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S. HRG. 107–701

HISPANIC HEALTH: PROBLEMS WITH COVERAGE,

ACCESS, AND HEALTH DISPARITIES

HEARING

BEFORE THE

SUBCOMMITTEE ON PUBLIC HEALTH

OF THE

COMMITTEE ON HEALTH, EDUCATION,

LABOR, AND PENSIONS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

SECOND SESSION

ON

EXAMINING HISPANIC HEALTH PROBLEMS, FOCUSING ON COVERAGE,

ACCESS, AND HEALTH DISPARITIES

SEPTEMBER 23, 2002

Printed for the use of the Committee on Health, Education, Labor, and Pensions

(

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut

TOM HARKIN, Iowa

BARBARA A. MIKULSKI, Maryland

JAMES M. JEFFORDS (I), Vermont

JEFF BINGAMAN, New Mexico

PAUL D. WELLSTONE, Minnesota

PATTY MURRAY, Washington

JACK REED, Rhode Island

JOHN EDWARDS, North Carolina

HILLARY RODHAM CLINTON, New York

JUDD GREGG, New Hampshire

BILL FRIST, Tennessee

MICHAEL B. ENZI, Wyoming

TIM HUTCHINSON, Arkansas

JOHN W. WARNER, Virginia

CHRISTOPHER S. BOND, Missouri

PAT ROBERTS, Kansas

SUSAN M. COLLINS, Maine

JEFF SESSIONS, Alabama

MIKE DeWINE, Ohio

J. MICHAEL MYERS, Staff Director and Chief Counsel

TOWNSEND LANGE MCNITT, Minority Staff Director

SUBCOMMITTEE ON PUBLIC HEALTH

EDWARD M. KENNEDY, Chairman

TOM HARKIN, Iowa

BARBARA A. MIKULSKI, Maryland

JAMES M. JEFFORDS, Vermont

JEFF BINGAMAN, New Mexico

PAUL D. WELLSTONE, Minnesota

JACK REED, Rhode Island

JOHN EDWARDS, North Carolina

HILLARY RODHAM CLINTON, New York

BILL FRIST, Tennessee

JUDD GREGG, New Hampshire

MICHAEL B. ENZI, Wyoming

TIM HUTCHINSON, Arkansas

PAT ROBERTS, Kansas

SUSAN M. COLLINS, Maine

JEFF SESSIONS, Alabama

CHRISTOPHER S. BOND, Missouri

DAVID NEXON, Staff Director

DEAN A. ROSEN, Minority Staff Director

(II)

CONTENTS

STATEMENTS

MONDAY, SEPTEMBER 23, 2002

Page

Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico .................. 1

Rodriguez, Hon. Ciro, a U.S. Representative from the State of Texas ............... 3

Beato, Cristina, M.D., Deputy Assistant Secretary For Health, U.S. Department of Health and Human Services, Washington, DC; Francisco Cigarroa,

M.D., President, University of Texas Health Science Center at San Antonio,

TX; Glenn Flores, M.D., Chair, Latino Consortium of the American Academy of Pediatrics Center For Child Health Research; Director, Community

Outcomes, and Associaate Director, Center For the Advancement of Urban

Children, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI; Dan Reyna, Director, Border Health Office, New Mexico Department of Health, Las Cruces, NM; and Elena Rios, M.D., President, National

Hispanic Medical Association, Washington, DC ................................................ 9

ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:

Francisco G. Cigarroa, M.D. ............................................................................ 33

Glenn Flores, M.D. ........................................................................................... 36

Ciro D. Rodriguez ............................................................................................. 41

Cristina Beato, M.D. ........................................................................................ 48

Dan Reyna ......................................................................................................... 59

Elena Rios, M.D. ............................................................................................... 74

(III)

(1)

HISPANIC HEALTH: PROBLEMS WITH COVERAGE, ACCESS, AND HEALTH DISPARITIES

MONDAY, SEPTEMBER 23, 2002

U. S. SENATE,

SUBCOMMITTEE ON PUBLIC HEALTH,

OF THE COMMITTEE ON HEALTH, EDUCATION, LABOR, AND

PENSIONS,

Washington, DC.

The subcommittee met, pursuant to notice, at 2:00 p.m., in room

SD–430, Dirksen Senate Office Building, Senator Bingaman (chairman of the subcommittee) presiding.

Present: Senator Bingaman.

OPENING STATEMENT OF SENATOR BINGAMAN

Senator BINGAMAN. We will go ahead and start the hearing.

Thank you all for coming today. Our hearing today is focussed on

the health of the Hispanic population in the United States. The figures that all of us are generally aware of are shocking. Over a

third or 35 percent of Hispanic adults lack health insurance. Despite the passage of the Children’s Health Insurance Program, 27

percent of Latino children remain uninsured. That compares to 9

percent of white children, 18 percent of black children, 17 percent

of Asian-Pacific Islander children.

In the case of poor children who are largely eligible for Medicaid

and SCHIP, 1.1 million poor Latino children are uninsured, compared again with 806,000 white, 704,000 black and 95,000 Asian

poor uninsured children.

The Centers for Disease Control and Prevention keeps figures on

morbidity and mortality rates and again those are very adverse to

the Hispanic community. For example, age-adjusted mortality rates

for diabetes are over 50 percent higher among Hispanic persons

than with non-Hispanics. HIV infection rates are over three times

those for non-Hispanics. Tuberculosis rates among Latin children

are 13 times as high as in the white population.

This hearing will raise particular attention to the problems that

we face along the U.S.-Mexico border where we have 11 million

people, five of the seven poorest metropolitan statistical areas in

the country. If the region were a State the border would rank number one in the number of uninsured, it would rank last in terms

of per capital income, and first in the number of diseases.

The purpose of today’s hearing is to get an updated assessment

of the status of Hispanic health in the country, begin to put forth

an agenda that can take the next steps in addressing these proVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00005 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
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found disparities in health that should be viewed as unacceptable

in our society.

Representative Rodriguez, who is the new chair of the Congressional Hispanic Caucus, he and I have worked together in an effort

to respond to the challenges before us with regard to coverage and

access and health disparities and as a result, we’ve put together a

legislative initiative we are introducing today entitled ‘‘The Hispanic Health Improvement Act of 2002.’’ While that legislation puts

forth several initiatives to address what are disproportionately Hispanic problems, it needs to be noted that each section of the bill,

including those to reduce the number of uninsured and to improve

access to care, would substantially improve the overall health of

our entire Nation, regardless of their race or ethnicity.

Let me just begin by introducing Representative Rodriguez. He

is our first witness to testify about the legislation and the issues

that he believes call on us to pass this legislation. It is a pleasure

for me to work with him jointly on this effort and we appreciate

him coming over for this testimony today. Why do you not go right

ahead, Congressman?

Before we begin I have a statement from Senator Clinton.

[The prepared statement of Senator Clinton follows:]

PREPARED STATEMENT OF SENATOR CLINTON

I am pleased that my colleague on this committee, Senator

Bingaman, and Representative Ciro Rodriguez have worked to

bring a much-needed spotlight to the important issue of healthcare

disparities among our nation’s Hispanic population. In fact, I believe that this issue deserves floodlights, given that minority health

barriers are a significant burden for millions of Americans of color

today.

In New York, the healthcare hurdles are truly disappointing and

the lack of access to healthcare must be addressed. For example,

nearly 30 percent of Latinos in New York were uninsured from

1999-2000, and nationwide, there are currently 1.1 million uninsured Hispanic children in the U.S., compared to 806,000 uninsured white children or 703,000 uninsured black children.

The prevalence of health disparities speaks to a complex, multilayered problem with many causes, including a need for education

on part of healthcare providers, a need for greater awareness

among patients, discriminatory actions, and inaccessible or

unaffordable healthcare options. The public health risks that result

from unchecked illnesses are far costlier and more troubling than

education programs, outreach initiatives, or cultural training in

healthcare facilities or universities. Perhaps the costliest, most intolerable expense is an expanding number of unhealthy, Hispanic

families and children.

In my home state of New York, Latino constituents face multiple

challenges on a daily basis. We have heard often from community

health workers who stress the importance of recognizing the

unique health struggles that the heterogeneous Latino population

experiences from neighborhood to neighborhood, community to community, whether Puerto Rican, Mexican, Dominican, or Columbian.

While some communities may battle asthma, another may battle

diabetes. In Buffalo for example, Hispanics are likely to stiffer from

3

asthma because of the region’s extreme weather and the prevalence

of older homes, whereas in New York City, though Hispanics make

up 24 percent of the city’s population, Hispanics also account for

31 percent of all the city’s reported AIDS cases.

However, if we look closely enough, common barriers emerge as

well. Many Hispanics experience language barriers, which can compromise the quality of their care. Cultural barriers in certain communities have engendered mistrust of healthcare providers. Worse

still, some may feel a lack of entitlement to visit a physician in

their time of need. Even if these obstacles were removed, without

health insurance coverage, families will never access high-quality,

affordable, accessible health care. Currently. Hispanics represent a

disproportionate percentage, one-quarter. of the 44 million Americans who are uninsured. If these conditions continue, a growing

number of Hispanics will continue to be without medications or

professional assistance.

While the numbers may project a grim outlook, Senator Bingaman and Representative Rodriguez have certainly taken a strong

step toward a creating brighter, more productive future for the Hispanic population in this nation by meeting their healthcare needs.

It is certainly time for steps to improve bilingual services, educational and outreach field programs, and training the next, truly

diverse generation of physicians and nurses.

I firmly believe that this gap in care must be addressed immediately. I am committed to addressing this disparity as well as educating patients and healthcare professionals about this injustice in

our healthcare system.

STATEMENT OF HON. CIRO RODRIGUEZ, A REPRESENTATIVE

IN CONGRESS FROM THE STATE OF TEXAS, AND CHAIRMAN,

CONGRESSIONAL HISPANIC CAUCUS

Mr. RODRIGUEZ. Thank you, Mr. Chairman. Let me first of all

take this opportunity to thank you for the invitation for this historic hearing on Hispanic health. I am currently serving as the first

vice chair of the Congressional Hispanic Caucus and chairman of

the Task Force on Health and looking forward to becoming the

chairman of the caucus. So I want to thank you personally for allowing us to come before you and I do feel that this is a historical

hearing in terms of the fact that we have an opportunity to talk

about health care as I impacts Latinos throughout this country.

In my own district, which stretches from San Antonio to the

Mexican border, over 60 percent of my constituency is Hispanic.

One of my border counties, which is Starr County, is about 98 percent Hispanic and Starr County unfortunately is also the poorest

county in the Nation. It has over 44 percent that live in poverty.

It is truly an honor to be here with you, Senator, and I have enjoyed working with you and look forward to continuing to work

with you. I would like to extend special thanks to also Senator

Kennedy and yourself and your staff for their hard work that has

brought us to this day.

In addition, I would like to recognize the witnesses in the next

panel, especially of our own hometown, Dr. Francisco Cigarroa of

the University of Texas Health Science Center at San Antonio. I

have worked with Dr. Cigarroa on a variety of issues and consider

4

him a leader in health care at both the local and national levels.

Dr. Cigarroa is the first Hispanic to ever be president of an institution regarding health, so we are real pleased to have him there in

San Antonio.

As you also know, September 15 marks the beginning of Hispanic

Heritage Month. The many events of this month mean little if we

cannot have some positive change, and that is with regard to policies, so I want to thank you for bringing up the legislation as it

deals with health during this particular month.

Today’s hearing represents an important part of that whole equation and our celebrations of Hispanic Heritage Month but I commend the subcommittee for the desire to learn more about what I

consider to be a national emergency, the status of Hispanic health.

I will focus on what I believe are the three most critical and comprehensive areas of need. First, we need to dramatically expand

health care coverage for the growing Hispanic population. Second,

we need to improve access to services for Hispanics in areas of particular need, such as diabetes, AIDS and border health, including

mental health. Third, we need to build a health profession system

that will reduce health disparities in the long run through improving training opportunities, as well as educational opportunities.

On improving coverage, the 2000 Census revealed what many of

us already knew, and that is that the Hispanic community has

grown by leaps and bounds over the past decades. Hispanics are

now the fastest growing community in the United States, making

13 percent of the U.S. population, yet Hispanics make up 23 percent of the uninsured population. Nearly 37 percent of Hispanics

under the age of 64 are uninsured. Sadly enough, 31 percent of the

Hispanic children are uninsured.

Research shows that about 87 percent of the uninsured Hispanics

come from working families. These are families that are working

hard trying to make ends meet and yet find themselves uninsured.

Additionally, only 43 percent have employer-based coverage compared to 73 percent of Anglos. Close to 60 percent of Hispanic families have annual incomes less than 200 percent of the Federal poverty rate. Access to affordable, quality health care is challenging.

This includes economic challenges, language barriers, cultural differences, citizenship status. Even location plays a key role and we

know that it is a direct relationship to health disparities.

A recent report of the National Institutes of Medicine outlined

four areas that contribute to the health disparities. One of these

areas is the language barrier. The second is the inadequate health

coverage; the third, health care provider biases, as well as the

fourth, which is the lack of minority physicians. In addition, the report showed that even when controlling for factors such as access

to care, racial and ethnic health disparities still exist.

This report documents what health care advocates have been

talking about for years. There is a level of unequal treatment for

racial and ethnic minorities in health care systems. We need to target public health changes to reverse these trends in both the short

term and the long-term. I believe we can do so by greatly expanding insurance and other coverages, by also addressing specific diseases that disproportionately impact Hispanic communities, and

also by making institutional changes in our health professions and

5

training so that more doctors become sensitive to the particular

needs of the Hispanic community.

The Hispanic population encounters many of the diseases at

rates that are far beyond their numbers in the population. We need

to improve access to affordable treatment in these specific areas if

we are serious about addressing the needs of Hispanic health. I

have included greater detail in the written testimony but I would

like to be able to mention a few of the items that disproportionately

hit and these diseases, such as diabetes, HIV/AIDS, and along the

border with Mexico, Hispanics also encounter unusual high levels

of infectious diseases, such as tuberculosis and hepatitis.

