This archiving and publishing of the proceedings of the third and fourth plenary sessions of the First National Conference on Primary Health Care Access (April 20 and 21, 1990) is made possible, in part, through the generous support of the San Joaquin General Hospital Department of Family Medicine (Stockton and French Camp, California):
Hector Flores, MD; White Memorial Medical Center, Los Angeles. [Dr Flores is a Senior Fellow of the Coastal Research Group.] : I want to thank John Midtling and Bill Burnett for inviting me to come and speak today. This certainly is an area of personal interest to me and also of interest to my organization, the Chicano/Latino Medical Association of California, which is a network of over 1,000 Latino physicians, primarily trained in California schools, but mainly trained in the United States.
I think that’s important because there’s a history that goes along with that. If I have some time, I’ll get into that later. Both John and Bill asked me to come and speak on the Hispanic experience, I guess, in the issue of access to health care. I want to talk bout the demographics in this country and particularly in California and also how that relates to the barriers to health care and the level of access that our people achieve. Then I will make some recommendations on what we should all be focusing on.
Demographically, in the United States Hispanics are the fastest growing ethnic minority group and, depending to whom you talk, approximately 8% of the U.S. population is now Hispanic. At the rate it is growing, by the year 2000 it will reach the 10% mark. That’s due in part to high fertility rates, but also the the large level of immigration that, depending on political and economic pressures in Central and Latin America, tends to fluctuate but usually is on the increase.
If we look at the 20 million or so Hispanics in this country, 63% are of Mexican-American descent; 11% are of Puerto Rican descent; 18% are Central Latin American and the remainder are Cuban, Caribbean, or Spanish ancestry. That’s important because part of my message today is that we’re not a homogenous group. Although culture and language unite us, there are some basic differences in terms of our history. 13 million Hispanics in this country live in the Southwestern United States and 53% of those live in California. Because I live in California. Of the 6.8 million Hispanics in California 80% are of Mexican-American descent. The total Hispanic population in California is 24% of the population.
I think we need to look at some of the issues that have already been addressed quite eloquently by John Arradondo and some of the other folks yesterday in terms of the health care access. But I want to give you some idea of the economic background of the Latina community in California. The median family income is $22,000 which is 25% lower than the Anglo counterpart in California.
It translates to a poverty rate that is two times greater than the rest of the community in California. IT also translates to unemployment rates that are almost twice the rest of the community. I think that’s important because when we talk about access that really leads to people who have very little expendable cash on hand to access health care.
The median family income figures tell us that even those who are employed are usually working poor – people who don’t have access to employer provided insurance. Approximately 30% of Hispanics in California are uninsured. Many of them work, but as I mentioned, they are working poor. There is evidence that a lot of Hispanics in California are also under-insured, so that even if they have some insurance through employment, the deductibles and co-payment involved are quite prohibitive and limit their access to health care.
Age is also another barrier. We don’t often think of it as such but among the Hispanics in California the median age is 22 years old as compared to 34 years old for the rest of the community. Typically, the medically indigent adults in our state come from the age groups between 18 and 45 and that certainly represents a lot of our community. Lack of formal education is another access problem. John Arradondo touched on it, but unfamiliarity with using health care systems and bureaucracies is a big limitation to access. That’s certainly part of the Hispanic experience.
But more than that, I just want to touch on the fact that Hispanics in California have about nine years of school as an average to 12 years for the rest of the community. That tends to decrease as the level of immigration increases, because most of the folks, coming in California have lower levels of education. In addition to that, inner city schools have a greater than 50% dropout rate.
In some cases such as John Locke High School in South Central Los Angeles, there is a greater than 85% dropout rate. What’s even more distressing are statistics from the junior high schools in the area. Bethune Junior High School which feeds into John Locke High School and two other high schools, has a 90% dropout rate when the students reach high school. Of the 10% that finish, you probably can count on your hand the number who go to college.
