Hispanics or Latinos

Previous NHDRs showed that Hispanics had poorer quality of care and worse access to care than non-Hispanic Whites for many measures tracked in the reports. Findings based on core report measures of quality and access to health care that support estimates for Hispanics are shown below.

Figure 4.17. Hispanics compared with non-Hispanic Whites on measures of quality and access

Better = Hispanics receive better quality of care or have better access to care than non-Hispanic Whites.

Same = Hispanics and non-Hispanic Whites receive about the same quality of care or access to care.

Worse = Hispanics receive poorer quality of care or have worse access to care than non-Hispanic Whites.

CRM = core report measures (Table 1.2).

Note: Data presented are the most recent available.

• For 23 of the 38 core report measures of quality, Hispanics had poorer quality of care than non-Hispanic Whites (Figure 4.17). Differences ranged from Hispanics being over 2.5 times as likely to be diagnosed with AIDS to Hispanics being 13% less likely to have adequate urea reduction for hemodialysis. The median difference over all 38 core report measures was 22%.
• For 7 of the 8 core report measures of access, Hispanics had worse access to care than non-Hispanic Whites. Differences ranged from Hispanics under age 65 being 2.8 times as likely to lack health insurance to Hispanics being 21% less likely to report difficulties or delays getting care. The median difference over all 8 core report measures was 71%.

Figure 4.18. Change in Hispanic-non-Hispanic White disparities over time

Improving >5% = Hispanic-non-Hispanic White difference becoming smaller at rate greater than 5% per year.

Improving 1-5% = Hispanic-non-Hispanic White difference becoming smaller at rate between 1% and 5% per year.

Same = Hispanic-non-Hispanic White difference not changing.

Worsening 1-5% = Hispanic-non-Hispanic White difference becoming larger at rate between 1% and 5% per year.

Worsening >5% = Hispanic-non-Hispanic White difference becoming larger at rate greater than 5% per year.

CRM = core report measures (Table 1.2).

Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 41 core report measures could be tracked over time for Hispanics and non-Hispanic Whites.

• Of core report measures of quality that could be tracked over time for Hispanics and non-Hispanic Whites, Hispanic-non-Hispanic White differences became smaller for 14 measures but larger for 11 measures (Figure 4.18). For 10 measures, Hispanic-non-Hispanic White differences did not change over time.
• Of core report measures of access that could be tracked over time for Hispanics and non-Hispanic Whites, Hispanic-non-Hispanic White differences became smaller for 2 measures but larger for 3 measures. For 1 measure, Hispanic-non-Hispanic White differences did not change over time.

Focus on Hispanic Subpopulations

The Hispanic population in the United States is highly heterogeneous. Almost 60% are of Mexican origin, making it the largest Hispanic subpopulation in the country. People originating from Puerto Rico, Central America, and South America are the next largest subgroups.

The following section features selected measures from the California Health Interview Survey (CHIS). These include breast cancer screening, diabetes care, uninsurance, and emergency/urgent care visits for asthma. The CHIS is an example of a data source that can provide data for Hispanic subgroups. California's Hispanic population is nearly twice the percentage in the United States overall (6.8% in California compared with 3.6% of the U.S. population).¹⁶ Almost 30% of the Hispanic population in the United States lives in California.¹⁷ These data show that disparities for Hispanics in California exist, not only in comparison with non-Hispanic Whites but also within Hispanic subgroups (Mexican, Puerto Rican, Central American, and South American) and across Hispanic subgroups by income and insurance status. The following section shows only some of the significant disparities for these groups in California from CHIS data.

Figure 4.19. Women age 40 and over who reported they had a mammogram in the past 2 years, by ethnicity and insurance status, California only, 2005

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized women age 40 and over in California.

• The proportion of women age 40 and over in California who had a mammogram was lower for Hispanic than non-Hispanic White women overall (74.3% compared with 80.7%; Figure 4.19).
• The proportion who reported a mammogram in the past 2 years was significantly lower for Hispanic women who were publicly insured (65.8%) and uninsured (63.8%) than for those who were privately insured (77.8%).