About approximately 10.2 percent of all Hispanic Americans have

diabetes. For those that are 50 and over, about 30 percent have diabetes. Worse yet, Type 2 diabetes is spreading among Hispanic

youth. According to the Centers for Disease Control, Hispanics account for 18 percent of the cumulative AIDS cases and 20 percent

of the total AIDS cases among women and 23 percent of the total

AIDS cases among children. In 1999, Senator, approximately 19

percent of the new AIDS cases were among Hispanics.

Hepatitis A also, which is mainly spread through unclean food

and water migration, is two or three times more prevalent along

the border than in the U.S. as a whole. We still have the need for

infrastructure development when it comes to potable water. We

still have people we call the water haulers that are hauling water

in buckets and they still need those services. And I am not talking

about the other side of the border; I am talking about on the U.S.

side.

One-third of the new TB cases also in this country are in the border States. While the challenge seems daunting, I am confident

that we have resources and the passion to change those outcomes.

This past August we helped organize the first National Hispanic

Health Leadership Summit in San Antonio, TX. Dr. Richard

Carmona, the new U.S. Surgeon General, delivered a striking keynote address on the need for ensuring that all sectors of society

have access to health care services. We were joined also by a selected group of over 150 health experts nominated from across the

country by partners that also helped to participate in this conference. Participants navigated through a series of facilitated workshops to build consensus on program and policies that can be delivered and enhanced to improve the quality of health care delivery

to Hispanics in the United States for the next 5 years.

This leadership summit was sponsored by the National Hispanic

Medical Association with the Congressional Hispanic Caucus serving as an honorary chair. Dr. Elena Rios, president of the National

Hispanic Medical Association, should be commended for her leadership and her hard work in making the summit a success. I am sure

she will share some of her thoughts on the leadership summit during her testimony.

However, I want to highlight some of the recommendations that

came from the eight workshops that were done. The recommendations included increasing outreach and enrollment in Federal programs by creating State initiatives for community-based outreach

programs, not only for AIDS but also in the area of SCHIP and

Medicaid enrollment and high uninsured populations. Second, inVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
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fusing cultural competencies into medical literacy and medical

error debate. Third, building workforce capacity to deliver quality

health services, including interpreters and promotoras. Third, creating a Federal clearinghouse for health information and a regular

report on the status of Hispanic health in this country. And finally,

building community-based Hispanic research, just to name a few.

A report is going to be put together and the recommendations are

going to be laid out and we look forward to continuing to work with

you but I am pleased that the Hispanic Health Improvement Act,

of which you are the main author and I want to thank you, Senator, incorporates a lot of the concerns that were raised during that

summit, and that is why I have taken the time to mention that

summit, because it took people from throughout the country to address those issues.

Congressional action is needed to address the needs of the Hispanic community so Senator, I want to thank you for introducing

the legislation entitled ‘‘The Hispanic Health Improvement Act of

2002.’’ I will also introduce the companion bill tomorrow in the

House, since it turns out that we are not in session today. This

landmark legislation, as you well know, is based on the previous

Hispanic Health Care Act that we had introduced in the 106th

Congress and on existing legislation that you yourself have had

and you have championed in the Senate.

In addition, we have taken some of the Federal recommendations

from the Hispanic Health Leadership Summit and incorporated

them into what I consider to be one of the most comprehensive bills

aimed at improving Hispanic health in the United States. The legislation offers a variety of different strategies for expanding health

care coverage. It helps to improve access and affordability and

helps to reduce health disparities. While I consider each provision

in our bill to be important, I am just going to highlight some of the

important things that I think are urgent ones.

In order to address the lack of health care and coverage, the leg- islation provides $33 billion between fiscal year 2003 and 2010 for

the expansion of the successful State Children’s Health Insurance

Program or SCHIP, to cover the uninsured low income pregnant

women and parents.

In addition, it provides States the option to enroll legal immigrant pregnant women and children in Medicaid and SCHIP. The

Congressional Hispanic Caucus considers the expansion of Medicaid and SCHIP eligibility to those that are here legally critical legislation as a priority, so we want to thank you in those efforts.

Second, the title also deals with access and affordability. Our bill

requires an annual report to Congress on how Federal programs

are responding to improving the health status of Hispanic individuals with respect to diabetes, cancer, asthma, HIV infection, AIDS,

substance abuse, and mental health. The legislation provides $100

million targeted to diabetes prevention, education, and school-based

programs and screening activities in the Hispanic community.

Similarly, the bill also provides for targeted funding for programs

aimed at prevention of suicide among Hispanic young ladies. We

found some alarming data and research that shows that Latina

young ladies are committing suicide at alarming rates and so I

want to thank you for including that in your legislation.

7

Targeted grants also will be available for funds also to provide

support for promotoras, improving the health of women and families in medically underserved areas, such as the border.

The third title focuses on the reduction of health care disparities

by addressing the lack of providers who provide for the culturally

competent and linguistically appropriate care. The bill also provides for increasing funding for the HRSA’s health professions diversity programs. And, as you well know, the president’s 2003

budget proposal eliminates virtually all the funding for these important programs that are drastically needed in our community

and throughout our country.

In addition to promoting diversity, these programs support the

training of health professionals in the fields experiencing shortages, such as pharmacy, dentistry, allied health, as well as nursing, and promoting access to health care services in medically underserved communities. The Hispanic Caucus considered increased

funding for these programs a high priority. As the Hispanic community continues to grow, the implementation of these provisions

will take on an even greater importance.

Mr. Chairman and members of the subcommittee, I ask for your

support of the Hispanic Health Improvement Act and I want to

thank you for your leadership in this area.

And I just want to close by indicating the importance of the cultural relevancy. When I first heard testimony and we allowed individuals to come before us in the year 2000, we had a lady who basically testified that she had been told, and she testified in Spanish

and indicated to us that she had been told that she was positive,

positiva, when it came to AIDS and she understood that as being

positive, that everything was okay. And when she had a baby, her

baby contracted AIDS, not knowing full well that she had AIDS.

She had misunderstood her doctor when she was told that she did

have it. So by indicating that she was positive, positiva, for AIDS,

that was interpreted as being positive, so everything was okay, versus the other.

So when we hear stories like that of what continues to occur, it

only emphasizes the need for us to continue to reach out, the need

for us to continue to provide the education that is needed and the

interpretation that is required and especially when we are dealing

in cases of mental health and psychiatric help where those interpretations even become more critical.

Mr. Chairman, thank you for your leadership. I look forward to

continue working with you and I really do appreciate your hard

work in this area. Your staff has done a tremendous job and I want

to thank you for being there for us and for all Americans. Thank

you.

Senator BINGAMAN. Well, thank you very much, Congressman

Rodriguez. I think your leadership is absolutely essential for us to

succeed with this legislation, so we very much appreciate it.

Let me also just acknowledge Bruce Leslie, who used to be in the

House, on the staff there, and has been working here with me in

the Senate now for some time. He, of course, is from the border,

as well, and understands these issues very well, as well as understanding the way the Congress functions.

8

So we are anxious to move ahead and I will not pose a series of

questions to you at this point. I think it is clear to both you and

me what the real questions are here. We have five very distinguished witnesses on the next panel and I am looking forward to

hearing what they can contribute to this effort.

But again thank you very much and we will continue to work

with you in the remaining weeks of this session and then into the

next Congress, as well.

Mr. RODRIGUEZ. Looking forward to working with you, Senator.

Thank you very much.

[The prepared statement of Mr. Rodriguez may be found in additional material.]

Senator BINGAMAN. Why do we not go ahead with the second

panel and let me ask all five witnesses to come forward. Dr.

Cristina Beato, Dr. Francisco Cigarroa, Dr. Glenn Flores, Dan

Reyna, and Dr. Elena Rios.

Let me give a little more complete introduction for each of these

witnesses before they begin their testimony. First let me welcome

Dr. Cristina Beato, who is the Deputy Assistant Secretary for

Health. I am happy to add that she comes from my home State of

New Mexico, which we are very proud of, and served as the chief

medical officer at the University of New Mexico Health Sciences

Center.

Next to her, Dr. Cigarroa, Dr. Francisco Cigarroa, who is the

president of the University of Texas Health Sciences Center at San

Antonio. Congressman Rodriguez referred to Dr. Cigarroa. He is

the Nation’s first Hispanic president of a medical school and a renowned pediatrician and transplant surgeon. We very much appreciate you being here.

Dr. Glenn Flores has recently published an outstanding report as

lead author of the Latino Consortium of the American Academy of

Pediatrics Center for Child Health Research in the Journal of the

American Medical Association or JAMA entitled ‘‘The Health of

Latino Children,’’ so we very much appreciate you being here.

Dan Reyna, who is the head of the Border Health Office for the

New Mexico Department of Health and has initiated a number of

outstanding and successful projects in the southern part of our

State with far too few resources, I would point out, but has done

a wonderful job in spite of that. He is also past president of the

U.S.-Mexico Border Health Association.

And our final witness is Dr. Elena Rios. She is the president of

the National Hispanic Medical Association and chief executive officer of the Hispanic-Serving Health Professionals Schools, Inc.

Thank you very much for being here.

Why do we not just go right across and we will hear from all of

you? If you could summarize your testimony, that would be most

appreciated. We will include the complete statement that you have

submitted in the record but if you could make the main points that

you think we should be aware of and then I will have a few questions.

Dr. Beato, go ahead.

9

STATEMENTS OF DR. CRISTINA BEATO, DEPUTY ASSISTANT

SECRETARY FOR HEALTH, U.S. DEPARTMENT OF HEALTH

AND HUMAN SERVICES, WASHINGTON, DC.; DR. FRANCISCO

CIGARROA, PRESIDENT, UNIVERSITY OF TEXAS HEALTH

SCIENCE CENTER AT SAN ANTONIO, TX; DR. GLENN FLORES,

CHAIR, LATINO CONSORTIUM OF THE AMERICAN ACADEMY

OF PEDIATRICS CENTER FOR CHILD HEALTH RESEARCH; DIRECTOR, COMMUNITY OUTCOMES, AND ASSOCIATE DIRECTOR, CENTER FOR THE ADVANCEMENT OF URBAN CHILDREN, DEPARTMENT OF PEDIATRICS, MEDICAL COLLEGE

OF WISCONSIN, MILWAUKEE, WI; DAN REYNA, DIRECTOR,

BORDER HEALTH OFFICE, NEW MEXICO DEPARTMENT OF

HEALTH, LAS CRUCES, NM; AND DR. ELENA RIOS, PRESIDENT, NATIONAL HISPANIC MEDICAL ASSOCIATION, WASHINGTON, DC.

Dr. BEATO. Thank you, Senator. Good afternoon. I am Cristina

Beato. I am Deputy Assistant Secretary for Health and I want to

thank you, Senator Bingaman and the other members of the Subcommittee on Public Health, for the invitation to testify at this important hearing on the health care needs of our Hispanic population. In my testimony today I will primarily focus on the efforts

of President George Bush and Secretary Tommy Thompson to

eliminate those health disparities that disproportionately affect

Hispanic Americans.

The department recognizes that Hispanics are disproportionately

affected by certain health conditions, such as heart diseases, breast

cancer, unintentional injuries, diabetes, and HIV/AIDS. Additionally, Health and Human Services notes that Hispanics are also the

largest group without any health insurance coverage.

Under the leadership of Secretary Thompson, the department

has made elimination of racial and ethnic disparities a health priority. Departmental efforts focus on six major areas where minorities, including Hispanic Americans, experience serious disparities

in health access and outcomes: diabetes, heart disease, stroke, cancer, infant mortality, child and adult immunizations, and HIV/

AIDS.

Health and Human Services continues to support a vigorous,

broad-based public health response to HIV/AIDS that include extensive research, prevention initiatives, and efforts to expand access to quality health care and services for those who need them.

We are also working to address disproportionate impact of HIV/

AIDS on racial and ethnic minorities. African-Americans and Hispanics account for more than half of our Nation’s AIDS cases although they only represent 25 percent of our population. Department funds will continue to be used for expanded treatment, services, and community-based prevention activities HRSA Ryan White

Care and Treatment Programs, minority HIV/AIDS and Office of

Minority Health RC expanded technical assistance program for

HIV.

Prevention of diabetes is primary in our department. The National Diabetes Education Program, a joint program sponsored by

CDC and NIH, has reached 3.6 million Hispanics to date, with public service ads, media broadcasts, print media, including the Hispanic/Latino Campaign called ‘‘Mas que Comida es Vida,’’ meaning

10

‘‘More than Food; It’s Life.’’ It focuses on Hispanics who have diabetes or who are at high risk to develop that disease and this effort

is slated to continue for the fiscal year 2003.

Health and Human Services also started ‘‘Take Time to Care

About Diabetes,’’ another bilingual campaign to make more women

aware of the dangers of diabetes. ‘‘Cuide Su Corazon’’ is one more

campaign aimed at Hispanic Americans to help them understand

the need to control all aspects of diabetes and to help prevent heart

disease.

Through the Racial and Ethnic Adult Disparities in Immunization Initiative, known as READII, HHS will continue the two-year

demonstration projects in five sites to improve influenza and pneumococcal vaccination rates both in African-American and Hispanic

communities. San Antonio, TX, a predominantly Mexican-American

community, is one of the selected sites and the efforts in Chicago,

IL also target a significant Hispanic population. We know that immunization rates for adult Hispanics are at least 43 percent lower

than those of their non-Hispanic white counterparts. Over the 2

years, the READII project sites will collaborate with stakeholders

to develop and implement a community-based plan utilizing existing and innovative approaches.

Our department has developed a bilingual booklet to provide information to Spanish-speaking parents whose children may be eligible for health insurance benefits through the State Children’s

Health Insurance Program or SCHIP program and Medicaid. The

State agencies and others involved in SCHIP and Medicaid programs are encouraged to use the booklet to assist our Spanishspeaking residents to learn about the availability of free and lowcost health insurance programs for children in low-income families

through their State’s SCHIP program.

Secretary Thompson recently launched Healthfinder Espanol, a

Spanish-language Web site that helps consumers track down reliable health information quickly and easily on the Internet on our

Web site. By providing essential resources in Spanish, Health and

Human Services is creating a gateway for Spanish-speaking people

to learn about preventing and treating illness and developing a

healthy lifestyle.

