American Journal of Law & Medicine

Equitable health systems: cultural and structural issues for Latino elders.

I. INTRODUCTION

This Article examines the extent to which the U.S. healthcare system is equitable for older Latinos, using the World Health Organization (WHO) and the related Organization for Economic Cooperation and Development (OECD) criteria on health outcomes, access/responsiveness and financing. We argue that improving health equity requires more than actions aimed at health behavior and culturally-based beliefs targeted at the individual. Improving equity also requires changes in broader social and political processes affecting entire populations and organizations of care, paying special attention to how these changes affect the Latino elderly.

Healthcare is particularly important for the older population. Persons age 65 and older have the highest overall rates of death, disease and disability, as well as the most frequent and intense use of medical services. (1) U.S. public policy has acknowledged the high medical care needs of many elderly by establishing Medicare as a universal health insurance starting at age 65, and supplementing it with Medicaid, the public-assistance program for low-income older persons. (2) Over the next five decades, members of the population age 65 and older are expected to double from nearly thirty-five million individuals to over eighty million, representing more than one-fifth of the total U.S. population. (3) In recent years, much has been written about the aging of the U.S. population and its implications for the financing of federal and state programs including Social Security, Medicare and Medicaid. (4)

The WHO has developed a set of criteria for evaluating the performance of health systems in their efforts to improve health. These criteria focus on three important areas of performance: health outcomes, the "responsiveness" of healthcare systems and the financing of those systems. (5) Moving beyond the fiscal policy emphasis promoted by international lending institutions and many U.S. economists, (6) the WHO argues that each area should be assessed on the equity of results in addition to a system's efficiency. (7) This emphasis on equity draws attention to the distribution of results in each area, requiring us to identify population characteristics that are markers of inequality and stratification in society. The OECD recently expanded this framework to incorporate more attention to the equity of access to healthcare. (8)

In the United States, race and ethnicity have historically served as principal fault lines in the distribution of social benefits and economic outcomes, notwithstanding the Fourteenth Amendment. (9) Regardless, the substantial public resources and policy effort focusing on elderly health tends to assume a relatively homogeneous elderly population. (10) Such assumptions are unwise given the increasing racial and ethnic diversity found among the elderly population. By 2050, an estimated 35% of this population will also be members of an ethnic minority population, double the number reported in 2000. (11) Indeed, the Census Bureau projects that while the non-Latino white population age 65 and older will increase by 81%, the Latino population age 65 and older is expected to increase 592% between 2000 and 2050. (12) While the Latino population is traditionally a younger population because of relatively high fertility rates, declines in mortality and reduced fertility, as well as the aging of immigrants have led to the "graying" of the Latino population. (13)

The diversity of the elderly population is not only important from a demographic perspective, but also because the experience of aging varies greatly across groups, revealing significant inequities in health and socioeconomic status. For example, while poverty rates over the past few decades improved among the elderly population, minority elderly persons remain overrepresented among the ranks of the poor. (14) Similarly, while the health of the older adult population has improved, (15) Latinos and other minority groups have disproportionately high prevalence rates for chronic and disabling conditions. (16) Additionally, access to the healthcare services to prevent and treat these conditions continues to vary by race and ethnicity. (17) The Department of Health and Human Services (HHS) recognizes these inequities and has set a national goal to eliminate health disparities among segments of the population, including differences that occur by gender, race, ethnicity, education and income. (18) Eliminating inequities in healthcare requires examination of the health of the population and the determinants of health at both the individual and broader sociopolitical level.

II. THE DEMOGRAPHY OF THE LATINO POPULATION

The Latino population is the fastest growing population in the United States, currently representing almost 12% of the total U.S. population. (19) The Latino population will surpass the African American population by 2005 to become the second largest racial/ethnic group in the United States, increasing to ninety-eight million individuals by 2050 and representing approximately one-quarter of the U.S. population. (20)

Yet, as the Latino population increases in number, it also ages. Currently, there are 1.9 million elderly Latinos representing 5.6% of the elderly population; by 2050 the Latino population age 65 and older will comprise 16.4% of the U.S. elderly population. (21) It is important to note that the Latino population includes different ethnic groups that share a common language but represent separate and distinct cultures. Mexican Americans account for 66% of the total Latino population living in the U.S., followed by South/Central Americans at 14%, Puerto Ricans at 9%, Other Latinos at 6% and Cubans at 4%. (22) The breakdown is somewhat different among the elderly Latino population. While Mexican Americans remain the clear majority, Cubans and Puerto Ricans have a higher representation. Among Latinos age 65 and older, Mexican Americans represent 53% of the population, followed by Cubans at 16%, South/Central Americans at 13% and Puerto Ricans at 10%. (23) Much of what we know about the health, social and economic status of the Latino population is based on the experience of Mexican Americans and, to a much lesser degree, the experience of the other Latino ethnic groups.

