Health Promotion & Prevention of Health Disparities for
Minnesota’s Refugee & Immigrant Communities
February 11, 2008
Welcome and Introductions
Senator Sandi Pappas and Representative Willie Dominguez welcomed the group and described their interest and activities in addressing health disparities and in working with refugee/immigrant communities. For more information, please visit the legislators’ webpages at http://www.senate.leg.state.mn.us/members/member_bio.php?mem_id=1046&ls=85 and http://www.house.leg.state.mn.us/members/members.asp?district=58B.
Joan Cleary and Jocelyn Ancheta of the Blue Cross & Blue Shield of Minnesota Foundation provided an overview of Minnesota’s health care situation and the Foundation’s initiative, “Healthy Together: Creating Community with New Americans.” (See http://www.bcbsmnfoundation.org/program.cfm?oid=7315)
“Minnesota is often rated one of the healthiest states in the country, which shows that a lot of things are working right here. But beneath the surface there are gaps, with both health disparities and health status. We have the potential to make a difference by working together.”
“We are increasingly looking at access to affordable coverage and quality health care that’s culturally and linguistically appropriate. The premise of our work in the Healthy Together initiative is that there are social determinants of health, such as income, education, early childhood development, housing, and social connectedness. There are larger social and economic environmental factors that have so much to do with the health status of families and communities. Our work as a Foundation supports efforts that pay attention to the larger social fabric in our communities and around our state.”
Three areas of Foundation investment:
- Mental health, to help make the landing for immigrants a little softer, and make clinical practices much more culturally competent in languages or terms that immigrants can understand. One good example is community health workers and group problem solving that helps reduce isolation.
- Strong nonprofits, to help develop and strengthen refugee and immigrant leadership.
- Public work model, to get everyone to identify common goals, a common vision, and to work toward common solutions.
Anna Spencer, Dirk Hegen and Ann Morse introduced the goals of NCSL and the activities of the Forum for State Health Policy Leadership and the Immigrant Policy Project. Our project with the Blue Cross Foundation had its genesis in a three–year national refugee integration project that aimed to support coalitions of refugee and immigrant groups, government agencies, and other partners to develop and implement their own integration plans. For the Blue Cross Foundation project, we surveyed a cross-section of policymakers and leaders to identify two topics for discussion in 2007 and 2008: early childhood education (2007), and health promotion and prevention of health disparities (2008). Our goal is to facilitate meetings, networking and information dissemination among state legislators and legislative staff, state agencies, refugee and immigrant community leaders, and other interested organizations.
Immigrants and Health Care: A National Perspective
Leighton Ku, Professor of Health Policy, Department of Health Policy
School of Public Health and Health Services, George Washington University
At the national level both the health care and immigration topics are receiving unusual interest from the public. They are at the top of national polls that people are interested in, but are rarely brought together. Health care is something that liberals and Democrats tend to care about and immigration is something that conservatives and Republicans care about.
There are three prevalent attitudes in public opinion:
- immigrants are hurting America, captured by the catchphrase “illegal is illegal” and no assistance should be offered;
- the mixed view, or view everyone on their own merits, recognizing that most of us have immigrant roots; and
- the religious perspective, as in help the stranger, a synonym for immigrants.
NCSL’s work on state immigration legislation shows activity across a range of policy arenas, with key topics being identification, employment, and public education. The general tendency nationally seems to be increasingly restrictive, but it is important to note that at the state level, there are also supportive pieces of legislation. In fact, within a given state or legislature, you can find both restrictive and supportive bills: views are mixed about immigration.
Some demographic background: Nationally, 3/5 of the population growth in the 1990s came from new immigrants and their children. One-half of the job growth in the 1990s was due to recent immigrant workers. Baby boomers are aging, fertility is low, and most economists would say that to keep the economy growing, immigration is key. America will have to become more multicultural - though this is not a universally accepted concept.
Immigrants are also vital as health care providers: 25% of physicians are foreign born, and 15% of nurses are foreign-born.
