Health Care Access of Hispanic Young Adults in the United States
Article Outline
Abstract
Purpose
Hispanic persons in the United States experience higher rates of many chronic conditions than non-Hispanic whites. Access to care, especially during young adulthood, may afford opportunities for prevention or early management of these conditions. Given the heterogeneity of the Hispanic population, the specific aims of this study were to assess health insurance coverage and health care access and utilization for different Hispanic subgroups young adults in the U.S.
Methods
We analyzed data from 5189 Hispanic and 13,214 white young adults (19–29 years old) completing the National Health Interview Survey (NHIS) from 1999–2002. Health care access/utilization measures included reports of 1) uninsurance, 2) lacking a usual source of care, 3) no health professional contact, and 4) delaying needed care because of cost. Multivariate analyses were used to estimate the risk of access barriers after adjusting for sociodemographic variables and citizenship.
Results
Young adults of Central/South American, Mexican, or Puerto Rican origins were more likely than whites to be uninsured (28%–64% vs. 22%; p < .01) and this was especially true for noncitizens. Central/South American and Mexican young adults without U.S. citizenship were most likely to be uninsured (63% and 73%, respectively). The majority of noncitizens also lacked a usual source of care and had no health professional contact in the prior year. After adjustment, the risk of uninsurance was 60% higher for Mexican and Central/South American young adults relative to white peers. Mexican young adults also had higher risk of lacking a usual source of care and having no health professional contact.
Conclusions
Substantial variability in rates of uninsurance and health care access/utilization measures exist among subgroups of Hispanic young adults participating in the NHIS. U.S. citizenship and sociodemographic factors explain much, but not all of the differences.
Keywords: Access to care, Young adults, Hispanic Americans, Uninsurance
Hispanics/Latinos constitute the fastest growing minority group in the United States, and their concentration in the Southwest, Northeast, south Florida, and urban centers of the Midwest makes them the majority group in many areas of the country [1], [2]. Although frequently studied as a monolithic group, Hispanics in the United States are a heterogeneous population in terms of socioeconomic status and acculturation and include persons whose cultures or origins are from the Caribbean, Central or South America, Cuba or Mexico [1], [2]. Hispanics bear a disproportionate burden of hypertension, diabetes and other chronic diseases and have higher incidences of human immunodeficiency (HIV) infection, cervical cancer, unintentional injury, homicide and obesity than non-Hispanic white U.S. residents [3], [4].
Young adults between the ages of 19 and 30 years comprise 20% of the Hispanic population in the United States (12% of the non-Hispanic white population is between 19 and 30 years old) [1]. Health care research is increasingly recognizing that young adulthood is a critical time for screening and intervention to prevent or slow progression of conditions like obesity, coronary heart disease, diabetes, and hypertension, that contribute significantly to morbidity and mortality in older adulthood and disproportionately affect the Hispanic population [5], [6], [7], [8], [9], [10], [11], [12], [13]. Young adults in the U.S. have been shown to have poor health care access relative to children or older adults [14], [15], [16], [17], [18], and an increasing body of literature shows that Hispanics have the highest rates of uninsurance among racial/ethnic groups in the U.S. and underuse preventive services relative to non-Hispanic whites [3], [19], [20], [21], [22], [23], [24]. Uninsurance and health care access are even more problematic for the one-third of Hispanics who are immigrants to the U.S. [25], [26]. Extrapolations from these studies would suggest that Hispanic young adults in the U.S. may have particularly poor health care access. However, studies of this growing population are lacking.
The specific aims of this study were to assess health insurance coverage and self-reported health care access and utilization for Hispanic young adults in the U.S. Given the heterogeneity of the Hispanic population, we were specifically interested in determining the rates of uninsurance and health care access and utilization for different Hispanic subgroups and assessing the association of U.S. citizenship and these measures.