Healthfinder Espanol brings together in one easy-to-use site

Spanish language health information on over 300 topics from 70

government agencies and nonprofit organizations, including the

health issues of the greatest concern to those of Hispanic heritage.

The site offers both a Spanish text search and a list of topics in

Spanish that can be browsed.

MEDLINEplus, the National Library of Medicine’s consumerfriendly health Web site, is also now in Spanish. The department

is using tools at its disposal to increase health education and

awareness to Americans across the country. MEDLINEplus en

Espanol is one more step to ensuring that Hispanic Americans

have real-time access to the important health information that they

need.

Vital to us are Community Health Centers. Health and Human

Services continues to support increased funding for the Community

Health Centers, which play a vital role in treating and serving the

health care of Hispanics. Last month Secretary Thompson anVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
11

nounced $30 million in grants to create 70 new and expanded

health centers. This is a vehicle to extend health care service for

people without health insurance. For fiscal year 2003 our department proposes to increase its funding of Community Health Centers to a level of $1.5 billion, a $114 million increase above the current year’s appropriation and $290 million above the funding level

of the last 2 years. This funding will add 1,200 new and expanded

health center sites over a five-year period and increase the number

of patients treated from 11 million to 16 million.

In terms of bilingual and bicultural services, Health and Human

Services continues to support principal demonstration grants

through the Office of Minority Health’s Bilingual/Bicultural Service

programs in communities to improve Minority Health Grant Programs. Both of these programs support the development of strategies geared at eliminating health care access barriers, improving

the coordination of integrated community-based screening, outreach, and other enabling services of the Spanish-speaking individuals.

The U.S.-Border Health Commission, created in July of 2000 by

joint action of the United States and the Mexican governments, exemplifies our department’s commitment to a binational framework.

The goals for the Commission are as follows: to create ‘‘Healthy

Borders 2010’’ objectives and health indicators pertinent to the region; to provide international leadership; and to optimize the

health and quality of life along the U.S.-Mexico border. Secretary

Thompson, who co-chairs the commission with the Mexican Minister of Health, has made border health a priority for our department.

A Healthy Border 2010 program was recently launched by the

BCH to promote and improve the health of people living on the

United States-Mexico border region. The two major objectives of

this program are to increase and improve the quality and the years

of healthy life and to eliminate health disparities. A Border Commission office now operates out of El Paso, TX and funding is provided to support the BCH objectives.

Recently, Secretary Thompson and the Mexican Minister of

Health signed a cooperative agreement to enhance the safety of

food supplies in both of our countries and to reduce the incidence

of food-borne illnesses on both sides of the border through improved

inspections. Other projects that address health issues along the

U.S.-Mexico border include HRSA’s HIV Border Health Initiative

and the HRSA and NIH Salud para su Corazon, a project to reduce

heart disease, and HRSA’s Workforce Diversity Border Initiative,

‘‘Building a Workforce for a Health Border.’’

Like Congressman Rodriguez said, Health and Human Services

Centers for Medicare and Medicaid Services funds researchers, including Hispanic researchers, to conduct research on access, utilization, quality of service, and activities related to health screening,

prevention, and education of Hispanic Medicare and Medicaid

beneficiaries.

The National Center on Minority Health and Health Disparities

at NIH is authorized to promote minority health and to lead, coordinate, support and assess the NIH effort to reduce and elimiVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00015 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
12

nate health disparities. Addressing the health research needs of

Hispanics is a key activity of this center.

Promoting NIH minority health disparities research and health

disparity career opportunities for minorities is a major goal of

NCMDH. Since fiscal year 2001, NCMDH has operated two loan

repayment programs—the Loan Repayment Program for Health

Disparities Research and the Extramural Clinical Research Loan

Repayment Program for individuals from disadvantaged backgrounds. There is outreach to Hispanic health professionals and researchers for participation in these two pipeline programs.

Grants administered by the Centers of Excellence in HHS’s

Health Resources and Services Administration assist health professions schools to support programs of excellence in health profession

education of minority individuals in allopathic and osteopathic

medicine, dentistry and pharmacy, graduate programs in behavioral or mental health, including clinical counseling psychology,

clinical social work, marriage and family therapy. The Centers of

Excellence strengthen the national capacity to train students from

minority groups that are underrepresented in these health professions and build a more diverse health care force. HRSA currently

supports 11 Hispanic Centers of Excellence.

In August of 2001 Secretary Thompson launched the Health Insurance Flexibility and Accountability waiver initiative to encourage States to expand access to health care coverage for low-income

individuals through Medicaid and State Children’s or the SCHIP

demonstrations. This initiative gives the governors more tools and

flexibility to coordinate State Medicaid and SCHIP programs and

offers a simpler application for States that commit to reducing the

number of people without health insurance. Thousands of Hispanic

Americans living now in California, New Mexico and Arizona,

among other States, now enjoy the ability to expand health insurance benefits as a result of waivers granted to their States under

the secretary’s initiative.

President Bush also has health insurance tax credits because the

absence of health insurance coverage for some 40 million Americans, including many that are Hispanic Americans, is a problem

calling for an immediate solution. The president in his 2003 budget

sets forth a package of solutions including, most importantly, a proposal for the use of tax credits to offset the cost of obtaining health

insurance. This proposal has received broad bipartisan support. If

enacted, it can lead to a significant reduction in the uninsured population and, at the same time, lead to improvements in the market

for individually purchased health insurance, greater choice and

flexibility for individuals for determining the coverage that best fits

their needs, and improving quality and price of health care provided not just to Hispanic Americans but to all Americans.

In closing, I have provided a snapshot of some of the president’s

and the secretary’s activities that focus on eliminating health disparities that disproportionately affect Hispanic Americans. Our department is making progress but we know that more can be done

and we will continue to do more in order to lessen the social and

economic burden of not improving the health status of Hispanic

Americans.

13

Again, Senator, I thank you for the opportunity to testify before

you today. Thank you.

Senator BINGAMAN. Thank you very much.

[The prepared statement of Dr. Beato may be found in additional

material.]

Senator BINGAMAN. Dr. Cigarroa, why do you not go right ahead?

Dr. CIGARROA. Senator Bingaman, I thank you very much for inviting me to speak and testify before this important subcommittee

but I would also like to give my appreciation to Congressman Ciro

Rodriguez, who has really been a tremendous leader in addressing

health disparities and health challenges in South Texas.

Senator BINGAMAN. Congressman Rodriguez, why do you not

move up here beside me? There is no reason to be clear down at

the end. I did not even see you sitting there. Please come over here.

We have plenty of room right up here at the front.

Go right ahead, Doctor.

Dr. CIGARROA. Sorry, Ciro.

Well, what I would like to do is discuss this testimony the subject

of Hispanics and the health professions. I have given written testimony so I would like to just summarize this in about five minutes.

The University of Texas Health Science Center is the academic

health center responsible for the vast South Texas border region,

which comprises more than 4 million people, almost 25 percent of

the land mass of the State of Texas. Our Health Science Center has

five schools but in addition to that, it has a regional academic

health center which resides right on the U.S.-Mexico border region.

We have been responsible for educating more than 15,000 health

professionals since the inception of the Health Science Center in

San Antonio and many of those health professionals have chosen

to practice in communities which are largely Hispanic. There is no

doubt that our role is extremely important to South Texas because

many of these regions in South Texas are among the most medically underserved. And Congressman Rodriguez actually cited

Starr County, which is probably the most medically underserved

region in this Nation.

We also have clinicians and scientists whose great interest is

really addressing diseases that affect the border population, predominantly diabetes and infectious diseases.

I would like to touch upon some of the challenges we face in

South Texas as we address the issues of Hispanic health. One of

the greatest challenges, and I do not believe anybody here will disagree on this, is that the shortage of Hispanics in the health professions is among our greatest challenges. If we want to improve

the health care of the Hispanic population, then it is essential that

we educate more Hispanic health care professionals. And if we

want to educate more Hispanic health care professionals, then we

must provide more role models for the Hispanic population in

South Texas and along the U.S.-Mexico border region.

So it is important that we provide these mentors and send these

young students encouraging messages at an early age. I have been

truly fortunate because my father, my grandfather and my uncle

were practicing physicians in South Texas and I remember very

clearly just about 25 years ago traveling with my uncle around the

surrounding communities of South Texas because he was the only

14

general surgeon in these communities. That was only 25 years ago

and we have done a lot to improve that but it is still extremely

medically underserved.

Also firsthand I realized the importance of being sensitive to cultural competencies and also the importance of being able to be bilingual in such an area.

So really it was these topics that I was actually addressed with

at home, growing up in this environment, that really set the stage

for myself. It set the stage to develop high goals, to leave Laredo,

among one of the poorest public school systems in the United

States, but to have the courage to become educated and among one

of the greatest educational centers in our Nation and among some

of the greatest residencies in our Nation. And it was these experiences that gave me the great desire to return to South Texas and

contribute to the education of health care professionals along the

U.S.-Mexico border region.

There is no doubt in my mind that if it was not for these important mentors that I had growing up in South Texas, I would not

have become a pediatric surgeon; I would not have become a transplant surgeon; I would not have returned to South Texas. But it

was these global experiences that I had that also gave me the courage to become the president of an academic health center.

I know firsthand that there are many young, bright, capable students that have not had the privilege that I have had to be able

to discuss health and the health professions around their dinner

table. So I personally recognize the importance of stimulating the

scientific interests of students long before they reach undergraduate or graduate school.

So at the Health Science Center we place a great emphasis on

these pipeline issues. One of our most successful programs is the

Med/Ed program, which I believe should be replicated in cities

around this Nation. This is a program which introduces young students from South Texas to the health professions by introducing

them at a very early age to physicians, to clinics, to our own Health

Science Center in San Antonio, and through that means hopefully

providing that stimulating experience that inspires youngsters to

enter the health professions and also to build big dreams.

As the students who have participated in the Med/Ed program

begin to graduate from college and enter the health professional

training, we are seeing successes. Since 1997 more than 750 high

school students have been a part of this program and now the first

class is beginning to graduate and more than 75 of these students

are entering the health professions and many of these students will

again practice in South Texas.

We are also very proud that through Med/Ed we have actually

established three Hispanic Centers of Excellence at the Health

Science Center—one in the medical school, one in the dental school,

and one in the school of nursing. There is no doubt that we have

a commitment to providing role models and that commitment was

demonstrated this past June when we established the Regional

Academic Health Center in Harlingen, TX. That opening ceremony

of the Regional Academic Health Center, at which 48 of our medical students are educated right along the U.S.-Mexico border region, in that 1 day we nearly doubled the number of MexicanVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00018 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
15

American physicians who serve as faculty at academic health centers in this Nation. Again the importance of establishing mentors

and individuals which the younger generation can aspire to become.

We are proud of these interventions we provide at the Health

Science Center but we also know that the number of Hispanics who

graduate from college is unacceptably low and this statistic is

worse the closer you get along the U.S.-Mexico border region.

As the demographics change in our Nation, if we do not change,

these two divergent trends—a rising Hispanic population and a

small number of Hispanic college and postcollege graduates—then

we are on a collision course. Unless we reverse the college and

postcollege success rate of underrepresented minorities, the future

and the health of our Nation are in jeopardy.

Our major challenge in reversing these statistics, of course, is

funding. Our past funding has allowed us to implement many of

these wonderful programs which I have commented upon but in fiscal year 2003 we face the possibility not only of a funding shortfall

but possibly even a virtual elimination of the current level of funding for Title VII health professional training programs. Now to discontinue this funding now would be to discontinue our progress

now, which would take us a step away from the goal that we want

to achieve.

Now there exist many more issues that are critical to Hispanic

health. Those are paucities of nursing and allied health professionals along this border region. There is also a severe shortage of

these professionals in our Nation, but it certainly worse in Hispanic areas. And there also exist diseases, as Congressman

Rodriguez has stated, such as diabetes, multidrug-resistant tuberculosis, that affect this border region so significantly. So we also

not only need to encourage students to enter the health professions

but we also need to encourage students to enter the field of biomedical science.

I, too, Congressman Rodriguez, agree with the report issued by

the Institutes of Medicine that calls for the government to recognize and reward academic health centers that actively recruit and

support well trained faculty and students who are from underrepresented minority populations. If we fail to take steps to address

the gap between the health of the majority population and the

health of the Nation’s rapidly growing minority population, then we

are on a course leading to an unhealthier Nation. The bill, Senator

Bingaman, that you are considering contains much that would be

of great assistance as we continue to progress toward many of the

goals that the Health Science Center and many other academic

health centers are making.

In Texas we know all too clearly that diseases care nothing about

borders. Just as there are rivers of commerce, there are rivers of

infectious diseases and though they may start at the border, they

are eventually seen all the way to our northern border which we

share with Canada.

I personally applaud you, sir, for the concern that you have for

the situations that we face along the U.S.-Mexico border, situations

which if left unchecked, will have a major impact on the State of

Texas and on our Nation. So I thank you, sir, for the opportunity

16

to present this testimony to this important and distinguished subcommittee and certainly a more formal statement is made in my

formal testimony.

Senator BINGAMAN. Thank you very much for that excellent testimony.

[The prepared statement of Dr. Cigarroa may be found in additional material.]

Senator BINGAMAN. Dr. Flores, we are glad to have you here.

Dr. FLORES. Thank you very much, Senator. I chair the Latino

Consortium of the American Academy of Pediatrics Center for

Child Health Research. I am a pediatrician who has cared for disadvantaged children for over 10 years, a researcher who studies

how to improve the health of America’s children, and a faculty

member at the Medical College of Wisconsin. I am pleased and

honored to be here today.

I am going to talk about kids. I will discuss the demographic

surge in our Nation’s Latino children, highlight urgent priorities

and unanswered questions in Latino children’s health, and show

why the Hispanic Health Improvement Act or HHIA would improve

the lives of millions of American children. For extensive details and

113 references on what I will discuss today, I refer you to my written testimony and an article of ours published in the Journal of

American Medical Association in July 2002.

Latinos are now the largest minority group of children in the

United States, numbering 12 million and comprising 17 percent of

the population under 18 years of age. In California Latinos surpassed whites as the largest racial and ethnic group of children in

2000 and by 2010 half of California’s children will be Latino.

