimated that 
providing adequate language services to all LEP persons in our nation's 
healthcare system would cost about $4.04 per visit, equivalent to about 
a 0.5% annual increase in national healthcare expenditures.
    There are other feasible solutions to eliminating language barriers 
in our nation's healthcare system. First, we must increase the number 
of current and future health care providers who speak Spanish and other 
second languages commonly spoken by Americans. This can be achieved by 
making medical Spanish and other language classes mandatory in medical 
schools in states with large Latino populations, and offering ongoing 
Spanish and other language courses for current healthcare 
professionals. Section 321 of the HHIA would also be helpful in that it 
would identify bilingual health professionals and train them with 
respect to minority health conditions. Second, health care institutions 
need to ensure that all LEP patients have access to trained medical 
interpreters. Fewer than one-fourth of hospitals nationwide provide any 
training for medical interpreters, and only 14% of US hospitals provide 
training for volunteer interpreters, and in half of these hospitals, 
the training programs are not mandatory. It is time for our healthcare 
institutions to require that all medical interpreters undergo fluency 
testing and proper training.
    Maria had no health insurance to cover her expensive 30-day 
hospital stay. Latinos are far more likely to be uninsured, at 25%, 
than any other racial or ethnic group of US children. In comparison, 7% 
of white and 14% of African-American children are uninsured. About 3 
million Latino children lack health insurance, and approximately one-
third of all poor Latino children are uninsured, despite eligibility of 
the vast majority for Medicaid and the State Children's Health 
Insurance Program (SCHIP). Among uninsured poor children in the US, 
Latinos outnumber all other racial/ethnic groups, including whites: 
there are 1 million poor, uninsured Latino children, compared with 
766,000 white, and 533,000 African-American poor, uninsured children. 
Congress enacted SCHIP in 1997 with a 10-year investment of about $40 
billion. Although 1999 marked the first time in many years that the 
proportion of uninsured Latino children actually decreased (from 30% to 
27%), recent national data suggest that outreach efforts to enroll 
Latino children have largely been unsuccessful. A Kaiser Commission 
report found that only 26% of parents of eligible uninsured children 
said that they had ever talked to someone or received information about 
Medicaid enrollment, and 46% of Spanish-speaking parents were 
unsuccessful at enrolling their uninsured children in Medicaid because 
materials were unavailable in Spanish. Additional research is needed on 
identifying the most effective interventions for outreach and 
enrollment of uninsured Latino children, and the Hispanic Health 
Improvement Act, or HHIA, would be a giant step forward in this area. 
The HHIA would provide grants to promote innovative outreach and 
enrollment efforts, and would target the most vulnerable populations, 
including children living in rural areas and in families for whom 
English is not their primary language.
    Rosa's and Maria's stories also emphasizes the importance of 
providing culturally competent health care. Cultural issues can have a 
profound impact on Latino children's health and their quality of care. 
Failure to consider these issues in clinical encounters can have a 
variety of adverse consequences, including difficulties with informed 
consent, miscommunication, inadequate understanding of diagnoses and 
treatment by families, dissatisfaction with care, medical errors, 
preventable morbidity and mortality, unnecessary child abuse 
evaluations, a lower quality of care, clinician bias, and ethnic 
disparities in prescriptions, analgesia, test ordering, and diagnostic 
evaluations. Unfortunately, cultural competency training still is not 
an integral part of the education of physicians, nurses, and other 
healthcare professionals. For example, a recent published study by my 
research team revealed that only 8% of all US medical schools have 
separate courses addressing cultural issues. We also found that only 
26% of US medical schools teach about Latino cultural issues, and only 
35% of the schools address the cultural issues of the largest minority 
groups in their particular states. More research is needed on the most 
effective course content and structure for teaching cultural issues, 
along with formal evaluation of the effectiveness of various curricula. 
In the meantime, given the substantial evidence that lack of 
culturally-competent care can have a major impact on Latino children's 
health and healthcare, cultural competency training should be a 
mandatory educational component in health professions schools, 
residency programs, and continuing professional education. The HHIA 
would ensure that all US children receive culturally-competent health 
care by creating a Center for Linguistic and Cultural Competence in 
Health Care within the Office of Minority Health, which would be 
responsible for developing education materials and providing technical 
assistance in carrying out programs.
