What health reform means for Colorado

2010-01-17T16:39:00.000-08:00

By Estevan Flores, Virgilio Licona and Marguerite Salazar DENVER POST 12/30/2009

With the Senate passing health care reform, Coloradans can acknowledge the hard work, clear thinking and principled stand from Sen. Michael Bennet. Still, there remains much work in the conference committee. What is clear is that there remain important differential health impacts on Latinos and other groups in society.

The Senate's version provides coverage to more than 800,000 uninsured Coloradans. This is significant, since about 40 percent of adult Colorado Hispanics are without health insurance. In addition, almost 34 percent of Native Americans are uninsured, while the rate of uninsured for the entire state is about 16.6 percent.

Health care reform has been a massive undertaking, and the Senate's version lacks a widely popular public option found in the House version. But significant progress has been made, and issues like spiraling costs, loss of coverage and lack of quality care are addressed.

Sen. Bennet voiced early on that he was willing to stake his next election on support of health care reform and he voiced displeasure at his own party members who held the public option hostage and those who secured porkbarrel concessions for the bill's passage. For his principled stand, he was attacked by the GOP and asked to vote against the bill. However, we know that Sen. Bennet's criticism was based on the conviction of providing the greatest good for the greatest number.

The Senate version provides many benefits, including extending coverage to 30 million Americans, a feat unparalleled since the creation of Medicare. Families who are struggling will receive subsidies and benefit, according to the Congressional Budget Office.

We will also be able to choose our own doctor, and insurance companies will not be able to deny coverage due to pre-existing conditions. Exorbitant premiums based on one's age, health or gender will also be prohibited. These are victories for all of us who are aging, facing health problems, or are female.

We can thank President Barack Obama and Democrats for initiating and persevering on health care reform.

For example, Medicare is strengthened through the Senate's version, as waste and fraud are continuing targets while the Medicare trust fund life is extended. Yes, many on the left are angry and frustrated that we lost the public option, but we must recognize that even the venerable U.S. Constitution was not complete until the passage of the Bill of Rights.

Likewise, those of us who see prevention as essential to fighting the major killers in our society — like obesity, heart disease, cancer and diabetes — were left out of this legislation. Yet, the Senate version provides for measures of quality of health care as an outcome rather than quantity of service.

In order to attain quality measures, this legislation calls for $2 billion to $3 billion for the National Health Service Corps. This addresses our critical primary care work force shortage. Additionally, community health centers will receive approximately $10 billion to expand on their high-quality, patient-centered medical home model.

The Senate's version creates health exchanges where health care would be more affordable for about 300,000 Coloradans. This will create competition for new customers. Small businesses will be able to buy coverage while employees will benefit from tax credits. This provides economic competitiveness as it shores up small businesses.

Again, we need to thank the Democratic Party, and Sens. Bennet and Mark Udall, for trying to rein in the costs of health care. Many Senate provisions do not go into effect until 2013 and 2014, but the projected savings in the deficit of over $130 billion is most welcome.

However, until we secure quality health care for all Americans, where prevention is at the heart of health programs, there is much more to accomplish.

Estevan Flores is a sociologist and a Denver area consultant with expertise in health and health disparities. Virgilio Licona is associate medical director for Salud Family Health Centers in Fort Lupton. Marguerite Salazar is president and CEO of Valley-Wide Health Systems in rural Colorado.

2009-11-28T17:29:00.000-08:00

Latinos and Public Health
By Estevan Flores and Vivian Chavez | in S. Obler and D. Pena (Eds.) The Oxford Encyclopaedia of Latinos and Latinas in the United States. Oxford Univ. Press, Oxford, England, 2005.

The Latinoa population is the fastest-growing minority group in the United States. The U.S. Latinoa population is defined here as communities and individuals with ancestry from Latin America. The term Latinoa is offered as the most accepted representation category. The 2000 census notes that Latinos and Latinas increased to 35.3 million persons, an increase of 57.9 percent since 1990. This remarkable population increase has not been met by an improvement in the overall health of the Latinoa community, which is now nearly 13 percent of the U.S. population. A variety of factors helps determine why access to care is not equitable in the United States and results in increased incidence and mortality from disease for Latinos and Latinas. Politics cannot be overlooked in public health. H. W. Cohen and M. E. Northridge state, Political action is the most efficient means of reducing and eliminating racial/ethnic health disparities in the United States (Thomas, The Color Line, p. 1047).

Because of the gross health inequities for people of color and because of growing minority and Latinoa political power over the last two decades of the twentieth century, the need to address health disparities and to document inequities has become politically viable. In 1998 Congress passed national legislation further assisting the Office of Minority Health in the Department of Health and Human Services (DHHS). This law established a twelve-person national advisory committee on minority health to meet under the auspices of the Office of Minority Health in DHHS. The committee advises the secretary of DHHS on reducing and eliminating racial and ethnic health disparities. It addresses six health problems: breast and cervical cancer, cardiovascular disease, diabetes, child and adult immunizations, infant mortality, and HIVAIDS.

