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March 5, 2003

The Latino Disparity in Health Coverage

JAMA. 2003;289(9):1167. doi:10.1001/jama.289.9.1167

Nearly one third of the 41.2 million uninsured in the United States are Latino despite the fact that Latinos compose only 13% of the population.1,2 Of all US Latinos, 33% are uninsured—three times the rate of the non-Hispanic white population.1 This disparity results from a combination of factors ranging from lack of employment benefits to citizenship issues and language barriers, many of which disproportionately affect the Latino community.

Despite equal rates of participation in the workforce, only 43% of Latinos are covered by employment-based health insurance compared with 73% coverage of non-Hispanic whites.3 Latinos often work in occupations that do not provide health coverage.4 They are five times more likely than non-Hispanic whites to work in agriculture and are also half as likely to be in administrative or managerial positions.5 An additional 25% of Latino workers said they were ineligible for offered plans because they did not work enough hours or they were still in a waiting period to receive benefits.6 Of all surveyed workers, 81% of both non-Hispanic whites and blacks reported being eligible to receive an offered health plan compared with 61% of Latinos.6

Working-class Latino families may have difficulty finding other forms of health insurance. Of the 57% of Latinos without job-based coverage, 4% purchase private coverage, 27% obtain Medicaid, 4% receive other public coverage, and 66% remain uninsured.3 Latinos are twice as likely as the general population to belong to families of which the primary wage-earner makes less than $7 per hour.4 Since such a high proportion of Latinos earn low incomes, they are less able to afford the $6000 average yearly premium of a family health plan.4 Furthermore, like other low-income workers, working Latinos often make too much money to qualify for publicly funded insurance. In 35 states, even a part-time minimum-wage job with earnings equal to the poverty line ($14 630 per year) could disqualify a single mother from Medicaid.7

For noncitizen Latinos, the problem of being uninsured is even more complex—coverage varies widely depending on whether a Latino noncitizen is documented or undocumented. Approximately 3.5 million Latinos in the United States are undocumented.4Since public insurance programs such as Medicaid and the Children's Health Insurance Program (CHIP) require proof of legal residency, noncitizens without documentation are not eligible for coverage. For example, among Mexican residents lacking documentation, approximately 75% are completely uninsured while the rest have job-based coverage.3 Undocumented workers are easily exploited and often work "off the books" in occupations such as domestic service, agriculture, and manufacturing—jobs that frequently do not provide health benefits.5

Even Latino immigrants who are legal residents face barriers and have a high rate of uninsurance (45%).3 While enrollment in public insurance plans does not affect citizenship applications, many Latino noncitizens remain skeptical, even to the extent of avoiding enrollment of their US-born children in Medicaid for fear of calling attention to themselves.3,4 Exacerbating this problem, welfare and immigration reforms enacted in 1996 require that legal residents who immigrated after 1996 be excluded from Medicaid or CHIP for five years.5

Although Medicaid and CHIP provide an important safety net for many Latino children, 25% remain uninsured compared with 7% of non-Hispanic white children and 14% of black children.1 A report by the US General Accounting Office suggested that Medicaid-eligible Latino children may not be enrolled by their parents because of lack of eligibility awareness, language barriers, changing eligibility rules, stigma, and difficulty obtaining required documentation for enrollment.8 Latino children are also three times more likely than non-Hispanic white children to have no usual source of care.3

Lack of coverage leads to diminished access to health care as well as possible serious illness and financial ruin.4,5 Nearly one third of Latinos in the United States had not seen a physician in the past year compared with 12% of blacks and 16% non-Hispanic whites.4 With the Latino population expected to double by 2025, this problem, if not addressed, will result in a dramatic increase in the number of uninsured Americans.4 Better understanding of the factors that cause such a high rate of uninsurance in this community is crucial to creating more appropriate and effective reform strategies.

US Census Bureau.  Health Insurance Coverage: 2001. Available at: http://www.census.gov/hhes/www/hlthin01.html. Accessed November 10, 2002.
US Census Bureau.  National Population Estimates. Available at: http://www.census.gov/Press-Release/www/2003/cb03-16.html. Accessed January 25, 2003.
Brown R, Ojeda V, Wyn R, Levan R. Racial and Ethnic Disparities in Access to Health Insurance and Health CareLos Angeles, Calif: UCLA Center for Health Policy Research; 2000.
Quinn K. Working Without Benefits: The Health Insurance Crisis Confronting Hispanic AmericansPublication 370. New York, NY: The Commonwealth Fund, Task Force on the Future of Health Insurance for Working Americans; 2000. Available at: http://www.cmwf.org/. Accessed November 10, 2002.
Schur C, Feldman J. Running In Place: How Job Characteristics, Immigrant Status, and Family Structure Keep Hispanics UninsuredPublication 453. New York, NY: The Commonwealth Fund; 2001. Available at: http://www.cmwf.org/. Accessed November 10, 2002.
Luchon L, Schoen C, Simantov E, Davis K, An C. Listening to Workers: Findings From the Commonwealth Fund 1999 National Survey of Workers' Health InsurancePublication 362. New York, NY: The Commonwealth Fund; 2000. Available at: http://www.cmwf.org. Accessed January 25, 2003.
Guyer J, Mann C. Employed but Not Insured: A State-by-State Analysis of the Number of Low-Income Working Parents Who Lack Health Insurance. Washington, DC: Center on Budget and Policy Priorities; 1999.
US General Accounting Office (GAO).  Medicaid: Demographics of Nonenrolled Children Suggest State Outreach StrategiesPublication GAO/HEHS-98-93. Available at: http://www.gao.gov/. Accessed January 25, 2003.