1. 1 Disparities in Immigrant Latino Children’s Health and Healthcare: How We Can Level the Playing Field Glenn Flores, MD Professor and Director, Division of General Pediatrics UT Southwestern & Children’s Medical Center Dallas

2. 2 Overview: 3 Goals of Today’s Presentation l Goal 1: share findings of latest national research on language spoken at home and disparities in medical and oral health, access to care, and use of services in immigrant Latino children l Goal 2: present results of study demonstrating successful elimination of racial/ethnic disparity for immigrant Latino children l Goal 3: propose priorities for research and policy action for immigrant Latino children which any young investigator can pursue

3. 3 The Language Spoken at Home and Disparities in Medical and Oral Health, Access to Care, and Use of Services in US Children Publication: Pediatrics 2008; 121;e1703-e1714.

4. 4 Background l 55.8 million Americans (20%) speak a language other than English at home l 24.4 million Americans (9%) limited in English proficiency l >10 million school-age children (20%) speak a language other than English at home u Number has tripled since 1979 l But very little known about whether children in non-English primary language households experience medical and oral health disparities u Vast majority of whom are immigrants

5. 5 Study Aim l To identify disparities for children whose primary language spoken at home not English, in: u Medical and oral health u Access to health and dental care u Use of health and dental services

6. 6 Methods: Data Source- National Survey of Childhood Health (NSCH) l Telephone survey in 2003-2004 of national random sample (in all 50 states and D.C.) of households with children 0-17 years old l Oversampled households with African-American and Latino children l Parent or guardian most responsible for child’s healthcare interviewed in English or Spanish (N=6035) l 102,353 interviews completed l Interview completion rate = 55% l Adjustments made for non-response and non-coverage of household without telephones l Estimates based on sampling weights generalize to entire non-institutionalized population of US children 0-17 years old

7. 7 Methods: Study Variables l Disparities in medical and oral health and healthcare examined for children in non-English primary language households, compared with children in English primary language households l Variables examined included u Medical and oral health  General health status by parental report  Prevalence of specific chronic conditions u Access to health and dental care u Use of health and dental services

8. 8 Methods: Statistical Analysis l Multivariable analyses performed to adjust for u Child’s age u Medical and dental insurance coverage u Family income u Race/ethnicity u Number of children and adults in household u Parental employment u Parental educational attainment

9. 9 Selected Characteristics: 0-17 Year-Old US Children in 2003-2004 (NSCH) CharacteristicNon-EnglishEnglishP Mean child age (±SE)7.7 (±.03)8.8 (±.11)<.001 Race/ethnicity Latino Asian/Pacific Islander White African-American Native American Multiracial 87% 7% 5% 2% 0.3% 0.2% 8% 1% 70% 16% 0.5% 4% <.001 >3 children in household22%13%<.001 No adult in household with high school diploma 37%14%<.001 Full-time employed adult in household83%91%<.001 Income <poverty threshold42%13%<.001

10. 10 Primary Language at Home and Medical and Oral Health: US Children Characteristic Non- English P Health not excellent/very good43%12%<.001 Teeth condition not excellent/very good62%27%<.001 Overweight or at risk for overweight (BMI ≥85%)48%39%<.001 On prescription medications11%22%<.001 ADHD1%8%<.001

11. 11 Primary Language at Home and Access Barriers to Medical Care: US Children Access BarrierNon-EnglishEnglishP Health insurance coverage None Public Private 27% 47% 24% 6% 25% 69% <.001 Sporadic health insurance in past year20%10%<.001 No usual source of medical care38%13%<.001 Unmet medical care needs due to Cost No insurance Health plan problem 43% 59% 8% 26% 39% 17%.02.01.001 Any problem getting specialist care40%22%<.001

12. 12 Primary Language at Home and Access Barriers to Dental Care: US Children Dental Access Barrier Non- English P Did not receive all needed routine preventive dental care*7%3%<.001 Unmet preventive dental care needs due to Health plan problem Didn’t know where to go for treatment Dentist didn’t know how to provide care 20% 4% 2% 8% 9% 5% <.001.03.15 *If made routine preventive dental care visit in past year; only for children > 12 months old

13. 13 Primary Language at Home and Use of Medical & Dental Services: US Children Service Use Issue Non- English P No medical visit in past year27%12%<.001 At least 1 ED visit in past year16%19%. 02 No dental visit in past year*34%21%<.001 No routine preventive dental visit in past year†14%6%<.001 Didn’t get prescription for needed medication2.5%3.2%.05 *Only for children >12 months old †Among those who have ever made dental visits