Methods
We analyzed data from the National Health Interview Survey (NHIS) for the years 1999–2002. Conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control, the NHIS uses a nationally representative sampling strategy to provide ongoing, cross-sectional data about the health and health care of the civilian noninstitutionalized U.S. population [27]. The NHIS oversamples the Hispanic U.S. population to improve the precision of health estimates and conducts surveys in Spanish and English. Data are collected for households, families and individuals, and are available in several public use data files. For this study, we analyzed data from Sample Adult files (containing health care utilization data obtained from a randomly selected adult in each household) augmented by Person files (containing sociodemographic information for each member of the household collected directly from the individual or from other adult members of the household). Weights provided by the NCHS account for selection probability and adjust for nonresponse, permitting users to make national estimates based on the data.
Hispanic Origin and Citizenship
NHIS respondents were asked “Do you consider yourself Hispanic/Latino?” Affirmative responses were followed by a request to choose one or more groups from a flashcard that represented Hispanic origin or ancestry (Puerto Rican, Cuban/Cuban American, Dominican, Mexican, Mexican American, Central or South American, other Latin American, or other Hispanic/Latino). All respondents were also asked if they were U.S. citizens and how long they had lived in the U.S. For this study, we include respondents who reported their national origin to be Mexican or Mexican American, Central/South American, or Puerto Rican, as these subgroups accounted for over 90% of Hispanic young adults participating in the NHIS from 1999 to 2002. Respondents from other Hispanic origin groups and those who reported more than one origin group were excluded because of insufficient numbers for analyses. We included white non-Hispanic respondents as the comparison group.
Insurance Coverage
The dependent variables included health insurance coverage at the time of the interview and respondents’ reports of unmet health care needs, having no usual source of health care, or no contact with a health professional in the last year. Uninsured young adults were those without coverage from private health insurance, Medicaid, State Children’s Health Insurance Plan (SCHIP), Civilian Health and Medical Program for Uniformed Services (CHAMPUS), the Indian Health Service, or other public programs. Over 97% of young adults reported that they were privately insured, had Medicaid, or were uninsured. Young adults who reported other insurance coverage or whose insurance status was unknown were excluded from multivariate analyses because of insufficient numbers.
Health Care Access and Utilization
Respondents were asked if they had a usual source of health care, when they last saw or spoke to a health care provider about their health, and if they delayed or missed needed medical care because of cost in the last year. Young adults without a usual source of health care were those who did not identify a usual source or who identified the emergency department as their usual source of health care.
Sociodemographic Characteristics
We used NHIS variables to determine sociodemographic characteristics of the participants, including educational attainment, marital status, major activity in the week before the survey, and household income. Marital status was collapsed to single (including those never married or who were widowed or divorced), married (including separated), and unmarried but living with a partner. Young adults were asked about the major activity in which they were engaged during the week before the survey. Major activity was classified as working at a job or business, going to school, keeping house, or something else. Working young adults were also asked if health insurance was offered through their employer. Household income included income from all sources. Because one-fourth of Hispanic respondents did not know or refused to give their household income, we used a follow-up NHIS question that asked if the household income was less than $20,000 per year or $20,000 and above. We excluded 1008 young adults (4.8% of the weighted sample) who reported that they did not know or refused to answer this income question.
Statistical Analyses
Population estimates and bivariate distributions of sociodemographic characteristics, health insurance status, and health care access and utilization measures are presented using weighted data from 5189 Hispanic young adults (stratified by national origin subgroup and U.S. citizenship) and 13,214 white non-Hispanic young adults. Four multiple logistic regression models were created to estimate the adjusted odds of reporting (1) no health insurance, (2) no usual source of care, (3) delayed or missed medical care, and (4) no contact with a health professional in the last year for Hispanic national origin groups and white non-Hispanic young adults. We also assessed the interaction between citizenship and national origin groups for each model; however, inclusion of the interaction term did not add substantively to the models. Final models adjusted for gender, age, educational attainment, marital status, major activity in the last week, household income, and years in the United States. The latter three models also adjusted for current insurance status. Final models included the 88% of Hispanic and 92% of white respondents who provided complete information. Adjusted odds ratios may overestimate risk ratios greater than one and underestimate risk ratios less than one when the incidence of an outcome is common, as in this study. To improve our estimation of true risk ratios, results are presented as adjusted relative risk and 95% confidence intervals as described by Zhang and Yu [28]. Final analyses were conducted using SUDAAN® (Version 9.0; Research Triangle Institute, Research Triangle Park, NC) to account for the complex sampling design employed in the NHIS. The study protocol was approved by the Institutional Review Board of Vanderbilt University (Nashville, TN).
