Islam, Oct - Dec 2003

Barriers to Healthcare for Latino Children

By Haneme Idrizi, MD

The present state of children’s health in the United States is not favorable. Although Americans spend almost one trillion dollars per year on health care, the US still appears to lag behind other nations in providing for our pediatric populations. The US ranks 24th among industrialized countries in the number of babies that die within the first year of life. The US had 23.1 million children who went without health insurance for all or part of 1995 and1996. The US currently has more obese children than ever before.

As discerning as these statistics may be, the situation within the Latino pediatric population is even more dismal. Latino children, who comprise the largest racial/ethnic minority group of US children, are the most uninsured group of children in the U.S. according to the Kaiser Commission report of 2000. This report determined that there are 1.1 million poor, uninsured Latino children compared with 806,000 white, 703,000 black, and 95,000 Asian poor uninsured children. In addition to lack of insurance, the Latino Consortium of the American Academy of Pediatrics Center for the Child Health Research which consists of 13 expert panelists (such as pediatricians, health service researchers, dentists, public health experts, nurses, etc) have published that Latino children are not being included in enough research projects. They also published that Latino children are at a higher risk for behavioral and developmental disorders, for school dropout, for obesity, diabetes mellitus, and asthma. Latino children are also more likely not be immunized, hospitalized longer, more likely to have tuberculosis, and not adequately treated for pain.

Although the federal and state governments recently began addressing the problems of uninsured children and enacted the Children’s Health Insurance Program (CHIP) as part of the Balanced Budget Act of 1997, why do Latino children continue to fall behind medically? What are the barriers that are hindering them from getting adequate health care? Only by identifying and addressing all the issues that hinder the Latino children of this nation from receiving adequate healthcare can changes be made. The Latino Consortium of the American Academy of Pediatrics Center for the Child Health Research has identified the most important issues concerning Latino child health. Although there are several obstacles in the way of Latino children’s health beyond the scope of this article, there are two essential impediments that continue to arise in all the literature: cultural/linguistic barriers and lack of health insurance.

In a recent study of pediatric primary care clinics, Latino parents cited cultural and language barriers as the single greatest barrier to healthcare access. Specifically, the parents identified lack of Spanish-speaking health care staff and inadequate interpreter services as the primary problem. Latinos are under represented in every level of health care professions. Although these difficulties can dramatically affect the ability of Latino children to receive adequate healthcare, cultural competency and linguistic training is still not an integral part of medical school education in this nation. For example, no Canadian medical schools and only 8% of all US medical schools teach Latino cultural issues. Failure to consider these issues in a nation where Latinos consist of 12% of the population can lead to a variety of adverse consequences such as decreased satisfaction with medical care, medical errors, difficulties with informed consent, fewer prescriptions, and use of harmful remedies.

The inadequacy of interpreter services also results in increased medical errors that effect the pediatric population. The Latino Consortium of the American Academy of Pediatrics Center for the Child Health Research reports that on average there are 18 interpreter errors of clinical consequence made per pediatric encounter. Nevertheless, only two US states provide third-party reimbursement for medical interpreter services, and less than one quarter of hospitals nationwide provide any training for medical interpreters. More research is needed on medical errors and the adverse consequences for Latino children associated with having untrained or no interpreters.

Current pediatric research suffers for a number of reasons. Research often excludes non-English speaking subjects, is rarely designed for Latino children, and research is not culturally or linguistically appropriate. Validity of research is often not tested. The Conner’s’ Parent Rating Scale and Teacher Rating Scale which assesses childhood behavioral problems has only been tested twice for its validity in the Latino Community. The Consortium recommends validating child health research instruments in Latino subgroups because without validity, results may be distorted. The ethnicity of personnel administering research may also introduce bias.

Language can also serve as a barrier to acculturation according to recent surveys conducted by the Institute for Health Policy Studies at the University of California. The researchers propose that the lack of acculturation plays a significant role in whether or not children receive medical services. Acculturation refers to the process whereby immigrants over time adopt U.S.-American views about the role and importance of health insurance. Recent findings from this California survey conducted in 2000 identified language as a barrier to enrollment among Latino children in California’s Public Children’s Insurance Program. The researchers hypothesize that the strength of language spoken may serve as a predictor because parents who speak only Spanish tend to be relatively new to this country and as such, are less accultured than English-speaking Latinos.

