Health Care Needs of the Growing Latino Population in Rural America: Focus Group Findings in One Midwestern State

Latinos represent nearly 13% of the U.S. population, surpassing African-Americans as the nation's largest racial/ethnic group. Many rural midwestern communities are seeing unprecedented growth in their Latino populations, creating new challenges and pressures for health and social service providers. This study is based on four focus groups conducted in three rural communities to examine concerns with health care services and access to care. Focus group analysis found several key barriers to health care access, including cost of health care services and frustration with the complexity of the U.S. health care system, as well as language and cultural issues that adversely affect patient-provider relationships. In addition, a number of impediments related to employer-sponsored health coverage were identified, including prohibitive premium costs as well as concerns about occupational injuries and access to care during work hours. The growth of the Latino population in the rural Midwest will require changes in existing health and social service systems to serve as a bridge to new systems in this country. We recommend several policy options including premium subsidies for low-wage jobs, community-based enrollment specialists for public programs, and continued research and data collection to monitor change and progress.     

Listening to rural Hispanic immigrants in the Midwest: a community-based participatory assessment of major barriers to health care access and use

Hispanic immigrants are increasingly residing in rural communities, including in the midwestern United States. Limitations in the ability of rural Hispanics to access and utilize health care contribute to patterns of poor health and health disparity. A conceptual model of "vulnerability" guides this community-based participatory assessment project designed to explore rural Hispanics' perceived barriers to accessing and utilizing health care. Findings from a series of 19 focus groups with 181 participants from three communities in the upper Midwest identified perceived barriers at the individual and health care system levels. The most commonly perceived barriers were the lack of and limitations in health insurance coverage, high costs of health care services, communication issues involving patients and providers, legal status/discrimination, and transportation concerns. Findings imply that these barriers could be addressed using multiple educational and health service delivery policy-related strategies that consider the vulnerable nature of this growing population.     

On the game: women and sex work

Latinos living with HIV residing in the US-Mexico border region frequently seek care on both sides of the border. Given this fact, a border health perspective to understanding barriers to care is imperative to improve patient health outcomes. This qualitative study describes and compares experiences and perceptions of Mexican and US HIV care providers regarding barriers to HIV care access for Latino patients living in the US-Mexico border region. In 2010, we conducted in-depth qualitative interviews with HIV care providers in Tijuana (n = 10) and San Diego (n = 9). We identified important similarities and differences between Mexican and US healthcare provider perspectives on HIV care access and barriers to service utilisation. Similarities included the fact that HIV-positive Latino patients struggle with access to ART medication, mental health illness, substance abuse and HIV-related stigma. Differences included Mexican provider perceptions of medication shortages and US providers feeling that insurance gaps influenced medication access. Differences and similarities have important implications for cross-border efforts to coordinate health services for patients who seek care in both countries.     

Providing health care to Latino immigrants: community-based efforts in the rural midwest

We examined case studies of 3 rural Midwestern communities to assess local health care systems' response to rapidly growing Latino populations. Currently, clinics provide free or low-cost care, and schools, public health, social services, and religious organizations connect Latinos to the health care system. However, many unmet health care needs result from lack of health insurance, limited income, and linguistic and cultural barriers. Targeted safety net funding would help meet Latino health care needs in rural communities with limited resources.     

Trends in health insurance coverage and access among black, Latino and white Americans, 2001-2003

Overall health insurance rates changed little among nonelderly black, Latino and white Americans between 2001 and 2003, according to new findings from the Center for Studying Health System Change (HSC). But sources of coverage shifted--especially for Latinos--from employment-based insurance to public coverage, suggesting the economic downturn took a greater toll on Latinos. Low-income Latinos and whites were particularly hard hit by declines in employer coverage. Shifting sources of coverage had little effect on access to medical care. With the sole exception of decreased access to specialists among blacks, access to care did not change between 2001 and 2003. Significant gaps in access to care among Latinos, blacks and whites persisted, with Latinos and blacks consistently reporting lower levels of access than whites.     