III. HEALTHCARE OUTCOMES: INEQUITIES IN ELDERLY LATINOS' HEALTH STATUS

The primary objective of health systems is to improve the health of populations. (24) While wealth and the social and physical environment are important determinants of inequitable health outcomes, (25) healthcare systems also play an important role. (26) Examining the equity of health status is therefore a key indicator of equity in healthcare systems. Equity in health outcomes can be determined by making a number of comparisons between Latino and non-Latino white elderly in terms of mortality rates, morbidity rates, functional status and self-assessed health.

A. MORTALITY

Studies focusing on mortality find that Latino older persons have lower mortality rates than non-Latino whites for certain disease conditions. Cross-sectional data from the National Center for Health Statistics (27) show that Latinos age 65 and older are less likely than older non-Latino whites to die from heart disease, cancer or stroke. The National Longitudinal Mortality study offers further evidence of the Latino mortality advantage: both genders and all Latino subgroups have lower death rates among middle-aged (45-64) and elderly Latinos as compared to non-Latino whites. (28)

Among the Latino subgroups, Cubans have the most pronounced advantage and Puerto Ricans the least. (29) Puerto Ricans have higher all-cause, age-adjusted mortality rates than Cubans (406.1 versus 299.5 per 100,000) or Mexican Americans (348.4 per 100,000). (30) This pattern among Latino ethnic groups seems logical since the socioeconomic status of the Cuban population is higher than that of Puerto Ricans and Mexican Americans. The Latino advantage for mortality relative to non-Latino whites is surprising, however, given the disproportionately high poverty levels, low education and greater risk profile for disease found among the Latino population. Some have referred to this pattern of high risk and low mortality as an epidemiological paradox. (31)

The mortality advantage enjoyed by Latinos for cancer and heart disease, however, does not extend to all other disease conditions. Latinos of both genders, for example, have a higher mortality at all ages from diabetes. (32) The mortality rate for diabetes among middle-aged and older Latinos is twice that of the general population. (33) In addition, Latinos have higher mortality from chronic liver disease, homicide and HIV as compared to the general population. (34)

The Latino mortality pattern results in Latinos having a higher life expectancy relative to other racial and ethnic groups. In 2000, the average life expectancy at birth for the total U.S. population was 73.9 years for males and 79.4 years for females, whereas the life expectancy for Latino males and females was 75.2 and 82.8, respectively. (35) Latino life expectancy at age 65 (males 19.1 additional years, and females 22.4 additional years) exhibits an advantage as well when compared to the total population (males 15.9 additional years, and females 19.5 additional years). (36) Yet while Latinos live longer than other populations, evidence suggests that they do so in relatively poor health.

B. MORBIDITY

Some of the advantages that Latinos experience in the areas of mortality and life expectancy do not extend to morbidity. Data on the incidence and prevalence of disease among the population find that Latinos have higher rates of a number of diseases that significantly impair individuals' functioning and quality of life. It is estimated that nearly 85% of elderly Latinos have at least one chronic condition. (37) Latino elderly experience major medical problems including high prevalence rates for arthritis, cognitive impairment, diabetes, cardiovascular disease, depression, hypertension and cerebrovascular problems. (38) Mexican Americans are more likely than non-Latino whites to report having high blood pressure, (39) and Latinos overall have a higher prevalence of influenza, pneumonia, gallbladder disease, and infectious and parasitic diseases. (40) Studies focusing on cancer indicate that Latinos are more likely to have cancer of the cervix, stomach, liver, esophagus, pancreas and gall bladder. (41) Additionally, elderly Latinos are at a greater risk for developing liver cancer, pancreatic cancer, stomach cancer and cervical cancer, as well as hypertension and lipid disorders. (42) They also have higher rates of undiagnosed hypertension compared to non-Latino whites. (43)

One of the most significant and consistent findings is the excessive prevalence of diabetes found in the Latino population, particularly among Mexican Americans. (44) This is particularly significant since diabetes is considered an "ambulatory sensitive condition," meaning that adequate outpatient medical care can reduce the severity of the condition and lower hospitalization and complication rates. …

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