Copyright 2000 Federal News Service, Inc.
Federal News Service
May 11, 2000, Thursday
SECTION: PREPARED TESTIMONY
LENGTH: 4710 words
HEADLINE:
PREPARED TESTIMONY OF ELENA RIOS, M.D., M.S.P.H. DIRECTOR, HISPANIC-SERVING
HEALTH PROFESSIONS SCHOOLS, INC. PRESIDENT, NATIONAL HISPANIC MEDICAL
ASSOCIATION
BEFORE THE HOUSE COMMERCE COMMITTEE
SUBCOMMITTEE ON HEALTH AND ENVIRONMENT
BODY:
Introduction
Honorable Congressmen and Congresswomen and
guests, I am deeply honored to join you today in support of the
Health Care Fairness Act, H.R. 3250 which has the strong
potential to create knowledge and innovation - medical and
health services research, cultural competence training for
health professions, and civil rights monitoring - which I
believe will tremendously decrease the disparities in health
that face Hispanics, African Americans, Asian Americans/Pacific Islanders, and
Native Americans in the United States today.
I am representing two
critical national Washington DC based organizations: a) National Hispanic
Medical Association, which represents 30,000 licensed Hispanic physicians in the
United States; and b) Hispanic-Serving Health Professions
Schools, Inc., (established in 1996 by the Department of Health
and Human Services in response to the White House Educational Excellence for
Hispanic Americans Initiative), which represents 20 medical schools from across
the nation with 9% Hispanic student enrollment. The missions of both
organizations are to improve the health of Hispanics. We work
closely with the Hispanic Health Coalition, representing 30
national and local organizations, and with minority coalitions to continue to
challenge policy-makers to address the economic, social, environmental and
cultural factors responsible for the poor health status and the
poor access and utilization of health and mental
health services of our communities. I am here today to urge you
to take up the challenge to pass HR 3250 and make America healthier.During my
brief presentation, I will focus on three major issues - 1) the current
health status of the Hispanic population in the United States,
2) the need for research and cultural competence in medical services for
Hispanics and all Americans, and 3) to provide you with our recommendations to
improve the Health Care Fairness Act, H.R. 3250. Hispanic
Health Status
Population Growth, Poor
Health and Access to Care
The Hispanic population has
become the largest minority group in the United States. According to the U.S.
Census estimate for 1999, there are 32 million Hispanics or nearly 12% of the
population. If you include the Immigration and Naturalization Service estimates
of Hispanic residents who lack legal status ( 3.5 million) and the Puerto Rico
Commonwealth population (4 million), the Hispanic population in 2000 numbers
about 40 million. By the year 2050, 1 in every 4 Americans will be Hispanic.
Indeed, the U.S. is soon to become the second largest Spanish speaking country
in the world, second to Mexico.
Hispanics are a heterogeneous group
representing more than 20 countries. The 1999 population statistics released by
the U.S. Census reported that Hispanic's county of origin were 66% Mexico, 14
%Central/South America, 10% Puerto Rico, 7% Caribbean and other countries, and
4% Cuba.Nearly 87% of all Hispanics live in ten states: California, Texas, New
York, Florida, Illinois, New Jersey, Arizona, New Mexico, Colorado, and Nevada.
Major Hispanic metropolitan areas include: Los Angeles-Orange-San Bernardino
Counties, California; New York-Northern New Jersey-Long Island- Connecticut, New
York; Miami- Fort Lauderdale, Florida; Chicago-GaryLake County, Illinois,
Indiana, Wisconsin; San Francisco-Oakland-San Jose, California; Houston-
Galveston-Brazbria, Texas; Dallas-Fort Worth, Texas; and San Antonio, Texas.