Legal problems are also another barrier for Hispanics, especially the fear of arrest and deportation. Penalties that threaten amnesty applicants certainly are a big deterrent to looking for health care, particularly in the Southwest. Then there are the cultural and linguistic barriers that we have touched on already. In Los Angeles County, a survey last year showed that 47% of Hispanic respondents declared that they had difficulty with the English Language. That’s fully half of the population.
In L.A. County about 40% of the population are new immigrants from Latin America, mainly Mexico. So we’re dealing with people who have a very clear problem with language and also with cultural issues. We talked about the cultural concept of disease, and communicating not only in language but experientially and culturally are equally important. And the poor coordination of services that John touched on already is itself a barrier.
I think when we look at the level of access not only are the barriers important but we should look at the access to primary care – basically what we’re touching on in this particular conference. According to the Office of Statewide Health Planning Development in California, 50% of Hispanics in California live in primary care physician shortage areas. As they define it, that’s one primary care physician for every 2,200 residents.
That translates to a shortage that obviously leads to poorer health outcomes, to a lack of intervention at the appropriate time leading to consequences of severe complications or even death in many situations. This is also evident in the Secretary’s report on Black and minority health in 1985 which showed that Hispanics have a higher disproportionate representation among chronic complications and deaths in cardiovascular disease, violence, and certain cancers.
Also important are the issues of infant mortality, perinatal complications and low birth weights. As John mentioned about Houston’s Hispanic population, an interesting phenomenon that is also occurring in Los Angeles County is that among Hispanics in general the low birth rates and infant mortality rates are quite surprisingly low.
One of the things we have noticed, though, in L.A. County is that among acculturated Hispanics – that is second or third generation Hispanics – there is a rapid rise in the number and percentage of low birth rates and infant mortality. Preliminary data show that a lot of them smoke and a lot of them drink. In a sense they’re adopting or responding to the heavy marketing that goes on in minority communities in terms of some of the lifestyle and habit decisions that are promoted through commercials and other endeavors by cigarette and alcohol industries.
I think the other parameter of shortage is the number of Hispanic physicians there is for our population. If you look in California, although Hispanics are 24% of the population, only 2.9% of practicing physicians are Hispanics. What that translates to is one Hispanic physician for every 4,000 Hispanic residents in California. We compare that to the Anglo population, where there is one physician for every 400 Anglo residents. That to me, when we deal with the cultural and linguistic issues of access to health care and quality of care, certainly has relevance.
In the United States the numbers are similar. Although Hispanics are 8% of the U.S. population, Hispanic physicians are only 3.7% of practicing physicians. Fewer of them are primary care physicians. It also translates to shortages in other health professions, particularly nursing. In California, only 5.5% of nurses are Hispanic and only 3.5% of dentists are Hispanic. It translates to similar impact on the access to care and on the quality of care that’s provided to them.
We talked about the uninsured. In California there are 5.5 million uninsured residents. One-third of them are Hispanic. The reasons this is mentioned is because a lot of them are undocumented, unfamiliar with utilizing the systems, and also because state cutbacks have limited eligibility to the entitlement programs such as Medicaid and because a lot of them are the working poor. They work in the service industry. They work in jobs that many people don’t want and, consequently, they work in the industries that can ill afford to provide them with health care benefits.
Well, what does that translate to in terms of what we must do? I think first we must recognize that despite the predicted physician glut, there is still a maldistribution of physicians and California is no exception; hat the physician diffusion model or the market forces model for providing access to primary care physicians is not working. We look at that in Southern California where I Have reviewed some of the data recently and we look at a community like Glendale, for example, which is an affluent community. It’s about 10 minutes away from White Memorial where I practice.
The ratio of physicians to patient population is 1:3000 and about ten minutes away in Santa Monica the ratio is 1:3000 also. So we can see that even though geographically physicians are located close to underserved areas, there still is a resistance to go and practice in those areas. So diffusion has really not worked in our communities.