English proficiency: this is commonly viewed as a problem connected with immigrants, whether noncitizens or illegal. But, almost half of the limited-English proficient (LEP) are citizens. Most immigrants know English is necessary for themselves and their children to integrate successfully.
The way immigrants accessed health care in their home countries is different from the United States. The perception is that immigrants are bankrupting the health care system, however, there is evidence that immigrants have very low medical use.
Why are so many immigrants uninsured? There are special problems for immigrants in accessing public insurance. Decisions in welfare reform limited Medicaid and SCHIP for legal immigrants. In addition, they are less likely to be offered private health insurance, because of the nature of the jobs they have, though there is also some likelihood of discrimination.
Noncitizen kids are three times as likely to be uninsured as citizen kids with native parents. Citizen kids with noncitizen parents are almost twice as likely to be uninsured as citizen kids with native parents. Parents with no health insurance means kids have no health insurance either. (See the powerpoint presentation p. 11.)
The average annual per capita cost for adults is very low: for recent immigrants (residing in the U.S. for less than 10 years) it is $135 for public medical expenditures. The average annual for full-year insured adults is $1400 for recent immigrants compared to $3211 for U.S. born. (pp. 18-19)
The question comes up of how to pay for English language translation/interpretation – but immigrants are cross-subsidizing care used by citizens. If we increase slightly the expenditures for recent immigrants, we can decrease the disparities.
The use of emergency rooms is low for everyone – citizens, long-term immigrants, and recent immigrants.
Regarding the use of preventive care, having blood pressure checked is very high – one reason is that it can be done in places other than a clinic, such as a grocery store, health fair, even at home.
Federal civil rights law requires health care providers to offer interpreters for limited-English proficient patients. Health care quality is an area where work really needs to be done; insurance rarely reimburses for these language services.
Many immigrants come to the United States relatively healthy (healthier diets), but health status declines over time due to factors such as poverty and isolation (p. 25).
Innovative projects (pp 26-28):
Child Health Initiatives. Several California counties made public health insurance available for all, which helps not only immigrant children but those eligible who were citizens.
Community enrollment case managers in Massachusetts – helped Latino children get coverage
Speaking together (multiple sites) – a Robert Wood Johnson project on language access, which pays off with effective treatment of diabetes.
State/local rules requiring documentation of citizenship or legal status for benefits. From 5-10% of U.S. born citizens have no passport, or no identification. One fifth of elderly African Americans over 65 lack a birth certificate because it was never issued to them. Discrimination in the south prevented women from having babies in hospitals, where birth certificates where issued.
Q - Related to the disparity in the use of health care systems, one possibility is that immigrants are healthier, one is that immigrants face barriers. On the barriers side, which is what we’re interested in, what are the priorities, the main barriers, besides language?
A – This is an area that is hard to do research, how severe is this problem versus that problem. There is the barrier to seeking care because of the fear that people will be reported to DHS and will lead to deportation. Legal immigrants are also unsure about their status – immigrant status is confusing to people. There are fears that it may impede the ability to become a citizen because of public dole/public charge. Also, it’s difficult to navigate the system – how to get insurance, how to get a primary care provider, how to get reimbursed.
Q - Do statistics include those who use alternative health care?
A - To the extent there are data, such as answering the question when is the last time you saw a doctor, the survey answers tend to show that the use of alternative health care is not a major diversionary process. It’s also important to recognize that to legally immigrate to the United States, part of the screening process is to demonstrate good health; applicants are rejected if their health status is not good (for example, HIV). For undocumented, people know that the work they are coming to do in the U.S. is hard physical work, if they are not relatively healthy, they are not going to immigrate.
Q/Comment: the lack of access for immigrant/refugee populations or minorities is the distrust of the system to begin with. These populations rarely see nurses as friends, patients need one specific problem solved, and they are used as last resort. Instead, people use home remedies or relatives to get care before seeing a doctor.
A – This is true for the immigrant population and the U.S. born as well.