    Much could be learned from Latino culture about improving the 
health of all American children. A growing body of research documents 
that first-generation US Latino children have several excellent health 
outcomes and indicators that deteriorate with greater acculturation and 
each successive generation. For example, less acculturation is 
associated with significantly lower rates of low birth weight, higher 
immunization rates, less depression, less suicidal ideation, less 
cigarette smoking, less illicit drug use, and older age at first sexual 
intercourse. These findings are particularly striking in light of data 
indicating that first-generation immigrant children have significantly 
decreased health care access and utilization. Yet we have little 
understanding about what factors are responsible for this ``healthy 
immigrant'' effect. Such compelling findings require that we abandon 
the traditional ``deficit'' view of Latino culture and its impact on 
health, and adopt a more balanced perspective that emphasizes 
appreciation and understanding of the salutary components of Latino 
culture. It is clear that more research needs to be conducted in this 
intriguing area.
    Neither of the physicians that cared for Maria and Rosa was Latino. 
Latinos are underrepresented at every level of the health care 
professions. Although 17% of children <18 years old are Latino, only 3% 
of medical school faculty, 5% of pediatricians, 2.8% of dentists and 2% 
of nurses are Latino. The Latino pediatrician-to-child population ratio 
is expected to fall from 17 Latino pediatricians per 100,000 Latino 
children in 1996 to 9 per 100,000 by 2025. Analyses indicate that to 
achieve parity with future ethnic changes in the US population, our 
nation would need twice as many Latino physicians, but there has been a 
recent decrease in minority medical school enrollment, especially in 
states with large Latino populations that have banned affirmative 
action policies, such as California and Texas. These trends are 
particularly alarming because studies document that Latino communities 
are substantially more likely to have physician shortages, Latino 
physicians are significantly more likely to care for Latino and 
uninsured patients,31 and Latino patients are more likely to be 
satisfied with health care from Latino vs. non-Latino physicians.
    Additional research is needed on the most effective ways of 
increasing the numbers of Latino health professionals and faculty at 
health professions schools. But we also need to fund programs that 
early on identify, recruit and retain talented minority students with 
an interest in the health professions. The expanded Health Career 
Opportunity Program described in the HHIA is an excellent example. This 
program would identify and recruit disadvantaged students with an 
interest in healthcare starting in elementary school, and provide 
counseling, additional educational opportunities and stipends. Not only 
would this program address the Latino workforce deficiency, but it 
would also increase the number of bilingual physicians, while at the 
same time addressing the staggering school dropout rate for Latino 
children, which, at 29% (compared with 13% for African-Americans and 7% 
for whites) is by far the highest for any group of American children. 
Another excellent program in the HHIA would provide grants to the 
Hispanic-Serving Health Professions Schools.
    Latino children like Maria and Rosa face formidable barriers to 
health care access. A comprehensive literature review revealed 22 
access barriers to health care frequently encountered by Latino 
children, including lack of health insurance, poverty, low parental 
educational attainment, lack of a regular source of care, 
transportation problems, excessive waiting times in clinics, decreased 
preventive screening, receipt of proportionally fewer prescriptions, 
language problems, and cultural differences. For example, 30% of Latino 
children live in families with annual incomes below the federal poverty 
level (second only to African-American children, at 33%), and 37% of 
Puerto Rican children live in poverty, making them the most 
impoverished racial/ethnic group in the U.S. Important unanswered 
questions include what are effective interventions to reduce or 
eliminate such formidable barriers, and what are the health 
trajectories of Latino children with impaired access to care?
    Maria is Puerto Rican and Rosa is Mexican-American. These subgroup 
distinctions are important, as several studies have demonstrated that 
substantial differences in health and use of health services exist 
among Latino subgroups (such as Mexican-Americans, Puerto Ricans, and 
Cuban-Americans) that would otherwise be overlooked, and that can 
exceed that magnitude of differences among major ethnic and racial 
groups. For example, major Latino subgroup differences have been 
documented for rates of prematurity and low birth weight, asthma 
prevalence, illicit drug use, vaccination coverage, the prevalence of 
chronic conditions, and several indicators of health status and use of 
services. Latino child health data, however, are rarely collected and 
analyzed by pertinent subgroups. Failure to perform subgroup analyses 
can result in missing critical findings that can have a major impact on 
child health, policy, and advocacy.