This new political and health terrain has specific meaning for Latinos and Latinas. Public health is about quality of life, community health, environmental justice, and daily well-being. Therefore, public health in the Latinoa community goes beyond recovering from illness or not getting sick. Health problems faced by Latinos and Latinas are tied to poor socioeconomic status, lack of political power, and a profit-first economic system. Public health in the Latinoa community is determined by individual lifestyle choices, the social conditions in which people live, and society's decisions about the distribution of resources and opportunities.

Latinos and Latinas have only recently been included in the national health policy agenda. There is insufficient data on the health status of Latinoa subpopulations and the health practices and use of health services by Latinos and Latinas. Information gathered from the U.S. census, birth and death certificates, or other national data systems has failed to identify the various subpopulations that make up the Latinoa community in the United States. Aggregation of all Hispanics into one group for analysis without precise measurement of socioeconomic status yields limited health data. Spanish-speaking populations are excluded because most health surveys are written and conducted in English.

Access to Health Care

Lack of access to health care because of the widespread lack of health insurance is the most pressing health policy problem facing Latinos and Latinas. Even though Latinos and Latinas are about 13 percent of the U.S. population, nearly a quarter of the nation's 44 million uninsured are Latinos and Latinas. In cities with large Latinoa populations, 40 percent of Latinos and Latinas under age sixty-five are without health insurance. A major reason for this lack of health insurance is that employers do not offer them coverage. Citizenship appears to play a role, as workers who are not U.S. citizens have lower odds of being insured by their employers. Educational status is also a contributing factor, since individuals with more than a college education are about twice as likely to have health insurance coverage as those with less as a high school education.

When uninsured Latinos and Latinas fall ill, they are less likely to see a doctor, and they go without prescriptions for needed medications and without recommended medical tests or treatments. Latinos and Latinas with low literacy and limited English proficiency tend to have difficulty navigating bureaucratically complex health care systems. Often health professionals do not speak the patient's language or have negative attitudes toward cultural health beliefs.

The Lack of Culturally and Linguistically Competent Health Professionals

Another concern is the lack of Latinoa physicians, dentists, nurses, and other health professionals. Latinos and Latinas are only 5 of the total physicians, 2 of the total nurses and lesser proportions in allied health professions (National Hispanic Medical Association). The Latinoa community is in dire need of culturally competent health care delivered by Latinoa health professionals. Consequently the minority advisory committee on health disparities made training of minority health professionals its highest priority in its first set of recommendations to DHHS secretary Thompson.

The lack of culturally and linguistically diverse health professionals is problematic. Community-based public health clinics and health services agencies are often the sole providers of health services for immigrant communities. Treatment adherence and patient satisfaction improve significantly when the cultural and linguistic gap between health services providers and patients and clients is narrowed. This is true for all health professionals, including social workers, nurses, dentists, doctors, nutritionists, pharmacists, and psychologists.

The Latino and Latina Health Paradox

Latinoa immigrants with generally lower socioeconomic status than whites have health indicators similar to those of whites. This relationship has been referred to as the Latinoa health paradox. Acculturation is the process of incorporating aspects of mainstream culture into an individual's repertoire of behaviors. Changing food habits and styles of clothing and learning English tend to take place first, followed by the adoption of cultural beliefs, values, and more complex patterns of behavior. Various studies have documented that rapid acculturation to American values and behaviors can result in negative health outcomes for Latinos and Latinas.

Newcomer Latinos and Latinas who maintain indigenous cultural dietary practices with better nutrition (less sodium, less fat, more fruits and vegetables) and extended family support networks buffer the stress generated by U.S. culture. As low-income Latinoa immigrants integrate into society, there is an increase in risk factors such as higher use of alcohol and cigarettes, lower physical activity, poor nutrition, and higher rates of intimate-partner violence and adolescent pregnancy. The stress of daily living and the struggle to make ends meet often mean allocating limited funds for rent and food over education or health needs.

Teen Pregnancy

Latina women have the highest fertility rates and birth percentages in the United States. It is important to note that the Latinoa community in the United States is overall a young population, approximately 35 percent of it younger than eighteen years. Latinas begin having children at a young age and continue until their older years.
Most of the births are to Mexican American mothers (70 percent). Puerto Ricans have the highest teen births of all racial or ethnic groups. Of Latinas ages fifteen to seventeen, 50 percent are sexually active, compared to 34.9 percent for whites and 48 percent for African Americans. This is important because adolescent pregnancy is related to increased sexual activity at an earlier age. Another factor in teen pregnancy is that Latino/a adolescents report having less access to contraceptives and using condoms inconsistently or not at all.