I think we’ve talked about the issue of medical students selecting less and less the primary care specialties, perhaps the cost of education being a big factor. We need to recognize that we should not be complacent about that. In fact, we should do something about it.
I think it’s important to recognize that Hispanics are primarily an urban based population. In this country, about 90% are urban based and California is no exception. 90% in California are also urban based. I think that relates a little bit to what we talked about with the National Health Service Corps yesterday that when we look at providing primary care services, particularly family practice, to Hispanic populations, we’re really talking about providing family practice to urban underserved populations.
A corollary problem is the lack of Hispanic health providers in academia. Dr. Arradondo alluded to that. We look at how many faculty there are in our country. According to the AAMC, 1% of all medical school faculty in United States medical school are of Mexican-American or Puerto Rican descent. Those are two groups that I am going to be focusing on who enter into medical school have very few role models to help them academically, to be their advisors, and to be the people who guide them on into their health centers. That’s a very important issue when we talk about the admission to and retention in medial schools.
I am going to give you some data that demonstrate that Hispanics tend to choose the primary care fields more than their counterparts, but it’s important for us to recognize also we need to support those Hispanics when they look at academia and becoming professors and faculty in medical schools because it is medical school faculty who will become the deans of admissions and deans of medical schools and who will sit on boards that make very important decisions as far as future health manpower needs.
I think also we do need to pay attention to the level of indebtedness that minority students are encountering. Dr. Midtling mentioned that yesterday and that is particularly true for minority students. The average minority medical student graduates from medical school with a $45,000 debt. There is evidence that not only does the cost of medical education deter talented young minorities from pursuing careers in medicine, but that once they are in medical school it deters them from choosing primary care fields.
The other issue is the fact that we also are beginning to recognize that minorities tend to return to their communities which are often underserved and with a great preponderance tend to establish practice in underserved areas.
Two papers that come to mind are papers by Dr. Stephen Keith in the New England Journal of Medicine in 1985 and by Drs. Davidson and Montoya in 1987 in the Western Journal of Medicine addressing that very issue. I think the other important point to remember is that among Hispanics, in particular among Mexican-Americans, there is a great preponderance of choosing primary care fields.
If you look at the California experience, where we have quite a network that allows us to access most – if not all – of the Hispanic students in California medical schools. Over the past three years, 30% of graduating Hispanic students have gone into family practice. If we look at primary care involving family practice, internal medicine, pediatrics and OB, over 80% of those students are graduating into those fields. I think that has some important implications in terms of the strategies that we begin to develop for providing the health manpower needs of underserved communities, particularly the Hispanic community.
But above all, I want to make sure that we remember that the numbers coming out are quite small. We need to really work to develop ever larger pools of applicants as well as larger numbers of students entering and graduating from medical school. I think we need to look at the experience of the Black medical schools and see them as role models for what can be achieved for Hispanics.
Not that it would take away the responsibility of our state supported schools and other institutions from fulfilling their commitment to minority opportunities, particular Hispanic opportunities. Yet, if you look at the Black medical schools, each year they graduate about one-fifth of all new Black physicians. I think the time is coming where we need to look at developing a medical school for Hispanics that begins to address the same issues.
We have some exemplary models in Morehouse, Drew-UCLA, Meharry, and Howard that should be replicated for Hispanics as well. That relates to what I am doing now in working with the White Memorial Medical Center Family Practice Program. Our residency program is part of the Hispanic Medical Education Center. [HISMET] initiative that originally was seeded by the California Area Health Education Center.
HISMET was directed towards the manpower needs of Hispanic communities. It seeks to develop a comprehensive program of recruitment into the health professions among college students up to postgraduate training and residency. Part of the HISMET programs was to develop pre-baccalaureate support programs for MCAT preparation, for academic support during pre-med years, on to post-baccalaureate programs for those young Hispanics who failed to gain admission to medical the time that they applied. It also involved bringing in medical student support by means of HISMET clerkships. Those link up minority students with physicians already in practice in shortage areas so that they can model that fee-for-service or other types of practice are indeed possible and that viable practices are indeed possible in underserved areas.