14. 14 Multivariate Analyses: Disparities in Medical & Oral Health of US Children Measure Odds Ratio* (95% CI) Non-English vs. English Health not excellent/very good2.7 (2.3-3.1) Teeth condition not excellent/very good2.3 (2.0-2.7) Overweight or at risk for overweight (BMI ≥85%)NS On prescription medications0.6 (0.5-0.7) ADHD0.2 (0.1-0.2) *Adjusted for age, health or dental insurance coverage, income, race/ethnicity, no. of children and adults in household, parental employment, and parental educational attainment

15. 15 Multivariate Analyses: Disparities in Access to Medical & Dental Care in US Children Measure Odds Ratio* (95% CI) Non-English vs. English Uninsured3.5 (2.9-4.1) Sporadically insured in past year † 1.9 (1.6-2.0) No usual source of care1.7 (1.4-1.9) Unmet medical care needs due to No one accepts child’s insurance Dissatisfaction with doctor 4.8 (1.3-18.0) 10.3 (3.3-33.0) Any problem getting specialist care1.7 (1.2-2.3) Unmet dental care needs1.8 (1.2-2.7) Unmet dental care needs due to Dentist not knowing how to provide care3.2 (1.2-8.5) *Adjusted for age, income, race/ethnicity, no. of children and adults in household, parental employment, and parental educational attainment; †Referent= those continuously insured

16. 16 Multivariate Analyses: Disparities in Use of Medical & Dental Services in US Children Service Use Issue Odds Ratio* (95% CI) Non-English vs. English No medical visit in past year1.6 (1.4-1.9) At least 1 ED visit in past year0.7 (0.6-0.8) No dental visit in past year1.2 (1.01-1.4) No routine preventive dental visit in past yearNS Didn’t get prescription for needed medication0.7 (0.5, 0.95) *Adjusted for age, health or dental insurance coverage, income, race/ethnicity, no. of children and adults in household, parental employment, and parental educational attainment

17. 17 Multivariate Analyses: Racial/Ethnic Disparities in US Children in Non-English Language Households OR* (95% CI) vs. Whites Health Status MeasureLatino Asian/Pacific Islander Health not excellent/very good3.1 (1.9-5.0)NS Teeth condition not excellent/very good 2.2 (1.5-3.4)NS Overweight or obese2.1 (1.3-3.6)NS Bone/muscle/joint problem14.3 (3.2–63.9)NS *Adjusted for age, income, health or dental insurance (where applicable), no. of children and adults in household, parental employment, and parental educational attainment

18. 18 Multivariate Analyses: Racial/Ethnic Disparities in US Children in Non-English Language Households OR* (95% CI) vs. Whites Access/Use of Services MeasureLatinoAsian/Pacific Islander Uninsured1.8 (1.1-3.0)NS No usual source of care (USC)3.0 (1.7-5.1)NS USC never/only sometimes spends enough time with child2.1 (1.3–3.3)3.1 (1.5–6.3) Unmet dental care needs4.4 (1.6-12.4)12.9 (2.7-61.5) Needed but did not get prescription medication in previous 12 mo8.6 (3.0–24.1)5.6 (1.3–24.7) Interpreter needed to speak with doctors or nurses3.4 (1.2-9.0)0.04 (0.01-0.2) *Adjusted for age, income, health or dental insurance (where applicable), no. of children and adults in household, parental employment, and parental educational attainment

19. 19 Conclusions l Compared with children in English primary language households, children in non-English primary language households experience multiple disparities in u Medical and oral health u Access to care u Use of services l Among children in non-English primary language households, Latinos and Asian/Pacific Islanders experience several unique disparities, compared with whites

20. 20 Conclusions l Latino NEPL children have higher adjusted odds than white NEPL children of u Suboptimal health status and teeth condition u Overweight and obesity u Bone/joint/muscle problems u Lack of medical insurance u No usual source of care (USC) u USC not spending enough time with child u Needing but not getting prescription medications l One in four Latino NEPL children and their families require medical interpretation, equivalent to more than triple the odds of white NEPL children

21. 21 Implications l Reducing language barriers may be most effective way to eliminate medical and dental disparities for children in non-English primary language households, such as by u Providing all limited English proficient patients and their families with trained interpreter services u Increasing number of states reimbursing for medical interpreter services, which currently includes only 13 (but not California)

22. 22 The Successful Elimination of a Racial/Ethnic Disparity in Immigrant Latino Children’s Healthcare: A Randomized Controlled Trial of the Effectiveness of Community-Based Case Managers In Insuring Uninsured Latino Children Funding: RWJF, AHRQ, CMS Publication: Pediatrics 2005;116:1433-1441

