Insurance, Access, and Quality of Care Among Hispanic Populations 2003 Chartpack Prepared by...

Insurance, Access, and Quality of CareAmong Hispanic Populations

2003 Chartpack

Prepared byMichelle M. Doty

The Commonwealth Fund

For the National Alliance for Hispanic Health MeetingOctober 15–17, 2003

This Chartpack is intended to serve as a quick reference and overview of insurance, access, and quality of care experiences among Hispanic populations in the United States. The charts draw from recent reports published by The Commonwealth Fund, as well as new analyses of Current Population Surveys, the 2000 Medical Expenditure Panel Survey, the 1996 Panel of the Survey of Income and Program Participation, the 2001 Behavioral Risk Factor Surveillance System Survey, and The Commonwealth Fund 2001 Health Care Quality Survey.

The charts profile uninsured rates and insurance instability over time among Hispanic populations; examine the link between lack of insurance, access to health care, and the receipt of preventive health services; and document the extent to which limited English language proficiency undermines patient-provider communication and overall quality of care for Hispanic populations.

The Chartpack is divided into the following seven sections:

Uninsured Rates and Insurance Instability over Time

Profile of Uninsured Hispanics: Income, Wage, and Immigration

Insurance and Access to Health Care

Use of Preventive Health Services Among Hispanic Populations

Insurance and Preventive Health Care: Preventive Care Rates Lower for Adults with Any Time Uninsured

Care Experiences and Satisfaction with Quality of Care: Insurance and Language Ability

Insurance and Access Among Adults Ages 50–64

Introduction

1. Uninsured Rates andInsurance Instability over Time

Hispanics Disproportionately Uninsured: In 2002, They Comprised 14 Percent of

Total Population But 29 Percent of the Uninsured

Data: March 2003 Current Population Survey. Except for Hispanics, race categories based on reports of only one race: White alone, non-Hispanic; Black alone; Asian alone; and Hispanic, any race.Source: The Commonwealth Fund analysis of data from Robert J. Mills and Shailesh Bhandari, September 2003, U.S. Census Bureau.

Hispanic 13.7%

Total Population Uninsured Population

White 68%

43.6 Million285.9 Million

African American 12.5%

Asian/Pacific Islander

4%

African American

16.6%Other 1.6%

Hispanic 29.3%

White 47.7%

Asian/Pacific Islander

4.9%

Other 1.5%

Chart 1-1

Hispanic Uninsured Rates Have Remained Consistently High over the Past Decade

14 1511 11

20 2017 18

33 32

0

30

60

1990 2002

Total White A fric an Americ an As ian Hispanic

Data: March 1991, 2003 Current Population Surveys.Source: Robert J. Mills and Shailesh Bhandari, September 2003, U.S. Census Bureau.

Percent of Total Population Uninsured

Chart 1-2

The Number of Uninsured HispanicsNearly Doubled from 1990 to 2002

6.9 7.4

9.29.9

11.1 10.8

12.4 12.8

1990 1992 1994 1996 1998 2000* 2001* 2002*

Source: Michelle M. Doty. Hispanic Patients’ Double Burden: Lack of Health Insurance and Limited English. The Commonwealth Fund, February 2003.

Total Uninsured Hispanics in Millions

Data: March 1991–2002 CPS.* Uninsured estimates from 2000 and beyond take into account the insurance verification question introduced in March 2001 CPS. Data for 2002 come from Robert J. Mills and Shailesh Bhandari, September 2003, U.S. Census Bureau.

Chart 1-3

Nearly Half of Hispanics Under Age 65 Were Uninsured for All or Part of the Year During 2000

10 1627

1312

14

18

130

20

40

60

Total White A fric an

A meric an

Hispanic

Uninsured Part Y ear

Uninsured A ll Y ear

Percent of Population Under 65 Uninsured All or Part Year, 2000

Source: The Commonwealth Fund and Columbia University analysis of MEPS 2000.