Results
Sociodemographic Characteristics
The Central/South American, Mexican (including Mexican American) and Puerto Rican respondents participating in the NHIS represent an estimated 5.7 million young adults and 14% of all 19–29-year-olds in the U.S. (Table 1). Hispanic young adults were less likely than non-Hispanic white peers to have attended college, more likely to be working at a job that did not offer health insurance, and more likely to live in a household with an income of less than $20,000. These findings were particularly pronounced for noncitizen Mexican and Central/South American young adults.
Table 1. Sociodemographic characteristics of young adults by Hispanic subgroup
| Central/South American | Mexican | Puerto Rican n = 538 | Non-Hispanic white n = 13214 | |||
|---|---|---|---|---|---|---|
| U.S. citizen n = 269 | Noncitizen n = 526 | U.S. citizen n = 2037 | Noncitizen n = 1819 | |||
| U.S. population estimate | 321,000 | 615,000 | 2,112,000 | 2,092,000 | 575,000 | 26,476,000 |
| % (SE) | ||||||
 % of US 19–29-year-olds | .8(.1) | 1.5(.1) | 5.2(.2) | 5.2(.2) | 1.4(0.1) | 65.3(.5) |
| Gender | ||||||
| Female | 57.8(3.6) | 47.8(2.8) | 51.2(1.2) | 44.2(1.4) | 54.6(2.6) | 50.4(.5) |
| Age | ||||||
| 19–24 years | 58.6(3.4) | 49.5(2.6) | 60.8(1.5) | 52.5(1.5) | 61.3(2.6) | 56.2(.6) |
| Education | ||||||
| ≤ 8th grade | 2.7(1.0) | 20.3(2.1) | 3.8(.5) | 35.9(1.6) | 3.7(1.0) | 1.2(.1) |
| 9–12th grade | 10.8(2.1) | 20.6(1.8) | 21.8(1.2) | 30.6(1.4) | 22.0(2.2) | 8.1(.3) |
| High school grad/GED | 21.8(3.1) | 23.7(2.4) | 33.6(1.4) | 20.3(1.4) | 31.3(2.2) | 26.9(.6) |
| Some college | 61.2(3.4) | 33.8(2.8) | 40.5(1.5) | 10.4(.9) | 41.0(2.7) | 63.4(.7) |
| Marital status | ||||||
| Single | 57.4(3.8) | 46.0(2.7) | 49.0(1.6) | 37.7(1.6) | 53.4(2.4) | 51.5(.7) |
| Married | 30.7(3.2) | 43.4(2.1) | 40.3(1.4) | 52.4(1.6) | 34.7(2.6) | 35.8(.7) |
| Unmarried, living with partner | 11.7(2.6) | 10.4(1.8) | 10.6(.8) | 9.7(.9) | 11.5(1.3) | 12.5(.4) |
| Major activity in last week | ||||||
| Going to school | 10.3(2.2) | 5.6(1.2) | 5.9(.7) | 2.2(.4) | 6.5(1.3) | 8.4(.6) |
| Working at job (insurance offered) | 40.3(3.3) | 27.8(2.2) | 40.7(1.8) | 18.0(1.3) | 38.4(2.7) | 49.6(.7) |
| Working at job (insurance not offered) | 32.0(3.8) | 41.9(2.4) | 30.9(1.4) | 47.4(1.7) | 28.6(2.5) | 27.3(.5) |
| Keeping house | 5.8(1.3) | 13.6(1.6) | 10.4(.9) | 24.0(1.2) | 10.6(1.5) | 6.4(.3) |
| Something else | 8.4(1.9) | 7.6(1.3) | 9.7(.8) | 6.0(.7) | 14.0(2.0) | 7.0(.3) |
| Household income | ||||||
| < $20,000 | 16.8(2.6) | 31.8(2.2) | 24.5(1.3) | 38.8(1.6) | 30.9(1.8) | 21.3(.8) |
| Years in the U.S. | ||||||
| < 5 years | 2.9(1.0) | 45.8(2.9) | 1.0(.3) | 38.0(1.5) | 5.5(1.0) | 1.3(.1) |
| 5 to < 10 years | 5.7(1.8) | 24.9(2.2) | 1.7(.4) | 30.3(1.4) | 3.1(.7) | .7(.1) |
| ≥ 10 years | 31.2(3.5) | 26.4(2.2) | 8.0(.7) | 23.9(1.3) | 17.8(1.7) | 1.7(.1) |
| Born in the U.S. | 60.4(3.9) | 2.9(0.8) | 89.3(.9) | 7.8(.9) | 73.6(1.9) | 96.2(.2) |
Insurance Characteristics
Table 2 compares insurance status and health care access and utilization for Hispanic subgroups and non-Hispanic white young adults. Hispanic young adults, particularly those without citizenship, were more likely to be uninsured and less likely to have private health insurance than non-Hispanic white peers. Sixty-three percent of Central/South American and 73% of Mexican young adults without citizenship were uninsured, and only 31% and 21%, respectively, held private health insurance. Hispanic young adults with U.S. citizenship were more likely than non-Hispanic whites to have Medicaid coverage.