23. 23 Uninsured Children in US l About 7.3 million US children (10%) uninsured l Children at greatest risk of being uninsured: u Latinos u Poor u Immigrants u Non-citizens u Citizen children of non-citizen parents

24. 24 Children’s Health Insurance Program (CHIP) l Enacted by Congress in 1997 to expand insurance coverage for uninsured children l Targets uninsured children < 19 years old with family incomes < 200% of federal poverty level ineligible for Medicaid and not covered by private insurance l Matched block grant program that allocates $39 billion over 10 years l Increases state coverage of uninsured children by u Raising Medicaid income limit u Creating new, non-Medicaid state insurance program u Doing both

25. 25 CHIP & Medicaid Not Reducing Number of Uninsured Children l Since CHIP’s inception, number of uninsured US children has more or less remained unchanged l Some states cannot find enough eligible uninsured children to use all funds they’re entitled to l States used < 20% of $24 billion allocated by Congress for CHIP for first 5 years l CHIP money for given year remains available for 2 years, but some states have built up huge reserves because they’re not close to spending their Federal allotment l Congress already has taken back several states’ unused CHIP funds to use for other purposes

26. 26 CHIPRA l On 2/4/09, President Obama signed into law Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) u Adds $33 billion in federal funds for children’s coverage over next 4 ½ years u Aims to cover additional 4.1 million children by 2013 through Medicaid and CHIP l Under CHIPRA, states will be able to u Strengthen existing programs u Cover additional low-income, uninsured children u Increase outreach and enrollment efforts through grants and express-lane eligibility

27. 27 Research Issues: Insuring Uninsured Children l Although Medicaid and CHIP outreach and enrollment programs exist, few have been formally evaluated u Prior to our study, there were no published randomized controlled trials comparing effectiveness of various outreach/enrollment programs l Critical need for innovative, rigorously tested outreach and enrollment interventions

28. 28 Relevant Findings: Community-Based Studies of Uninsured Latino Children l Boston communities with highest proportions of Latinos and uninsured children u East Boston: 29% Latino, 37% of Latino children uninsured u Jamaica Plain: 32% Latino, 27% of Latino children uninsured u State of Massachusetts: 7% Latino, 5% of children uninsured l Focus groups of parents of uninsured children from East Boston and Jamaica Plain revealed many barriers to insuring uninsured children u Strict rules for pay stubs and identification u Language barriers u Not knowing how to apply u Misconceptions about work, welfare and immigration rules u System problems: excessive waits for decisions, misinformation from representatives, loss of applications, and arbitrary suspension of insurance l Focus group parents universally agreed that case managers would be very useful, helpful alternative (Ambulatory Peds 2005;5:332-340)

29. 29 Study Goal l Conduct randomized trial to evaluate whether community-based case managers more effective than traditional CHIP and Medicaid outreach/enrollment methods in insuring uninsured children

30. 30 Methods l Design = randomized controlled trial u Single blinded: outcomes monitored by research assistant unaware of whether participant allocated to intervention or control group u Double blinding not possible, given that participants immediately aware of assignment to case manager

31. 31 Methods l Uninsured children recruited at community sites and randomized to: u Trained case managers (intervention) u Control group (no intervention) l Setting: supermarkets, bodegas, beauty salons, Laundromats, and churches in 2 Boston communities (East Boston and Jamaica Plain) with highest proportions of u Uninsured children u Latinos l Subjects in both groups u Received participation incentives u Contacted monthly by blinded research assistant to monitor outcomes for 1 year

32. 32 Intervention Case managers: trained bilingual Latina staff (from same communities as participants) who l Provided information and assistance on eligibility for insurance programs l Filled out and submitted child’s insurance application together with parent l Expedited final coverage decisions by early and frequent contact with Medicaid and Children’s Medical Security Plan (CMSP = CHIP equivalent in Massachusetts that covers non- Medicaid eligible, including non-citizens) l Acted as family advocate by being liaison between Medicaid/CMSP and family l Sought to remedy situations where children inappropriately had coverage discontinued or deemed ineligible

33. 33 Control Group l Received traditional Medicaid and CHIP outreach and enrollment, which in Massachusetts currently consist of u Direct mailings, press releases, newspaper inserts, health fairs, and door-to-door canvassing u Special attempts to reach Latino communities, such as Spanish radio spots u Mini-grants to community organizations u A toll-free telephone number for applying for health benefits

34. 34 Main Outcome Measures l Proportion of children obtaining health insurance l Proportion of children with episodic coverage (obtained but then lost insurance coverage) l Number of days from study enrollment to child obtaining coverage l Parental satisfaction with process of trying to obtain coverage for child

