Vernellia R. Randall
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| VII. Policies to Alleviate Inequities for Older Latinos
in the Healthcare System
excerpted Wrom: PTCXLYRWTQTIPWIGYOKSTTZRCLBDXRQBGJSNBO Equitable Health Systems: Cultural and Structural Issues for Latino Elders, 29 American Journal of Law and Medicine 247-267 (2003) (159 Footnotes Omitted) To promote policy change, we must usually first raise political awareness about the problem that is the target of the policy change. Since elders of color tend to be overlooked in the political process, the first step in improving equity for Latino elderly in healthcare is to increase the quantity of research and publicity about the health status, process of care and financial burdens faced by this population and other elders of color. Organizations that focus on Latino health need to join with other minority group organizations that focus on health disparities and also partner with those that focus on aging to highlight these problems to a federal government that has become preoccupied with other issues. Prioritizing these issues requires data on Latino elders, which will become more scarce if current proposals to strike race and ethnicity from routine government data collection are successful. Medicare is an active policy area that needs both analysis and publicity about the implications of changes for Latino and other elders of color. A slowing economy in the early 2000s and resurgent medical cost inflation is renewing interest in changing the Medicare system in ways that will reduce spending. Absent from these discussions, however, is the differential impact that the changes are likely to have on Latino and other minority elderly. A common approach to changing Medicare is to make it more like private insurance, with older persons obtaining a fixed sum that they can apply to purchasing insurance in the private market. This encourages the elderly to be more price conscious by increasing the out-of-pocket costs of most older persons. Yet, as discussed supra, the distribution of out-of-pocket spending is already inequitable for older persons and creates disparities between older Latinos and non-Latino whites. The equity consequences of policy changes and budgetary consequences would suggest that subpopulations of the elderly in fact need increased coverage for medical care. In addition to raising awareness of the equity issues involving Latino elders, a number of policy levers available could improve equity in the health of older Latinos as compared to non-Latino whites. The most obvious health policies and programs focusing on Latino elders address the cultural dimensions of health. Traditional health education programs concentrate on trying to change the knowledge, attitudes and practices of populations. They include attempts to make patients more knowledgeable about risk factors for diseases, more motivated to follow doctors' recommendations and more likely to use services when doctors deem it most effective. These types of programs also try to educate individuals to change their diets, increase exercise and otherwise modify their lifestyles to improve their health independently of the medical care system. A fully informed population would then be expected to balance culturally derived preferences against known outcomes, making any resulting differences between populations equitable because they were freely chosen. It has been argued, for example, that the logical target for decreasing the prevalence of diabetes among Latinos is reducing obesity through the adoption of healthy dietary habits and physical activity. In fact, one of the objectives of HHS is the reduction of obesity as a risk factor for disease through a healthy diet and regular physical activity, particularly among Latinos. These programs, however, risk "blaming the victim," as well as being of limited effectiveness in addressing structural causes of the patterns. They assume a relatively uniform structural context that allows freely chosen options, which we argue is not the case for Latino elders. Health policies that focus on structural factors such as the organization and financing of medical care or the social environment where older Latinos live affect entire populations. Population-based interventions that potentially affect all elderly, such as expanding Medicare benefits, also have the potential political advantage of drawing beneficiary support that includes the middle class and politically influential individuals. At the community level, programs that improve neighborhood safety help older Latinos feel safer when exercising, while expanding the availability of affordable fruits and vegetables provides better nutritional alternatives. Regardless of one's culture, for example, following a diabetic diet is difficult if fresh foods are expensive or difficult to obtain, as they often are in inner-city areas. New construction of large supermarkets in the inner- cities increases the consumption of fruits and vegetables by the poor. Policies that encourage such construction, which may be conceptualized by some as economic development or zoning policies, are also important health policies that help ameliorate inequities. At the healthcare system level, improving the health of the older Latino population requires changing the current healthcare delivery system to improve the process of care and to ensure that older Latinos receive appropriate levels of care. One of the main obstacles to the treatment of diabetes among Latinos, for example, is inadequate health insurance and impaired access to appropriate healthcare settings. Since many diseases, such as diabetes, require ongoing medical management, reducing the out-of-pocket burdens on all low-income elders would greatly benefit the Latino elderly. Since prescription medications are the source of significant out-of- pocket costs, adding prescription benefits to Medicare would assist them, assuming that the benefits did not have significant new premiums or excessive cost sharing. Improving health insurance benefits would improve both access to care as well as the equity of financing. Public policy can influence other important healthcare system changes including the composition of the workforce and the financial incentives within the system. Since patient satisfaction with doctors is higher when they can choose a physician of the same ethnicity, equity in the process of medical care depends in part on the ethnic composition of the medical labor force. In 2000-2001, Latinos comprised 5.9% (n=887) of doctors entering medical residency programs in the United States, representing half the proportion of Latinos in the general population. As a result, there will be a shortage of Latino physicians for the Latino elderly to select in the foreseeable future. More policy efforts need to be directed at increasing the number of qualified and interested Latino primary school students who develop interests in becoming medical providers, in addition to fostering pathways through college and into medical schools through programs such as the Health Careers Opportunity Program. Patients are also more satisfied with their care when financial incentives for the providers are tied to levels of patient satisfaction, so tracking and rewarding satisfaction rates separately for Latino and other elders of color could improve the process of caring for them. Finally, providing Latino elders with the financial resources to obtain adequate housing, nutrition and medical care would contribute to reducing many of the financing, process of care and health status inequities experienced by Latino elderly. At a minimum, the federal government should raise Supplemental Security Income (SSI), which provides need-based cash benefits to the aged, blind and disabled, to the poverty level. Few Latino elders are currently raised above poverty by SSI because its benefits are so low and because elders with more than minimal liquid assets are ineligible. In addition, less than half of those eligible for SSI are enrolled in the program, even though it provides automatic Medicaid benefits. For the longer term, public policy should encourage the payment of a living wage so that lifetime earnings can lead to social security and pension benefits that provide a reasonable income. [d1]. Professor, UCLA School of Public Health; Associate Director, UCLA Center for Health Policy Research. |
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