Q/Comment: Immigrants have been arriving to the U.S. in good health over time; but what I see among refugees is that they come with at risk conditions or infectious disease. As they adapt to the American lifestyle, we are seeing diabetes, hypertension, obesity, combined with dangerous, repetitive work – chronic disease, enduring over the rest of their lifetime.
Minnesota: Opportunities and Challenges
Scott Leitz, Assistant Commissioner, Minnesota Department of Health
Jonathan Watson, Associate Director, Minnesota Association of Community Health Centers
Mitchell Davis, Director, Office of Minority and Multicultural Health, Minnesota Department of Health
Scott Leitz, Assistant Commissioner, Minnesota Department of Health, described the challenge of health care reform by discussing the cost, quality and access triangle. We need to figure out ways to lower the cost of health care in ways that don’t in any way do harm. What we spend on health care is a lot compared to other countries: we are not getting a very good value for our health care dollar. The percentage of US children who receive recommended care for their conditions is only one-half (powerpoint p. 7)
According to a Dartmouth study, the amount spent and the quality of care gets the reverse of what you would expect: the most expensive care should be best care, but actually it is inverse to the amount of spending.
When we look at diabetes, only 10% of the diabetics in Minnesota in 2006 were receiving optimal care.
Minnesota does well nationally, but when you look at race or ethnicity, there are substantial variations, 2-3 times the rates of minorities versus white Minnesotans. (p. 12). Uninsurance rates are higher for new arrivals and lower over time: less than 5 years of residence 28%; 10 or more years, 12.5%. Uninsurance rates for US born citizens is 6%, for those from Hispanic nations, nearly 50%, and for African-American, 10%.
We know rates of obesity impact disparately on populations. Obesity trends darken year by year – to more than 25% by 2004 (pp. 16-35). And Minnesota is becoming more diverse – the obesity trends with diabetes death rates by ethnicity show some improvements for African American, American Indian and Latino, but worsening rates for Asians.
In Minnesota’s 2007 omnibus health and human services bill, two commissions/task forces were created:
- The Legislative Commission On Health Care Access (which has been dormant for the last few years) to develop a plan to achieve the goal of universal coverage; http://www.commissions.leg.state.mn.us/lchca/lchca.htm and
- The Governor’s Health Care Transformation Task Force charged with developing a statewide action plan to improve affordability, quality, access and health status. Key goals include reducing health expenditures and improving the health status of Minnesotans and reducing disparities. http://www.health.state.mn.us/divs/hpsc/hep/transform/
Serving on the task force are four legislators (Representative Huntley as co-chair, and Senator Berglin, Senator Rosen, and Representative Thissen as members) and 13 private sector representatives appointed by the governor.
Both reports talk about the need to go toward universal coverage, to get to 97% by a point certain, then a trigger for an individual mandate.
Five areas of recommendations: (p. 41)
- health improvement – reduce rates of chronic diseases and risk factors associated with them (long term strategy) do better job across populations, build off existing pilot projects;
- insurance reform – more affordable, accessible, available;
- transparency of price, quality and value. The jury is out on how useful it is to get information out to the general population – the most effect is at the provider level, which can spur provider groups to want to do better relative to others.
- administrative efficiencies – improve health records electronically; and,
- payment reform – spur improvements and reduce disparities in a couple of ways. To lower the cost of care, we need to find a way to change the payment of health care. 3 approaches: 1) more explicit payment for quality than we currently have; 2) medical homes and care coordination – particularly for new residents; the problem is providers are not getting paid to do it, we need to pay for care coordination; and 3) realignment of care delivery incentives to focus on preventive care, and give providers incentive to focus more on prevention.
Jonathon Watson, Associate Director, Minnesota Association of Community Health Centers described Community Health Centers (CHCs) in the context of a medical home for refugee and immigrant communities. CHCs are not for profit and operate in medically underserved areas. One out of every six uninsured Minnesotans uses a CHC.
