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

Steven P. Wallace, Ph.D. UCLA Center for Health Policy Research

UCLA School of Public Health

swallace@ucla.edu

Key elements of US medical care system

► Regulated primarily by states, not federal government

Key elements (2)

►Provision of services and payment are usually separated

Fragmentation of Payer and Provider – Los Angeles County

►Providers• 119 hospitals

•65 different owners• 4 county owned• 1 Veteran’s Admin.

• 203 primary care clinics• 6 County• rest nonprofit/community

(often with county contracts)

• 1000s of MD offices & groups

► Payers• 23 licensed private

insurance companies in fee for service

• 7 large licensed HMOs• Medicare (federal)• Medi-Cal, Healthy

Families (state/federal)• Workers compensation • Healthy Kids

(county)

Most insurance companies are private

► Focus on profits• Aetna, Inc., CIGNA Corp., Health Net, Inc.,

UnitedHealth Group and WellPoint Health Networks, Inc. CEO’s each have salaries over $US1 million

• Anthem Blue Cross spends 21% of premiums on administrative costs (marketing, salaries, etc) vs. Kaiser (one of the few non-profit companies) that spends 9.4%

source.: SJ Mercury Newshttp://origin.mercurynews.com/news/ci_9679172?nclick_check=1

Key Elements (4)

►Primary source of insurance is via employment

►Government insurance common for low-income children & families, disabled, and elderly

Type of health insurance, all U.S. residents, 2008

58.5%

8.9%14.3% 14.1%

3.8%

15.4%

Employer Otherprivate

Medicare Medicaid Otherpublic

None

Source: http://www.census.gov/prod/2009pubs/p60-236.pdf

46.3 million persons

Type of medical insurance, 2007

30.9% 38.0%

66.1% 72.2%9.8%9.1%

12.0%12.0%

52.9%

21.9% 15.2%

59.3%

Mexicanimmigrants

Major Central/South America*

Other immigrants US Born NL White

Private only Any public None

http://www.healthpolicy.ucla.edu/pubs/Publication.aspx?pubID=274 * Guatemala, El Salvador, Honduras, Nicaragua, Colombia & Ecuador.

Percent using clinics (vs. private doctor) for medical care, U.S.37.1%

30.1%

18.7%14.7%

Imm MexAm, inUS <10 yrs

Immg MexAm, inUS 10+ yrs

US BornMexicanAm

US Born NL White

http://www.healthpolicy.ucla.edu/pubs/publication.asp?pubID=155

Percent using clinics (vs. private doctor) for medical care, CA

72.1%

44.9%

28.1%15.8%

62.9%51.8%

32.4%

76.8%

Imm MexAm, inUS <10 yrs

Immg MexAm, inUS 10+ yrs

US BornMexicanAm

US Born NL White

insured uninsured

Source: California Health Interview Survey, 2005

CA resident w/ medical, dental, or prescription in Mexico past year

2.1%

5.3%

15.0%

11.4%

3.5%

US Born NLWhite

US BornMexicanAm

Immg MexAm,in US 15+ yrs

Imm MexAm,in US <15 yrs

Other LatAmimmigrants

Source: Wallace, Mendez-Luck, Castañeda, Medical Care, 2009

Distance from border, CA resident using Mexico MD

18.1%28.1% 22.7% 19.6%

0.0%

34.1% 14.4%16.3% 22.0%

9.6%

38.9% 40.6% 37.7%84.2%

18.9% 18.5% 20.4% 20.7%6.1%

28.9%

US Born NLWhite

US BornMexicanAm

Immg MexAm,in US 15+ yrs

Imm MexAm,in US <15 yrs

Other LatAmimmigrants

0-20miles 20-100 miles 100-250 miles 250+

(3) U.S. health care system is most expensive in the world

9.0%5.9%

16.0%

$890

$7,536

$3,230

U.S. U.K. Mexico

% GDP $/person

Source: WHO, The world health report 2006

Summary of Characteristics

1. Health care largely regulated by states

2. Separation of services and payment

3. Most insurance through work; public insurance mostly for children and elderly

4. U.S. the most expensive in the world

Context of need

► Immigrants are healthier than average, so need less acute medical care

► Need for preventive care and occupational coverage higher than average

► Immigrant wages are low, so ability to pay is low. Often sending money to Mexico, many time to help pay for medical care.