Figure 4.20. People age 40 and over with diabetes who had hemoglobin A1c measurement, retinal exam, and foot exam within the past year, by ethnicity and insurance status, California only, 2005

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized adults age 40 and over in California with diabetes.

• The proportion of Hispanic adults age 40 and over with diabetes who received all three recommended services for diabetes varied significantly by insurance status (Figure 4.20). The proportion who received all three recommended services for diabetes was significantly lower for Hispanic adults who were publicly insured (28.2%) and uninsured (23.2%) compared with those who were privately insured (48.9%).
• Overall, the proportion of Hispanic adults in California with diabetes who received all three recommended exams for diabetes care was not statistically different from the proportion for non-Hispanic Whites.

Figure 4.21. People under age 65 uninsured all year, by ethnicity and Hispanic subgroup, California only, 2001, 2003, and 2005

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized population under age 65 in California.

• From 2001 to 2005 the proportion of people in California who were uninsured all year decreased for total Hispanics (from 22.0% to 17.8%) and for Mexicans (from 23.9% to 18.4%; Figure 4.21).
• In 2005, all Hispanic subgroups had a higher proportion of people uninsured all year than non-Hispanic Whites (5.8%). The percentage for Mexicans was over three times higher (18.4%); for Central Americans, over four times higher (25.2%); and for South Americans, over two times higher (13.9%) than the proportion for non-Hispanic Whites.
• Overall, 11.1% of Californians were uninsured all year in 2005.

Figure 4.22. People with current asthma who had an emergency department or urgent care clinic visit for asthma within the past year, by ethnicity, income, and insurance status, California only, 2005

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey

Note: Thresholds for income categories—poor, near poor, middle income, and high income—vary by family size and composition and are updated annually by the U.S. Bureau of the Census. For example, in 2005, the Federal poverty threshold for a family of two adults and two children was $19,806.

Reference population: Civilian noninstitutionalized population in California with current asthma.

• In California, the proportion of Hispanics who had an emergency department or urgent care visit for asthma was more than twice that of non-Hispanic Whites (24.3% compared with 11%; Figure 4.22).
• The proportion was significantly higher for poor (32.0%) and near poor (38.1%) Hispanics compared with high income Hispanics (14.2%).
• The proportion was also significantly higher for Hispanics who were publicly insured (35.1%) compared with those who were privately insured (20.1%).

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Recent Immigrants and Limited-English-Proficient Populations

Recent Immigrants and Language Barriers

Immigrants often encounter barriers to high quality health care. About 33.3 million persons living in the United States in 2003 were born outside the United States, up from 20 million in 1990.¹⁸ Asians and Hispanics are much more likely to be foreign born: about 70% of Asians and 40% of Hispanics in the United States are foreign born, compared with 6% of Whites and Blacks.¹⁹

Certain diseases are concentrated among Americans born in other countries. For example, 55% of tuberculosis cases in the Nation are among foreign-born individuals,²⁰ and the case rate among foreign-born individuals is more than eight times higher than among individuals born in the United States.²¹ The percentage of cases of tuberculosis among U.S.-born individuals is decreasing while the percentage of cases among foreign-born individuals is increasing.²²

Quality health care requires that patients and providers communicate effectively. Persons who speak a language other than English at home may have less access to resources, such as health insurance, that facilitate getting needed health care. The ability of providers and patients to communicate clearly with one another can be compromised if they do not speak the same language. Quality may suffer if patients with limited English proficiency are unable to express their care needs to providers who speak English only or who do not have an interpreter's assistance. Communication problems between the patient and provider can lead to lower patient adherence to medications and decreased participation in medical decision-making, as well as exacerbate cultural differences that impair the delivery of quality health care.