2622

30

45

Chart 1-4

Hispanic Children as Well as AdultsAre at High Risk of Being Uninsured

9 7 917 15 11

213414

1320

16

14

111413

0

25

50

75

T otal White Afric an

Americ an

Hispanic T otal White Afric an

Americ an

Hispanic

U ninsured A ll Y ear U ninsured P art Y ear

23 20 23

37

2822

35

50

Adults Ages 19–64

Percent of Population Uninsured All or Part Year, 2000


Children Ages 0–18

Chart 1-5

Among Low-Income Children and Nonelderly Adults, Uninsured Rates Are Highest for Hispanics

12 9 1120

3025

31

4521 22 15

24

2123

18

20

0

25

50

75

Total White African

American

Hispanic Total White African

American

Hispanic

Uninsured All Year Uninsured Part Year

33 3126

44

5148 49

65

Low-Income AdultsAges 19–64

Percent of Population with Income Below 200% Poverty Uninsured All or Part Year, 2000


Low-Income ChildrenAges 0–18

Chart 1-6

2. Profile of Uninsured Hispanics: Income, Wage, and Immigration

Three-Quarters of Uninsured Hispanics Are Low-Income*

Low-Income Adults with Children

23%

Low-Income Adults Without Children

30%

Low-Income Children22%

Other Adults20%

* Low-income defined as under 200% poverty, $28,500 for a family of three in 2001.Source: The Commonwealth Fund and Columbia University analysis of March 2002Current Population Survey.

Other Children5%

12.4 Million Uninsured Hispanics, 2001

Chart 2-1

Source: The Commonwealth Fund and Columbia University analysis of March 2002Current Population Survey.

Household Income Distribution of Uninsured Nonelderly Hispanics

Forty-One Percent of Uninsured Nonelderly Hispanics Have Household Incomes of Less than $15,000

12.3 Million Uninsured Hispanics Under Age 65, 2001

$15,000–$30,00033%

Greater than $30,000

26%

Less than$10,000

26%

$10,000–$14,999

15%

Chart 2-2

2318

2517

24

47

21

58

25

49

0

25

50

75

All Hispanics Cubans Mexicans Puerto Ricans Central/ South

Americans

U.S.-Born Foreign-Born

Data: 1997 National Health Interview Survey.Source: Claudia L. Schur and Jacob Feldman. Running in Place: How Job Characteristics, Immigrant Status, and Family Structure Keep Hispanics Uninsured. The Commonwealth Fund, May 2001.

Uninsured Rates Among Hispanics Varyby Immigration Status and Country of Origin

Percent of Nonelderly Hispanics Uninsured, 1997

Chart 2-3

28

72

34

57

19

49

14

34

0

20

40

60

80

Foreign-Born Hispanics Foreign-Born Non-Hispanics

<5 Years 5 to <10 Years 10 to <15 Years 15 Years+

Data: 1997 National Health Interview Survey.Source: Claudia L. Schur and Jacob Feldman. Running in Place: How Job Characteristics, Immigrant Status, and Family Structure Keep Hispanics Uninsured. The Commonwealth Fund, May 2001.

Immigrant Uninsured Rates Decline with Length of Time in the U.S., Yet Foreign-Born Hispanics Are MoreLikely to Be Uninsured than Other Immigrant Groups

Percent Length of Time Uninsured, Nonelderly, 1997

Chart 2-4

A Large Proportion of Primarily Spanish-Speaking Hispanics Lacks Insurance

2520

3036

61

0

35

70

Total White A fric an

Americ an

Hispanic ,

P rimarily

English-

Speaking

Hispanic ,

P rimarily

Spanish-

Speaking

Percent of Nonelderly Adults Uninsured All or Part Year, 2001

Data: The Commonwealth Fund 2001 Health Care Quality Survey.Source: Michelle M. Doty. Hispanic Patients’ Double Burden: Lack of Health Insurance and Limited English. The Commonwealth Fund, February 2003.

Chart 2-5

The Vast Majority of Uninsured NonelderlyAdult Hispanics Work Full-Time

65 60 68

15 1716

11

64

0

25

50

75

100

Total Adults

Uninsured

Uninsured White Uninsured

African American

Uninsured

Hispanic

Part-Time

Full-Time

Percent of Uninsured Adults Ages 19–64 Who Work Full- or Part-Time

Source: The Commonwealth Fund and Columbia University analysis ofPooled March 2000–2002 Current Population Surveys.

79 82 7976

Chart 2-6

Hispanics Are Substantially Less Likely to Have Health Insurance Coverage Through an Employer

65%

72%

54%

43%

11%

8%

9%

21%

18%

7%

8%

9%

5%

4%

16%

12%

19%

20%

35%

63%

Total, Under 65

White, Non-Hispanic

Asian

African American

Hispanic

Employer Public* Individual/Military/Other Uninsured

Source: The Commonwealth Fund and Columbia University analysis of March 2002Current Population Survey.

Insurance Sources for Under-65 Population, 2001

* Includes Medicare, Medicaid, and other public insurance.