One of the socializing problems that we run into in medical school is that we’re told constantly that practice in shortage areas is going to burn us out and economically we’re never going to make it. That’s part of what we’re trying to do at White Memorial.
Beyond medical school retention and support, the centerpiece of the entire HISMET initiative has been developing a residency oriented to training young physicians in shortage areas and particularly addressing the health care needs of the Hispanic community. This residency came about as a result of a two-year feasibility study, that told us there was a commitment to make sure that this was a quality program from the very beginning.
The right kind of consultants were brought in, not the least of whom was Dr. Sanford Bloom who had run the Santa Monica program in family practice for 14 years and brought it to national prominence. Basically, he brought the blueprint for that residency and adapted it to the multi-cultural population of East Los Angeles, a community of 300,000.
About 80% of the residents of East Los Angeles are Hispanic. About half of those are monolingual Spanish speaking. Dr. Bloom adapted it in such a way that it would take into account the type of payer mix that was not like Santa Monica as I mentioned earlier, but certainly would incorporate strategies to make sure that it became financially successful.
The next task was to recruit a faculty that was basically oriented to the HISMET mission. Having been part of the HISMET committee that planned this residency, it was not difficult for me to see that there was a place for me in that residency as well. I’ve always had an interest in teaching and always had an interest in serving in that community where I grew up.
There were several other individuals whom I knew who would also be interested in joining us in this project. The bottom line was that seven of us came together to become physicians and faculty in that area. It’s interesting that up until that point there was only one other family practice residency trained physician practicing in East Los Angeles. So when we came in, we basically increased the number by 700% of residency trained family physicians. Particularly, we were all bilingual.
I think what’s really important is we all grew up in the area and we all had an interest in returning to that community. This really relates to the issue of health manpower development. We can’t expect people who are not culturally and experientially affiliated with a community to leave everything and suddenly decide that they want to practice there. They must have an incredible commitment in order to do something like that. I give a lot of credit to the folks who have been practicing in those types of areas for many years.
I think what’s much more natural and much more cost effective is to start identifying students, young people in those communities who have an aptitude and an interest in health careers and nurture them as early as junior high and high school, because of the dropout rates, and nurture them throughout their entire education, supporting them in any way that we can so that they can succeed. We know that they will return to their communities as the data have begun to show and that our group as a microcosm has already shown.
What’s equally important for us is that we want to model successful inner city practices to young physicians who have similar goals. One of the things we have done is developed a practice management curriculum for our residents, basically modeled on what we have been able to achieve. Coming into that community, we know that a large percentage of the community was uninsured, cash-paying, and unable to pay the types of fees that we would have to charge to remain viable.
A large percentage was on Medicaid and other entitlement programs. But what we have done is: 1) looked at planning; 2) made sure that we had the type of training in utilization, management, and quality assurance to make the most of our resources. We were quite fortunate that the seven faculty members (which by the way are now nine total faculty members) all had training in one way or another in managed care and in understanding cost-effectiveness and quality assurance. That has helped us in developing successful practices. We’re trying to impart that knowledge to the young physicians who are a part of our residency.
The residency is slated to reach a level of 18 residents total, six per year. Right now we’re at five per year. We have been able to attract the type of resident who has a commitment to those communities. They are primarily Hispanic but not all of them are, because we’ve always recognized that the people who have been our role models by and large were not Hispanic. It doesn’t mean that simply because someone is not Hispanic they cannot provide sensitive care to these individuals. By the same token, somebody being Hispanic doesn’t automatically make them good candidates for providing services to those areas.