Limited English proficiency is a barrier to quality health care for many Americans. About 52 million Americans, or 19.4% of the population, spoke a language other than English at home in 2000, up from 32 million in 1990. Of these individuals, 32 million (about 12% of the population) spoke Spanish, 10 million (about 4% of the population) spoke another Indo-European language, and 7.8 million (about 3% of the population) spoke an Asian or Pacific Islander language at home. Almost half of persons who spoke a foreign language at home reported not speaking English very well.²³ A study of health plan members and use of interpreters showed that the use of interpreters reduced disparities for Hispanic and API members (28% and 21%, respectively).²⁴

As in previous NHDRs, findings are presented below for several quality and access measures based on data from the National Tuberculosis Surveillance System and the Medical Expenditure Panel Survey; this year these sources are supplemented with data from the California Health Interview Survey. Information on disparities in health care quality and access for Americans born outside the United States and for Americans with limited English-speaking skills are presented for tuberculosis therapy, poor communication with health providers, uninsurance, breast cancer screening, and diabetes care.

Figure 4.23. Completion of therapy for tuberculosis within 12 months of being diagnosed among persons born outside the United States, by race (left) and ethnicity (right), 1999-2003

Key: API = Asian or Pacific Islander.

Source: Centers for Disease Control and Prevention, National Tuberculosis Surveillance System, 1999-2003.

Reference population: Foreign-born U.S. resident population with verified tuberculosis, all ages.

• From 1999 to 2003, the proportion of persons who completed therapy for tuberculosis within 12 months of being diagnosed improved for foreign-born Blacks (from 78.1% to 83.6%) and foreign-born APIs (from 79.0% to 81.6%; Figure 4.23).
• In 2003, the proportion of persons who completed therapy for tuberculosis within 12 months of being diagnosed was significantly higher for foreign-born Blacks than for foreign-born Whites (83.6% compared with 80.5%).
• In 2003, the proportion of persons who completed therapy for tuberculosis within 12 months of being diagnosed was significantly lower for foreign-born Hispanics than for foreign-born non-Hispanic Whites (79.8% compared with 84.8%).

Figure 4.24. Ambulatory patients age 18 and over who reported poor communication with health providers, by race, ethnicity, and language spoken at home, 2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Denominator: Civilian noninstitutionalized population age 18 and over.

Note: Average percentage of adults age 18 and over who had a doctor's office or clinic visit in the last 12 months and were reported to have had poor communication with health providers (i.e., their health providers sometimes or never listened carefully, explained things clearly, showed respect for what they had to say, or spent enough time with them). Data were insufficient for this analysis for Non-Hispanic White non-English speakers.

• The overall proportion of adults who had a doctor's office or clinic visit in the last 12 months who reported poor communication with their health provider was significantly higher for individuals who speak a foreign language at home than for individuals who speak English at home (Figure 4.24).
• The proportion of adults who reported poor communication with their health provider was significantly higher for Whites and Asians who speak some other language at home (11.2% and 19.1%, respectively) than for Whites and Asians who speak English at home (8.9% and 9.4%, respectively).

Figure 4.25. Adults under age 65 uninsured all year, by race and ethnicity, stratified by language spoken at home, 2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Reference population: Civilian noninstitutionalized population ages 18-64.

• The overall proportion of adults under age 65 uninsured all year was significantly higher for individuals who speak a foreign language at home than for individuals who speak English at home (Figure 4.25).
• The proportion of persons uninsured all year was significantly higher for Whites, Blacks, and Asians who speak some other language at home than for their counterparts who speak English at home (34.9% compared with 10.7% for Whites, 34.0% compared with 14.8% for Blacks, and 15.0% compared with 7.8% for Asians).
• The proportion of persons uninsured all year was over twice as high for Hispanics who speak some other language at home than for Hispanics who speak English at home (38.2% compared with 16.5%).

Figure 4.26. Women age 40 and over who reported they had a mammogram in the past 2 years, by English proficiency and place of birth, California only, 2005

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized women in California age 40 and over.