The following areas were home to 58% of Hispanics in 1994: Los Angeles
County - nearly 7 million or 1 in 4 persons New York - nearly 3 million San
Francisco, Miami, Chicago - nearly 1 million -- Houston and Dallas - 800,000 San
Antonio - 600,000
In 1994, the Census estimated that 39% of Latinos were
born outside of U.S. Median Age = 26 years old, 10 years younger than
non-Hispanic whites
Socioeconomic factors determine the lifestyle of
people in the U.S. One out of three Hispanics in 1998 were below the Federal
poverty level. The 1993 median income was$ 23,700 for Hispanics
vs. $ 41,100 for non-Hispanic whites. In 1998, Hispanics
continued to have the lowest education levels of attainment with 54.7% having
attained high school graduation and 10% BA degrees. For Mexican Americans, 50%
of those 25 years old and above have 8 years of education or less.
Hispanics and Disease Mortality Rates (age adjusted, in order of
frequency)
Heart Disease Cancer
Unintentional Injuries
Cerebrovascular Disease Diabetes HIV/AIDS
Immigrant
health issues are very important for the Hispanic community,
since the majority of immigrants to the U.S. are from Mexico. There continues to
be an emphasis on isues of access to health care services with
Spanish language translators and information and restoring benefits such as food
stamps that impact on health.
Spanish language use is a
major factor for communicating with Hispanics in the U.S. 68% are monolingual in
Spanish, 86% of Hispanics report Spanish as their first language, 64% feel more
comfortable with Spanish, and 69% report Spanish spoken at home. It is no wonder
that Spanish media that has loyal viewers, listeners, and readers, including TV
and radio and newspapers have been extremely successful in the U.S.
To
add to the poor socioeconomic status of the Hispanic population, in general,
they do not have adequate access to the health care delivery
system. The numbers of uninsured in the United States has
increased to 44 million and are increasing at a faster rate due to a myriad of
factors.Hispanics are the largest group of uninsured in the
United States. 2 out of 5 Hispanics are uninsured according to
a February 2000 Commonwealth Fund Report, introduced at the National Hispanic
Medical Association Annual Conference, the so called "working poor." The lack of
health insurance coverage varies depending if they are children
or adults, if they are poor, if they work in the service or farming industries,
or if they are immigrants or undocumented workers.
Hispanics are least
likely to be linked to a regular source of care. Over 30% do not have a family
doctor, or clinic to go when they need care and the Hispanics, 25 years and
older, have the least number of dental visits compared to Whites or Blacks.
For children, Hispanics had the highest rates without a
physician visit in the past year and Hispanics had 3 times the rate of Whites
and 2 times the rate of Blacks for no regular source of care. Most non-citizens
who have become legal residents since 1996 are barred from Medicaid for five
years, regardless of need.
This situation is more severe among
Spanish-speaking populations due to the shortage of bilingual and bi-cultural
physicians and other health and mental health
professionals. The United States medical schools have been able to produce only
about 5% Hispanic physicians and with the demise of affirmative action, we
recognize the worsening numbers of underrepresented minority medical students.
Furthermore, due to health care providers' lack of familiarity
with the culture and language of patients, and with the limited medical
education about cultural competence, Hispanics do not receive the state-of the
art treatment that the American health care system is so proud
to provide. With the trend toward managed-care systems of care the access and
the quality of medical care has become worse for Hispanics and is expected to
become evenmore disastrous.