Table 2. Insurance status and health care access and utilization of young adults by Hispanic subgroup
| Central/South American % (SE) | Mexican % (SE) | Puerto Rican % (SE) | Non-Hispanic white % (SE) | |||
|---|---|---|---|---|---|---|
| U.S. citizen | Noncitizen | U.S. citizen | Noncitizen | |||
| Insurance status | ||||||
| Private | 59.0(3.8) | 30.6(2.4) | 50.4(1.6) | 20.9(1.3) | 45.8(2.6) | 71.0(.6) |
| Medicaid | 8.9(2.4) | 3.8(1.0) | 9.3(.8) | 4.9(.6) | 19.6(2.2) | 4.4(.2) |
| Uninsured | 30.0(3.4) | 63.4(2.6) | 37.6(1.5) | 72.6(1.5) | 28.0(2.4) | 21.6(.5) |
| No usual source of care | 25.7(3.1) | 51.9(3.0) | 32.3(1.2) | 58.9(1.6) | 27.4(2.8) | 23.4(.5) |
| Last contact with health professional | ||||||
| ≤ 1 year ago | 77.3(3.3) | 56.5(2.4) | 67.0(1.4) | 46.0(1.5) | 77.2(2.0) | 78.2(.4) |
| >1 but ≤ 2 years ago | 10.1(2.2) | 11.6(1.7) | 14.6(1.0) | 14.1(1.1) | 11.9(1.4) | 11.6(.3) |
| > 2 years ago | 10.7(2.5) | 30.1(2.6) | 17.1(1.2) | 37.5(1.4) | 10.4(1.6) | 9.2(.3) |
| Delayed/missed care due to cost | 9.3(2.0) | 14.0(1.8) | 9.1(.8) | 7.0(.6) | 14.4(2.0) | 12.4(.3) |
Health Care Access and Utilization
Mexican and Central/South American, but not Puerto Rican young adults were more likely than white peers to lack a usual source of care and to have no contact with a health professional in the prior year. When stratified by citizenship, over half of noncitizen Central/South American and Mexican young adults identified no usual source of health care, with nearly as many (44% of Central/South American, 54% of Mexican young adults) reporting no health care contact in the prior year. Central/South American young adults who were U.S. citizens were similar to white peers in these measures. Young adults of Mexican origin were less likely than non-Hispanic whites to report delaying or missing medical care due to cost.
After adjusting for socioeconomic variables and citizenship status, the risk of uninsurance was over 60% higher for Mexican and Central/South American young adults relative to white young adults in the U.S. (Table 3). The adjusted risk of uninsurance for Puerto Rican young adults was not increased relative to whites. Mexican young adults in the U.S. had significantly higher risk of having no usual source of health care and no contact with a health professional, and significantly lower risk of reporting delayed or missed medical care relative to whites. After adjustment, Central/South American and Puerto Rican young adults were not significantly different from white young adults in these measures. After adjustment, noncitizens had significantly higher odds of uninsurance, having no usual source of health care and no contact with a health professional and significantly lower odds of reporting delayed or missed health care.