• The proportion of women age 40 and over who reported a mammogram in the past 2 years was significantly lower for California non-native-English speakers, both those with proficient English (77.3%) and those with low or no English proficiency (70.9%), than for native English speakers (80.3%; Figure 4.26).
• The proportion of women age 40 and over who reported a mammogram in the past 2 years was lower for foreign-born Californians (74.6%) compared with U.S.-born Californians (80.0%).

Figure 4.27. People age 40 and over with diabetes who had hemoglobin A1c measurement, retinal exam, and foot exam in the past year, by English proficiency and place of birth, California only, 2005

Source: University of California, Los Angeles, Center for Health Policy Research, California Health Interview Survey.

Reference population: Civilian noninstitutionalized population in California age 40 and over.

• The proportion of California adults age 40 and over with diabetes who received all three recommended services for diabetes was significantly lower for people with low or no English proficiency (27.1%) than for native English speakers (49.3%; Figure 4.27).
• The proportion was also significantly lower for foreign-born Californians (38.1%) compared with U.S.-born Californians (48.1%).

Language Assistance

Clear communication is an important component of effective health care delivery. It is vital for providers to understand patients' health care needs and for patients to understand providers' diagnoses and treatment recommendations. Communication barriers can relate to language, culture, and health literacy.

For persons with limited English proficiency, having language assistance is of particular importance. Persons with limited English proficiency may choose a usual source of care in part based on language concordance; thus, not having a language-concordant provider may limit or discourage some patients from establishing a usual source of care.

The NHDR includes a supplemental measure of access: provision of language assistance by the usual source of care. Language assistance includes bilingual clinicians, trained medical interpreters, and bilingual receptionists and other informal interpreters.

Figure 4.28. Adults with limited English proficiency, by whether they had a usual source of care with or without language assistance, 2003 and 2004

Key: USC = usual source of care.

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2003-2004.

Reference population: Civilian noninstitutionalized population age 18 and over.

Note: Language assistance includes bilingual clinicians, trained medical interpreters, and informal interpreters (e.g., bilingual receptionists).

• Approximately half (47%) of individuals with limited English proficiency did not have a usual source of care in 2004 (Figure 4.28).
• A similar proportion (46%) of individuals with limited English proficiency had a usual source of care that offered language assistance in 2004.
• Only 7% of individuals with limited English proficiency had a usual source of care that did not offer language assistance.

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Low Income Groups

In this report, the poor are defined as persons living in families whose household income falls below specific poverty thresholds. These thresholds vary by family size and composition and are updated annually by the U.S. Bureau of the Census.^{x, 25} After falling for nearly a decade (1990-2000), the number of poor persons in America rose from 31.6 million in 2000 to 37.0 million in 2005, and the rate of poverty increased from 11.3% to 12.6% over the same period.²⁶

Poverty varies by race and ethnicity. In 2005, 25% of Blacks, 22% of Hispanics, 11% of Asians, and 8% of Whites were poor.²⁶ Persons with low incomes often experience worse health and are more likely to die prematurely.²⁷ In general, poor populations have reduced access to high quality care. While people with low incomes are more likely to be uninsured, income-related differences in quality of care that are independent of health insurance coverage have also been demonstrated.²⁸

In previous chapters of this report, health care differences by income were described. In this section, disparities in quality of and access to health care for poor^xi compared with high income^xii individuals are summarized. For each core report measure, poorer persons can have health care that is worse than, about the same as, or better than health care received by high income persons. Only relative differences of at least 10% that are statistically significant with alpha = 0.05 are discussed in this report. Access measures focus on facilitators and barriers to health care and exclude health care utilization measures.

