One of the reasons often given for Minnesota’s consistently high rank in national health surveys is an above average percentage of residents covered by some form of health insurance. However, the percentage of uninsured has been creeping upward for several years. In fact, according to a study by the Minnesota Department of Health, the University of Minnesota School of Public Health and the Minnesota Department of Human Services, the state’s uninsured rate rose from 5.4 percent in 2001 to 6.7 percent in 2004. Fewer businesses providing coverage for their employees was cited as the primary reason for the increase.
What this study did not take into consideration—and what is still going virtually unacknowledged in discussions about health care—is the number of uninsured immigrants in the state of Minnesota, both documented and undocumented, who would drive that percentage even higher if they were taken into account.
Evidence of just how widespread being uninsured actually is among Latinos can be found at West Side Community Health Services, a community healthcare clinic in Saint Paul primarily serving Latinos. The clinic averages between 300 and 500 patient visits per day. Its Executive Director, Mavis Brehm estimates that three out of four individuals do not have any healthcare coverage.
According to Ramon Leon, Executive Director of the Latino Economic Development Center (LEDC), one of the most distinguished economic development organizations in Minnesota, among LEDC’s membership base of Latino-owned businesses, less than five percent of the businesses LEDC works with provide healthcare coverage for their employees.
Complicating the issue of providing health insurance is an underlying cultural bias. In Latin American countries, healthcare is a service provided to all, in much the same way as police and fire services. Latino business owners have no experience with the prevailing cultural practice in the United States that it is an employer’s obligation to provide—or at least subsidize—its employees’ health insurance. And with the mediocre to non-existent marketing efforts to Latino business owners by most of Minnesota’s HMOs, Latino employers simply aren’t getting the message.
To fill this educational gap and to address what is becoming a full-blown healthcare crisis in the Latino community, LEDC’s Leon, along with a group of other Latino community leaders, began meeting informally earlier this year. The group’s goal is to create a consortium of Latino business owners who have the power to buy into a health plan. “We have to create a situation where HMOs view the Latino market as an investment, and not a cost,” said Leon. Preparations are currently underway for a feasibility study.
|The rest of the country has long viewed Minnesota as a leader in state-of-the-art medical treatments, innovative health care options and the quality of life made possible by this level of attention to health issues.
One of the reasons often given for Minnesota’s consistently high rank in national health surveys is an above average percentage of residents covered by some form of health insurance. However, the percentage of uninsured has been creeping upward for several years. In fact, according to a study by the Minnesota Department of Health, the University of Minnesota School of Public Health and the Minnesota Department of Human Services, the state’s uninsured rate rose from 5.4 percent in 2001 to 6.7 percent in 2004. Fewer businesses providing coverage for their employees was cited as the primary reason for the increase. What this study did not take into consideration—and what is still going virtually unacknowledged in discussions about health care—is the number of uninsured immigrants in the state of Minnesota, both documented and undocumented, who would drive that percentage even higher if they were taken into account.
An HMO Culture Clash
All Health Maintenance Organizations (HMOs) are required by Minnesota law to be set up as non-profits. The thinking behind this piece of legislation was to ensure that there would not be excessive profiteering on the part of HMOs. (This same law has barred one of the largest HMOs in the nation—ironically, Minnesota’s own United Healthcare—from competing against the non-profit HMOs to provide healthcare services to residents of its home state.) But there are no mandates made on HMOs for a measurable level of community outreach, and in terms of engagement in the Latino community, not all HMOs have the same mission—as this side-by-side comparison of Blue Cross and Blue Shield of Minnesota and Medica demonstrates.
Blue Cross and Blue Shield of Minnesota
• One of the state’s first health plans, Blue Cross and Blue Shield of Minnesota was chartered in 1933 and now serves more than 2.7 million members.
• In 2006, Blue Cross and Blue Shield of Minnesota generated more than $7.8 billion in revenue. And as the state’s leading health philanthropist, the Blue Cross and Blue Shield of Minnesota Foundation made $2,188,972 in grants that same year.