Latinos are one of the youngest and fastest growing groups in our

Nation. Despite this dramatic population growth, Latino children

continue to experience a disproportionate burden of illness, injuries, impaired access to health care, and health disparities.

Here is a true story. Maria was a three-year-old Latino girl

brought to the emergency room because of severe stomach pain.

Maria’s mother spoke no English and no medical interpreter was

available. A pediatrician examined Maria and discharged her with

a diagnosis of colic. An hour later Maria’s parents brought her back

to the emergency room because her pain had worsened. The same

pediatrician examined her and Maria’s mother found the physician

to be quite angry. Maria’s father was upset because no interpreter

was available and he felt Maria was treated poorly because his

family was Latino. The pediatrician sent Maria home again.

Several hours later Maria and her family returned to the emergency room. Maria’s condition had deteriorated and was not quite

serious. The pediatrician hospitalized Maria immediately. In the

operating room Maria was found to have a perforated appendix and

peritonitis. Maria was hospitalized for 30 days because of complications, including two infections of her surgical incisions. Maria had

no health insurance.

The issues faced by Maria and her family typify those confronting millions of U.S. Latino children and their families. Maria’s family spoke no English. 44 million Americans speak a language other

than English at home and 19 million are limited in English proficiency, or LEP. Latino parents cite language barriers as the single

17

greatest obstacle to health care access for their children but medical interpreters frequently are not called when needed, inadequately trained, or simply not available at all. Only a few States

provide third-party reimbursement for medical interpreters and

only one-fourth of hospitals actually train their interpreters.

The HHIA would provide Medicare and Medicaid reimbursement

for hospital interpreters and fund identification and training of bilingual health professionals. All third-party payers should reimburse for medical interpreters because we can either pay a little

now for high quality medical care for all children or pay a lot more

later when preventable medical errors, hospitalizations, lawsuits

and deaths result because no interpreters were available.

The Office of Management and Budget estimates that providing

adequate language services to all LEP Americans would cost $4.04

per visit, a 0.5 percent annual increase in national health care expenditures. Medical Spanish classes should be mandatory in medical schools in States with large Latino populations and health care

institutions should require that all medical interpreters undergo

fluency testing and proper training.

Maria had no health insurance coverage for her 30-day hospital

stay. Latinos are far more likely to be uninsured at 25 percent than

any other group of U.S. children. In comparison, 7 percent of white

and 14 percent of African-American children are uninsured. SCHIP

efforts to enroll Latino children have largely been unsuccessful.

Only 26 percent of parents of uninsured children ever obtain information about Medicaid enrollment and 46 percent of Spanishspeaking parents are unsuccessful at enrolling their uninsured children in Medicaid because materials are unavailable in Spanish.

Additional research is needed on effective interventions for insuring uninsured Latino children and the HHIA would be a giant step

forward because it would provide grants to promote innovative outreach and enrollment.

Maria’s story emphasizes the importance of culturally competent

health care. Failure to consider cultural issues in health care can

result in dissatisfaction, medical errors, inadequate pain management, fewer prescriptions, and use of harmful remedies, but cultural competency training is still not an integral part of educating

health professionals, with only 8 percent of U.S. medical schools offering separate courses on cultural issues and only 26 percent

teaching about Latino cultural issues. Cultural competency training should be mandatory in health profession schools and continuing professional education. The HHIA would enhance provision of

culturally competent health care by creating a national center for

cultural competency responsible for providing educational materials

and programmatic assistance.

The physician that cared for Maria was not Latino. Latinos are

underrepresented in all health professions. Although 17 percent of

children are Latino, only 3 percent of medical school faculty, 5 percent of pediatricians, 3 percent of dentists and 2 percent of nurses

are Latino. To match future population growth, our Nation would

need twice as many Latino physicians but minority medical school

enrollment recently fell. These trends are alarming because Latino

communities are more likely to have physician shortages and

18

Latino physicians significantly more often care for Latino and uninsured patients.

We need programs targeting minority students interested in the

health professions at an early age. The HHIA’s Health Career Opportunity Program and Hispanic-Serving Health Professions

Schools Grants are excellent examples.

Latino children like Maria frequently receive a lower quality of

health care. In children hospitalized for surgical correction of serious limb fractures, whites receive significantly higher doses of narcotic pain medications than Latinos. Other noteworthy health disparities for Latino children include the highest rates in U.S. children of tuberculosis, cavities, unintentional injuries, suicide in adolescent girls, obesity in boys, and asthma in Puerto Rican children.

More research is needed on why health professionals treat minority

children differently and effective interventions for eliminating

health disparities. Mandatory medical school cultural competency

courses examining health disparities are a critical first step.

Because Latino children are frequently not included in medical

research, we need mechanisms to ensure better recruitment. Federally funded research should always include methods to recruit and

appropriately study diverse populations, including educating minorities about clinical trials, recruiting non-English speakers and

immigrants, and collecting and analyzing data by race and ethnicity. The HHIA includes several important mechanisms for reducing health disparities for Latino children.

In conclusion, one out of every six American children is Latino.

It’s time for our health policies, services, and research to address

this dramatic demographic change, which can be accomplished by

one, ensuring all children and families with limited English proficiency have access to trained medical interpreters reimbursed by

third-party payers or bilingual health professionals; two, providing

all children with health and dental insurance; three, requiring cultural competency training for health professionals; four, increasing

the number of Latinos in health care professions; five, including

more Latino children in medical research; and six, eliminating

health disparities for Latino children.

The Hispanic Health Improvement Act would address all of these

issues and result in significant improvements in the health and

well-being of the 12 million Latino children in America. Thank you.

Senator BINGAMAN. Thank you very much for the excellent testimony.

[The prepared statement of Dr. Flores may be found in additional

material.]

Senator BINGAMAN. Next is Dan Reyna, who, as I indicated before, is director of the Border Health Office for the New Mexico Department of Health in Las Cruces. Dan, please go right ahead.

Mr. REYNA. Thank you, Senator Bingaman, Congressman

Rodriguez. I appreciate the invitation to be with you today. I appreciate also the opportunity to share some thoughts with you today

on the issues of Hispanic health as they affect this Nation and the

Hispanic heartland of the Southwest, the U.S.-Mexico border.

The U.S.-Mexico border is my neighborhood. It is a complex binational, bilingual, multistate, multicultural, multieconomic 10-State

region that stretches nearly 2,000 miles horizontally with no less

19

than five distinct vertical border regions that are more directly defined by those communities 100 kilometers on either side of the

international border. The border is an area with multiple public

health systems among the 10 States, local county jurisdictions and

two Federal Governments. Today it is, as Congressman Rodriguez

mentioned, most appropriate that the discussion of a new strategy

for the improvement of the Nation’s Hispanic health occurs during

our celebration of Hispanic Heritage Month.

The U.S.-Mexico border factors significantly in the overall Hispanic demographic picture, as is evident by the following and as

mentioned by some of the presenters. Half of all Hispanics live in

just two States—California and Texas. New Mexico has the highest

percentage of Hispanics of any State, at 42 percent, followed by

California and Texas at 32. New Mexico led all States in the percentage of people aged five and up who spoke Spanish at home, followed by Texas at 27 and California at 26 percent.

Targeting the health status improvement of the growing Hispanic population is both a public policy challenge and opportunity.

It is a true opportunity to engage in a systems approach that can

target long-term improvements in health status.

As to health care coverage, the New Mexico Border Health Office

has been a State partner with the Rural Health Office at the University of Arizona in Tucson since 1996 and the Health Resources

and Services Administration’s ‘‘Border Vision Fronteriza’’ Project.

Although the project began as an initiative to develop model outreach projects, the focussed shifted in 1999 toward outreach and

enrollment of children into Medicaid and SCHIP. The project for

the current funding cycle referred to as BVF II was funded for 1

year from October 2001 to September 2002.

The BVF II project is unique in New Mexico such that I refer to

it as an integrated program approach model. HRSA provided funds

taken from at least three internal program sources, since there was

no specific line item, to the University of Arizona who thereafter

subcontracted to a community nonprofit organization in Las

Cruces, NM to support the project in Dona Ana County, a border

county just north of El Paso County, Texas. The role of the Border

Health Office is to operate as the coordinating entity directing the

activities of the 13 partner agencies.

The BVF II project provides at least a half-time community

health advisor or promotora, Spanish for promoter of health, to the

primary partners, which includes a hospital outreach clinic, two

community health centers, a State public health clinic, a behavioral

health center, a juvenile criminal detention facility, and partial

support to a primary school. A key ingredient to our partnership

list is the active involvement of the local staff of the Income Support Division of the State Department of Human Services, the

State Medicaid agency and the leadership of the local, surprisingly

so, Immigration and Naturalization Service, INS, district office.

The New Mexico project was to receive nearly $79,000 for this fiscal year but program cuts will limit us to only $60,000. It is probable that funding may not be provided after the end of this month,

although we remain hopeful.

The effectiveness of this model approach for outreach and enrollment of children is evident in the results. For the project period of

20

January 1, 2000 to August 15, 2001, BVF I phase, the project in

Dona Ana County achieved 549 percent of its target. This amounted to direct processing of no less than 12 percent of all Medicaid

and SCHIP enrollments in the county. For the project BVF II from

October 2001 to September 2002, the project has to date, through

August of this year, achieved 190 percent of the target enrollments.

The legislation as proposed will provide $50 million to improve outreach and enrollment of children into Medicaid/SCHIP.

We are confident that the replication of the BVF-type programs

throughout the county will ensure that no child misses an opportunity to access the appropriate health care services. Using

promotoras as in the BVP model is cost-effective and appropriate

in targeting the Hispanic populations in need. It is a model they

recognize and accept. It has performed as advertised.

As to access, an example of a similar integrated program approach is that of the development of the Healthy Gente initiative

for the U.S.-Mexico border region. Healthy Gente—Gente is the

Spanish word for people—is a risk-population-targeted and outcome-based health planning initiative established by the U.S. State

Border Health Offices specifically designed to be compatible with

the United States Healthy People 2010 program. The Healthy

Gente program includes 25 Healthy Gente objectives that relate directly to the 46 national Mexican health indicators on the Mexican

side.

Progress in achieving the Healthy Gente objectives for the U.S.

border region is a significant challenge when you consider that if

the U.S. border region were a separate State it would rank last in

access to health care, first in the highest rates of uninsured, second

in deaths related to hepatitis, third in deaths related to diabetes,

first in the number of cases of tuberculosis with 34 percent of all

U.S. cases found in the four border States, first in children living

in poverty and last in per capital income. Additionally, the average

percent of uninsured for Hispanics in the four States of the border

exceeds 34 percent, as mentioned earlier, slightly higher than the

national uninsured rate for Hispanics at 32.

Diabetes, Senator, is a major chronic disease confronting the Hispanic population. It is one of the leading causes of death on both

sides of the U.S.-Mexico border.

The Las Cruces Sun News editorial of September 17 described diabetes as the ‘‘darkest cloud’’ upon the review of the recently released report on the Status of U.S. Health by the Department of

Health and Human Services. Diabetes, I contend, is essentially the

center of gravity for the Hispanic population in the U.S. Prevention

and control efforts require the maximum support at all levels. All

available means and approaches focussed on early screening and

diagnosis, including at the primary school age, require immediate

attention.

The U.S. Mexico border region is the unavoidable front line to

many of the growing and emerging public health challenges. The

funding of the border health initiatives at $200 million for fiscal

year 2003 will allow the stakeholders to address the problems in

their totality. Effective solutions require resources for prioritization

and coordination and strengthening of joint efforts and sustainability.

21

Adequate funding to the Border Health Commission—$10 million

for fiscal year 2003—will ensure strengthening its capacity to serve

as a platform from which public health problems can be assessed,

collective policy development coordinated and assurance of actions

adequately evaluated. The U.S.-Mexico Border Health Commission

is an appropriate venue to undertake these significant impact

issues of Hispanic health for the border region, developing and supporting bold interventions by local and State partners in areas such

as diabetes, substance abuse, and infectious diseases.

The utility and appropriateness of the promotora model has been

proven effective for the range of outreach and community support

activities. The approach is compatible with all Hispanic populations. It is, as I have referred to it at times, the ‘‘Mary Kay’’ approach to community health. It has worked throughout the country

and I ask that you support the requested funding of $5 million for

fiscal year 2003 through 2005.

As to health disparities, the emerging national demographics will

bring additional challenges in meeting the health manpower capacities needed by the increasing minority populations. Latinos, African-Americans and Native Americans account for about 25 percent

of the U.S. population yet they represent only about 6 percent of

practicing physicians in the United States, according to the report,

‘‘The Color of Medicine: Strategies for Increasing Diversity in the

U.S. Physician Workforce.’’ A quick look at the data on the availability of Hispanic faculty

in the health professions schools is no less than disturbing, as may

be seen by the following institutional self-reporting statistics on the

percentage of Hispanic faculty. As to medical colleges, Hispanic faculty make up 3.33 percent of all faculty, as to colleges of nursing,

1.3 percent, as to social work, 4 percent, dental, 3 percent. We cannot engage in a systems approach to addressing the health problems of the Hispanic population if we cannot open the doors to the

future and widen the hallways of opportunity for aspiring and

qualified health professions students and faculty.

It is no less a crisis for the next generation, considering the gestation time from high school graduation to medical practice, and

surely much more to reach for a medical or dental school faculty

position. It could take a half-century to reach 10 percent in any one

professional category, or possibly more. We should hope not.

Senator, Congressman, I thank you for the opportunity to be

with you today.

Senator BINGAMAN. Thank you very much, Dan, for that excellent testimony.

[The prepared statement of Mr. Reyna may be found in additional material.]

Senator BINGAMAN. Dr. Rios, you are the final witness today. We

are very pleased to have you here. Please go right ahead.

Dr. RIOS. Thank you very much, Senator and Congressman

Rodriguez. I am very honored to be here.