Chart 2-7

The Pattern of Low Rates of Employer-Sponsored Coverage Extends Across Various Wage Groups

and Firm Sizes

59

29

59

19

63

34

72

23

83

59

78

34

0 20 40 60 80 100

White, Non-H ispanicB lac k, Non-H ispanicHispanic

Hourly Wage Under $7

Hourly Wage$10–$15

Firm Size Under 25

Firm Size Over 100

Percent of Under-65 Working Family Population with Employer Coverage, 1998

Data: March 1999 Current Population Survey.Source: Kevin Quinn. Working Without Benefits: The Health Insurance Crisis Confronting Hispanic Americans. The Commonwealth Fund, March 2000.

Chart 2-8

Working Hispanic Families Are Uninsuredat a Substantially Higher Rate than White or

African American Families in Similar Situations

28

52

31

5237

19

35

1612

9

22

32

0 20 40 60 80

White, Non-HispanicBlack, Non-HispanicHispanic

Hourly Wage Under $7

Hourly Wage$10–$15

Firm Size Under 25

Firm Size Over 100

Percent of Under-65 Workers Who Are Uninsured, 1998

Data: March 1999 Current Population Survey.Source: Kevin Quinn. Working Without Benefits: The Health Insurance Crisis Confronting Hispanic Americans. The Commonwealth Fund, March 2000.

Chart 2-9

Hispanic Employees Take Insurance When They Can, But Are Less Likely to Have the Opportunity

8981 8287

81 86

7261

82

0

20

40

60

80

100

Offer: Employer Offers

P lans to Some

Employees

Offered and Employee

E ligible to P artic ipate

T ake-U p Rate: P erc ent of

T hose E ligible Who

P artic ipate

White, N on-H ispanic Blac k , N on-H ispanic H ispanic

Note: Excludes self-employed.Data: The Commonwealth Fund 1999 National Survey of Workers’ Health Insurance.Source: Kevin Quinn. Working Without Benefits: The Health Insurance Crisis Confronting Hispanic Americans. The Commonwealth Fund, March 2000.

Percent of Nonelderly Adult Workers, 1999

Chart 2-10

Low-Income Hispanics Have Low Rates of Public Coverage

36%

43%

33%

25%

26%

22%

15%

35%

26%

9%

12%

12%

5%

4%

30%

23%

31%

27%

45%

36%

Total, Under 65

White, Non-Hispanic

Asian

African American

Hispanic

Employer Public* Individual/Military/Other Uninsured

* Includes Medicare, Medicaid, and other public insurance.Source: The Commonwealth Fund and Columbia University analysis of March 2002 Current Population Survey.

Insurance Sources for Under-65 Population with Incomes Below 200% Poverty, 2001

Chart 2-11

3. Insurance and Access to Health Care

Hispanics Are More Likely to Rely on Community or Public Clinics as Their Regular Source of Care, 2001

9

7

10

20

12

33

82

85

76

64

79

8

7

13

14

9

2343

0% 25% 50% 75% 100%

Total, 18–64

White

Afric an Americ an

All H ispanic s

H ispanic English-Speak ing

H ispanic -Spanish Speak ing

Community or public c linic Doc tor's offic e/Other Hospital ER /No regular sourc e


Chart 3-1

Nearly Two of Five Uninsured Spanish-Speaking Hispanics Have Little Choice of Where to Go for Medical Care

1714

18 2017

2529 28

38

322824

0

25

50

Total U.S. White African

American

Total

Hispanic

Hispanic,

Primarily

English

Speaking

Hispanic,

Primarily

Spanish

Speaking

Insured Uninsured

Percent of Adults Reporting They Have “Very Little” or “No Choice”, 2001

Base: Adults with health care visits in past two yearsAdjusted percentages controlling for poverty and education.Data: The Commonwealth Fund 2001 Health Care Quality Survey.Source: Michelle M. Doty. Hispanic Patients’ Double Burden: Lack of Health Insurance and Limited English. The Commonwealth Fund, February 2003.

Chart 3-2

More Than Half of Uninsured HispanicsAre Without a Regular Doctor

37

2126

191620

66

464453

4337

0

20

40

60

80


American

Total

Hispanic

Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Insured Uninsured

Percent of Nonelderly Adults Without a Regular Doctor, 2001

Base: Adults with health care visits in past two years. Adjusted percentages controlling for poverty and education.Data: The Commonwealth Fund 2001 Health Care Quality Survey.Source: Michelle M. Doty. Hispanic Patients’ Double Burden: Lack of Health Insurance and Limited English. The Commonwealth Fund, February 2003.