35. 35 Results: Enrollment, Randomization, and Follow-up l 275 subjects enrolled and randomized u N=139 randomized to community-based case managers (intervention group) u N=136 randomized to control group l N=18 lost to follow-up or withdrew prior to follow-up l Participated in at least 1 follow-up visit: 97% (N=135) in intervention group, 90% (N=122) of control group l Participated in final follow-up visit (12 months after study enrollment): 72% (N=97) of intervention group and 62% (N=76) of control group

36. 36 Results: Baseline Sociodemographics Characteristic Intervention (N = 139) Control (N =136) P Mean age of child (in years)8.9 NS Latino subgroup: Colombian Salvadorian Dominican Other 42% 21% 19% 18% 35% 24% 18% 23% NS Single Parent Household55%57%NS Median annual household income$13,200$14,400NS Parent limited in English proficiency91%93%NS Parent high school grad52%57%NS Parent not US citizen90%89%NS

37. 37 Results: Obtaining Health Insurance Coverage l Significantly higher proportion of case management (intervention) group obtained health insurance vs. control group, at 96% vs. 57% (P <.0001) l Intervention group more than twice as likely to obtain insurance coverage as control group (Adjusted Relative Risk, 2.30; 95% CI, 1.87-2.81) and had approximately 8 times the odds of being insured (Adjusted Odds Ratio, 7.78; 95% CI, 5.20-11.64) u After adjustment for child’s age, annual combined family income, parental citizenship, parental employment, and state policy changes in Medicaid/CHIP (temporary enrollment cap and premium increases)

38. 38 Proportion Insured by Site and Group Assignment

39. 39 Adjusted Incidence Curve l Marked difference between groups in obtaining insurance coverage emerged at approximately 30 days and was sustained

40. 40 Coverage Continuity and Time Interval to Obtain Coverage VariableInterventionControlP Continuously insured78%30%<.0001 Sporadically insured18%27%<.0001 Continuously uninsured4%43%<.0001 Mean time to insurance- days (± SD) 87.5 (±68)134.8 (±102)<.0001

41. 41 Parental Satisfaction: Process of Obtaining Insurance Coverage

42. 42 Conclusions Compared with traditional Medicaid/CHIP outreach and enrollment, community-based case managers substantially more effective in l Obtaining health insurance for Latino children l Obtaining insurance quicker l Continuously insuring children l Achieving high parental satisfaction with process of obtaining insurance

43. 43 Conclusions l Community-based case management highly effective in insuring uninsured children documented to be at greatest risk for continuing to lack insurance coverage u Latinos u Poor u Immigrants l Findings suggest it’s possible to eliminate a racial/ethnic disparity, using an evidence-based, family-oriented, community-based approach

44. 44 Policy Consequences of Study l Privileged to present Congressional Research Briefing on this study on Capitol Hill in 2005 l Led to introduction of Community Health Workers Act (S 586; HR 1968), now in committee (HELP) in Senate u Authorizes Secretary of Health and Human Services to award grants to promote positive health behaviors for women and children, especially minority women and children in medically underserved communities u Permits funds to be used to support community health workers to educate and provide outreach regarding enrollment in health insurance l Led to CHIPRA legislation including community health workers as means of outreach/enrollment of uninsured children

45. 45 Implications Community-based case management l Could be an effective means for reducing or eliminating racial/ethnic disparities in insurance coverage l Could potentially serve as potent economic revitalization force in impoverished communities u Employing community members (such as welfare-to-work participants) as case managers might reduce unemployment and reinvest capital in community while reducing number of uninsured children l Could serve as national model for insuring uninsured children and adults, given u Rigorous evidence base provided by randomized trial u Potential utility in spectrum of universal coverage options being considered, from single-payer to mandatory purchasing with subsidies

46. 46 Proposed Priorities: Research and Policy Action for Immigrant Latino Children l Develop interventions to eliminate disparities in u Medical and oral health u Overweight and obesity u Bone/joint/muscle problems l Eliminate disparities in insurance coverage through u Interventions using community health workers u Enhanced outreach/enrollment opportunities afforded by CHIPRA u Including immigrant children in future healthcare reform initiatives

47. 47 Proposed Priorities: Research and Policy Action for Immigrant Latino Children l Ensure that every Latino child has u Medical home u Quality of care in their medical home u Access to needed prescription medications l Provide all limited-English-proficient patients and their families with adequate language services u Medicaid, CHIP, private insurers, and all third- party payers should reimburse for language services across our nation (not just in 13 states)