Other major factors that need to be
addressed to improve access to health care in this country
include: Health Care Facilities (hospitals, clinics, private
medical offices) -- Transportation Child Care Language Services Access
Hispanics have one of the worst health status in this
country. To begin with, diabetes type 2 is three times higher among Hispanics,
compared to non-Hispanics; cervical cancer is the highest among Hispanic women
(followed by Vietnamese women); mortality for breast cancer is one of the
highest among Hispanic and African American women due to the fact that minority
women do not have access to health care for early cancer
prevention and screening, and they come at a later stage for diagnosis and
treatment; prostate cancer is killing our men, and due to the heavy marketing of
the tobacco and alcohol industries, lung cancer (due to smoking) and alcoholism
are very serious health problems in our community; HIV/AIDS and
other sexually transmitted diseases, combined with tuberculosis, continue to be
devastating for the health of our youth and adults. For
example, HIV is the third cause of death among Hispanics, in the U.S., and
Puerto Rico has the second highest HIV rate in the country. Furthermore,
Hispanics tend to live in neighborhoods with high environmental pollution;
exposed to violence in the street, in their homes and in their workplace; and
they are most likely to work in occupations where they are exposed to dangerous
chemicals (e.g., pesticides) and poor working conditions. This isparticularly
true among janitors, landscapers, agricultural workers, etc. I could go on and
on documenting the seriousness of our problems. However, it is important for
policy-makers like yourselves to keep in mind that the health
status of Hispanics vary by age, nationality, gender, socioeconomic status,
immigration status and by levels of acculturation and assimilation to the
mainstream society.
Need for Better Medical Research about Hispanics
We know that medical and health services research can
lead to information that will improve the health of our nation.
In order to better understand the disease patterns that affect
Hispanics, factors that lead to decreasing barriers for Hispanics to access to
care, and factors that can increase outreach to Hispanics for
health promotion programs and treatment services in physical
and mental health, and research programs that can train
Hispanic health professions students to become researchers, we
critically need to increase biomedical and health services
research that targets all the major population groups fairly and equitably. This
bill should promote support for research by biomedical institutions, community
based agencies, non-profit entities that target all minority communities in the
U.S. There has been minimal Federal support for Hispanics to be included in
medical and health services research, and we urge you to
encourage increased Hispanic research and Hispanics entering research careers
with this bill.One of the most serious problems impacting the
health of Hispanics is the lack of data on their
health and medical needs and the lack of biomedical research on
the diseases with the greatest prevalence in this population. Until 1990, we did
not even know how many Hispanics die in this country or the mortality rates of
certain diseases. As a member of the National CDC HIV Strategic Planning
Committee and the Medicare Education Advisory Committee, we find that we can not
develop many measurable objectives for Hispanics because the data is not
available. This situation is more severe at the local level where departments of
healths in smaller communities do not have the infrastructures
to collect data. Some states, especially in the South, with recent great
influxes of Mexican immigrants have databases that only recognize Black, White
and Other.
Another very important research finding has been the
disparities in health, including access, utilization of
health services, health status, medical
treatment and disease patterns for minorities. A recent report on the from the
Agency for Health Care Research and Quality found that
Hispanics were more likely than whites to be in fair or poor perceived
health status but less likely to be reported as having
functional limitations. Indeed, the DHHS has challenged the U.S. to develop
partnerships for outreach and research through its Racial and Ethnic Disparities
in Health Initiative.
A major focus of the Department
of Health and Human Services "Hispanic Agenda for
Health" and the Health Care Fairness Act is to meet the
challenge of little research on Hispanics. DHHS, through this initiative
established the Hispanic-Serving Health Professions Schools,
Inc., inresponse to President Clinton's Executive Order 12900, "Educational
Excelence for Hispanic Americans" to develop comprehensive, coordinated faculty
development Fellowships to increase research on Hispanic health
at member institutions - 20 medical schools. In the future, HSHPS plans to
expand to public health schools, nursing schools, dental
schools and other health professional schools. HSHPS has
developed collaborative efforts for the first time among medical schools to
develop Hispanic research and Hispanic health researchers.
HSHPS also represents all the HRSA Centers of Excellence. We urge your support
that can continue these efforts.
The National Hispanic Medical
Association has also encouraged research careers at our national conference, and
has developed a Research Network to identify physicians who are Hispanic
researchers and to encourage grant applications to the Federal government. NHMA
physicians have a tremendous base of patients who are Hispanic for research in
our community that could prove valuable for efforts to eliminate disparities in
health in our country. We urge you to support the research
efforts of other Hispanic organizations with expertise in working with the
Hispanic community.
