U.S. health system: challenges and opportunities for migrants

1. U.S. health system: challenges and opportunities for migrants Steven P. Wallace, Ph.D. UCLA Center for Health Policy Research UCLA School of Public Health July 3, 2008 Supported in part by the California-Mexico Health Initiative, UC Office of the President swallace@ucla.edu

2. Key elements of US medical care system • Regulated primarily by states, not federal government

3. Key elements (2) • Provision of services and payment are usually separated

4. Providers 119 hospitals 65 different owners 4 county owned 1 Veteran’s Admin. 203 primary care clinics 6 County rest nonprofit/community (often with county contracts) 1000s of MD offices & groups Payers 23 licensed private insurance companies in fee for service 7 large licensed HMOs Medicare (federal) Medi-Cal, Healthy Families (state/federal) Workers compensation Healthy Kids (county) Fragmentation of Payer and Provider – Los Angeles County

5. Most insurance companies are private • Focus on profits • Aetna, Inc., CIGNA Corp., Health Net, Inc., UnitedHealth Group and WellPoint Health Networks, Inc. CEO’s each have salaries over $US1 million • Anthem Blue Cross spends 21% of premiums on administrative costs (marketing, salaries, etc) vs. Kaiser (one of the few non-profit companies) that spends 9.4% source.: SJ Mercury News http://origin.mercurynews.com/news/ci_9679172?nclick_check=1

6. (3) U.S. health care system is most expensive in the world Source: WHO, The world health report 2006

7. Key Elements (4) • Primary source of insurance is via employment • Government insurance common for low-income children & families, disabled, and elderly

8. Type of health insurance, all U.S. residents 2006 47 million persons Source: http://www.census.gov/prod/2007pubs/p60-233.pdf

9. Type of medical insurance, 2005 http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196

10. Percent using clinics (vs. private doctor) for medical care, U.S. http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=155

11. CA resident w/ medical, dental, or prescription in Mexico past year Source: CHIS 2001

12. Distance from border, CA resident using Mexico MD

13. Context of need • Immigrants are healthier than average, so need less acute medical care • Need for preventive care and occupational coverage higher than average • Immigrant wages are low, so ability to pay is low. Often sending money to Mexico, many time to help pay for medical care.

14. Mexican immigrants have better health indicators except for diabetes, ages 18-64 Source: U.S. NHIS 2005

15. Immigrant advantage remains when age adjusted (2000 Census population standard), ages 18-64 Source: U.S. NHIS 2005, age adjusted to 2005 total adult population

16. Low wages = high poverty Source: Current Population Survey, 2005. See http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=196

17. Odds ratios*, health care access vs. U.S.-born Mexican Americas, CA * Adjusted for sex, marital status, health insurance, age, education, employment, federal poverty level, location of residence, and self-reported health status. Source: CHIS 2003 in Arch Intern Med, Vol 167, Nov 26, 2007, p 2354

18. Adequate use of health care • Availability – are services located in the community where immigrants live • Accessibility – can immigrants afford the care; are the hours of service appropriate • Acceptability – do the immigrants have confidence in the provider, can they communicate

19. Opportunities? • Expand employer health coverage • Expand government coverage for low-income workers with a green card • Expand binational health insurance • Develop discount cards for community clinics • Expand ventanillas de salud

20. Expand employer insurance: Advantages • It is the most common type of insurance in the U.S. currently; plenty of capacity • Private health insurance companies do not ask about immigration status • Can be tied to immigration reform legislation that will establish a guest worker (bracero-like) status

21. Expand employer health insurance: Disadvantages • Difficult or impossible for states to require employers to offer insurance under current federal law • Employers oppose because it will increase costs • Would not cover part time, temporary, or migrant workers

22. Expand government programs for low-waged workers: Advantages • Many uninsured immigrants who hold green card would be eligible • Programs exist that have had political support in the past for expansion (e.g. Healthy Families) • Infrastructure and capacity already exist

23. Expand government programs for low-waged workers: Disadvantages • Government programs may scare off many who are eligible, especially those in mixed-status families • Political support for expansion weakens during recessions, like now • Will not help undocumented

24. Expand binational health insurance • Three companies offer California-Mexico insurance • About 250,000 covered • Primary care in U.S., hospital care in Tijuana

25. Expand binational health insurance: Advantages • Lower cost, uses familiar providers in Mexico • Feasibility demonstrated by existing plans in California • Could benefit families remaining in Mexico in addition to migrants in the U.S.

26. Expand binational health insurance: Disadvantages • Many administrative and technical issues remain to expand networks • Limited demand for current cross-border insurance; still too expensive for many & most appealing on border • Undocumented can’t cross border freely • Some providers oppose due to competition; Some immigrant advocates oppose as establishing a “two class system”

27. Discount cards for community clinics • Community clinics already in immigrant communities • Already offer services on ability to pay, but capacity is limited due to $$ AltaMed Health Services, E.LA

28. Discount cards for community clinics: Advantages • Builds on existing network of providers • Carries little fear of government services • Can provide care without involving the complex insurance system • Mexican government and U.S. charities (foundations) can help finance

29. Discount cards for community clinics: Disadvantages • Would likely only cover primary care, leaving most expensive hospital care uncovered • Is not insurance so creates two class system • Monitoring/accountability might be difficult

30. Ventanillas de Salud • Services in 23 Mexican consulates • Mostly information and referral • Health education • Mobile clinics, health fairs http://www.ime.gob.mx/programas_salud/vds.htm

31. Ventanillas de salud: Advantages • Location at Mexican consulates is safest for undocumented immigrants • Could use funds from Mexico with least political resistance • ?? Could use staff with only Mexican medical licenses??

32. Ventanillas de salud: Disadvantages • Consulates are not designed or staffed to provide medical care • Care would only be primary care, not more expensive hospital care • Consulates are not conveniently located for many to use as a primary care center

33. Summary • Each option for immigrants (especially undocumented) contains a different mix of + and – for availability, accessibility, and acceptability. • It is essential to consider political feasibility: “don’t let the perfect get in the way of the good” • Care versus Coverage