I just wanted to start out by saying I just flew in this morning

from California where I was with the California Latino Medical Association, which is a group that I was actually president of before

I came to Washington in 1993. And on Friday I was in San Diego

with a sponsored conference, along with our partner national

22

groups, the National Medical Association representing AfricanAmerican doctors and the American Association of Indian Physicians representing Native American doctors. And in both meetings

I think there is a lot of enthusiasm among the medical community

for the support of activities such as this bill that really show potential for how the health system can improve American health for all

Americans. And I just want to say that we are actively seeking

support for this bill.

The National Hispanic Medical Association represents licensed

Hispanic physicians in the United States. The mission of NHMA is

to improve the health of Hispanics. The Health-Serving Health

Professions Schools, Inc. represents 22 medical schools and three

public health schools and the mission of this organization is also

to develop Hispanic student and faculty and research capacity to

improve Hispanic health.

We all know Hispanics are now 14 percent of the U.S. population

and by the year 2050 one out of every four Americans will be of

Hispanic origin. In the case of Hispanic patients, as we have heard,

we are challenged by the language needs, literacy levels, lower levels of poverty and education, citizenship status, strong cultural beliefs and attitudes, family group decision-making, poor awareness

of public health programs or how to follow instructions that come

with complex treatment regimens, prescription drug labels, referrals for specialty care or elaborate x-ray preps and exams.

Our health system is the best in the world but in order to be

proud of that system the Hispanic Health Improvement Act of 2002

challenges the U.S. Senate to develop new strategies to improve

the quality of health care delivery that responds to the needs of

Hispanics.

In August, as Congressman Rodriguez mentioned, NHMA was

proud to co-sponsor, with the Congressional Hispanic Caucus and

the Department of Health and Human Services, the National Hispanic Health Leadership Summit. Also partners included the EPA,

the National Highway Traffic Safety Administration, the Robert

Wood Johnson Foundation, California Endowment, Amgen,

Aventis, PhRMA, GlaxoSmithKline, and several national Hispanic

organizations. One hundred and fifty health providers from Hispanic communities around the country and our partner representatives put forward several recommendations to improve programs

both at the Federal and State level and at the community level for

our private sector community-based organizations and many of

those recommendations overlap with issues addressed by this bill.

We will have a report on those recommendations this fall and I am

not going to address that here, just to say that we are very proud

to see people on the same page.

I would like to address proposed strategies that this bill addresses for the Department of Health and Human Services to continue

to improve health programs and activities targeted to Hispanics.

First of all, on access to care, I think we do know the major barrier to access is that two out of five Hispanics do not have insurance and this legislation addresses this barrier by creating grants

for outreach and enrollment and increasing eligibility for both

SCHIP and the Medicaid program and we applaud these efforts.

However, we also believe that employers need incentives that inVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00026 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
23

crease their ability to provide insurance, since smaller employers

who employ Hispanics cannot afford insurance benefits.

We also applaud the special programs that would be targeted at

families with limited English proficiency and we recommend that

there be reimbursement for interpreters added to this legislation.

Moreover, the U.S. Department of Health and Human Services,

currently reviewing its guidance to the Nation on LEP services

under Title VI and supported by the administration, should have

a clear and firm guidance to direct to our health providers. It is

critical that communication be enhanced between providers and patients and we are supportive of the Federal Government, representing the largest insurance programs in the Nation, taking the lead

in this area. We recognize the importance of this bill in moving this

area along.

We recognize the vision for the development of the reimbursement policy for LEP services for Medicaid program and SCHIP in

this bill and also recognize that the bill for the reauthorization of

community clinics introduced earlier this Congress also provides a

provision for reimbursement. We hope that there could be a strategy, perhaps starting with a Congressional task force, linked to the

future of Medicare, Medicaid and SCHIP on LEP services reimbursement and the evaluation of interventions to guide further policy-making.

In terms of the U.S.-Mexico border, it has already been addressed. The U.S.-Mexico Border Health Commission is very key

and has great potential to serve as a conduit for advancing many,

many health programs if properly supported and funded. It is also

critical that we investigate further research along the U.S.-Mexico

border.

In terms of disparities in health, it has already been mentioned,

all of the different areas—diabetes, HIV/AIDS, cancer, mental

health. I think we are especially aware of these new programs supported in this bill and would hope that it would include also the

patient navigator system, the community health workers, and the

Special Population Networks, such as Redes en Accion, that are

models right now for targeting chronic disease interventions in the

Hispanic communities.

In terms of diversity in the health professions, the U.S. Federal

Government has supported the national policy to recruit disadvantaged and minority students into the health professions since the

1960s. The literature has proven over and over again that the Federal Health Careers Opportunity Program has resulted in two to

three times the number of graduates practicing in medically underserved areas and Hispanic and black physicians provide more care

to their communities and to Medicaid and uninsured patients than

nonminority doctors. Surely we can recognize these programs as

successful.

In addition, in this era of increasing health care costs, we must

also consider that minority patients, who tend to be uninsured, will

eventually create more costs in the system as they demonstrate

chronic illnesses. Thus it is more effective for the health system to

finance recruitment programs for future minority doctors who can

provide targeted services. The consequences of not supporting miVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
24

nority health workforce development will be greater cost to the taxpayers of America, who would bear the brunt of shifting costs.

But even three decades of Federal funding of HCOP have not resulted in enough Hispanics in the health workforce. We are only

5 percent of the total physicians, 3 percent of the total dentists, 2

percent of the total nurses, and there are many, many reasons why

this is so. I think a major reason though is the limited support

from the health system for academic skills-building and admissions

preparation services available in minority community schools in

the grammar schools and in the high schools and the colleges. The

Federal Government and, I believe, the private industry and private businesses need to get involved in supporting HCOP at the

$40 million level that has been recommended in this bill.

So, too, the Congress should support the Center of Excellence at the $40 million level, which is the HRSA program that not only

continues the HCOP’s recruitment, but adds curriculum development and research and minority faculty development that is so

much needed for role models in our health professions.

Last in terms of health professions, I have to say that the concept of having special grants to those schools that are designated

as Hispanic-Serving Health Profession Schools is a unique opportunity for this country to recognize the importance of those schools

with important track records of having Hispanic students and having Hispanic faculty, that have the potential to promote much more

curriculum that is needed for the whole country to understand Hispanics.

In terms of data collection and research, we strongly support this

area and we need to have racial and ethnic identifiers and data collection and research in order to demonstrate trends and new

knowledge for our program development and a more effective policy

analysis and policy debate on what is needed to improve Hispanic

health. And we have to recognize all of our Hispanic subgroups— Mexican, Puerto Rican, Cuban, Central and South American and

other Hispanics.

Data collection through community-based research is most important, as is being done by the Federal agencies now, as was mentioned earlier, CMS, also NIH, AHRQ, and CDC. We strongly support expanding the opportunities for research in these agencies

and, for example, specific projects—the NIH has a new Export Program; NIH and HRSA have Centers of Excellence Programs; the

AHRQ agency has the Exceed Program, which is the Excellence

Center to Eliminate Racial Disparities in Health; CDC has REACH

programs and I know that CMS has a special Hispanic Health

Services Research Program.

But really what is critically needed is that we start putting more

funding into the development of more research and more researchers that are from the Hispanic community and that we link the

academic centers with the communities and have real communitybased research. That is something that this Nation really has not

done in terms of Hispanic health. And not only that, but we need

research institutes, publications, journals and clearinghouses so

that we can have better use of the research that we should develop.

Then the last area really is about cultural competence. It has already been mentioned, the important needs, so I am not going to

25

go over that. I just think that what is critical now is that we start

developing a sense of where to go and having clearinghouses on

cultural competence, and that is really one of the major roles of the

Office of Minority Health and why I think the Office of Minority

Health was included in this bill. The Office of Minority Health at

HHS and all of the agency’s Offices of Minority Health would continue to coordinate the outstanding internal programs of the development, as well as linking to the constituents through all of their

HHS regional offices.

But I think that what is most important in this bill is the Center

for Cultural Competence and Language is a new center that needs

to be funded at the highest levels—I believe it is mentioned at $5

million in this bill—so that demonstration projects can be not only

started and enhanced but that we can publish the results of those

demonstration programs, evaluate the outcomes, and learn from

the demonstration programs. And we recognize the opportunity

here for the Office of Minority Health to promote leadership in this

whole area of cultural competence.

And last, I might add that leadership development is something

that we sorely need in the Hispanic health care community. We believe that Hispanic leaders need to be promoted within Hispanic

health programs. The Federal Government and the private sector

need to have leaders who are from the Hispanic health care community to better educate others about the important needs that we

discuss here today. Thank you very much.

Senator BINGAMAN. Thank you very much. Thank you for the excellent testimony.

[The prepared statement of Dr. Rios may be found in additional

material.]

Senator BINGAMAN. I think all of this testimony has been very

good. Let me ask a few questions and then defer to Congressman

Rodriguez for his questions.

Dr. Beato, let me ask you a couple of questions first. We have

a bill, S. 724, which we passed out of the Senate Finance Committee. This is a bill involving prenatal care for women and babies, to

add pregnant women, to expand the SCHIP to cover pregnant

women, and we passed that out in July.

In April, April 12, Secretary Thompson wrote a letter to me in

which he said the following. He said, ‘‘Prenatal care for women and

their babies is a crucial part of medical care. These services can be

a vital life-long determinant of health. We should do everything we

can to make sure this care is available for all pregnant women. It

is one of the most important investments we can make for the longterm good health of our Nation.’’

‘‘As I testified recently at a hearing of the Health Subcommittee

of the House Energy and Commerce Committee, I also support legislation to expand SCHIP to cover pregnant women.’’

We got that legislation passed out of our committee and we have

been anxious to get a letter of support from the administration for

the bill, S. 724. Could you get that done for us?

Dr. BEATO. Yes, sir, we will.

Senator BINGAMAN. Thank you very much. That would be a big

help.

26

Border health. Secretary Thompson in October of 2001 visited El

Paso and Cuidad Juarez and committed at a meeting of the U.S.

Border Health Commission that he would work to come up with an

additional $25 million for health projects along the border. A week

later Dr. Frank Cantu of the Health Services and Resources Administration reiterated that commitment at the University of Texas

Health Sciences Center at San Antonio.

Do you know the status of the effort to get that $25 million?

Dr. BEATO. I do not, Senator, but we will check on that and follow up with your office.

Senator BINGAMAN. If you could get back to us on that, that

would be appreciated. I think that funding is certainly needed.

Dr. BEATO. Yes, sir.

Senator BINGAMAN. Let me ask on the health professions, Dr.

Cigarroa and various others have asked or have emphasized the

importance of training more health professionals who are bilingual

and who are from the Hispanic community.

The administration’s budget to us this year proposed major

cuts—I think a 72 percent cut—in health professions funding. Also

it proposed zeroing out funds for a number of the programs that

we have discussed here today.

Do you know what the administration’s position is now on that?

Have they changed their views on that? Would they support a

higher level of funding than was asked for in the budget?

Dr. BEATO. What the administration proposed was indeed eliminating some of those HRSA diversity programs and shifting those

funds to the National Health Services Corps program. What we

found is that individuals that went to the National Health Service

program in the Public Health Service tended to stay in those communities longer than individuals who went to the HRSA program.

So what the administration did was sort of refocus from the

HRSA to the National Health Service Corps. The funds were reshifted to National Health Service Corps. That is what we proposed, I think in April, when the president put forth that.

Senator BINGAMAN. Obviously in my own view, I support the National Health Service Corps but I had not thought that the two

were really trying to target the same need. My impression was that

the funding which had been substantially cut was really for training of people in the health care professions and that that would be

needed even if there were increased funding for the National

Health Service Corps.

Dr. BEATO. What the administration proposed was increasing the

scholarships in the National Health Service, so it would be also for

training health care professionals, including allied health and dentistry.

Senator BINGAMAN. I see. So you basically stand by the position

that you took in the budget proposal as to where the funds ought

to be put?

Dr. BEATO. That is correct.

Senator BINGAMAN. Dr. Cigarroa, let me ask you about some of

the figures that you cited and that several others have cited here

about the need for training of health care professionals. All of the

statistics for the number of Hispanics in these professions are dismal. I am particularly concerned when I see the figure on nursing

27

because it would seem to me that the barriers to entry to that profession should be substantially less or are, just as a de facto matter; they are substantially less than the barriers to becoming a doctor. I mean you can become a nurse more easily, with less years

of education than you are required to put in to become a doctor.

It would seem that there would be a chance to do much better than

the 1.3 percent was the figure that Dan Reyna said; 1.3 percent of

the nurses in our country are Hispanic.

Do you have some insights you could give us as to how to solve

that problem? Also, if you have any comments as to the importance

of funding for training in this area.

Dr. CIGARROA. There is no doubt about it that this is a significant problem. In fact, when I became president 2 years ago of the

University of Texas Health Science Center, I was also equally as

alarmed as you are in regards to the very low percentage of students enrolling into the nursing profession.

What has happened, at least over the past 5 years, is that a significant number of faculty who serve as educators in our nursing

schools have retired, so we had to actually put a lot of energy in

recruiting and retaining faculty members in order to increase enrollment. We are making headway on that but I do believe that

just like in the medical school professions, the individuals in the

Hispanic population need more role models not only in medical

school but also in the nursing schools. We have increased enrollment by about 33 percent in the past 3 years but we just have a

significant way to go.

Now why is there such a discrepancy between—why do we have

more Hispanics becoming physicians than nurses? I still have not

put my finger on that but it requires a lot of significant effort on

all our parts to try to solve that problem.

Senator BINGAMAN. Dr. Flores, I do not know if any of the work

you have done gets at this question of why we are doing so poorly

at bringing Hispanics into these professions and with particular

emphasis on nursing. Is that something you have looked at or not?

Dr. FLORES. I think the first place you have to start is with the

fact that Latinos by far have the highest school drop-out rate of

any group—29 percent. Compare that to 13 percent for AfricanAmericans and 7 percent for whites. So the first thing we have to

do is keep Latinos in school.

The next thing is if they are interested in health care, we need

to encourage that. We need to have pipeline programs like HCOP

and I share your concern in looking at the 2003 budget and the fact

that we are going to completely zero out that program, and also

that we are going to completely zero out another important program called the Minority Medical Program for faculty who are minority and want to stay in medicine.