Need for Health Professions
Cultural Competence Curriculum
Cultural competence has been defined as a
set of academic and interpersonal skills that allow individuals to increase
their understanding and appreciation of cultural differences andsimilarities
within, among, and between groups. This requires a willingness and ability to
draw on community-based values, traditions, and customs and to work with
knowledgeable persons of and from the community in developing focused
interventions, communications and other supports.
There is an urgent
need to adopt legislation that promotes health professions
cultural competence curriculum, given the growing diversity in the U.S.
population and especially, given the tremendous increase in Hispanics across the
nation, and given the critical levels of uninsured Hispanics.
We believe that successful strategies for increasing access to
health insurance must include cultural competence standards for
health professions education as well as for the
health system facilities and services and standards for
language services.
There is a critical need for cultural competence
training for the future health workforce and the current
workforce to eliminate the health disparities for Hispanics and
others with cultural backgrounds, to increase quality care, to decrease the
likelihood of liability/malpractice claims, and to encourage utilization to
services. By supporting this legislation, we can support all these outcomes
which will decrease costs and improve the health of the nation.
We find that once Hispanics enter the medical care system, they find
that the health care system in this country is not user
friendly, it has no capacity to deal with populations who have differentcultural
backgrounds or different illnesses; and that classicism, racism and social
discrimination impact negatively the quality of the services provided. On the
other hand, the literature shows that, in general, Hispanic physicians provide
services to a predominant Hispanic clientele. There is a growing demand for
Hispanic physicians.
Why is this?
We believe that there are
important principles that enhance the cultural competence of the physician in a
physician-patient relationship: respect for values, health and
illness beliefs, respect for family dynamics and decision-making, cultural
awareness, assimilation and acculturation levels and health
behaviors, role of traditional healers, role of pharmacists, Spanish use,
elimination of biases, awareness of Hispanic sub-group nuances, language, and
diet. We believe that more patients from the Hispanic community and other ethnic
communities would access services if they were provided in a culturally
competent manner.
The NHMA and HSHPS are dedicated to sharing our
expertise of Hispanic physicians who have served numerous Hispanic patients and
their families with the development of curriculum for future generations of
health professionals. We all benefit by this bill that provides
support for the collection of this unique knowledge and the development of
formal training programs in medical schools, nursing schools, public
health schools, dental schools, mental health
professional training programs, etc.
There has been an acceptance of
cultural competence over the past decade by the Federal government, state
governments, undergraduate and graduate medical education, nursingeducation and
mental health education focused on service delivery and
curriculum development for health professions and
health staff in public clinics. The following are important
milestones: 1992 - State of California Cultural Competency Task Force for
Medicaid 1995 - U.S. Department of Health and Human Services
Office on Women's Health and Office of Minority
Health National Conference on Cultural Competence and Women's
Health Medical Education Curricula; Curricula Collection
Distributed 1996 - DHHS Hispanic Agenda for Action establishes a Cultural
Competence Workgroup to stimulate activities across the Department -- 1997 -
Substance Abuse and Mental Health Services Administration
develops Cultural Competence Principles for Mental Health and
Substance Abuse Treatment 1998 - Council on Graduate Medical Education Minority
Workforce Report 1998 - DHHS OWH and OMH Review of the United States Medical
Licensing Examination for Cultural Competence 1998 - Health
Care Financing Administration Regulations on Cultural Competence for all
Medicaid and Medicare contractors published 1999 - Liaison Committee on Medical
Education Standard on Cultural Competence Approved (accreditation for all
medical schools) 2000 - Accreditation Council for Graduate Medical Education
Standard for Cultural Competence in process (accreditation for residency
programs) 2000 - OMH publishes Recommendations for Standards for Culturally and
Linguistically Appropriate Health Services for Public CommentIn
addition, over the past decade, private sector organizations including HMOs,
pharmaceutical companies, hospitals, and national health
professions organizations have sponsored conferences and training programs for
staff in order to develop cultural competence for more effective medical
delivery for Hispanic and other ethnic groups in their target areas.
