Glenn Flores, MD Professor and Director, Division of General Pediatrics

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. Overview:3 Goals of Today’s Presentation • 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 • Goal 2: present results of study demonstrating successful elimination of racial/ethnic disparity for immigrant Latino children • Goal 3: propose priorities for research and policy action for immigrant Latino children which any young investigator can pursue

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

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

6. Methods: Data Source- National Survey of Childhood Health (NSCH) • Telephone survey in 2003-2004 of national random sample (in all 50 states and D.C.) of households with children 0-17 years old • Oversampled households with African-Americanand Latino children • Parent or guardian most responsible for child’s healthcare interviewed in English or Spanish (N=6035) • 102,353 interviews completed • Interview completion rate = 55% • Adjustments made for non-response and non-coverage of household without telephones • Estimates based on sampling weights generalize to entirenon-institutionalized population of US children0-17 years old

7. Methods: Study Variables • 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 • Variables examined included • Medical and oral health • General health status by parental report • Prevalence of specific chronic conditions • Access to health and dental care • Use of health and dental services

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

9. Selected Characteristics: 0-17 Year-Old US Children in 2003-2004 (NSCH)

10. Primary Language at Home and Medical and Oral Health: US Children

11. Primary Language at Home and Access Barriers to Medical Care: US Children

12. Primary Language at Home and Access Barriers to Dental Care: US Children

13. Primary Language at Home and Use of Medical & Dental Services: US Children

14. Multivariate Analyses: Disparities in Medical & Oral Health of US Children

15. Multivariate Analyses: Disparities in Access to Medical & Dental Care in US Children

16. Multivariate Analyses: Disparities in Use of Medical & Dental Services in US Children

17. Multivariate Analyses: Racial/Ethnic Disparities in US Children in Non-English Language Households

18. Multivariate Analyses: Racial/Ethnic Disparities in US Children in Non-English Language Households

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

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

21. Implications • 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 • Providing all limited English proficient patients and their families with trained interpreter services • Increasing number of states reimbursingfor medical interpreter services,which currently includes only 13 (but not California)

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

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

25. CHIP & Medicaid Not Reducing Number of Uninsured Children • Since CHIP’s inception, number of uninsured US children has more or less remained unchanged • Some states cannot find enough eligible uninsured children to use all funds they’re entitled to • States used < 20% of $24 billionallocated by Congress for CHIP for first 5 years • 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 • Congress already has taken back several states’unused CHIP funds to use for other purposes

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

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

28. Relevant Findings: Community-Based Studies of Uninsured Latino Children • Boston communities with highest proportions of Latinosand uninsured children • East Boston: 29% Latino, 37% of Latino children uninsured • Jamaica Plain: 32% Latino, 27% of Latino children uninsured • State of Massachusetts: 7% Latino, 5% of children uninsured • Focus groups of parents of uninsured children from East Boston and Jamaica Plain revealed many barriers to insuring uninsured children • Strict rules for pay stubs and identification • Language barriers • Not knowing how to apply • Misconceptions about work, welfare and immigration rules • System problems: excessive waits for decisions, misinformation from representatives, loss of applications, and arbitrary suspension of insurance • Focus group parents universally agreed that case managers would be very useful, helpful alternative (Ambulatory Peds2005;5:332-340)

29. Study Goal • 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. Methods • Design = randomized controlled trial • Single blinded: outcomes monitored by research assistant unaware of whether participant allocated to interventionor control group • Double blinding not possible, given that participants immediately aware ofassignment to case manager

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

32. Intervention Case managers: trained bilingual Latina staff (from same communities as participants) who • Provided information and assistance on eligibility for insurance programs • Filled out and submitted child’s insurance application together with parent • 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) • Acted as family advocate by being liaison between Medicaid/CMSP and family • Sought to remedy situations where children inappropriately had coverage discontinued or deemed ineligible

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

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

35. Results: Enrollment, Randomization, and Follow-up • 275 subjects enrolled and randomized • N=139 randomized to community-based case managers (intervention group) • N=136 randomized to control group • N=18 lost to follow-up or withdrew prior to follow-up • Participated in at least 1 follow-up visit:97% (N=135) in intervention group,90% (N=122) of control group • 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. Results:Baseline Sociodemographics

37. Results: Obtaining Health Insurance Coverage • Significantly higher proportion of case management (intervention) group obtained health insurance vs. control group, at 96% vs. 57% (P < .0001) • 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) • After adjustment for child’s age,annual combined family income,parental citizenship, parental employment, andstate policy changes in Medicaid/CHIP (temporary enrollment cap and premium increases)

38. Proportion Insured by Siteand Group Assignment

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

40. Coverage Continuity and Time Interval to Obtain Coverage

41. Parental Satisfaction: Process of Obtaining Insurance Coverage

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

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

44. Policy Consequences of Study • Privileged to present Congressional Research Briefing on this study on Capitol Hill in 2005 • Led to introduction of Community Health Workers Act (S 586; HR 1968), now in committee (HELP) in Senate • 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 • Permits funds to be used to support community health workers to educate and provide outreach regarding enrollment in health insurance • Led to CHIPRA legislation including community health workers as means of outreach/enrollment of uninsured children

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

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

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