• In 2006, Blue Cross and Blue Shield of Minnesota created Fuerza Azul, a Latino employee resource Group focused on corporate-wide cultural competency. The group acts as an ambassador to Minnesota’s Latino community. In November of 2006, Blue Cross and Blue Shield of Minnesota was recognized by Comunidades Latinas Unidos en Servicio (CLUES) as its “Business of the Year.”
• In February of 2007, The Blue Cross and Blue Shield of Minnesota Foundation named Luz Maria Frias to its 13-member board of directors. As the External Affairs Director for Saint Paul Mayor Chris Coleman, Frias is actively engaged in Minnesota’s Latino community and is widely recognized as a distinguished leader.
• In July of 2007, Frank Fernandez was promoted to Vice President of Government Programs. A licensed attorney, Fernandez serves on the steering committee of Fuerza Azul.
• The Blue Cross and Blue Shield of Minnesota Foundation’s 13-member Board is comprised of nine women and four men, and includes three persons of color.
• Medica currently serves more than 1.3 million members.
• Medica began as the result of a 1991 merger between Physicians Health Plan (PHP) and Share. In 1994, as a for-profit organization, it merged with the not-for-profit HealthSpan Health Systems to form Allina Health System. In 2001, Minnesota’s then Attorney General, Mike Hatch accused Allina Health System of violating its not-for-profit status by misspending its money on image consultants, executive salaries and perks and corporate entertaining. Ultimately, the scrutiny force Allina Health Systems into a break-up that divided the organization into two separate entities. One entity, Medica, became an independent Health Plan.
• In 2006, Medica generated $2.4 billion in revenue, while in 2007, the Medica Foundation provided $1.5 million in grants, or .0006% of their annual revenue.
• One of three priorities of the Medica Foundation is “Reducing Racial and Ethnic Disparities in Health Care and/or Enhancing Cultural Competency.” To that end, the 2005 annual report indicated that Medica was reducing healthcare disparities by introducing two programs. The first was an e-learning program in “cross-cultural care” offered online to physicians. The second program introduced a “cultural disparities toolkit” that contained translated brochures and multilingual signs made available to Medica-affiliated providers. Beyond this initial report, no additional information could be located to indicate how widespread these programs use or if they had succeeded in making any impact on reducing disparities.
• Medica lists Diversity as one of five core values, which says, “Our people are our greatest asset. We are committed to a workforce that reflects the strength and character of the customers and communities we serve. We promote a spirit of openness, discovery and learning in order to live our mission and achieve our vision.” Yet there is not one single person of color on their 10-member executive team of eight men and two women, or on their 12-person Board of Directors.
• Leaders within Minnesota’s Latino community interviewed for this feature almost unanimously agreed that Medica is the least engaged HMO, with very few ties to the Latino community.
A Different Perspective
Mavis Brehm, Executive Director for the Westside Community Health Services, has experienced a more engaged Medica than other members of the forum panel—hence the qualifier “almost unanimously agreed” in the group’s assessment of Medica’s performance in the Latino community. Given the nature of a community clinic’s work, Brehm is in a position to offer a unique perspective.
According to Brehm, Medica once delivered a $50,000 grant to support health education and outreach at their clinic is South Minneapolis. (The clinic has since closed and is now operating under the stewardship of Hennepin County.) In spite of this act, Brehm observed, “Our greater relationship with Medica is through insurance reimbursement, as they are one of the Prepaid Medical Assistance Programs (PMAP).” As a large HMO with a large percentage of commercial enrollees, Medica’s focus is not specifically on low income minority populations like those served at community clinics.
In spite of Brehm’s defense of Medica she did observe, “I don’t think any of them are stellar,” said Brehm. “The best HMO, the one that is genuinely tuned in to low-income immigrant and refugee issues, is UCARE. They have funded several initiatives and since they focus on the Medical Assistance population, they are sensitive to and aware of those specific needs.”