Employers’ Role in Helping Latino Workers Obtain Access to Health Care Services: Results of a Community-Based Pilot Demonstration Project

A coalition of employers in the hotel and restaurant industries collaborated with community-based organizations to undertake a unique demonstration project, called the Employed Latino Health Initiative, aimed at improving access to basic health care services for low-wage Latino workers in Columbus, Ohio. With grant funding from the Robert Wood Johnson Foundation, the project developed and tested protocols allowing Latino workers from participating companies to obtain basic health care screenings, referrals to medical providers, health education training, and the services of a qualified community health navigator. Data from the pilot project indicated high screening participation rates, extensive referrals to providers for follow-up care, and a substantial need for facilitation services by community health navigators. The project provides a model for how employers can potentially promote their own interests in boosting work productivity through facilitating expanded access to basic medical services among vulnerable workers, despite the absence of conventional health insurance coverage.     

Better care at safety net providers? Utilization of recommended standards of diabetes care for rural Latinos in one Midwestern state

Latinos are overrepresented among the uninsured in the U.S., and rural Latinos face a variety of barriers to accessing quality health care. The present study investigated the degree to which Latinos with diabetes living in non-metropolitan towns in the state of Iowa receive the recommended diabetes care services from health care providers vis-à-vis access to care. Four process measures were selected from the American Diabetes Association standards of medical care for diabetes: glycated hemoglobin tests, comprehensive foot examination, dilated eye examination, and cholesterol test. Results from this research found that just over half (54%) of the sample received all four of these diabetes care services. Adjusted logistic regression analysis showed patients were four times more likely to receive the set of four diabetes care services at a community health center than at a private doctor's office. These community clinics deserve additional attention as more Latino immigrants move to the Midwest.     

Racial/ethnic minority and low-income hotspots and their geographic proximity to integrated care providers

Background

The high prevalence of mental health issues among clients attending substance abuse treatment (SAT) has pressured treatment providers to develop integrated substance abuse and mental health care. However, access to integrated care is limited to certain communities. Racial and ethnic minority and low-income communities may not have access to needed integrated care in large urban areas. Because the main principle of health care reform is to expand health insurance to low-income individuals to improve access to care and reduce health disparities among minorities, it is necessary to understand the extent to which integrated care is geographically accessible in minority and low-income communities.

Methods

National Survey of Substance Abuse Treatment Services data from 2010 were used to examine geographic availability of facilities offering integration of mental health services in SAT programs in Los Angeles County, California. Using geographic information systems (GIS), service areas were constructed for each facility (N?=?402 facilities; 104 offering integrated services) representing the surrounding area within a 10-minute drive. Spatial autocorrelation analyses were used to derive hot spots (or clusters) of census tracts with high concentrations of African American, Asian, Latino, and low-income households. Access to integrated care was reflected by the hot spot coverage of each facility, i.e., the proportion of its service area that overlapped with each type of hot spot.

Results

GIS analysis suggested that ethnic and low-income communities have limited access to facilities offering integrated care; only one fourth of SAT providers offered integrated care. Regression analysis showed facilities whose service areas overlapped more with Latino hot spots were less likely to offer integrated care, as well as a potential interaction effect between Latino and high-poverty hot spots.

Conclusion

Despite significant pressure to enhance access to integrated services, ethnic and racial minority communities are disadvantaged in terms of proximity to this type of care. These findings can inform health care policy to increase geographic access to integrated care for the increasing number of clients with public health insurance.

     

Improving Access to Primary Care for a Growing Latino Population: The Role of Safety Net Providers in the Rural Midwest

CONTEXT: Many rural Midwestern communities are experiencing rapid growth in Latino populations with low rates of health insurance coverage, limited financial resources, language and cultural differences, and special health care needs. PURPOSE: We report on 2-day site visits conducted in 2001 and 2002 in 3 communities (Marshalltown, Iowa; Great Bend, Kansas; and Norfolk, Nebraska) to document successful strategies to meet Latino health care needs. METHODS: We interviewed key informants to identify successful community strategies for dealing with health care access challenges facing the growing Latino population in the Midwest. FINDINGS: Interventions have been developed to meet new demands including (1) use of free clinics, (2) school health programs, (3) outreach by public health, social services and religious organizations, and (4) health care providers' efforts to communicate with patients in Spanish. Strain on safety net services for Latinos is due in part to a complicated and unstable mix of public and private funds, a large but overtaxed volunteer provider base, the dependence on a limited number of community leaders, and limited time for coordination and documentation of activities. CONCLUSIONS: We suggest the development of a Rural Safety Net Support System to provide targeted funding to rural areas with growing immigrant populations. Federal community health center support could be redirected to new and existing safety net providers to support the development of a safety net monitoring system.     