In addition, changes in differences related to income are examined over time. For each core report measure, racial, ethnic, and socioeconomic groups are compared with a designated comparison group at different points in time. Consistent with Healthy People 2010, disparities are measured in relative terms as the percentage difference between each group and a comparison group; changes in disparity are measured by subtracting the percentage difference from the comparison group at the baseline year from the percentage difference from the comparison group at the most recent year. The change in each disparity is then divided by the number of years between the baseline and most recent estimate to calculate change in disparity per year. Core report measures (Table 1.2) for which the relative differences are changing less than 1% per year are identified as staying the same. Core report measures for which the relative differences are becoming smaller at a rate of more than 1% per year are identified as improving. Core report measures for which the relative differences are becoming larger at a rate of more than 1% per year are identified as worsening. Changes of greater than 5% per year are also differentiated from changes of between 1% and 5% per year in some figures.

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^x For example, in 2005 the Federal poverty threshold for a family of 2 adults and 2 children was $19,806.

^xi Household income less than Federal poverty thresholds.

^xii Household income 400% of Federal poverty thresholds and higher.

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Figure 4.29. Poor compared with high income individuals on measures of quality and access

Better = Poor receive better quality of care or have better access to care than high income individuals.

Same = Poor and high income individuals receive about the same quality of care or access to care.

Worse = Poor receive poorer quality of care or have worse access to care than high income individuals.

CRM = core report measures (Table 1.2).

Note: Data presented are for the most recent data year available.

• Fewer than half of the core report measures supported estimates of quality for the poor.
• For 12 of the 19 core report measures of quality with income data, the poor had significantly poorer quality of care than high income individuals (Figure 4.29). Differences ranged from poor children being over three times as likely as high income children to be hospitalized for asthma to poor individuals being 25% less likely to receive recommended diabetes care. The poor did not have better quality than high income individuals for any of the 19 core report measures.
• For all 8 core report measures of access, the poor had significantly worse access to care than high income individuals. Differences ranged from the poor under age 65 being over three times as likely as high income individuals to lack health insurance to the poor being 50% more likely to lack a primary care provider. The median difference was over 1.5 (poor individuals were over 1.5 times as likely to have worse access as high income individuals).

Figure 4.30. Change in poor-high income disparities over time

Improving >5% = Poor-high income difference becoming smaller at rate greater than 5% per year.

Improving 1-5% = Poor-high income difference becoming smaller at rate between 1% and 5% per year.

Same = Poor-high income difference not changing.

Worsening 1-5% = Poor-high income difference becoming larger at rate between 1% and 5% per year.

Worsening >5% = Poor-high income difference becoming larger at rate greater than 5% per year.

CRM = core report measures (Table 1.2).

Note: The time period for this figure is the most recent and oldest years of data used in the NHDR. Only 25 core report measures of quality and access could be tracked over time for poor and high income individuals.

• Only about half of the core report measures for quality allow comparisons between poor and high income individuals over time.
• Of core report measures of quality that could be tracked over time for poor and high income individuals, poor-high income differences became smaller for six measures but became larger for seven measures (Figure 4.30). For four measures, the poor-high income difference did not change over time.
• Of core report measures of access that could be tracked over time for poor and high income individuals, poor-high income differences became smaller for three measures and larger for four measures.

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Focus on Uninsurance

Because low-paying jobs are less likely to offer health insurance as a benefit and the cost of health insurance leaves poorer individuals less likely to be able to afford it, this year's NHDR again focuses on uninsurance. Compared with insured persons, the uninsured report more problems getting care and are diagnosed at later disease stages.^{29, 30} They report poorer health status,³¹ are sicker when hospitalized, and are more likely to die during their hospital stay.³² Uninsured persons often avoid non-urgent care such as preventive screenings, have difficulty obtaining care for illness or injury, and must bear the full cost of health care. In addition, prolonged periods of uninsurance can have a particularly serious influence on one's health and stability.

Findings presented here highlight three quality measures related to prevention (breast cancer screening, counseling parents about healthy eating in children, and counseling obese adults about exercise) and one access measure (dental care) of special relevance to the uninsured. In addition, this section presents two bivariate analyses to show data by income and insurance status.