HIV Infection
While Latinos and Latinas comprise only about 13 percent of the U.S. population, they represent 18 percent of AIDS cases. Explanations include consistently low levels of condom use and negative attitudes toward condom use by both Latinoa men and women; Latino men having multiple sex partners, male and female, outside their primary relationships; and the use of alcohol and other drugs that reduce inhibition and impair appropriate decision making. Latinas now represent 20 percent of females ever diagnosed with AIDS. Social inequalities and gender role inequalities in relationships lie at the heart of HIV risks for poor Latina women. Recent Latina immigrants are at risk because of language barriers, new cultural norms, and fear of deportation, all of which discourage seeking health treatment and decrease access to prevention information.

Diabetes and Obesity
Latinos and Latinas with body mass indexes of greater than thirty are more likely to have gallbladder disease, coronary heart disease, hypertension, and diabetes. Mexican American youth in particular have high rates of being overweight and are less likely to engage in vigorous physical activities. However, it is important to note that most research on obesity and diabetes in Latinos and Latinas has been conducted on Mexican Americans. Rates for non-insulin-dependent diabetes are two to five times greater for Latinos and Latinas than for the general U.S. population in both sexes and at every age. Furthermore, there is much higher mortality from diabetes among Latinos and Latinas compared to African Americans and whites regardless of gender or age. The prevalence of type-2 diabetes in Latinos and Latinas in the United States is approximately twice that of whites and varies among Latinoa subgroups. Latinos and Latinas experience higher rates of diabetes-related complications, including kidney failure, loss of limbs, and blindness.

Alcohol and Tobacco
A major health problem for Latinos and Latinas in the United States is the high level of alcohol consumption per capita among both adolescent and adult males. Death rates linked to cirrhosis of the liver and other chronic liver diseases are high among Latinos and Latinas, and there is a strong relationship between heavy drinking and high-risk behaviors, such as driving while under the influence and interpersonal violence. The targeted advertising campaigns of the alcoholic beverage industry and the overconcentration of alcohol outlets (bars, liquor stores, and other places that sell alcohol) in low-income Latinoa neighborhoods impact alcohol problems. Marketing strategies exploit important cultural symbols and add to the objectification of Latina women to sell alcohol products. Latinoa organizations have attempted to curtail the presence of both alcohol outlets and alcohol advertisements in their communities and the sponsorship of community events by the alcohol industry.

At one time states had significant dollars to mobilize efforts to fight tobacco in the Latinoa community as well as in the general population. The National Latino Council on Alcohol and Tobacco (LCAT) held its first national conference in 2001, and innovative Latino/a initiatives across the country developed plans for using monies from the Master Settlement Agreement with tobacco. These efforts were curtailed as states redirected MSA monies to meet their budget deficits during the economic crisis of 2002 -- 2003.

Violence
Latinoa adolescents are at a higher risk of experiencing and witnessing violence and of attempting or committing suicide at a younger age than either African American or white youths. Latino males are more likely to carry a weapon to school. Carrying a weapon increases the risk of injury. Violence in the community contributes to a persistent worry about personal safety. High rates of poverty contribute to feelings of limited hope and high rates of depression. Studies suggest that Latinoa adolescents have the highest prevalence of depressive symptoms of any ethnic group.

Latinoa communities bear a disproportionate share of violence-related morbidity and mortality, yet little attention has been given to ethnic-cultural differences and their implications for violence prevention research and health promotion efforts. In the early twenty-first century much of what is known about violence among Latinos and Latinas is based on regional homicide studies. Little formal data assess and substantiate knowledge about Latinoa cultures and implications for the study of all aspects of violence, particularly prevention.

According to researchers at the University of California, Los Angeles (UCLA), a survey of a U.S.based Latinoa immigrant population shows that more than half have been exposed to political violence, including torture, in their homelands, yet few patients inform their primary-care physicians about their experiences. Exposure to violence and nondisclosure to doctors affect patients' overall health, diagnosis, and treatment. The study indicates that primary-care clinicians should ask their immigrant and refugee patients about past exposure to war and political violence.

Tuberculosis
Latinos and Latinas have the highest number of newly diagnosed tuberculosis cases among children under the age of fifteen of any U.S. ethnic group. Local data confirm that the majority of Latinoa children diagnosed with tuberculosis are born in the United States, suggesting that ongoing transmission in U.S. communities is a major problem. About half of all foreign-born children with tuberculosis were born in Mexico. Among Latino/a adults, immigration from countries with high tuberculosis rates, development of drug-resistant strains of tuberculosis, and less than optimal screening, treatment, and management of tuberculosis cases are factors in the higher rates of this illness.