Health care needs of Hispanic Americans and the responsiveness of the health care system

The Hispanic population in the United States is growing rapidly but this population has many health care needs that are not being met. The findings from recent research on the current health status of Hispanic people who live in the United States are presented. An assessment of how accessible and available medical care services are to Hispanic people is made. Serious gaps exist in the delivery of medical care services to this group. Human service providers, particularly social workers, can help make the current health care system more responsive to the needs of this group by helping Hispanic individuals who have no health insurance coverage to find employment that includes health insurance benefits or some other form of insurance, by establishing community-based health care centers in Hispanic communities, by developing counseling programs tailored to the alcohol and drug abuse problems of the Hispanic population, and by advocating for government agencies to improve existing sources of data on the health of this group.     

Understanding Factors that Influence Health Care Utilization Among Mixtec and Zapotec Women in a Farmworker Community in California

This paper examines health care utilization among indigenous immigrants from Oaxaca, Mexico, who have settled in a farmworker community in southern California. In 2016, two trained Spanish-Mixteco and Spanish-Zapoteco bi-lingual interviewers conducted in-depth interviews with 44 indigenous women residing in Oxnard, California on issues that affect health care utilization. Interviews were conducted in Mixteco, Zapoteco and Spanish and were coded to identify structural, cultural, and provider-related barriers to health care utilization. Five bi-lingual Spanish-Mixteco indigenous interpreters employed at local clinics were also interviewed. Many women reported lack of health insurance, inability to pay, language barriers, long waiting times, rushed encounters with providers, and seeking western medical care only after home remedies did not work. However, several women were able to access routine health care services, often with support from indigenous interpreters employed at clinics. Interviews with five interpreters found that they provided assistance with interpretation during medical encounters and appointment making. They also educated patients about upcoming exams, identified low-cost services and insurance programs available to patients, assisted with paperwork and occasionally educated physicians on behalf of their patients. In addition to addressing barriers to health care access our findings suggest the importance of identifying and leveraging community assets, such as indigenous navigators, when developing programs for such underserved communities. Our findings can inform best practice in settings that provide health care to indigenous populations and may also apply to settings that provide health care to other immigrant communities that have very limited familiarity and contact with western health care.     

State Medicaid Expansion,Community Interventions,and Health Care Disparities in a United States–Mexico Border Community