Table 3. aRR for health care access and utilization measures
| No health insurancea | No usual source of health careb | No contact with health professional last 12 mosb | Delayed/missed health care due to cost last 12 mosb | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| aRR | 95% CI | aRR | 95% CI | aRR | 95% CI | aRR | 95% CI | |||||
| Race/ethnicity | ||||||||||||
| Central/South American | 1.62⁎ | 1.40⁎ | 1.86⁎ | 1.16 | .98 | 1.36 | 1.10 | .91 | 1.29 | .81 | .63 | 1.04 |
| Mexican | 1.63⁎ | 1.50⁎ | 1.77⁎ | 1.20⁎ | 1.10⁎ | 1.31⁎ | 1.40⁎ | 1.28⁎ | 1.51⁎ | .49⁎ | .41⁎ | .59⁎ |
| Puerto Rican | .92 | .77 | 1.10 | 1.02 | 0.82 | 1.23 | .94 | .74 | 1.17 | .96 | .73 | 1.24 |
| White | 1.00 | Reference | 1.00 | Reference | 1.00 | Reference | 1.00 | Reference | ||||
| Citizenship | ||||||||||||
| Noncitizen | 1.56⁎ | 1.43⁎ | 1.69⁎ | 1.35⁎ | 1.23⁎ | 1.49⁎ | 1.36⁎ | 1.22⁎ | 1.52⁎ | .72⁎ | .57⁎ | .88⁎ |
| U.S. citizen | 1.00 | Reference | 1.00 | Reference | 1.00 | Reference | 1.00 | Reference | ||||
aAdjusted for age, gender, educational attainment, marital status, major activity in the last week and household income. |
bAdjusted for age, gender, insurance status, educational attainment, marital status, major activity in the last week and household income. |
⁎Significant results (p < .05). Data source: National Health Interview Survey 1999–2002 (National Center for Health Statistics). |
Discussion
A large body of literature details poor health care access among Hispanics in the United States, and an increasing number of studies demonstrates the poor health care access of young adults. This study examines the common ground of these two populations—Hispanic young adults in the U.S. As hypothesized, this study finds that Hispanic young adults in general have higher uninsurance rates and are more likely to lack a usual source of health care and report having no contact with a health professional in the prior year relative to non-Hispanic white peers. Further, this study notes differences between Hispanic subgroups, much of which is explained by U.S. citizenship and sociodemographic characteristics. The risk of uninsurance was higher for Mexican and Central/South American young adults than for white peers even after adjustment for citizenship and socioeconomic factors. The risk remained elevated only for Mexican young adults when citizenship, health insurance status, and sociodemographic variables were taken into account.
Non-citizen Mexican and Central/South American young adults in the U.S. had the highest rates of uninsurance and were most likely to report having no usual source of care and no contact with a health provider. Over 90% of these young adults were immigrants, but the majority reported residing in this country for more than five years. Although five years would seem to be a sufficient transition period, studies of Hispanic adult immigrants suggest that even after 15 years in the U.S., significant disparities in health insurance coverage persist among immigrant Hispanics and those born in the U.S. [29].
Disparate levels of private health insurance coverage explain the high rates of uninsurance among Hispanic young adults. Less than half of Central/South American, Mexican, or Puerto Rican young adults had private health insurance. Private insurance in the U.S. is most frequently obtained through employer-based plans. Even though the majority of young adults in each of these groups were currently employed, less than 60% of Hispanic workers held jobs that offered health insurance to them, and among noncitizens the percentage was significantly less. These findings are consistent with studies that show that Hispanics in the U.S. labor force are less likely to have employment-based coverage than non-Hispanic whites [14], [29], [30]. Differences in employment-based coverage have been attributed in part to the overrepresentation of U.S. Hispanics in agriculture, construction, forestry, and retail jobs and their underrepresentation in the professional workforce [14], [29], [30]. When offered coverage, Hispanic workers are as likely to enroll as non-Hispanic whites [29]. Employment-based coverage for Hispanic adults in the U.S. is reportedly on the decline, with a study from the Center for Studying Health System Change detailing that 48% of the Hispanic population had employer-sponsored health insurance in 2001, but only 40% held similar coverage in 2003 [23].