The Health Care Access Commission made recommendations on health care homes, including:
long term trusting physician-patient relationship; coordination of care; primary care and disease management; and public reporting of quality, outcomes and costs. The target population is state health care program enrollees and those with complex or chronic conditions. Criteria include: involving patients in the decision-making process; appropriate cultural and linguistic care; and enhanced access to care such as expanded hours and improved communication.
Other recommendations include a health care coordination fee, averaging $50/per person/per month; requiring state health care program enrollees to choose a primary care provider; expanding funding for primary care provider and rural provider training programs.
Barriers to care (from Opening Doors: Reducing Sociocultural Barriers to Health Care):
- language and communication
- differing medical practices
- fear and mistrust of system
- lack of knowledge of navigating system
Poverty is a barrier to health care, which CHCs respond to by offering expanded evening/weekend hours; a sliding fee schedule; and eligibility assistance.
CHC cost areas have undergone a dramatic change in the last 5 years. In 2001, 2/3 of the costs were medical services; by 2006, there is growth in mental health and enabling services.
CHC cost per patient: for all services there was a cost increase of 6% per year; enabling services increase was 9.8%. Enabling services include case management, transportation, outreach, patient education, translation/interpretation and eligibility assistance. For translation/interpretation – 28% of CHC patients are best served in a language other than English.
Enabling services are growing but not reimbursed. In the last session legislation was passed to provide CHC reimbursement for Medicaid enrollees.
The CHC workforce is reflective of the communities served. 69% of CHC patients are non-white (American and foreign-born).
Some case studies:
Migrant Health Services Inc (MHSI) out of Moorhead is waiving the enrollment fee; partnering with YMCA and funded by Blue Cross Blue Shield Foundation and Fargo-Moorhead Area Foundation. MHSI also partners with pharmacies; for example by using pre-stamped postcard to the pharmacy so the clinic can track if patients taking medications. They use bilingual/bicultural health care workers and health educators, who have been successful in diabetes prevention and reducing oral health disease in preschool Latino children.
The Cedar-Riverside People’s Center is focused on African born patients with a diabetes project and helping address mental health needs.
Community University Health Care Center (CUHCC) is working on mental health, tracking populations; hiring ethnic practitioners with the same life experience as the patients. Interpreters serve as the first point of contact to connect the patient to health care rather than provider.
Outcomes at CHCs:
- CHCs low birth weight score lower than Minnesota as a whole.
- Patient satisfaction is very good.
- Mental health indicators are improving.
- CHCs are cost-effective providers:
In a national study of CHCs, the CHC user spends $1800 less in total medical care than the general population.
CHC users are 19% less likely to use the emergency room.
The concept of medical home has been in Minnesota since 1967, hope this focus continues as health care reform evolves. Enabling services is key. We need a team approach to eliminating health care disparities.
Mitchell Davis, Director, Office of Minority and Multicultural Health, Minnesota Department of Health, stated there are 40 state offices of minority health around country – the work is mandatory, critical, urgent, and important. The office assesses public health, promotes sound policies, and assures effectiveness. The mission is to strengthen the health and wellness of Minnesota’s racial/ethnic, cultural, and tribal populations by engaging diverse populations in health systems, mutual learning, and actions essential for achieving health parity and optimal wellness.
The Eliminating Health Disparity Initiative focuses on 8 disease areas. There are 52 grantees in 40 counties in Minnesota. Priority is given to applicants whose proposed project is supported by the community, is research-based or based on promising strategies. Projects are designed to complement other community activities and reflect racial and ethnic appropriate approaches.
OMMH priorities (6) including health disparities. There is a small staff with a representative from each community. The model is to move into communities for collaborative partnerships, education and training.
Minnesota has ranked number one in health 11 times since national rankings began in 1990.
Minnesota has never ranked lower than second. -- United Health Foundation, America’s Health Rankings
But when you peel back the prism on each population of color, disparities exist. Poverty is a big factor in health disparities, and is getting worse.
Public/private funders addressing disparities through research and program development (the National Health Plan Collaborative).
National interest in primary/direct data collection (from patients/members) to measure disparities vs. “geocoding” or indirect methods.