Centers of Excellence --statement about their importance to Hispanic
health
HSHPS same type of statement - need for
coordinating programs under this legislation
NHMA - cultural competence
projects
Recommendations to Improve HR 3250
1. Research
The $100 million appropriation for minority research
should be distributed to research efforts focused on all four of the major
minority groups - Hispanic, African American Asian American and Pacific Islander
and Native American. There should be a fair and equitable distribution plan.
The research endowment program is only one program mentioned in the
bill. The HispanicServing Health Professions Schools, Inc.
conducts the HSHPS Research Fellowship Program todevelop faculty for its 20
member medical schools. Some research funding in this bill could be used to
develop faculty through fellowships, who would become leaders in the
health arena for Hispanic research.
Another important
aspect for minority research is consortium development among biomedical
institutions and partnership development with community based agencies and
health professional associations to enhance minority research.
In the case of Hispanics, we could better understand regional and sub-group
variations related to disease pathophysiology, medical treatment issues if the
HSHPS organization, for example, could develop consortiums and partnerships with
the 20 medical schools in our membership that have a demonstrated commitment to
Hispanic health.
Lastly, research skills development
and training for medical students and residents is needed to encourage them to
consider research careers. The bill could support these efforts through grants
to organizations other than biomedical institutions such as the National
Hispanic Medical Association and other Hispanic organizations that provide
training programs to younger students interested in health
careers.
2. Centers of Excellence for Research Training
The
Health Resources and Services Administration funds Black,
Hispanic, Native American and All Minority Centers of Excellence that are
granted to health professions schools that have thetrack record
and commitment to recruiting minority students and faculty and developing
curriculum and research that focuses on minority populations. The Centers of
Excellence have created several innovative accomplishments to enhance diversity
training and research for better health system. We applaud the
vision behind HR 3250 for challenging the National Institutes of
Health to develop a similar program that can only be as
successful. We hope that you would support this bill to continue to develop
Centers of Excellence programs that encourage research on minority populations.
3. Medical Education and Health Professions Curriculum
The eligibility for awards to develop innovative curriculum should not
be limited to health professions schools. Residency programs,
community based organizations, the health professions
associations such as the National Hispanic Medical Association should be allowed
to compete for NIH funds and to provide their expertise to the advancement of
cultural competence. Indeed the NHMA and the Association of American Indian
Physicians wrote a grant to develop cultural competence training of physicians
in Orange County, California about heart disease risk factors to the CDC REACH
Program. We see our role as sharing expertise in dealing with our communities
because we know that there is such a disastrous shortage of minority physicians
and other health professionals in the country.
4.
National Cultural Competence Conference
The national conference by the
Office of Minority Health on cultural competence curriculum
should not be limited to continuing medical education courses, but should
include undergraduate and graduate medical education as well as the other
health professions curriculum that are innovative. The
Department of Health and Human Services convened a major
national conference that brought together the major players in the medical
education (licensing, accreditation, medical schools, residency programs,
foundations, state government and Federal government) who were encouraged to
build innovative curriculum in cultural competence. This leadership needs to be
continued at all levels of health professions education.
Faculty who teach future providers for the health system need
to be educated about successful curricula and to be encouraged by Federal
leadership. Hispanic physicians and other minority health
providers need to be encouraged to share their vast knowledge base, the "art of
medicine" that has not been part of the Western medicine institutionalized
information sources - publications, curriculum, mainstream medical specialty and
academic conferences. This knowledge is needed especially for the future
health providers who will face increasing challenges of
diversity in their patients.