The findings of this study suggest that the majority of Hispanic adolescents with Medicaid coverage will lose that coverage during young adulthood. Medicaid and other public insurance programs are a major source of coverage for Hispanic children, insuring nearly 40% of this population in 2002 [30]. Public health insurance options for adults are more limited than for children—many states extend coverage only to pregnant or parenting young adults who meet income guidelines. Moreover, federal welfare reform legislation enacted in 1996 has severely limited the availability of Medicaid and the State Children’s Health Insurance Program (SCHIP) to immigrant adults [26]. Given budgetary constraints of many states, it is likely that some young adults who currently have Medicaid will find that coverage jeopardized in the future.
Mexican young adults were significantly less likely than non-Hispanic whites to report delayed or missed health care due to cost and having no contact with a health professional in the last 12 months even after adjusting for sociodemographic characteristics. The findings were similar for noncitizens relative to U.S. citizens. Foregone health care is a widely used but difficult to interpret measure, requiring both a perceived health care need and an inability to meet that need. Group differences in health care access and utilization may reflect economic, cultural, and social factors. Uninsurance, inadequacy of health facilities, lack of transportation, financial barriers, language barriers, lack of child care, inability to take off from work, and differences in beliefs about illness and their treatment are among the many factors implicated in studies of health care access and utilization of the Hispanic U.S. population [1], [2], [20], [21], [22], [23], [24], [31], [32]. Although studies of the “healthy immigrant effect” or “Hispanic paradox” describe better health care outcomes for subjects with less acculturation despite poverty, uninsurance, and less interaction with the U.S. health care system, these outcomes seem to diminish with time [33], [34]. Ultimately, our findings add to a growing body of literature that suggests that the provision of health insurance will be insufficient to guarantee access and use of preventive health care among some Hispanic subgroups and noncitizen residents in the United States [31], [35].
Young adulthood is an ideal time to initiate health care measures and screening to prevent or provide early identification of many of the conditions that contribute to excess morbidity among Hispanics in the U.S. Additionally, young adulthood is a high risk period for acute health problems and an increasing number of young adults have chronic medical conditions [36], [37], [38]. Having a usual source and receiving routine health care have both been shown to strongly predict receipt of preventive care [22], [39], [40]. Addressing health care access barriers for Hispanic young adults is a necessary step to facilitate the equitable use of screening and treatment programs that are known to be efficacious but underused by young adults [13] and to promote the investigation and implementation of new prevention and treatment strategies. This study suggests several targets for improving health care access, including addressing income and education disparities, increasing the availability of coverage to uninsured workers, and increasing the availability and accessibility of public health insurance for Hispanic young adults, particularly those without U.S. citizenship. Additional research addressing nonfinancial barriers to health care access is needed.
The findings of this study should be viewed in light of several potential limitations. The NHIS is based on self-report and may be subject to recall error and nonresponse. Because the data are cross-sectional, we cannot conclude that race/ethnicity caused the observed differences in uninsurance or access to health care. Moreover, these data do not allow us to ascertain differences in health status for the subgroups. Lower levels of health care use may reflect difficulties in accessing health care and/or a lower true or perceived need for care. Finally, other factors that have been shown to determine health care access, such as preferred language and measures of acculturation, were not included in the survey.
Many of the conditions that contribute to excess morbidity and mortality for Hispanic adults are potentially preventable with modification of lifestyle or risk behaviors. Where the conditions cannot be prevented, early detection and aggressive management may reduce morbidity. Improving health care access during young adulthood is an important prerequisite for successful prevention or early detection campaigns. Our findings demonstrate that health care access barriers are common among Hispanic young adults. Additionally, this study adds to the findings of other studies showing that Hispanic subgroups are heterogeneous with regards to health care access and utilization [1], [2]. Citizenship status, socioeconomic disadvantage, and high rates of uninsurance are significantly associated with the disparities and are important targets for efforts to improve access for this population. However, this study suggests that eliminating disparities in health care access and utilization will require efforts to identify and address specific access barriers for subgroups of the Hispanic young adult population.
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PII: S1054-139X(06)00145-5
doi:10.1016/j.jadohealth.2006.04.012
© 2006 Society for Adolescent Medicine. Published by Elsevier Inc. All rights reserved.