Objectives. We investigated whether access to and use of health care services increased among residents of a low-income, predominantly Mexican American border community affected by the expansion of Arizona’s Medicaid program in 2001 and multiple community-level programs and policies.Methods. We used data from a probability sample of 1623 adult residents of Douglas, Arizona, who participated in cross-sectional health surveys in 1998 and 2010. Response rates were 83% and 86%, respectively.Results. In 2010, participants were more likely to have a usual source of care, to have visited a provider in the previous year, and to have been screened for diabetes and hypertension and less likely to have delayed needed care or to have seen a regular provider in Mexico (P < .001 for all outcomes). Improvements in access to and use of health care were most pronounced among residents with less than a high school education, which reduced or eliminated educational disparities in health care.Conclusions. Expansion of public insurance programs can effectively reduce health care disparities when paired with other community-level policies and programs that target medically underserved populations.Mexican Americans and other Latinos suffer from a high burden of chronic disease.1,2 For example, 79% of Mexican American adults and 78% of all Latino adults are overweight or obese compared with 67% of non-Hispanic Whites, and half of Latinos born in 2000 will develop diabetes in their lifetimes compared with less than one third of non-Hispanic Whites.1,2 Identifying effective programs and policies to improve the health of Mexican Americans and other Latinos is a top public health priority, both to reduce health disparities and because even small improvements can yield large health and economic benefits at the population level.Poor access, use, and quality of health care services may contribute to high rates of chronic disease among Mexican Americans and other Latinos. Latinos are less likely than are other racial/ethnic groups to have health insurance, attend regular medical checkups, have a usual source of care, or be regularly screened for several forms of cancer and other chronic conditions.3–8 Latinos are also more likely to delay needed care, have chronic conditions that go undiagnosed or are diagnosed at later stages, have negative outcomes related to their chronic conditions, and be unsatisfied with their providers.4,9,10 Health care access and use is even poorer among Mexican Americans than most other Latino subgroups.4Latinos face numerous social, economic, and structural barriers to health care. As a group, Latinos have low income, high poverty rates, and poor educational attainment, factors consistently found to affect health and health care.11–13 One third of Latinos are immigrants and 41% of Latino immigrants speak English less than very well, factors that can lead to linguistic and cultural barriers to health care.13,14 Many immigrants, including 6 million who are undocumented, are ineligible for public health insurance programs that subsidize health care for other low-income populations.15–17One potential way to reduce health care disparities faced by low-income and minority populations, including Latinos, is through public policy. The Affordable Care Act (ACA) includes several provisions expected to curb uninsurance and increase access to and use of health care services among medically underserved populations, including an individual mandate requiring most Americans to have health insurance; public health insurance exchanges that can be used to buy affordable, high-quality, and often subsidized insurance; and expanded eligibility for Medicaid to include individuals with incomes up to 138% of the federal poverty level (FPL) as set by the US Department of Health and Human Services.18 It is important to understand whether the ACA and other policy- and community-level interventions can effectively reduce health care disparities that Latinos and other low-income and minority populations face.     

Health Insurance and the Homeless

There is very little known about health care utilization among the homeless or about the role of health insurance on utilization patterns. Many health care reform proposals advocate expanding health insurance coverage for various segments of society, including the homeless. Although homeless people who lack health insurance face strong financial barriers to health services, providing them with health insurance may not appreciably increase their demand for health care if they also face important non-financial barriers. We investigate the relationship between insurance and utilization for this group based on estimates from an empirical model of medical care use and insurance coverage. Using our estimates, we simulate potential effects of policy changes on various types of utilization, including use of mental health services and treatment for alcohol or other drug abuse. © 1997 by John Wiley & Sons, Ltd.     

Unmet Need and Problems Accessing Specialty Medical and Related Services Among Children with Special Health Care Needs

OBJECTIVES: To extend what is known about parent reports of their child's need for specialty medical and related services, unmet need, and specific types of access problems among children with special health care needs (CSHCN). METHODS: Using data from a 1998-1999 20-state survey of families of CSHCN, we examined differences in parent report of need for services by child characteristics, investigated parent report of unmet need and access problems by service area and number of services needed, and estimated the likelihood of four access problems and unmet need by child, family, and health insurance characteristics. RESULTS: Overall, the sample children had numerous service needs, although the prevalence of need varied by service type and child characteristics. Reports of unmet need were greater for older children and for children with multiple service needs, unstable health care needs or a behavioral health condition, parents who were in poor health or had more than a high school education, and families whose insurance coverage was inconsistent or lacked a secondary plan. Reports of access problems were greatest for mental health and home health services. The two most prevalent access problems were finding a skilled provider and getting enough visits. CONCLUSIONS: The results underscore the importance of finding new ways to link children with behavioral health problems to mental health services, implementing coordinated care and the other core dimensions of the medical home concept, increasing the number of specialty pediatricians and home health providers, and expanding coverage for a wider range of mental health services.     