On top of that, we are going to have all the minority student

scholarships. Then finally, the ultimate blow, as well, is we are

going to cut AHRQ funding and, as Dr. Rios mentioned, HRQ supports these Exceed grants, the Excellence Centers to Eliminate

Ethnic and Racial Disparities, and I sat on the study section for

those projects and I was so impressed with how creative those

were. I thought those were some of the first programs we were

28

looking at that actually made a difference and now with the budget

cut, those will probably be the first programs to go.

So I would say we have to restart that pipeline, not cut it off,

and begin early on, as early as the Head Start programs, where we

know that Latino kids, despite the fact that they have high rates

of poverty, are less likely than African-American kids to enroll in

Head Start and we also know that Latino kids are more likely to

be left back as early as elementary school grades.

So from early age on, we need to encourage bright, talented, enthusiastic Latino students to stay with school and to go on into

health care professions, like several of the doctors here.

Senator BINGAMAN. Let me ask Dan Reyna on the promotora program that you have talked about, how extensive is that? Do we

have a lot of people who are employed in that capacity and doing

that throughout our State or is it just in a few locales or how extensive is that program today?

Mr. REYNA. Senator Bingaman, we are fortunate in New Mexico.

We have a citizen legislature and they are very much involved in

the community. One of the charges that we received in 1994 with

some State funding was replicate the promotora programs in

Southern New Mexico, in our border region.

So we have done so. We have all our six border counties with a

promotora program. There are a number of similar programs in

Northern New Mexico but we have the southern portion completely

covered. For instance, we have I would say FTE equivalent, we

have only 10 in the south that we fund through the Border Health

Office but the Department of Health also funds promotora programs from other sources. And because of the success of this community-based program, our last review of one county, Dona Ana,

there were 98 promotoras, outreach workers, in that one county

provided by different sources of funds and projects.

We think that we can do much with little. They are people from

the community, people that know their neighbors. One of the key

elements of community outreach is trust. If you do not trust the

person that is trying to help you, you are not going to listen; you

are not going to be educated. That is the success that we have had.

The success with the BVF project cannot be discounted. When

you exceed your target that HRSA has set by 549 percent and we

are wondering 2 weeks before the end of the month whether we are

going to have any funding next month, I am curious as to how we

look at those kinds of things.

Senator BINGAMAN. I would agree. Of course, around here we do

not know if anything is going to be funded next, is the reality of

things.

Dr. Rios, did you have any experience with the promotora program in the work you have been doing? Is that something that is

a useful expenditure of Federal funds or is that need being met?

What is your thought on that?

Dr. RIOS. I have had experience dealing with leaders who have

started promotora programs. In fact, in Arizona along the border,

one of the clinics there, they had the beginning of a large program.

I used to be in the Office on Women’s Health and we actually

worked with quite a few different women’s health groups and

promotoras were used back in the early 1990s. I think it was just

29

starting to gain awareness by the Federal Government and I think

that it is very crucial in our communities to have community workers who can relate to the communities and, like Dan said, the issue

of trust in our health system needs to be overcome in terms of the

Latino patients for several different reasons that I will not go into.

But I think the promotora program is a model that has been

used successfully in other countries and has been successful in this

country and I think the Federal Government would be wise to support it.

Senator BINGAMAN. Thank you very much.

Let me call on Congressman Rodriguez for any questions that he

has.

Mr. RODRIGUEZ. Thank you, Senator.

I want to hit on a couple of items on the area of AIDS. It seems

like we have been making a great deal of inroads, yet when it

comes to the Hispanic community, we are losing ground there.

There is a great disparity between the 13 percent population that

we have and the almost 18 percent of the cases that are out there.

And I know that one of the issues that is brought up by the community is the fact that in other communities, such as the AfricanAmerican, they have community-based organizations and that ours,

we have very few of them and there is a large number of communities that do not have any.

I was wondering as to what ways would be some of the ways, not

only in terms of community-based organizations, but other things

that we could reach out or some of the programs that you might

already be familiar with that we could look at providing resources.

I just wanted to throw that out to the panel as a whole.

Dr. RIOS. I can answer from East Los Angeles, where I grew up.

There is a large community health center, Federal community

health center, the Ultimate Health Services Corporation that has

their own AIDS clinic in the middle of East L.A. and I know that

they have had speakers to testify here for the Congress in the past

as a model community program. And I think that, you know, there

are so many people in the whole Los Angeles County and this is

only one major clinic and it is community-based and a lot of people

know about it but you do not have clinics in every city, in every

suburb in Los Angeles, for public awareness about the HIV/AIDS

services.

In New York and other cities I know that there are very, very

targeted HIV/AIDS services for Latinos. They are culturally competent and very good services but there are very, very few. That

is the major problem. And I think that some of the strategies to

get at that would be the Ryan White funding out of HRSA and the

programs at CDC that the leadership within the agencies and the

leadership on the review committees and the actual community

boards that help to disseminate the awareness of the needs for

these programs, that they be in tune with the needs.

And I know that the Latino—I was on as task force for CDC on

the implementation of their five-year strategic plan and the Latino

rates are rising tremendously and we are in for a big disaster in

HIV/AIDS.

Mr. RODRIGUEZ. We are hearing also in that area that the community-based groups. as the grants go out, have a great deal of difVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6633 81950 SLABOR2 PsN: SLABOR2
30

ficulty of competing, at least in our communities, and competing

with the other communities in those resources. I do not know if you

want to add to that.

Dr. BEATO. There are two things I would like to add. Two months

ago we had the first—with the Office of HIV/AIDS, faith-based Initiatives, just for Latino faith-based leaders around the country, we

had 27 of them, Puerto Rico included, and it is the first time that

the department sat down with faith-based Latino leaders to bring

up the issue of HIV/AIDS, to try to engage at the community level

leaders in the Latino communities to make education, prevention

and treatment options available to them through issues like the

Ryan White Act.

Also, the Office of Women’s Health, the fastest rising percentage

is now in Latinas in HIV/AIDS. It is a large concern for Latinas.

Tailoring programs to go reach out with the women in women’s

groups through education, again in prevention and treatment options, especially in anything that has to do with prenatal. As the

example that you brought up, there is no need if we have an HIVpositive woman that we do not start taking steps to ensure that

that baby does not get treatment before it is born.

So there are several programs but including faith-based communities and forming partnerships with existing State health departments and sort of expanding that, CDC is looking at some of those

programs, as Dr. Rios has said, and expanding, tailoring more to

Latino women right now.

Mr. REYNA. Congressman, I can add a point. For a number of

years now the New Mexico Border Epidemiology Center at New

Mexico State University, a component office of the Border Health

Office, has had a unique project on the Mexican side funded with

initial moneys provided by the U.S. Mexico Border Health Association about four or 5 years ago. We call that project Espejo. One of

the ways to work on the AIDS issue is to try to prevent it and we

have focussed on the Mexican side with the sex workers, the prostitutes in Palomas, Chihuahua. It is a community of less than

20,000 and it has almost a three-digit number of sex workers every

weeks.

So we are working with the health system on the Mexican side

as they work with their sex workers every weekend because the

customers come from the U.S. And in the years that we have

worked that project, we have had only one AIDS confirmed case of

a sex worker on the Mexican side but we work on that side and

because of that, there are no sources for funding for us to help the

Mexican public health system that although prostitution is illegal

in Mexico, the public health system still works to try to prevent

issues and health problems with the sex workers.

I was in Matamoros, Mexico this past summer and visiting one

of the hospitals in Matamoros across from Brownsville, TX. We

spoke about the Espejo project in New Mexico, Chihuahua and they

were trying to begin a similar project in Matamoros with about

1,000 sex workers. Unfortunately, we heard the news that in 1

week they had five confirmed AIDS cases of sex workers. Those clients—clients that they use come from the U.S. because they are

paid in dollars. We have to find ways where we can work with Federal funding on the Mexican side to work with our colleagues in

31

Mexico to help them help themselves so that eventually it ends up

helping us.

Mr. RODRIGUEZ. Let me ask you one other question. I think when

we talk about health, one of the areas that is almost an afterthought is the area of mental health and esp with children. I know

that the piece of legislation talks about looking at the suicide rates

among Latinas but I was wondering if you want to make any comments in the area of mental health services because I know it is

one of the areas that is lacking.

A recent report also talked about the great number of disparities

among children, Latino children, in terms of access even after they

have been diagnosed, of not getting access to health. I just wanted

to throw that out to the panel if there are any comments.

Dr. FLORES. There is actually now an accumulating body of research on exactly what you are talking about, where there is some

disturbing disparities. For example, we know that Latino children

are substantially less likely to be hospitalized for mental health

conditions across the board, whether you talk about all of them or

individual diagnoses, despite the fact that they are more likely to

have these diagnoses, even compared to African-Americans, and we

do not understand why that is.

And for some reason, Puerto Rican children lead the pack in all

U.S. ethnic and racial groups as far as chronic developmental disorders, which I also would put under that general grouping.

I think it is a good example, as well, when we are talking about

HIV. I think there is an intriguing cultural phenomenon going on

that we do not have enough research on and it is something called

the healthy immigrant effect. Basically there is now a larger body

of research that grows each year that shows that first generation

U.S. Latino children have several excellent health outcomes and indicators and that deteriorates with greater acculturation in each

successive generation. This has been found to be true for adults, as

well.

So we always talk about cultural competency as a deficit issue

in many events, like avoiding harmful folk remedies——

Mr. RODRIGUEZ. Can I get a clarification? You said that as they

assimilate they get worse in terms of their health?

Dr. FLORES. Yes. Let me give you an example. First generation

Latino kids are more likely to have—sorry. The less acculturation

you have, in other words, the less American you are, the better

your health outcomes, whether you are talking about rates of low

birth weight. Your rates are lower and once you have been in the

U.S. for one or more generations, they go up.

We also know that there are higher immunization rates when

you first come to the U.S. Those go right downhill the longer you

have been in the country and the more generations.

We also know that when you have less acculturation you have

less depression, less suicidal ideation, less cigarette smoking, less

illicit drug use and an older age of first sexual intercourse. Once

you have been in the U.S., all those outcomes become adverse outcomes, and this is called the healthy immigrant effect where the

epidemiologic paradox—we do not understand what that is but is

fascinating because there is something protective that Latinos

32

bring to this country and then it gets destroyed by generations,

probably of poverty, in the U.S.

So if we could do some more research and find out what it is that

is protective and maybe use our own community resources and our

values and whatever it is that is healthy to then promote good behaviors and avoid AIDS and avoid mental health problems, I think

we could make some fantastic strides, but we need to understand

that better and we need to do more research on this.

Mr. RODRIGUEZ. Finally I just wanted to make a comment and

I would hope a message to the administration, as well as to all of

us. That is that in the area of the importance of resources and opportunities in training for health careers, I know that last year, the

previous year, we had brought in about 190,000 people through

those H1 visas. A lot of them were in health professions. I know

that in Texas, I will quote you a figure, not necessarily the exact

numbers but we certify about 1,200 doctors who graduate and then

certify 4,500. So we basically import them from other States and

other countries.

And nationally the figures are also that we are not producing the

number of doctors that we should. My understanding is that we

graduate between 12,000 and 15,000 and then bring in 3,000 to

5,000 from abroad. And with the problems after 9/11, a lot of that

is going to stop. And at a point in time, you know, we are a brain

drain on the rest of the world so that we need to begin to prepare

and educate our own so that it is a real need for us to put some

real resources in that area.

And I would hope the administration looks at those numbers and

the fact that we complain, Senator, we complain about the Mexican

that comes over but we forget that we have been a brain drain on

them in terms of bringing a lot of their doctors over. After they pay

for their education on the other side, they come over here and become doctors and they have been a great asset to us but at some

point we also need to begin to prepare our own.

Thank you, Senator.

Senator BINGAMAN. Thank you very much, all of you. I think it

has been very useful testimony. I appreciate it and I think this will

help us in our efforts to persuade our colleagues, both in the House

and the Senate, to move ahead with this legislation. Thank you

very much.

[Additional material follows.]

33

ADDITIONAL MATERIAL

PREPARED STATEMENT OF FRANCISCO G. CIGARROA, M.D.

Good afternoon. Mr. Chairman, members of the Committee, I am Dr. Francisco

Cigarroa, President of The University of Texas Health Science Center at San Antonio.

I want to give you a brief overview of are region and the university I lead, so that

as I discuss the importance of this issue, you will understand that it is not just a

theoretical issue with me. It is at the very core of what we do every day.

The UT Health Science Center at San Antonio is the medical center responsible

for the vast South Texas/Border Region, which comprises more than 4 million people, and is one of the most rapidly growing areas of the nation. The Health Science

Center has five schools, (Medical, Dental, Nursing, Allied Health Sciences and Graduate School of Biomedical Sciences.) We have educated more than 15,000 health professionals and are the center of the biosciences in San Antonio, the city’s largest economic generator and one that has an annual impact of more than $8 billion on the

area. We are also the source of internationally-recognized medical breakthroughs,

major medical research, and extensive patient care. Each year, we also give more

than $80 million in uncompensated health care to the medically indigent in our region.

We also have extensions campuses throughout the region. Much of our focus is

on the Hispanic population. In San Antonio, the Hispanic population is more than

50% and as you go further toward the Border, it is more than 90%. This is the most

rapidly growing segment of our nation, and it is a true statement that we cannot

have a healthy America unless we take the steps necessary to ensure a healthy Hispanic population. And we do just that. We are the only post-graduate institution in

the nation to have earned the distinction of being the site of three Hispanic Centers

of Excellence—in our Medical, Nursing and Dental schools. We are also the lead

center for the United States/Mexico Center of Excellence Consortium, an entity that

includes major universities from California, Arizona, Texas, and, Senator Bingaman,

your own state of New Mexico.

I am also a pediatric transplant surgeon who is still doing surgery so that, even

as Health Science Center President, I am never very far away from the front lines

of medicine. It is an honor to be with you today and I am so pleased to have so

many Congressional leaders gathered in support of this common cause today. Thank

you all for being here and for the leadership you are providing on this most important issue.

HISPANICS AND THE HEALTH PROFESSIONS: FOCUS ON THE FUTURE.