Quality of Health Care

Prevention: Screening for Breast Cancer (Mammography)

Screening for breast cancer with mammography is an effective way to reduce new cases of late stage disease and mortality caused by this cancer.

Figure 4.31. Women age 40 and over who reported they had a mammogram within the past 2 years, by income, stratified by insurance status, 2005

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey, 2005.

Reference population: Civilian noninstitutionalized women age 40 and over who reported a mammogram in the past 2 years.

• Overall, the proportion of women age 40 and over who reported they had a mammogram within the past 2 years was significantly lower for uninsured women (38.3%) than for privately insured women (74.2%) or publicly insured women (57.9%; Figure 4.31).
• The proportion was significantly lower for poor (48.5%), near poor (55.1%), and middle income women (66.8%) than for high income women (75.3%).
• Among poor women, the proportion was significantly lower for uninsured than for privately insured women (32.3% compared with 52.6%).
• Among near poor women, the proportion was significantly lower for uninsured (34.9%) and publicly insured (54.7%) than for privately insured women (66.3%).
• Among middle income women, the proportion was significantly lower for uninsured (44.1%) and publicly insured women (54.7%) than for privately insured women (71.0%).
• Among high income women, the proportion was significantly lower for uninsured than privately insured women (41.7% compared with 78.1%).

Prevention: Counseling Parents About Healthy Eating in Children

Counseling about healthy eating can play an important role in helping children to lose excess weight and establish healthy lifestyle behaviors.

Figure 4.32. Children ages 2-17 with ambulatory visit who ever received advice about healthy eating, by insurance status, 2002-2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2004.

Reference population: Civilian noninstitutionalized population ages 2-17.

Note: Estimates were for children whose parents or guardians reported ever receiving advice from a health provider for their children about healthy eating.

• From 2002 to 2004, the gap between uninsured children and privately insured children whose parents or guardians reported advice about healthy eating remained the same. In 2004, the proportion was significantly less for uninsured children than privately insured children (38.7% compared with 55.4%; Figure 4.32).
• During this period, there was no significant difference between publicly insured and privately insured children whose parents or guardians reported advice about healthy eating.

Prevention: Counseling Obese Adults About Exercise

Regular exercise aids in weight loss and blood pressure control, reducing the risk of heart disease, stroke, diabetes, and other diseases.

Figure 4.33. Obese adults given advice about exercise by their doctor or other health provider, by insurance status, 2002-2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2004.

Denominator: Civilian noninstitutionalized population age 18 and over.

• From 2002 to 2004, the gap between uninsured and privately insured persons in the proportion of obese adults who were given advice about exercise did not change significantly (Figure 4.33).
• The gap between publicly insured persons and privately insured persons in the proportion of obese adults who were given advice about exercise decreased. In 2004, the disparity was eliminated.
• In 2004, the proportion of obese adults who were given advice about exercise was significantly lower for uninsured than for privately insured persons (36.0% compared with 61.3%).

Access to Health Care

Dental Care

Regular dental visits promote prevention, early diagnosis, and optimal treatment of oral diseases and conditions.

Figure 4.34. Persons with a dental visit in the past year, by income, stratified by insurance status, 2004

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2004.

Reference population: Civilian noninstitutionalized population, all ages.

• Overall, the proportion of persons with a dental visit in the past year was significantly lower for publicly insured and uninsured persons than for privately insured persons (31% and 18.4%, respectively, compared with 51.3%; Figure 4.34).
• Among poor persons, the proportion did not differ significantly between publicly insured and privately insured persons (29.5% compared with 34.5%) but was significantly lower for uninsured persons than for privately insured persons (12.7% compared with 34.5%).
• Among near poor, middle income, and high income persons, uninsured persons were less than half as likely as privately insured persons to have had a dental visit in the past year.
• Only high income persons with private health insurance met the Healthy People 2010 target of 56% of persons with a dental visit in the past year (59.9%).

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