    Latino children like Maria and Rosa also frequently receive a lower 
quality of health care. For example, among children with 
gastroenteritis, Latinos are significantly less likely than whites and 
African-Americans to have diagnostic laboratory tests and X-rays. Among 
preschool children being discharged from the hospital for asthma, 
Latino children are 17 times less likely to be prescribed a key piece 
of equipment for asthma treatment at home, called a nebulizer. In 
children hospitalized for surgical correction of serious limb 
fractures, researchers found that whites receive significantly higher 
doses of narcotic pain medications, at 22 mg/day, compared with blacks 
at 16 mg/day and Latinos at 13 mg/day. There also is a long list of 
serious health disparities for Latino children.2 Some of the most 
noteworthy include: Latino children are 13 times more likely than white 
children to be infected with tuberculosis; Latina adolescent girls have 
the highest suicide rate in the US, at 19%, compared with 9% for white 
and 8% for African-American adolescent girls; Latino children have the 
highest numbers of cavities and untreated dental conditions among 
American children; Latino boys are the most overweight and Latina girls 
the second most overweight racial/ethnic groups of US children; Latino 
children have one of the highest risks of being hospitalized for or 
dying from unintentional injuries; and Puerto Rican children have the 
highest prevalence of asthma in the US.
    More research is needed on why health professionals treat children 
from different racial and ethnic groups differently, and what 
interventions are most effective in eliminating racial/ethnic 
disparities. Mandatory medical school cultural competency courses 
examining these health disparities would be an important first step. In 
addition, because Latino children frequently are not included in 
medical research, we need to develop mechanisms to ensure better 
recruitment of Latino children into studies. For example, federally-
funded research should always include methods to recruit and 
appropriately study diverse participants, including efforts to educate 
minorities about clinical trials, to recruit non-English-speaking and 
immigrant populations, and to collect and analyze data by appropriate 
racial/ethnic groups and subgroups. The HHIA includes several important 
mechanisms for reducing health disparities for Latino children, 
including grants to improve the provision of dental health services 
through schools, community health centers and public health 
departments; coverage of immunizations and dental care under SCHIP; 
establishing a program for the prevention of Latina adolescent 
suicides; research requirements for collecting data on race and 
ethnicity; expanding programs in the Office of Minority Health; 
establishing individual offices of minority health within agencies of 
the Public Health Service; and establishing an Assistant Secretary of 
Health and Human Services for Civil Rights.
    The two stories I shared with you are about urban Latino children, 
and we too often disregard the health of rural Latino children, 
especially migrant children. Children of migrant Latino farm workers 
are particularly at risk for sub-optimal health and use of services, 
and face additional unique health challenges due to their migratory 
status. Of the more than one million children that travel with their 
parents annually in pursuit of farm labor, 94% are Latino. These 
children have been shown to receive inadequate preventive care; 
experience high rates of infectious diseases including tuberculosis, 
parasites, and sexually transmitted diseases; have inadequate 
preparation for school entry and low rates of school completion; have 
impaired access to appropriate day care, forcing parents to bring them 
to the fields where they have increased risks of pesticide exposures 
and injuries; work as farm laborers often in unsafe working conditions; 
and to be at risk for nutritional disorders such as anemia, diabetes, 
failure to thrive, and obesity. In addition, migrant Latino children's 
eligibility for Medicaid and SCHIP is hindered by high interstate 
mobility and difficulties with residency and citizenship status. The 
HHIA will substantially improve the plight of migrant Latino children 
by 1) giving states the ability to enroll legal immigrant pregnant 
women and children in Medicaid or SCHIP, and the ability to provide 
important preventative and public health services to immigrants with 
state resources; and 2) calling for a study by the Institute of 
Medicine of binational health insurance efforts.
    In conclusion, the 2000 Census definitively documents that Latinos 
are the predominant racial/ethnic minority group of US children, 
representing one out of every six children in America. It is time for 
our health policies, services and research to address this dramatic 
demographic change, which can be accomplished by 1) ensuring that all 
children and families with limited English proficiency have access to 
either trained medical interpreter services reimbursed by third-party 
payers, or bilingual health professionals; 2) providing all children 
with health and dental insurance through innovative outreach and 
enrollment strategies; 3) requiring cultural competency training for 
health care professionals; 4) increasing the number of Latinos in 
health care professions; 5) including more Latino children in medical 
research; and 6) eliminating health disparities for all Latino 
children. The Hispanic Health Improvement Act would address all of 
these issues, and result in significant improvements in the health and 
well-being of the 12 million Latino children in America. Thank you.














































































    [Whereupon, at 3:45 p.m., the subcommittee was adjourned.]

                                    

      
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