Providing Health Care to Latino Immigrants: Community-Based Efforts in the Rural Midwest

Abstract

We examined case studies of 3 rural Midwestern communities to assess local health care systems’ response to rapidly growing Latino populations. Currently, clinics provide free or low-cost care, and schools, public health, social services, and religious organizations connect Latinos to the health care system. However, many unmet health care needs result from lack of health insurance, limited income, and linguistic and cultural barriers. Targeted safety net funding would help meet Latino health care needs in rural communities with limited resources.

Most studies of health care access for Latino immigrants focus on urban areas and the states where immigrants first arrived.1–5 Research on health care access for rural Latinos, especially in the Midwest, is limited.6 Yet many rural Midwest communities are experiencing unprecedented growth in their Latino populations.7 Many new immigrants are long-term residents who came to work in meatpacking and other processing plants.8–10 Rural health care systems are being challenged to ensure access to care for a population with low rates of health insurance coverage, limited financial resources, language and cultural differences, and special health care needs.11–16

METHODS

Expanding upon initial work in rural Minnesota,17–19 we used a qualitative case study approach to assess Latino health care access in rural communities in Iowa, Kansas, and Nebraska. We analyzed 2000 census data to identify 36 rural Midwest counties where the Latino population numbered at least 1000, represented at least 5% of the population, and grew 50% or more from 1990 to 2000.20 We then solicited recommendations from rural health and Latino organizations regarding communities in these 36 counties that were implementing programs and strategies to increase access to health care for Latino residents. From the recommendations provided, we selected 3 communities for site visits: Marshalltown, Iowa; Great Bend, Kan; and Norfolk, Neb. Some general characteristics of these communities are shown in Table 1 ▶. From September 2001 through April 2002, we conducted a 2-day site visit in each community, directing 6 focus groups in Spanish with 54 Latino participants and key informant interviews with 55 health care, social services, public health, education, religious, business, and community leaders.

TABLE 1—

Characteristics of Site Visit Communities

State	Iowa	Kansas	Nebraska
County	Marshall County	Barton County	Madison County
City	Marshalltown	Great Bend	Norfolk
City population	26 009	15 345	23 516
No. (%) Latino	3265 (12.6)	2025 (13.2)	1790 (7.6)
County population	39 311	28 205	35 226
No. (%) Latino	3523 (9.0)	2344 (8.3)	3042 (8.6)
Percentage growth in Latino population, 1990–2000	1110.00	188.00	440.00
Median 2000 household income, $	38 268	32 176	35 807
Percentage of population below poverty level	10.20	12.90	11.20

Source. Data from US Census Bureau, 2000 Census.7

RESULTS

Access to Care

We found that local safety net programs are partially meeting the need for health care among Latino residents. Clinics that recently received federal community health center funding in Great Bend and Marshalltown and a part-time community clinic in Norfolk meet some of the needs for urgent and primary care among the uninsured. Hospital emergency departments provide emergency and after-hours care. Job-related injuries (primarily from food processing) are treated by private physicians, clinics, and hospitals and are covered by employers as required by law. Pregnancy-related care for women is available through maternal health clinics and Medicaid-covered services, including emergency coverage for deliveries. Children’s medical needs are generally being met through child health clinics, school health programs, and Medicaid-covered services. Public health and social service programs also serve Latino residents.

Barriers to Care

School and community surveys and our interview and focus group data indicate that a large proportion of Latinos in these communities are uninsured.21 The growing number of Latino patients in community hospitals who have only emergency Medicaid coverage or who qualify for charity care are additional indications of high uninsured rates. This lack of insurance reflects national trends; Latinos have the highest uninsured rates among racial and ethnic groups in the United States.22–23

Interpreter services and culturally appropriate care are essential to the provision of quality health care to Latinos.11–12,24 Health care providers in these rural communities are trying to address language and cultural barriers, but they are hampered by an insufficient supply of bilingual health professionals and a lack of third-party reimbursement for interpreter services. Bilingual staff and on-call and volunteer interpreters help meet interpretation needs in the hospitals, community health centers, and community clinics. Communication is more problematic in private physician practices, where Latino patients usually bring friends, family members, or bilingual staff from social services or religious organizations to interpret.

Unmet Health Care Needs

Nonemergency care for Latino adults, especially men and older nonworking adults, is a major unmet need. Preventive services are underused, even among some insured families, because of coverage limitations, large deductibles, and co-payments. Other unmet needs include continuity of care for adults with chronic health problems such as diabetes, access to dental care, mental health care, and chemical dependency treatment; and coverage for prescription drugs. High lead poisoning rates among Latino children result from a scarcity of safe, affordable housing for low-income families.

DISCUSSION

Many of the health care access problems experienced by rural Latinos in this study are the result of no insurance, low income, and language and cultural barriers related to their recent immigrant status, difficulties also faced by urban Latinos. At the same time, rural Latinos’ access problems also reflect larger systemic problems in rural health care, such as shortages of physicians and other health care professionals (including bilingual professionals and qualified medical interpreters) and reluctance on the part of many dentists and some physicians to participate in Medicaid and the State Children’s Health Insurance Program (SCHIP).

Shortages of physicians and other health care professionals in rural communities may make existing providers reluctant to take on new patients, especially publicly insured or uninsured patients. The shortages also put pressure on practitioners to spend less time with each patient, and practitioners may be less willing to see patients who need interpreters, because visits take longer when an interpreter is used.

Extensive problems with access to dental care for low-income persons are not confined to rural areas.25–26 However, the limited number of rural dentists puts a large burden on the few local dentists who will take Medicaid and SCHIP patients. Uninsured and publicly insured persons often have to seek dental care a long distance from their homes.

The limited supply of bilingual providers and insufficient interpreter services in these rural communities are of serious concern. Several studies have demonstrated that language difficulties negatively affect access to care and use of health care services by Latino children and adults.27–30 A lack of trained medical interpreters has serious negative implications for the quality of care provided to Latino patients who are not proficient in English.5,31

Local providers currently bear a large share of the responsibility for meeting new immigrants’ health care needs in rural communities. States and the federal government could help meet those needs by adding language assistance as a covered Medicaid service in the 45 states that do not currently cover it32 and allowing use of state and federal matching funds for interpreter services provided to Medicaid and SCHIP enrollees. States and the federal government could help also by providing additional federal community health center funding for rural communities with immigrant populations and funding for targeted, transitional safety net services for immigrants in communities that do not qualify for community health center funding.