Minnesota clinics and plans are working together in key areas to improve cultural competency, language access and measuring disparities.
The National Association of State Offices of Minority Health is looking at what can we do together to bring focus on this issue, and engage in regional conversations to create blueprint to address health disparities.
It is imperative to engage all communities to develop the infrastructure.
Looking at the MPI statistics for Minnesota, some surprised me. A couple of examples: the foreign-born population changed by 30% between 2000 and 2006; and from 1990-2000, it increased by 130%.
Q – Were undocumented immigrants discussed in the Health Care Transformation Task Force? Did the task force address the barriers to care that the professor is talking about or enabling services?
A - No, there was not much focus on immigrants in either the Task Force or the Commission.
Q - We can help immigrants navigate the system but at a policy level, how can we avoid penalizing doctors for spending more than 15-20 minutes per patient?
A – [Regarding Minnesota’s two commissions]: The focus is on universal insurance, and the universal coverage piece is viewed as relatively straightforward. Payment reform from their perspective more difficult.
Q - How do we support the medical home concept at the community level, especially for those unused to navigating the system?
A – The report recommendations are really focused on the payment reform piece and how to support that. It doesn’t get prescriptive on how care is delivered.
Q - Is there a need for voiceless populations for best practices or minimum level practices as there is with disease x, to bring managed care in line. Where is the place for that conversation?
A - What is needed is the information from you as experts. If that is a good outcome, an efficient way to provide care. Eliminate barriers in current insurance system, allow providers to get the payment that they need to serve those populations, and then expect an outcome. Help providers at the beginning to measure outcomes better.
Q/comment – How do we close the gap? Who else is at the table when policymakers come to make decisions. For example in June at the national caucus of minority health advisory committee and with other big projects happening around the country.
Q - Is there an effort to have a common language about what we’re talking about – citizens, undocumented, legal immigrants, that are all on different tracks now. Can we create common baselines, common trajectories, common goals, common definitions of disparities.
A – For the CHC, what drives the definition is what the state will reimburse us for in public programs, with billing codes for noncitizens, etc. There is pushback from the CHC – it is not our business to figure out status. And with strained resources it is difficult to track immigrant status. The classic Office of Minority Health definitions come from reports a decade ago.
Q - Is the state working to get a better picture of populations in Minnesota by breaking out not just by African Americans but by the groups that are growing exponentially?
This is a Census issue – but within the African, Asian, Latino groups there are many more subgroups. The state demographer’s office has data on these. But if the state can’t count them, then how can the state respond?
Q - Refugees get a job but then lose the 8 months of medical assistance?
A – There is a federally required service called transitional Medicaid which should be available for 6-12 months after the refugee’s income goes up.
Q - What can legislators do?
Change incentives around payment reform, measurement of quality and cost.
The workforce and community health worker project received tremendous uplift in December and needs to go even farther.
We will still need safety net providers with language and cultural specialty – remember us.
We are getting bad value for our health care dollar. We need to measure better the quality, the cost, and after we get good metrics we can begin to pay for quality and reward the providers with good quality.
We need accountability for the system that we want, outcomes, the flexibility to innovate, that works for the population they serve and they should be held accountable.
Roundtable Discussion – Summary of Participants Responses
1. What’s the most useful or surprising thing you learned from the presentations today?
- The information from the Governor’s task force and his support for universal care.
- The research demonstrating that immigrants did not use the emergency room as much as others.
- Community Health Centers and enabling services are really important and should be encouraged.
- The facts about how immigrants interact with social services, like accessing emergency room care.
- The information that dispels certain myths.
- That one-fourth of physicians are foreign born – how interesting, and important to note the contributions of immigrants to our communities.
- What surprised us is that our group of mostly immigrants is that we seem to be healthier when we arrive, then we gain weight here.
- The indepth data comparing health care usage between immigrants and native born that seems to bust the myth that immigrants have negative patterns such as high emergency use.
- The most surprising thing is that immigrants don’t overuse health care.