Latinos and Latinas and Environmental Justice
Environmental justice, with its emphasis on public health, social inequality, and environmental degradation, provides a useful framework for public policy debates about the impact of discrimination on the environmental health of Latinoa communities in the United States. For example, in Southern California, Latinos and Latinas, followed closely by African Americans, have twice the likelihood of living in a Los Angeles neighborhood tract with a toxic release inventory facility with ambient air exposure.

Rural Latinos and Latinas play a prominent role in the U.S. economy. Workers in the agricultural, meat, poultry, fishery, and mining industries are exposed to pesticides, injuries, and poor sanitation. Many suffer from a multitude of health problems related to these occupational hazards. They encounter institutional barriers to obtaining heath care, are excluded from traditional workers' benefits, experience poor enforcement of health and safety standards, and lack adequate housing and access to clean water. Latinoa agricultural workers have more clinic visits for diabetes, ear infections, pregnancy, hypertension, dermatitis, and eczema than both the general population and the Latino/a population in urban areas. HIV infection and tuberculosis are significant among certain segments of this mobile population.

Cancer: A Case Example for Progress
The fight against cancer has advanced more significantly than the fight against any other disease for Latinos and Latinas. The National Cancer Institute (NCI) launched a Hispanic cancer control program in 1987 that funded five large-scale research initiatives in 1990 and the National Hispanic Leadership Initiative on Cancer (NHLIC) in 1992. This specific NCI research initiative, brought about by Elva Ruiz, a determined Latina program officer, published twenty-three articles on various aspects of Latino/a health research and cancer in the Journal of the National Cancer Institute in 1995.

There is some good news: Hispanics have lower incidence and death rates from all cancers combined and from the four most common cancers (breast, prostate, lung, and colorectal) than non-Hispanic whites and blacks (Huerta, p. 204). There is also bad news: Hispanics have higher incidence and mortality rates from cancers of the stomach, liver, uterus, cervix, and gallbladder (Huerta, p. 204). It should be noted that some gender areas show differences in the order of importance of various cancers: The top five cancers for Hispanic men included kidney and bladder cancers, liver cancer, and non-Hodgkin's lymphomas. For women, other leading cancers mentioned were ovarian cancer, non-Hodgkins lymphoma and gallbladder cancer (Trapido et al., p. 17). Cancer among Hispanics is often detected at a late stage, leading to increased mortality; consequently, cancer prevention efforts aimed at Latinoa screening is of paramount importance.

The issue of cancer among minority groups is instructive. A promising national model is the NCI's Special Population Networks (SPNs), which funds eighteen projects, three of which are specifically Latinoa. Redes en Accin is a national Hispanic network covering six areas of the country; another project operates in the Greater Denver metro area; and the third is in Washington, D.C. For example, the Denver SPN has built a cancer-prevention network with twenty-one community-based organizations, including Denver Health, the city public health agency, and thirteen scientific institutions, including the University of Colorado Cancer Center. Pilot research projects on cancer prevention are underway in all SPNs to fight cancer in the Latinoa population.

This kind of collaborative effort, where the lay and scientific communities join with public health, can make systematic progress in cancer awareness and education and can develop and implement rigorous research prevention projects. These three Latinoa networks have received almost 9 million for the five-year project. Such funds are necessary to combat this disease, and DHHS should develop other disease-specific networks for Latinos and Latinas. The NCI is embarking on a DHHS-wide progress review group to spread the concept of the SPNs to all of DHHS.

Conclusions
The struggle for access to good health for Latinos and Latinas is a question of national import. Obesity, cardiovascular disease, cancer, and diabetes are problematic in the Latinoa community and limit this group's social and economic potential and life span. Yet these killers have a common set of risk factors: bad diets in which fat intake predominates, lack of exercise, overconsumption of alcohol and tobacco products, and stress. Clearly, health promotion, prevention, and intervention activities are needed in the Latinoa community.

Following September 11, 2001, the federal allocation of hundreds of billions of dollars for both homeland security (aimed at defeating terrorism) and winning a war in Iraq put funding for public health for people of color and Latinos and Latinas on hold. A promising political option is the Hispanic Health Improvement Act of 2003, which will go a long way to improving many of the issues discussed in this essay.

How will the nation's largest minority group attain health parity The existing public health system has not served the Latino/a population well, and the U.S. health system has not improved the health conditions of this population. President Bill Clinton began a lively debate in his first administration over universal health coverage. That effort was fruitless and was abandoned. However, this policy debate must begin anew if health progress for Latinos and Latinas is to be achieved. A successful outcome overall will entail community-based organizations working with both public health agencies and scientific institutions.

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From the Heart: Politics and Health

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