The impact of insurance lapse among low-income children

Children living in poverty not only have disproportionately more health problems, but also have disproportionately lower health care service utilization. Change, whether in health care delivery system or in family living situation, may interfere with or jeopardize insurance status and thereby influence access to health care services. We hypothesized that children who have maintained Medicaid insurance compared to those who have not will be more likely to have preventive care visits and less likely to have emergency room visits. We further hypothesized that transient situations such as homeless episodes, foster care placement, and living in more than one location in the same 1-year period will contribute to loss in Medicaid coverage. This retrospective cohort study was conducted at an urban children’s hospital outpatient clinic at which 210 family respondents were recruited over a 1-year period. An in-person interview containing several standardized instruments was administered to the caregiver. In addition, children’s medical records were retrospectively abstracted from point of study entry to first contact. Findings indicated that children who lost Medicaid coverage, compared to others, had significantly fewer preventive care health visits. There were no differences in emergency room visits. Transient situations did not appear to influence preventive or emergency room care. In addition, the change into a managed-care delivery system also increased loss of coverage. Loss of coverage may be a barrier to preventive care services. To ensure optimal preventive care services, the onus is on the providers and plants to facilitate continued insurance coverage.     

Peer Reviewed: The Latino Health Insurance Program: A Pilot Intervention for Enrolling Latino Families in Health Insurance Programs,East Boston,Massachusetts, 2006-2007

Background

Thirteen percent of Latinos in Massachusetts lack health insurance, the highest rate of any ethnic or racial group. Families without health insurance are more likely to be in poor or fair health, to lack a regular medical provider, and to not have visited a medical provider in the past year.

Context

The Latino Health Insurance Program is designed as a response both to the high rate of uninsurance among Latinos in Boston and to the multiple obstacles that keep Latino parents from applying for insurance for their families.

Methods

In 2006, we designed and implemented a culturally competent model of health insurance outreach, education, enrollment and maintenance, and referral for primary care and social services for Latino families.

Consequences

Year 1 results of the Latino Health Insurance Program are promising. Six community members were hired and trained as case managers. A total of 230 children and adults were enrolled or re-enrolled in health insurance programs and received other needed services. Retention was near 100% after 1 year.

Interpretation

The Latino Health Insurance Program may serve as a model health insurance access program that can be adapted by community-based organizations and also can be incorporated into public agency programs for Latinos and other immigrant and minority groups. The program continues to serve East Boston residents and was expanded in 2008.     

Shifting the financial burden: the VA ambulatory care discharge policy.

The Department of Veterans Affairs is a primary source of health care services for many of the nation's uninsured and underinsured. Changes in congressionally mandated eligibility criteria and limited increases in appropriations have forced the Department to adopt a policy of discharging chronic but stable outpatients who have been treated for non-service-connected health conditions. Survey data from one VA medical center suggest that many, but not all, of those discharged: 1) have either Medicare or private insurance coverage; 2) have not sought or found alternative physician services in their local communities; 3) have discontinued taking previously prescribed medications; 4) report worsened health status since discharge; and, 5) have been hospitalized. In general, discharged patients from the lowest income group report the greatest financial access barriers. Preliminary analyses of the discharge policy suggest the potential for decreased access to needed medical services due to financial factors and cost-shifting from the VA to patients and other federal, state and local payers and providers.     

'Reasonable access' to primary care: assessing the role of individual and system characteristics

Access to health care continues to be an important issue for health policy makers, researchers, service providers and consumers alike. In countries with universal health care coverage, services are generally free at the point of delivery which is intended to provide equitable access to care for all residents regardless of their individual situations. Past studies have pointed to the importance of individual characteristics such as age, gender, and socioeconomic status in shaping access to health care but much less is known about the role of health system characteristics. The purpose of this study is to explore, by means of qualitative research methods, the extent to which individual and system factors shape access to primary health care services for residents living in two contrasting neighbourhoods in Hamilton, Ont., Canada. Semi-structured, in-depth interviews were conducted with 40 men and women. The interviews probed participants about their experiences with primary care, barriers to receiving care and their general perceptions of the health care system. The interviews demonstrated the existence of many system-related barriers to receiving health care (e.g., wait times, geographic inaccessibility and quality of care) and some individual-related barriers (e.g., work or family responsibilities). While the findings revealed little difference between the neighbourhoods in terms of accessibility problems and barriers, differences between men and women were evident.