Others counter this claim by stating that a person’s linguistic skills may be more of an indicator of their economic status and thus their ability to acquire healthcare than their acculturation. Indeed, financial barriers should be addressed. There is a high risk of school dropout among Latinos – 29% compared with 13% blacks and 7% whites. A greater proportion of Latino children are held back, a major predictor of dropout in later years. Disparity persists even after adjustment for socioeconomic status. Only 20% of Latino children younger than 5 are enrolled in early childhood education classes compared with 44% blacks and 42% whites.

One of the most important healthcare barriers to Latino children has already been touched upon-lack of insurance. Latino children are more likely to be uninsured than any other ethnic group. The fact that currently 30% of Latino children are uninsured and that by 2005 they will be the largest minority population under age 18 illustrates that we are facing a tremendous health crisis in the upcoming years. As the Latino community continues to grow, their lack of health insurance will have an increasing impact on the nation’s health status.

Because Latinos are more likely to be uninsured, they are also more likely to experience the health risks of being uninsured, which include reduced access to care and poorer medical outcomes. For example, lack of insurance means that Latino children’s mental health needs will continue to be unmet, and consequently, Latinos will continue to be at a higher risk for behavioral and developmental disorders. Puerto Rican children have the highest national prevalence of developmental disorders and functional limitations. In 1999, 20% of Latino youth reported considering suicide and Latinos (19%) were significantly more likely than blacks (8%) and whites (9%) to have attempted suicide. Latinos are also less likely to be hospitalized for mental illness.

Even with programs such as CHIP available, why aren’t Latinos running to their local Department of Human Services to sign up-even with the new enrollment initiatives and public education campaigns? In addition to reasons already discussed, many families are unaware of current programs available to them or are mistrustful of heath care establishments. The reason for this mistrust may lie with the bad experiences they have had with institutions in the past. According to Marisa de la Garza, the Covering Kids Project Director for the Association of Community Health Centers, “Latinos won’t come in until they feel confianza (trust).” This is the reason why one of their most successful strategies has been working with promotoras (promoters) along the US-Mexican border. These promotoras are experts who know the language, culture, and thus, gain the confidence of the community.

Another reason why so many Latino children remain uninsured even with federal programs is that their non-citizen parents erroneously fear that enrolling their children in public insurance programs may hurt their chances of becoming citizens. According to a 2000 survey performed in California, Spanish-speaking Latinos are more likely than non-Latinos to indicate that they are concerned about the effect of participation on their immigration status.

Unfortunately, much confusion and fear exists among Latino families about who can get Medicaid or CHIP coverage and who cannot. The Welfare Reform Act of 1996 did prohibit immigrants arriving after August 22, 1996 from Medicaid eligibility. Those who entered on or after this date are not eligible for five years, and then other restrictions apply. Many of these immigrants are unaware that these laws do not apply to their American-born children. A Kaiser Commission report from 2000 found that only 26% of parents of eligible uninsured children said that they had ever talked to someone or received information about Medicaid enrollment. Some states, such as California, have opted to fill the coverage gaps to recent immigrants with the use of state funds, but most immigrants are unaware of this.

Results of the recent US census show that Latinos are now the predominant racial/ethnic minority group of US children representing about 1 in every 6. It is time for our health policies and services to represent this dramatic demographic change. Further cultural and linguistic training must be provided at the medical institutions of our nation-especially in major cities where the Latino communities predominate. In addition, trained and competent interpreters must be used in more healthcare settings in order to provide adequate healthcare to Latino children. Changes must be made that address the confusing nature of the existent programs, and those in positions of trust should provide information about these programs.

Change will only happen when we identify and address the various issues that prevent the Latino children of this nation from receiving adequate healthcare. Lack of insurance contributes to the endangerment of the health of each uninsured child as well as the collective health of the nation. The lack of health care coverage in the Latino pediatric population should be viewed with the same urgency as other issues such as diabetes and obesity. The state of uninsured Latino children must change.

“Barriers to Enrollment in Health Families and Medi-Cal: Differences by Language and Ethnicity.” Institute for Health Policy Studies. University of California. Revised February 2001.

“Children’s Health Insurance-How will it affect young Latinos?” El Futuro Newsletter. Institute for Hispanic Health.

Flores, Glen. “The Health of Latino Children.” JAMA. Vol. 288 No.1. July 3, 2002.

“Health Coverage in Latino Communities: What’s the problem and what can you do about it?” Families USA. September 2001.

“Kaiser Commission Report.” June 2000.