A “Growing” Population’s Greatest Health Risk
Latinos are the fastest growing population in the United States—in number and size. Obesity has become a national epidemic and unfortunately, Latinos (children, in particular) are ahead of the curve. A study led by Robert Whitaker of Mathematica Policy Research, Inc., of Princeton, New Jersey, and published in the June 2006 issue of Archives of Pediatric & Adolescent Medicine, found that around 26 percent of Hispanic children studied were obese by the age of three compared to 16 percent of black children and 15 percent of white children. The study looked at families’ ethnic background, education level, income and access to food. Perhaps the most important finding of the study was that the levels of socioeconomic status of the families studied were very similar between blacks and Hispanics, yet Hispanic were at a 50 percent higher risk of obesity by the age of three. In a feature article originally published on foodnavigator-usa.com, Whitaker observed, “”It is suspected that Hispanics are at an increased risk of obesity on a genetic basis, but no one has as yet identified the genes that would be responsible for this. It is a scientific hypothesis but is yet to be proven…”
The Latino Nutrition Commission (LNC) is not waiting for scientists to establish a genetic link to Latinos’ higher obesity rates. As LNC’s Liz Mintz noted in the original foodnavigator-usa.com article, “Because Latinos have a certain genetic predisposition toward health—for example, they are twice as likely to develop diabetes—they must adapt their diet with this in mind.” On October 17, 2007, the group unveiled its redesigned Camino Magico, a tool that features healthier versions of Latino recipes, portion control and hydration guide, a revamped Latin American Diet Pyramid and more. While the Camino Magico Guide is currently available only at grocery stores in Connecticut, Florida, Massachusetts, Rhode Island and Texas, much of the guide’s contents can be accessed at the group’s web site, latinonutrition.org.
Weighty Issues – No Easy Answers
While many studies are currently examining the sharp rise in childhood obesity in the United States in recent decades, obesity in adults continues to fuel our nation’s healthcare crisis. According to Shape Up American, a not-for profit organization founded in 1994 and committed to raising awareness of obesity as a health issue and to providing responsible information on healthy weight management, obesity is associated with:
• Up to 97 percent of all cases of Type II diabetes
• Up to 70 percent of coronary artery disease
• 70 percent of gallstone cases
• 33 percent of hypertension cases
• 11 percent of breast cancers
• 10 percent of colon cancers
Nationally recognized as an expert on metabolism an obesity, panelist Michael Gonzalez-Campoy, MD, emphasized that we will never turn get this crisis under control until we learn to prevent obesity with the same diligence we have used to prevent childhood diseases, and not just intervene medically after obesity is a foregone conclusion. As the founder of the Minnesota Center for Obesity, Metabolism and Endocrinology, Gonzalez-Campoy practices what he preaches and counsels other doctors on how to address his patients’ obesity issues. According to Gonzalez-Campoy’s article “Obesity in Minority Populations” found on the American Medical Association Web site, “Obesity…is affecting minority groups at a disproportionate rate, with Hispanic teens having the highest rates of BMI growth, and black women having the largest membership in the extreme BMI (greater than 40) group. Native Americans with obesity have the highest incidence of diabetes, and health care outcomes for these groups fare poorly compared to whites…”
So much for the diagnosis. What is Gonzalez-Campoy’s recommended treatment? Behavior modification, and not just on the part of the American public in general (and his fellow Latinos in particular) but on the part of healthcare providers and third-party payers to treat those who are currently obese and prevent obesity in those who are predisposed. Many of his practices are not the current healthcare industry standard—referring patients for dietician consultations; prescribing obesity medications, which he has found to be largely safe and effective, especially if the alternative is further weight gain; and providing culturally and linguistically appropriate care to make it understandable to all of his patients proper nutrition and physical activity a quality and quantity to life—but treating and preventing obesity has been his life’s work.