- The huge differences in health disparities by states – that Minnesota is better in some areas, and worse in others.
- That the Health Care Task Force did not address health care access for foreign born
2. What are the top priorities in your communities related to health promotion and prevention of health disparities?
- Community services with ethnic communities and with mainstream communities are very important and can be enhanced.
- Community health workers is a great concept and would be helpful to our communities. There is not much detailed research around our communities but the health need is there.
- Mental health is also important.
- Increased use of preventive health services, and assure that immigrants have access.
- Increased cultural competency.
- (Comment: Health is a basic human right irrespective of your immigration status. Two different perspectives: illegal is illegal, or health as a basic right – how do we meet in the middle and demonstrate that this is important for all communities.)
- The elderly are more isolated. and with that isolation they experience depression, which can result in somatic treatment but not treatment of the root cause. There seems to be no real priority to address that, even with agencies serving those communities, and this is a potential area for more action;
- The lack of access – we noticed that there is substantial difference between rural and urban areas, and the suburbs get completely neglected. Perhaps they are considered to be in ok shape, but the poor people and refugees who move into the suburbs are outweighed by more established neighbors and fall through the cracks.
- The uninsured that are not eligible because they make more than the income cutoff, $12,500, and they can’t obtain insurance because they can’t pay for it.
- The unintended consequences – translation is seen as real benefit but in dialogue between physician and patient can take away focus on patient. Especially for older patients, this might cause an added lack of interest, and result in the doctor disrespecting the elderly patient by paying more attention to the translator.
- Education for the foreign born in things like diet and nutrition.
- Need for community health workers.
- Need to be connected to clinic currently and that needs to change – people can’t get around. Need interpreters: qualified, well-trained reimbursable interpreters, especially for rural communities.
- Make medical assistance accessible to refugees for firs t8 months, if they get a job they lose health insurance.
- Cross-cultural competence for clinic staff, education, licensure.
- Eliminate out of state tuition rates for students who are not citizens (the Dream act). Education and jobs will help with prevention of health disparities.
- Do not restrict access to resources based on legal status.
- Network providers to help refugees get their needs.
- More accessible affordable health care in rural Minnesota.
- Application assistance for medical assistance.
3. What’s working well that should be replicated or strengthened?
- Community health workers.
- Refugee health screening that’s done by the state is important.
- Cultural bridging and competence of community organizations is something to be encouraged. Mosques, churches, wherever the people are should be encouraged.
- Community centers with culturally appropriate care.
- Refugees are eligible for services, but how do we deal with them with respect to other immigrants – different backgrounds, maybe they are not comparable, but see how well we do refugee care and if it can be replicated to other immigrant groups. Minnesota has a long history of doing refugee resettlement well, and has a good infrastructure in place. Lots of nonprofit community organizations work together even though compete for resources.
- We applaud the community health services and hope there can be more money to them. They are appreciated and frequented by the communities we are talking about the most.
- Standards for interpretation and legal interpreters and medical interpreters.
- retired doctors as volunteers but need medical malpractice covered.
- Hire staff dedicated to refugee health.
- WIC works but make sure it’s not restricted by having to get medical assistance (problem for undocumented women.)
- Hmong provider network for family needs.
- Community health workers works.
- Portable health care – sign up for health care.
- Walk-in clinics that are affordable.
- ECHO emergency community health organization is a working television program that will be accessible statewide soon in 6 languages.
- Domestic violence is a concern. Resources for women when man deported to be able to stay. “Civil society” as a statewide network for women experiencing violence.
- Another resource is the immigrant law center.
Comment: If we achieve universal health care would we still have uninsured falling through the cracks, such as the undocumented or immigrants here less than 5 years. Probably yes.
Other useful websites:
Minnesota Immigrant Health Task Force:
Prepared by Ann Morse
NCSL Immigrant Policy Project
This program is made possible through the generous support of
The Blue Cross and Blue Shield of Minnesota Foundation and
The David and Lucile Packard Foundation