5. Coordination and Dissemination of
Cultural Competence Curriculum
Although we agree that the dissemination
function would best be served by the OMH Resource Center, we strongly urge you
to support that the coordination function be under the responsibility of the OMH
Center for Cultural and Linguistic Competence in Health Care
(CCLCHC). TheCCLCHC was established by the Office of Minority
Health in 1995, upon Congressional mandate. The mission of this
CCLCHC is to promote the removal of health care service
barriers and increase access to health care for limited
English-speaking (LEP), racially and ethnically diverse populations. The CCLCHC
should be the focal point for the cultural competence efforts outlined in this
legislation and we urge funding for it.
6. Office of Civil Rights
Recently, the U.S. Commission on Civil Rights focused attention on
Federal health care programs and called for the enhancement of
the Office of Civil Rights in order to decrease disparities in
health for minorities in the health system. We
support the efforts in the bill to expand the efforts of the OCR.
Conclusion
We have mutual goals with everyone in this room - to
increase access to health care services for the most vulnerable
and to simultaneously decrease health care costs to our
society. After all, creating legislation is an exercise for the public good.I
would argue if we don't pass this legislation, we are asking for greater
health care costs to Americans. One cost is the major decrease
in individual productivity and a decreased productive workforce. Another cost we
would face is drastically reduced public health of all sectors
of the population. After all, take a look around at any restaurant, hotel,
airport, office buildings, hospitals- the workers are from many countries from
around the world with different cultural backgrounds. If they cannot understand
our health system because they are not provided appropriate
information, or are not comfortable or respected by our physicians and
health providers, why would they attempt to obtain medical
treatment for TB, Hepatitis, AIDS or debilitating conditions like hypertension,
heart disease, asthma, diabetes, cancer, etc.?
HR 3250 is an opportunity
to develop strategies to increase knowledge that will improve the quality of
life for all minorities in the United States.
We applaud Secretary Donna
Shalala and the Department of Health and Human Services under
the Clinton administration for laying the foundation for addressing Hispanic
health care research and cultural competence through the
"Hispanic Agenda for Action." Much more needs to be done by the Department to
meet the needs of the growing Hispanic population.
We commend the
Chairman of the Subcommittee on Health and Environment,
Congressman Bilirakus, and the efforts of Congressman Thompson and the
supporters of HR3250 to provide yet another great opportunity for research and
cultural competence on Hispanics, African Americans, Asian Americans/Pacific
Islanders, and Native Americans to advance knowledgeabout disease unique to each
group, to increase researchers from each group and to develop quality
health services with cultural competence training of providers.
The health of all Americans will be enhanced by this
bill. We strongly urge all of you to vote for passage of the bill into law.
References
National Center for Health
Statistics. Health, United States, 1999, Hyattsville, MD, 1999.
U.S. Census Bureau Population Estimates Program, Population Division,
Washington, DC.(Internet Release Date April 11, 2000)
U.S. Department of
Commerce, Economics and Statistics Association, Bureau of the Census. We the
American Hispanics, 1993.
The Commonwealth Fund. Hispanics and
Insurance. February 2000.
U.S. Department of Health and
Human Services and Grantmakers in Health. Call to Action:
Eliminating Racial and Ethnic Disparities in Health Conference
Proceedings. September 1998.
U.S. Department of Health
and Human Services. Hispanic Agenda for Action. September 1996.
Rios, E.
and Simpson, C. Summary of National Conference. Cultural Competence and Women's
Health in Medical Education. JAMWA. Vol 53, No. 3, Supplement
1998.
Komaromy, et all. The Role of Black and Hispanic Physicians in
Providing Health Care for Underserved Populations. NEJM. Vol
334. No. 20, Mar 16, 1996.U.S. Department of Health and Human
Services. Public Health Service. Agency for
Health Care Policy and Research. Health Status
and Limitations: A Comparison of Hispanics, Blacks, and Whites, 1996. AHCPR Pub.
No. 00-0001, October 1999.
U.S. Commission on Civil Rights. The
Health Care Challenges: Acknowledging Disparity, Confronting
Discrimination, and Ensuring Equality. September 1999.
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