As president of the Health Science Center, I would like to talk to you about some

of the challenges we face in South Texas as we address the issue of Hispanics and

health, particularly Hispanics and the health professions. Increasing the number of

Hispanics who enter the health professions is a critical element to improving the

overall health care of the Hispanic population. And if we want to educate more Hispanic health care professionals, then we must begin by providing young Hispanics

with encouraging role models and mentors in the health professions.

It is so important that we provide these role models and send these positive encouraging messages at an early age. I am fortunate, because my father and grandfather were both physicians. I didn’t have to seek out role models; they sat around

my dinner table. That made it easy for me to set high goals for myself, and to go

from the Laredo public schools to Yale, Harvard and Hopkins. My mentors were always available to me and it made all the difference in the world in my own

career... from an early age, all the way to when I assumed the role as the first

Hispanic in the nation to become the President of a major health and research university.

But I am all too aware that so many young, bright, capable students do not have

the privilege of discussing health careers around the dinner table. Far too many of

our young people, who are just as bright as others, never even have the opportunity

to consider a career in the biosciences. And that severe lack of professionals is taking a major toll on the health, the wellbeing, and, ultimately, even the economy of

this vast region which is so reflective of the America of tomorrow. At the Health

Science Center, we recognize the importance of stimulating the scientific interests

of students long before they reach undergraduate or graduate school. We place a

great deal of emphasis—and resources—on the ‘pipeline’.

I would like to describe a couple of our most successful programs, because they

are easily replicable and because they have been so successful.

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One of our most successful programs—our Med/Ed program—should be replicated

in cities around the country. This year-round program introduces young students

from the Rio Grande Valley in Texas to the health professions by allowing them—

at an early age—to visit labs, doctors’ offices, and hospitals, and our Health Science

Center, years before they will start their future careers. These young students, in

high school and even in middle school, see our doctors, dentists, and nurses-and our

students-in action. They get help with difficult science course work. They talk to

students and see that many of our students are not that different from themselves.

And they begin to build big dreams—many for the first time in their lives.

As the students who participated in the Med/Ed program begin to graduate from

college and enter health professions training, we are seeing success in the results

of this program. Since 1997, a total of 750 students have participated in our Med/

Ed Program. Of the 1997 and 1998 high school graduates who participated, we have

a total of 78 students who are entering the health professions. And because many

of the other participants are still in college, we know that the number of students

who enter the health professions will continue to grow.

We are very proud of our Med/Ed program, and we are proud to be the only

Health Science Center in the nation with three Hispanic Centers of Excellence on

campus to support the needs and goals of our Hispanic students. As I mentioned,

we hold this distinction in our Medical, Dental, and Nursing Schools. Through these

Centers of Excellence, we provide support for our students through faculty mentors,

pre-matriculation programs, and tutoring opportunities. In addition, through the

Hispanic Centers of Excellence, we are able to provide additional outreach programs

to high school and college students. Through our partnership with a local undergraduate university, St. Mary’s University, and the Health Careers Opportunity

Program, we offer a six-week intensive summer academic enrichment and career

preparation program. This program, like many others offered through the Centers

of Excellence, immerses young students in the clinical setting and provides them

with the unique and inspiring opportunity to shadow health professionals.

Our Health Science Center’s commitment to providing role models was shown

again this past June when we opened the Medical Education Division of our Regional Academic Health Center in Harlingen. In that one day, we nearly doubled

the entire national number of Mexican-American physicians who serve as faculty

physicians—and therefore as mentors—for medical students and the younger students of the community.

We are very proud of the early intervention programs that we offer at the Health

Science Center.

But we also know that the number of Hispanics who graduate from college is unacceptably low. As the demographics in our nation change, if we don’t change these

two divergent trends—rising Hispanic population and small number of Hispanic college and post-college graduates, physicians and other health professionals—then we

are on a collision course with disaster. Unless we reverse the college and post-college success rate of under-represented minorities, the future and the health of our

nation are in serious jeopardy.

Our major challenge in reversing these statistics will be funding. Our past funding has allowed us to implement so many wonderful and successful programs. But

now, for the Fiscal Year 2003, we face the possibility not only of a funding shortfall,

but possibly even a virtual elimination of the current level of funding for all Title

VII health professions training programs. To discontinue this funding now, to discontinue our progress now, would be to take a large step away from, rather than

toward, our goal.

As a nation, we must continue to provide positive role models and early intervention opportunities for our young people who are underrepresented in the health professions. We must continue to provide the resources to support these important programs. We must commit ourselves to improving the college and post-college success

rate of under-represented minorities in order to provide a healthier, more prosperous future for all people.

I have had some of my colleagues ask why we place such an emphasis on these

early intervention programs when, after all, we are a post-graduate institution. The

answer is easy. Our vision for our region, our state and our country is a seamless

transition of success: from elementary school, through high school, college and medical school.

These pipeline programs are an integral part of the success and the future of our

country, and I would be pleased to send additional information to anyone who would

like to know more about these initiatives.

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OTHER CHALLENGES

But there are many more issues that are critical to Hispanic health. We have a

desperate shortage of nurses in this country, and the shortage is even more severe

in the largely Hispanic areas. Even as President in my own medical school in San

Antonio, I was called to do a transplant and was then told that we could not proceed

with the operation because the hospital could not find sufficient nurses. As President, I had the authority to do whatever it took to save a life that day. How many

surgeons have heard that same message: ‘‘We don’t have enough nurses for you to

operate today’’ and been unable to do anything about it.

Our nursing school turned away more than 300 qualified students, a great many

of them Hispanic, because we couldn’t find enough faculty to keep the required oneto-eight ratio. Through some creative financial steps, I was able to increase our faculty and add many new students... but we need more resources, so that we can

hire more faculty, so that we can educate more students. This is a high priority for

the entire country.

RESEARCH BREAKTHROUGHS: THE KEY TO A HEALTHIER FUTURE

We are focusing our basic research on conditions most prevalent in this region,

diseases that take a tremendous financial toll on our country. Diabetes: diseases related to aging, infectious diseases, multi-drug resistant tuberculoses, which is undergoing a terrible resurgence. We need programs that encourage students, and particularly Hispanic students, to enter the research field and complete their PhDs. An

alarming twenty percent of our Mexican American population will develop adultonset diabetes. That is a rate substantially higher than the non-Hispanic population. What follows are an array of diseases of the heart, eyes, circulatory system,

neuropathy of all kinds. What this does to the quality of life is hard for us to imagine. What this does to our state and national budget is also hard to imagine. We

have scientists who already have identified genes that are involved in diabetes. We

believe we are close to the critical ‘‘next steps’’ that lead toward prevention. What

an overwhelming difference that will make on this country, once we are successful

in that search.

STEPS TO ENSURE SUCCESS

I agree with the report issued by the Institute of Medicine that calls for the government to recognize and reward medical schools that actively recruit and support

well-trained faculty and students who are from under-represented minority populations.

We should do this because it is the smart thing to do. If we fail to take steps to

address the gap between the health of the majority population and the health of the

nation’s rapidly growing minority populations, we are on a course leading to a collision. We are far too great a nation to allow this to happen.

We know that it is futile to continue to do the same things, but expect different

results. Well, as a nation, if we continue to treat issues of Hispanic health as we

are doing now, we will indeed see the same results: lack of coverage, access and

care. And those results are not sufficient to ensure a healthy America in the future.

At The University of Texas Health Science Center at San Antonio, we are doing

all that we can, and with great success, to ensure a healthier region. I am proud

of our record of success, which also includes leveraging government resources with

private philanthropy and we have also been very successful in that arena as well.

We look forward to continuing our partnership with the government—federal as

well as state—as we work together in this most worthy common cause of a healthier

America, achieved by ensuring a healthier Hispanic population.

The bill you are considering contains much that would be of such great assistance

to us as we continue the progress we have already made. It addresses topics that

we address every day: diabetes, addiction, issues of early care for pregnant women

and children, pipeline issues, and funding for Border and Hispanic health concerns.

In Texas, we know all too clearly that diseases care nothing about green cards.

Germs respect no INS regulations. We truly must work with our neighbors to the

South if we are to avoid a major influx if new conditions and diseases. It can be

seen so clearly on a map. Just as there are ‘rivers of commerce’ there are ‘rivers

of infectious disease’ and though they may start at the Border, they are eventually

seen all the way to the northern Border that we share with Canada. We can and

do work with Mexico on these, and other environmental-related diseases. I applaud

all of you for the concern you have for the situations we face along the Border, situations which, if left unchecked, will have a major impact on every state in the nation.

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Thank you for the opportunity to present this testimony to this important and distinguished Senate Committee.

PREPARED STATEMENT OF GLENN FLORES, M.D.

The views presented are those of the author, and do not necessarily represent

those of the American Academy of Pediatrics or Medical College of Wisconsin.

Good afternoon, Mr. Chairman, and distinguished Members of the Committee. I

appear before you as Chairman of the Latino Consortium of the American Academy

of Pediatrics Center for Child Health Research. I am a pediatrician who has cared

for disadvantaged children for over 10 years, and Associate Professor of Pediatrics,

Epidemiology and Health Policy at the Medical College of Wisconsin, where I am

Director of Community Outcomes, and Associate Director of the Center for the Advancement of Urban Children in the Department of Pediatrics. I am a researcher

with expertise on Latino children’s health issues, access to health care, children’s

health disparities, and cultural and linguistic issues in health. Prior to coming to

the Medical College of Wisconsin, I founded and was Co-Director of the Pediatric

Latino Clinic at Boston Medical Center

I am pleased and honored to be here today to discuss with you the important

issue of the health of Latino children. I will talk about the dramatic demographic

surge in our nation’s Latino children, highlight the urgent priorities and unanswered questions in Latino children’s health, and show why the Hispanic Health

Improvement Act would substantially improve the lives of millions of American children. For further details and 113 references on these issues, I refer you to the article of ours published in the Journal of the American Medical Association (Flores G,

et al. The health of Latino children: Urgent priorities, unanswered questions, and

a research agenda.

Latinos are now the largest minority group of children in the United States, numbering 12.3 million, and comprising 17% of the population less than 18 years of age.

In California, Latinos surpassed whites as the state’s largest racial/ethnic group of

children in 2000, and by 2010, half of all California children will be Latino, outnumbering white children in the state by 1.9 million. The 2000 Census documents

that Latinos are one of the youngest and fastest growing groups in our nation. But

despite this dramatic population growth, Latino children continue to experience a

disproportionate burden of health risk factors, illness, injuries, impaired access to

health care, and health disparities.

I would like to share with you two stories about children that we recently cared

for at the Pediatric Latino Clinic at Boston Medical Center (the names have been

changed to protect confidentiality):

Maria Fuentes was a 3-year-old Latino girl brought to the emergency room by her

parents at midnight because of complaints of severe stomach pain. No medical interpreter was available in the emergency room, and because Maria’s mother spoke no

English, she was unable to adequately describe her daughter’s condition. The emergency room pediatrician examined Maria, and discharged her with what Maria’s

mother understood to be a diagnosis of ‘‘colic.’’ One hour later, both parents brought

Maria back to the emergency room, because her pain had worsened. The same pediatrician examined her, and Maria’s mother found the physician to be quite angry.

Maria’s father was extremely upset because no interpreter was available, and he felt

that Maria was treated poorly because his family was Latino. The pediatrician sent

Maria home again, this time with a medication, the name of which the Maria’s

mother did not recall.

Several hours later, Maria and her family returned to the emergency room.

Maria’s condition had deteriorated, and was now quite serious. The pediatrician hospitalized Maria immediately.

In the operating room, Maria was found to have a perforated appendix and peritonitis, a serious infection of the lining of her abdomen due to her appendix bursting.

Maria was hospitalized for 30 days, because of complications including two infections of her surgical incisions. Maria had no health insurance.

My second story is about a two-year-old Latino girl named Rosa Morales, whose

parents brought her to the emergency room for right shoulder pain. X-rays revealed

that Rosa had fractured her right collarbone. Rosa’s mother spoke Spanish almost

exclusively. When Rosa’s mother was asked what happened, she responded, ‘‘Se

pego, se pego.’’ The resident physician interpreted this to mean, ‘‘She was hit.’’

Rosa’s mother then showed the nurse a discharge summary from a previous emergency room visit to another hospital two months prior to the first visit, when Rosa

also was diagnosed with a right collarbone fracture after a fall from her bed.

Child abuse was suspected by the emergency room staff, and the state Department of Social Services was contacted. A Department of Social Services caseworker

37

came to evaluate Rosa and her 4-year-old brother, Jose. Without a Spanish interpreter, the caseworker spoke with Rosa’s mother, and then asked her to sign over

voluntary custody of Rosa and Jose. Rosa and Jose immediately were taken from

their mother and placed in Department of Social Services custody.

When the Spanish interpreter arrived, Rosa’s mother was interviewed again, and

she reported that Rosa had fallen from her tricycle and struck (‘‘se pego’’) her right

shoulder. The primary care physician was contacted, and denied any history of

abuse or neglect in the family, or having concerns. Rosa’s mother regained custody

of Rosa and Jose after 48 hours.

The issues faced by Rosa, Maria and their families typify those confronting millions of Latino children and their families in the United States. For example, neither Rosa nor Maria’s family spoke English. About 45 million people in the US

speak a language other than English at home, and about 19 million are limited in

English proficiency, or LEP. Spanish is the language spoken by 26.7 million, or 60%,

of those who speak a language other than English at home, and 12.5 million, or 64%

of LEP Americans. Five percent of school aged US children (or about 2.4 million)

are LEP, an 85% increase since 1979. Multiple studies demonstrate a wide range

of adverse effects that LEP can have on health and use of health services, including

impaired health status, a lower likelihood of having a usual source of medical care,

lower rates of mammograms, pap smears, and other preventive services, non-adherence with medications, a greater likelihood of a diagnosis of more severe psychopathology and leaving the hospital against medical advice among psychiatric patients, a lower likelihood of being given a follow-up appointment after an emergency

department visit, an increased risk of intubation among children with asthma, a

greater risk of hospital admissions among adults, an increased risk of drug complications, longer medical visits, higher resource utilization for diagnostic testing,

lower patient satisfaction, and impaired patient understanding of diagnoses, medications, and follow-up.