Chart 3-3

Uninsured Hispanics with Health ProblemsAre Least Likely to Visit a Doctor

30

1924

1512

17

40

18

2833

24 22

0

25

50


American

Total, Hispanic Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Insured Uninsured

Base: Adults with fair/poor health status, chronic illness, or disability. Adjusted percentages controlling for poverty and education.

Percent of Sicker Nonelderly Adults with NO Health Care Visitin the Past Year, 2001


Chart 3-4

4. Use of Preventive Health Services Among Hispanic Populations

4147

26 24 2631

22

0

20

40

60

T otal U S White A fric an

A meric an

A ll

H ispanic s

P uerto

R ic an

Cuban Mex ic an

Percent of Adults Ages 19–64 Receiving a Dental Exam Within Past Year, 2000


Rates of Dental Exam Visits During the YearAre Very Low Among Hispanics

Chart 4-1

87 91 898182

85 86

0

50

100


A meric an

A ll

H ispanic s

P uerto

R ic an

Cuban Mex ic an

Percent of Women Ages 19–64 Receiving Pap Test Within Past Three Years, 2000

Rates of Routine Pap Tests Varyby Race/Ethnicity and Hispanic Origin


Chart 4-2

71 71

80

616472 74

0

20

40

60

80

100


A meric an

A ll

H ispanic s

P uerto

R ic an

Cuban Mex ic an

Percent of Women Ages 40–64 Receiving Mammogram in Past Two Years, 2000

Rates of Routine Mammograms Varyby Race/Ethnicity and Hispanic Origin


Chart 4-3

4238

25

19

30

38 39

0

20

40

60


A meric an

A ll

H ispanic s

P uerto

R ic an

Cuban Mex ic an

Percent of Men Ages 40–64 Receiving Prostate Exam in Past Two Years, 2000

Hispanic Men Are Less Likely to Have HadProstate Screening: Rates Vary by Hispanic Origin


Chart 4-4

5. Insurance and Preventive Health Care: Preventive Care Rates Lower

for Adults with Any Time Uninsured

19

25

813

21

4852

32 32

23

3034

0

30

60

Total U.S. White African American Hispanic

Uninsured all year Uninsured part year Insured all year

Percent of Adults Ages 19–64 Receiving a Dental Exam During Past Year, 2000

Insurance Matters for Routine Dental Exams: Ratesof Dental Visits by Race/Ethnicity and Insurance


Chart 5-1

73 75 7672

83 8291

8688 88 88 87

0

50

100



Percent of Women Ages 19–64 Receiving Pap Test Within Past Three Years, 2000


Insurance Matters for Routine Pap Tests: Pap Test Screening Rates by Race/Ethnicity and Insurance

Chart 5-2

47 49 46 5056 57

69

52

77 78 77 74

0

50

100



Percent of Women Ages 40–64 Receiving Mammogram in Past Two Years, 2000

Insurance Matters for Routine Mammograms: Mammogram Rates by Race/Ethnicity and Insurance


Chart 5-3

21 23

29

16

29 31

37

21

42 4245

40

0

20

40

60



Percent of Men Ages 40–64 Receiving Prostate Exam in Past Two Years, 2000

Insurance Matters for Routine Prostate Exams: Prostate Exam Rates by Race/Ethnicity and Insurance


Chart 5-4

Insurance Matters for Management of Diabetes: Careof Diabetic Adults by Race/Ethnicity and Insurance

49 49 47 50 51 5462

39

70 6974 72

68 6774

67

0

25

50

75

100

Total White African

American


American

Hispanic

Uninsured Insured

Foot Exam in Past Year

Percent of Diabetic Adults Ages 18–64 with Eye or Foot Exam in Past Year, 2001

Note: The eye exam is to check for signs of glaucoma, cataracts, and retinopathy, for which people with diabetes are at increased risk; the foot exam is to check for loss of feeling, blood flow, and changes in shape (American Diabetes Assn.).Source: Analysis of BRFSS 2001 for The Commonwealth Fund by John Z. Ayanian, Joel S. Weissman, and Alan M. Zaslavsky, Department of Health Care Policy, Harvard Medical School.

