[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
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
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___________________________________________________________________________
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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
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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.]