Latino parents cite language barriers as the single greatest barrier to health care

access for their children. But research documents that medical interpreters are frequently not called when needed, are inadequately trained, or are simply not available at all. In Maria’s case, if an interpreter had been present when she initially

presented to the emergency room, the nature and severity of the symptoms might

have been recognized immediately. The outcome with an interpreter, indeed, could

potentially have been prompt diagnosis of appendicitis, a routine short hospital stay

for an appendectomy, and a satisfied family, in stark contrast with the costly, complicated 30-day hospital stay that actually occurred and left the family dissatisfied

and embittered. A recent study of ours underscores that lack of adequately trained

medical interpreters can result in increased medical errors. We found that an average of 19 interpreter errors of clinical consequence are made per pediatric encounter, with untrained interpreters, such as family members, making significantly more

such errors than trained interpreters. In a case where a child was visiting his physician for an ear infection, an untrained interpreter incorrectly told a mother that an

oral antibiotic should be placed in the child’s ear, and in another case, a hospital

interpreter told a mother to rub a steroid cream prescribed for an infant’s facial

rash over the infant’s entire body.

But only five states in the US currently provide third-party reimbursement for

medical interpreter services, and less than one-quarter of hospitals nationwide provide any training for medical interpreters. The HHIA would ensure many children

and families with limited English proficiency would have access to health care without language barriers by providing for use of Medicare and Medicaid funds to pay

for hospital interpreters. I would also suggest that all third-party payers should reimburse for medical interpreters, because we can either pay a little now to provide

high quality medical care to all children, or pay a lot more later when preventable

medical errors, hospitalizations, lawsuits, and even deaths result in LEP patients

because no interpreters were available. Indeed, a 2002 report to Congress by the Office of Management and Budget estimated that providing adequate language services to all LEP persons in our nation’s healthcare system would cost about $4.04

per visit, equivalent to about a 0.5% annual increase in national healthcare expenditures.

There are other feasible solutions to eliminating language barriers in our nation’s

healthcare system. First, we must increase the number of current and future health

care providers who speak Spanish and other second languages commonly spoken by

Americans. This can be achieved by making medical Spanish and other language

classes mandatory in medical schools in states with large Latino populations, and

offering ongoing Spanish and other language courses for current healthcare professionals. Section 321 of the HHIA would also be helpful in that it would identify bilingual health professionals and train them with respect to minority health condiVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6621 81950 SLABOR2 PsN: SLABOR2
38

tions. Second, health care institutions need to ensure that all LEP patients have access to trained medical interpreters. Fewer than one-fourth of hospitals nationwide

provide any training for medical interpreters, and only 14% of US hospitals provide

training for volunteer interpreters, and in half of these hospitals, the training programs are not mandatory. It is time for our healthcare institutions to require that

all medical interpreters undergo fluency testing and proper training.

Maria had no health insurance to cover her expensive 30-day hospital stay.

Latinos are far more likely to be uninsured, at 25%, than any other racial or ethnic

group of US children. In comparison, 7% of white and 14% of African-American children are uninsured. About 3 million Latino children lack health insurance, and approximately one-third of all poor Latino children are uninsured, despite eligibility

of the vast majority for Medicaid and the State Children’s Health Insurance Program (SCHIP). Among uninsured poor children in the US, Latinos outnumber all

other racial/ethnic groups, including whites: there are 1 million poor, uninsured

Latino children, compared with 766,000 white, and 533,000 African-American poor,

uninsured children. Congress enacted SCHIP in 1997 with a 10-year investment of

about $40 billion. Although 1999 marked the first time in many years that the proportion of uninsured Latino children actually decreased (from 30% to 27%), recent

national data suggest that outreach efforts to enroll Latino children have largely

been unsuccessful. A Kaiser Commission report found that only 26% of parents of

eligible uninsured children said that they had ever talked to someone or received

information about Medicaid enrollment, and 46% of Spanish-speaking parents were

unsuccessful at enrolling their uninsured children in Medicaid because materials

were unavailable in Spanish. Additional research is needed on identifying the most

effective interventions for outreach and enrollment of uninsured Latino children,

and the Hispanic Health Improvement Act, or HHIA, would be a giant step forward

in this area. The HHIA would provide grants to promote innovative outreach and

enrollment efforts, and would target the most vulnerable populations, including children living in rural areas and in families for whom English is not their primary

language.

Rosa’s and Maria’s stories also emphasizes the importance of providing culturally

competent health care. Cultural issues can have a profound impact on Latino children’s health and their quality of care. Failure to consider these issues in clinical

encounters can have a variety of adverse consequences, including difficulties with

informed consent, miscommunication, inadequate understanding of diagnoses and

treatment by families, dissatisfaction with care, medical errors, preventable morbidity and mortality, unnecessary child abuse evaluations, a lower quality of care, clinician bias, and ethnic disparities in prescriptions, analgesia, test ordering, and diagnostic evaluations. Unfortunately, cultural competency training still is not an integral part of the education of physicians, nurses, and other healthcare professionals.

For example, a recent published study by my research team revealed that only 8%

of all US medical schools have separate courses addressing cultural issues. We also

found that only 26% of US medical schools teach about Latino cultural issues, and

only 35% of the schools address the cultural issues of the largest minority groups

in their particular states. More research is needed on the most effective course content and structure for teaching cultural issues, along with formal evaluation of the

effectiveness of various curricula. In the meantime, given the substantial evidence

that lack of culturally-competent care can have a major impact on Latino children’s

health and healthcare, cultural competency training should be a mandatory educational component in health professions schools, residency programs, and continuing professional education. The HHIA would ensure that all US children receive culturally-competent health care by creating a Center for Linguistic and Cultural Competence in Health Care within the Office of Minority Health, which would be responsible for developing education materials and providing technical assistance in

carrying out programs.

Much could be learned from Latino culture about improving the health of all

American children. A growing body of research documents that first-generation US

Latino children have several excellent health outcomes and indicators that deteriorate with greater acculturation and each successive generation. For example, less

acculturation is associated with significantly lower rates of low birth weight, higher

immunization rates, less depression, less suicidal ideation, less cigarette smoking,

less illicit drug use, and older age at first sexual intercourse. These findings are particularly striking in light of data indicating that first-generation immigrant children

have significantly decreased health care access and utilization. Yet we have little

understanding about what factors are responsible for this ‘‘healthy immigrant’’ effect. Such compelling findings require that we abandon the traditional ‘‘deficit’’ view

of Latino culture and its impact on health, and adopt a more balanced perspective

that emphasizes appreciation and understanding of the salutary components of

39

Latino culture. It is clear that more research needs to be conducted in this intriguing area.

Neither of the physicians that cared for Maria and Rosa was Latino. Latinos are

underrepresented at every level of the health care professions. Although 17% of children <18 years old are Latino, only 3% of medical school faculty, 5% of pediatricians, 2.8% of dentists and 2% of nurses are Latino. The Latino pediatrician-to-child

population ratio is expected to fall from 17 Latino pediatricians per 100,000 Latino

children in 1996 to 9 per 100,000 by 2025. Analyses indicate that to achieve parity

with future ethnic changes in the US population, our nation would need twice as

many Latino physicians, but there has been a recent decrease in minority medical

school enrollment, especially in states with large Latino populations that have

banned affirmative action policies, such as California and Texas. These trends are

particularly alarming because studies document that Latino communities are substantially more likely to have physician shortages, Latino physicians are significantly more likely to care for Latino and uninsured patients,31 and Latino patients

are more likely to be satisfied with health care from Latino vs. non-Latino physicians.

Additional research is needed on the most effective ways of increasing the numbers of Latino health professionals and faculty at health professions schools. But we

also need to fund programs that early on identify, recruit and retain talented minority students with an interest in the health professions. The expanded Health Career

Opportunity Program described in the HHIA is an excellent example. This program

would identify and recruit disadvantaged students with an interest in healthcare

starting in elementary school, and provide counseling, additional educational opportunities and stipends. Not only would this program address the Latino workforce

deficiency, but it would also increase the number of bilingual physicians, while at

the same time addressing the staggering school dropout rate for Latino children,

which, at 29% (compared with 13% for African-Americans and 7% for whites) is by

far the highest for any group of American children. Another excellent program in

the HHIA would provide grants to the Hispanic-Serving Health Professions Schools.

Latino children like Maria and Rosa face formidable barriers to health care access. A comprehensive literature review revealed 22 access barriers to health care

frequently encountered by Latino children, including lack of health insurance, poverty, low parental educational attainment, lack of a regular source of care, transportation problems, excessive waiting times in clinics, decreased preventive screening,

receipt of proportionally fewer prescriptions, language problems, and cultural differences. For example, 30% of Latino children live in families with annual incomes

below the federal poverty level (second only to African-American children, at 33%),

and 37% of Puerto Rican children live in poverty, making them the most impoverished racial/ethnic group in the U.S. Important unanswered questions include what

are effective interventions to reduce or eliminate such formidable barriers, and what

are the health trajectories of Latino children with impaired access to care?

Maria is Puerto Rican and Rosa is Mexican-American. These subgroup distinctions are important, as several studies have demonstrated that substantial differences in health and use of health services exist among Latino subgroups (such

as Mexican-Americans, Puerto Ricans, and Cuban-Americans) that would otherwise

be overlooked, and that can exceed that magnitude of differences among major ethnic and racial groups. For example, major Latino subgroup differences have been

documented for rates of prematurity and low birth weight, asthma prevalence, illicit

drug use, vaccination coverage, the prevalence of chronic conditions, and several indicators of health status and use of services. Latino child health data, however, are

rarely collected and analyzed by pertinent subgroups. Failure to perform subgroup

analyses can result in missing critical findings that can have a major impact on

child health, policy, and advocacy.

Latino children like Maria and Rosa also frequently receive a lower quality of

health care. For example, among children with gastroenteritis, Latinos are significantly less likely than whites and African-Americans to have diagnostic laboratory

tests and X-rays. Among preschool children being discharged from the hospital for

asthma, Latino children are 17 times less likely to be prescribed a key piece of

equipment for asthma treatment at home, called a nebulizer. In children hospitalized for surgical correction of serious limb fractures, researchers found that whites

receive significantly higher doses of narcotic pain medications, at 22 mg/day, compared with blacks at 16 mg/day and Latinos at 13 mg/day. There also is a long list

of serious health disparities for Latino children.2 Some of the most noteworthy include: Latino children are 13 times more likely than white children to be infected

with tuberculosis; Latina adolescent girls have the highest suicide rate in the US,

at 19%, compared with 9% for white and 8% for African-American adolescent girls;

Latino children have the highest numbers of cavities and untreated dental condiVerDate 11-MAY-2000 09:57 Mar 19, 2003 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 81950 SLABOR2 PsN: SLABOR2
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tions among American children; Latino boys are the most overweight and Latina

girls the second most overweight racial/ethnic groups of US children; Latino children have one of the highest risks of being hospitalized for or dying from unintentional injuries; and Puerto Rican children have the highest prevalence of asthma in

the US.

More research is needed on why health professionals treat children from different

racial and ethnic groups differently, and what interventions are most effective in

eliminating racial/ethnic disparities. Mandatory medical school cultural competency

courses examining these health disparities would be an important first step. In addition, because Latino children frequently are not included in medical research, we

need to develop mechanisms to ensure better recruitment of Latino children into

studies. For example, federally-funded research should always include methods to

recruit and appropriately study diverse participants, including efforts to educate minorities about clinical trials, to recruit non-English-speaking and immigrant populations, and to collect and analyze data by appropriate racial/ethnic groups and subgroups. The HHIA includes several important mechanisms for reducing health disparities for Latino children, including grants to improve the provision of dental

health services through schools, community health centers and public health departments; coverage of immunizations and dental care under SCHIP; establishing a program for the prevention of Latina adolescent suicides; research requirements for collecting data on race and ethnicity; expanding programs in the Office of Minority

Health; establishing individual offices of minority health within agencies of the Public Health Service; and establishing an Assistant Secretary of Health and Human

Services for Civil Rights.

The two stories I shared with you are about urban Latino children, and we too

often disregard the health of rural Latino children, especially migrant children.

Children of migrant Latino farm workers are particularly at risk for sub-optimal

health and use of services, and face additional unique health challenges due to their

migratory status. Of the more than one million children that travel with their parents annually in pursuit of farm labor, 94% are Latino. These children have been

shown to receive inadequate preventive care; experience high rates of infectious diseases including tuberculosis, parasites, and sexually transmitted diseases; have inadequate preparation for school entry and low rates of school completion; have impaired access to appropriate day care, forcing parents to bring them to the fields

where they have increased risks of pesticide exposures and injuries; work as farm

laborers often in unsafe working conditions; and to be at risk for nutritional disorders such as anemia, diabetes, failure to thrive, and obesity. In addition, migrant

Latino children’s eligibility for Medicaid and SCHIP is hindered by high interstate

mobility and difficulties with residency and citizenship status. The HHIA will substantially improve the plight of migrant Latino children by 1) giving states the ability to enroll legal immigrant pregnant women and children in Medicaid or SCHIP,

and the ability to provide important preventative and public health services to immigrants with state resources; and 2) calling for a study by the Institute of Medicine

of binational health insurance efforts.

In conclusion, the 2000 Census definitively documents that Latinos are the predominant racial/ethnic minority group of US children, representing one out of every

six children in America. It is time for our health policies, services and research to

address this dramatic demographic change, which can be accomplished by 1) ensuring that all children and families with limited English proficiency have access to either trained medical interpreter services reimbursed by third-party payers, or bilingual health professionals; 2) providing all children with health and dental insurance

through innovative outreach and enrollment strategies; 3) requiring cultural competency training for health care professionals; 4) increasing the number of Latinos

in health care professions; 5) including more Latino children in medical research;

and 6) eliminating health disparities for all Latino children. The Hispanic Health

Improvement Act would address all of these issues, and result in significant improvements in the health and well-being of the 12 million Latino children in America. Thank you.

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[Whereupon, at 3:45 p.m., the subcommittee was adjourned.]

Æ