Eye Exam in Past Year

Chart 5-5

6. Care Experiences and Satisfaction with Quality of Care:

Insurance and Language Ability

Availability of Language Interpretation Services Is Limited Among Hispanic Adults, 2001

Always, usually, or sometimes have a hard time speaking with/understanding doctor because of language barrier 44%

Of those who need interpreter, percent who always or usually get interpreter

49%

Usual interpreter:

Staff person 55%

Family or friend 43%

Trained medical interpreter 1%

With interpreter’s help, fully understood what doctor was saying

70%


Chart 6-1

Hispanics Have Greater Problems Understanding and Communicating with Their Doctor

19 16

3326

43

0

20

40

60

Total U.S. White Total Hispanic Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Percent of Adults Ages 18–64 Who Had at Least One ProblemCommunicating* with Their Provider, 2001

Base: Adults with health care visits in past two years. * Doctor didn’t listen to everything, patient didn’t understand fully, or patient had questions but didn’t ask them. Data: The Commonwealth Fund 2001 Health Care Quality Survey.Source: Karen Scott Collins, et al. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. The Commonwealth Fund, March 2002.

Chart 6-2

Lack of Insurance and English ProficiencyAre Associated with Communication Problems

17 15 16 16

2730 31

45

2831

0

20

40

60


American

Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Insured Uninsured

Percent of Adults Ages 18–64 Reporting One or MoreCommunication Problems,* 2001

Base: Adults with health care visits in past two years.* Doctor didn’t listen to everything, patient didn’t understand fully, or patient had questions but didn’t ask them. Adjusted percentages controlling for poverty and education.Data: The Commonwealth Fund 2001 Health Care Quality Survey.Source: Michelle M. Doty. Hispanic Patients’ Double Burden: Lack of Health Insurance and Limited English. The Commonwealth Fund, February 2003.

Chart 6-3

Spanish-Speaking Hispanics Have the Most Difficulty Understanding Prescription Instructions

48

7363

8079 83

0

20

40

60

80

100


American

Hispanic

Total

Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Percent of Adults Ages 18–64 Reporting It Is “Very Easy” to Understandand Read Instructions on Prescription Bottle, 2001


Chart 6-4

Spanish-Speaking Hispanics Have the Most Difficulty Understanding Information from Their Doctor’s Office

35

5044

5658 61

0

20

40

60

80


American

Hispanic

Total

Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Percent of Adults Ages 18–64 Reporting It Is “Very Easy” to Readand Understand Written Information from Their Doctor’s Office, 2001


Chart 6-5

English-Speaking Hispanics Are Less Satisfiedwith the Amount of Time Spent with Their Doctor

6761

73716859

6552

60 63

0

20

40

60

80

100


American

Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Insured Uninsured

Percent of Adults Ages 18–64 Reporting Their Doctor Spent Sufficient Amount of Time with Them, 2001


Chart 6-6

Uninsured Spanish-Speaking HispanicsAre Least Likely to Report a “Great Deal”

of Confidence in Their Doctor

70 73 7361 565854 57 56

43

0

20

40

60

80

100


American

Hispanic,

Primarily

English-

Speaking

Hispanic,

Primarily

Spanish-

Speaking

Insured Uninsured


Percent of Adults Ages 18–64 Reporting “Great Deal” of Confidence in Their Doctor, 2001

Chart 6-7

7. Insurance and Access Among Adults Ages 50–64

Low-Income Hispanic Adults Ages 50–64 Have High Rates of Being Uninsured During the Year

11 819

30 28 26 23

437

1311

18

813

6

7

0

25

50

75

Total White African

American


American

Hispanic

Uninsured All Year Uninsured Part Year

19%

All Adults Ages 50–64 Adults Ages 50–64 with Incomes Below 200% Poverty

Percent of Adults Ages 50–64 Uninsured All or Part Year, 2000


1815

25

41 41 39

31

61

Chart 7-1

12 9

26 2727

6065

47

3736

30 27

0

20

40

60

80

Total U .S. White Afric an Americ an H ispanic

U ninsured Insured, Without Rx Coverage Insured, w ith Rx Coverage

Percent of Adults Ages 50–64 Uninsured, and Insured with and Without Prescription Drug Coverage, 2001

Source: The Commonwealth Fund 2001 Health Care Quality Survey.

Inadequate Insurance: Hispanics Ages 50–64 Are Least Likely to Have Prescription Drug Coverage

Chart 7-2

A Quarter of Hispanics Ages 50–64 Are Unable to Access Care Because of Cost

25 25

13 1211 11

20

10

0

20

40

Did Not Fill a Prescription Skipped Medical Test, Treatment,

or Follow-Up

Total White African American Hispanic

Percent of Adults Ages 50–64 Who Went Without Needed Carein the Past Year Due to Cost, 2001

Source: The Commonwealth Fund 2001 Health Insurance Survey.

Chart 7-3

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