Key dimensions of health services

Access to care

Cost of careQuality of care

Equity

Odds ratios*, health care access vs. U.S.-born Mexican Americas, CA

0.820.75 0.70

0.83

1.00

1.28

0.830.73

1.06

0.70

0.52 0.50

1.001.00 1.00

US BornMexicanAm

Naturalized Green card Undocumented US Born NLwhite

Usual source of care MD visit ED visit* Adjusted for sex, marital status, health insurance, age, education, employment, federal poverty level, location of residence, and self-reported health status. Source: CHIS 2003 in Arch Intern Med, Vol 167, Nov 26, 2007, p 2354

Hard time understanding doctor last visit, by language spoken at home,

age 60+, California

17.9%

8.9%

2.6%

9.3%

3.1%5.0%

Latino AfricanAmerican

Asian nonLatinoWhite

Spanish only English & Spanish English only

Source: 2003 California Health Interview Survey

Age-adjusted total per capita health spending, 2008 dollars

Stimpson, Wilson, Eschbach, Health Affairs 2010.doi: 10.1377/hlthaff.2009.0400

Mixed status families complicate equitable health care

14.90%

25.30%59.80

%

Citizen parents1-citizen parentNoncitizen parents

Children of Mexican immigrants

47.10%

27.30%

25.70%

Citizen parents1-citizen parentNoncitizen parents

Children of NonLatino immigrants

Senate bill p. 126

►(c) APPLICATION OF EMERGENCY SERVICES LAWS.— Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1867 of the Social Security Act (popularly known as ‘‘EMTALA’’).

Senate bill p. 292

►(d) NO FEDERAL PAYMENTS FOR INDIVIDUALS NOT LAWFULLY PRESENT.—Nothing in this subtitle or the amendments made by this subtitle allows Federal payments, credits, or cost-sharing reductions for individuals who are not lawfully present in the United States.

CBO estimates of those remaining without insurance

► 23 million nonelderly residents (down from estimated 53 million otherwise)• 1/3 undocumented (7+ million )

• 1/3 insurance too expensive & exempt

• 1/3 opt to pay “fine” vs. buy coverage

http://www.cbo.gov/ftpdocs/113xx/doc11379/Manager%27sAmendmenttoReconciliationProposal.pdf

Adequate use of health care

► Availability – are services located in the community where immigrants live

► Accessibility – can immigrants afford the care; are the hours of service appropriate

► Acceptability – do the immigrants have confidence in the provider, can they communicate

Opportunities?

► Expand employer health coverage

► Expand government coverage for low-income workers with a green card

► Expand binational health insurance

► Develop discount cards for community clinics

►Expand ventanillas de salud

Expand employer insurance: Advantages

► It is the most common type of insurance in the U.S. currently; plenty of capacity

► Private health insurance companies do not ask about immigration status

► Can be tied to immigration reform legislation that will establish a guest worker (bracero-like) status

Expand employer health insurance: Disadvantages

► Difficult or impossible for states to require employers to offer insurance under current federal law

► Employers oppose because it will increase costs

► Would not cover part time, temporary, or migrant workers

Expand government programs for low-waged workers: Advantages

► Many uninsured immigrants who hold green card would be eligible

► Programs exist that have had political support in the past for expansion (e.g. Healthy Families)

► Infrastructure and capacity already exist

Expand government programs for low-waged workers: Disadvantages

► Government programs may scare off many who are eligible, especially those in mixed-status families

► Political support for expansion weakens during recessions, like now

► Will not help undocumented

Expand binational health insurance

► Three companies offer California-Mexico insurance

► About 250,000 covered

► Primary care in U.S., hospital care in Tijuana

Expand binational health insurance: Advantages

► Lower cost, uses familiar providers in Mexico

► Feasibility demonstrated by existing plans in California

► Could benefit families remaining in Mexico in addition to migrants in the U.S.

Expand binational health insurance: Disadvantages

► Many administrative and technical issues remain to expand networks

► Limited demand for current cross-border insurance; still too expensive for many & most appealing on border

► Undocumented can’t cross border freely

► Some providers oppose due to competition; Some immigrant advocates oppose as establishing a “two class system”

Discount cards for community clinics

► Community clinics already in immigrant communities

► Already offer services on ability to pay, but capacity is limited due to $$

AltaMed Health Services, E.LA

Discount cards for community clinics: Advantages

► Builds on existing network of providers

► Carries little fear of government services

► Can provide care without involving the complex insurance system

► Mexican government and U.S. charities (foundations) can help finance

Discount cards for community clinics: Disadvantages

► Would likely only cover primary care, leaving most expensive hospital care uncovered

► Is not insurance so creates two class system

► Monitoring/accountability might be difficult

Ventanillas de Salud

►Services in 23 Mexican consulates

►Mostly information and referral

► Health education

► Mobile clinics, health fairs http://www.ime.gob.mx/programas_salud/vds.htm

Ventanillas de salud: Advantages

► Location at Mexican consulates is safest for undocumented immigrants

► Could use funds from Mexico with least political resistance

► ?? Could use staff with only Mexican medical licenses??

Ventanillas de salud: Disadvantages

► Consulates are not designed or staffed to provide medical care

► Care would only be primary care, not more expensive hospital care

► Consulates are not conveniently located for many to use as a primary care center

Summary

► Each option for immigrants (especially undocumented) contains a different mix of + and – for availability, accessibility, and acceptability.

► It is essential to consider political feasibility: “don’t let the perfect get in the way of the good”

► Care versus Coverage is important