So the bottom line is, first, that we need to develop strategies in health manpower development that really focus on the types of things we’ve seen successfully done, such as bringing the types of students like minority students who return to their communities. We need to focus our health manpower development on those individuals and give them the type of support, economic as well as academic, in order to succeed.
Secondly, we need to look at programs such as the White Memorial program. I am sure there will be others that will rise in the wake of of this program because I am sure it will be successful in providing the health manpower needs for the particular region in which it exists. We need to support those types of programs. Whenever someone talks about creating one, we need to be there to give them the type of expertise they need to develop such a program.
Thirdly, we need to start thinking seriously about a medical school that is oriented to the Hispanic student, because that is tone way – as we have seen in the good models in the Black medical schools – of beginning to meet those needs.
I want to talk a little bit about what our philosophy is in the Chicano-Latino Medial Association. A lot of people ask me why we don’t use the term Hispanic when that seems to be the rubric everyone likes. The reason we chose Chicano-Latino is because it has a historical perspective to it. Our roots are in history. Our roots re in the civil rights movement and landmark issues such as the Brown vs. Board of Education, Plessy vs. Ferguson.
All of those decisions that occurred before us gave us the opportunities to become physicians in this country. What unites us all is that we all come from similar socio-economic backgrounds. That’s why we chose the term “Latino.” We are of Mexican-American descent; we’re Central American; we’re South American, but what binds us together is culture, language, and socio-economic backgrounds.
It’s very important to remember when we begin to work with health policy makers, that just because someone is Hispanic doesn’t necessarily mean they have the same priorities that our underserved communities have. They may be in this country because they were escaping very rigid economic sanctions from dictatorial governments and not necessarily because they came here looking for a better life. I think that’s a very important matter to remember.
What we do in CMAC is to look not only at health care issues such as access but also to look at increasing the educational opportunities for our communities. We really believe in community-oriented primary care. We need to get involved in the schools. We have an “adopt a school” program so that in a small measure we can address that, but on a policy level many of us are getting involved in the unfilled school districts and other areas of education. Secondly, we believe in the economic development of our communities.
I talked about poverty levels in our communities. But as physicians we can mobilize upwards of $1 million worth of resources simply by practicing medicine. We’ve begun to understand that and we’ve begun to understand the impact that we can have on a particular community by making sure those resources stay within that community.
Thirdly, we need to look at empowering ourselves politically as physicians while also empowering our communities. That’s an important role that physicians can have – making sure that people fill out their census cards and that they get out there and get their colleagues, friends, and family members to vote and to become politically aware. One of the hottest health issues in California is the reapportionment issue [at the level of county supervisorial districts]. That movement impacts directly on issues of self-determination and making sure that the expenditure of public funds benefits the right people.
We also need to look at developing our own leadership. That’s what CMAC is all about. Many of us are members of established medical organizations, yet we knew we had to develop an organization that addressed specifically the needs that were important to us and to able to have an organization that can mobilize people at a moment’s notice to support an issue that we feel is important.
It’s very important also to realize that we need to work within the established systems because the only way things are going to change is if we get into the mainstream. Lastly, we need to recognize the need to build coalitions. No one group can do it alone. We cannot afford to be cultural nationalists and say only Hispanics can answer Hispanic needs. We need to work together with our African-American colleagues, Native Americans, Asians, and the Anglo population because we are, indeed, a multicultural society that needs to work together.
I think one of the things that has always inspired me in my own medical education has been a mentor whom I had in medical school who happened to be an internist but who always supported my own goal of being a family practice physician. That was Dr. Ernest Gold who has since passed away. He always taught me that it was good to be important, but it was far more important to be good. And that’s exactly what we try to do in the CMAC.
Thank you very much.
This presentation was preceded by: First National Conference on Primary Health Care Access (4th Plenary Panel, Part 1, Arradondo)
This presentation was followed by: First National Conference on Primary Health Care Access (4th Plenary Panel, Part 3, Hullett, Ignace Q&A)