Robert Wood Johnson Foundation Center for HealthPolicyWORKING PAPERThis paper is one of a series of working papers, reporting researchsupported by a Seed Money Grant from the Robert Wood JohnsonFoundation Center for Health Policy at the University of New Mexico.The Center invites comments and recommendations for revision of thispaper prior to publication.Please address all correspondence to Gabe Sanchez, corresponding author, [email protected]

RWJF Center Working Paper Series2008.WP002.Sanchez2

The Impact of Ethnicity on Attitudes Toward Health Care Reform in New MexicoGabriel R. Sanchez *Department of Political ScienceAmy Sue GoodinThe Institute for Public PolicyAmelia A. RouseThe Institute for Public PolicyRichard SantosDepartment of EconomicsThe University of New Mexico* Direct correspondence to Gabriel R. Sanchez, Department of Political Science,University of New Mexico, Albuquerque, NM 87131, (505) 277-3337([email protected]).Paper Prepared for Submission to Social Science QuarterlyWe would like to thank the Robert Wood Johnson Foundation Center for Health Policy at the University ofNew Mexico for supporting this research http://rwjf.unm.eduRWJF Center Working Paper Series2008.WP002.Sanchez3

AbstractObjectives. Latinos tend to have significantly lower levels of access to general and topquality medical care than do non-Latino whites, and although disparities in access tohealth care have diminished for all other minority groups over time, they have widenedfor Latinos. Given these trends the current attempts to provide universal health care atboth the national and state levels across the United States have large implications to thehealth status of Latinos. The objective of this analysis is to determine whether Latinoshave different attitudes regarding health reform than non-Latino whites. Methods. Ourdata are from a state-wide random digit dialing telephone survey of New Mexicoresidents, age 18 and older, conducted in the Fall of 2007. With an Hispanic population of44% and on-going health care reform efforts by the state legislature, New Mexico is anideal location for this analysis. Results. After controlling for a host of individual levelfactors, our findings suggest that while Latinos are less likely to identify health care as asalient state issue, they are more likely than non-Latino whites to believe affordablehealth care programs are important, less likely to believe that individuals are responsiblefor assuring coverage for everyone, and more likely to support extending health coverageto undocumented immigrants.RWJF Center Working Paper Series2008.WP002.Sanchez4

Introduction: The Health Status of the Latino PopulationIn the past decade, the Latino population has become the largest minority group inthe United States.1 According to recent census polls, over 40 million Latinos currentlylive in the United States, which represents 14.5 percent of the total U.S. population (PewHispanic Center, 2006). As the Latino population continues to grow, however, there hasbeen a growing concern for health care disparities facing this community among scholarsand policy makers alike. Latinos tend to have much less access to both general and topquality medical care than do non-Latino whites, and although disparities in access tohealth care have diminished for all other minority groups, they have widened for Latinos.Specifically, researchers at the U.S. Department of Health and Human Services notewidening disparities between Latinos and Anglos in the following areas: diabetes carequality, higher rates of HIV/AIDS cases for Latinos, longer and more frequent delays inillness/injury care for Latino patients, and less access to mental health treatment forLatinos (National Alliance for Hispanic Health 2006). Further, Latinos receive fewermammograms, Papanicolaou tests, and influenza vaccinations, less prenatal care, fewercardiovascular procedures, and less analgesia for metastatic cancer, trauma, andchildbirth (Collins and Neauhaus 1999; Carlilse, Leake, and Shapiro 1995; Cleeland,Gonin, and Beaz et al. 1997; Todd, Samaroo, and Hoffman 1993; Hueston, McClaflin,Mansfield, and Rudy. 1994).Much of the disparity is the result of lower insurance rates for Latinos. In fact,Latinos currently maintain the highest levels of uninsured rates in comparison to nonLatino whites, African Americans, Asian/Pacific Islanders, and American Indian/Alaskannatives (James, Thomas, Lilli-Blanton, and Garfield 2007). Latino access to employmentbased health insurance (EBHI) is also lower than among other ethnic groups and has beenin a state of decline in the past decade (Cooper and Schone 1997). Approximately 34percent of non-elderly Latinos are without health coverage, 23 percent rely on Medicaidor other public provisions, and 3 percent on individual coverage (James, Thomas, LilliBlanton, and Garfield 2007). To explain disparities in health coverage, Greenwald,O'Keefe, and DiCamillo (2005) find that the most prominent factors contributing toworking Latinos' lack of health insurance are the combination of low income and highcosts of health insurance, absence of or ineligibility for a health plan at work, birthoutside the United States, and recent immigration (see also Eberhardt, Ingram, Makuc,Pamuck, and Fried, 2001; Short, Monheit, and Beauregard, 1989).2Given the racial and ethnic disparities in health insurance the health problems thatLatinos face are exasperated. Consequently, the rapidly growing Latino population has1We use Latino and Hispanic interchangeably throughout the analysis.Two of the most traditional explanations of health care disparities in the United States are lack of healthinsurance and low socio-economic status-both critical for Latinos. For example, researchers find thatinsurance coverage is the key to understanding access to mental health care (Frieman and Cunningham) andaccess to the use of primary care (Waidman and Rajan 2000; Weinick Zuvakas, and Cohen 2000). Othersfind that lower levels of education, occupational status, and education are associated with having lessaccess to health care (Leake, 1998; Zuvekas and Taliaferro, 2003). Finally, studies have also demonstrated asignificant causal association between language and disparities in health care access (Scheffler and Miller1989; Derose and Baker 2000; Weinack and Kraus 2000; Fiscell, Franks, Doescher, and Saver 2002).2RWJF Center Working Paper Series2008.WP002.Sanchez5

been exposed to a wide variety of serious health problems since the 1980s (see Klitch1991). The leading cause of death for Latinos of all ages is cardiovascular disease(Alcalay, Alvarado, Blcazar, Neman and Huerta 1999). Cardiovascular disease is highlycorrelated with many other illnesses associated with Latinos, mainly diabetes. Forexample, the American Diabetes Association has documented that the prevalence of type2 diabetes is 1.5 times higher in Latinos than non-Latino whites and that two million or8.2 percent of all Latino Americans aged 20 years or older have diabetes. Further, theLatino age-adjusted death rate of 18.8 per 100,000 population due to diabetes is nearly 64percent higher than non-Hispanic white rate of 11.5. In addition to diabetes, the Latinodeath rate due to HIV/AIDS is 16.3 per 100,000 population, more than twice the nonHispanic white rate of 6 (Hayes and David 2002).Given the significant health issues Latinos face it would be reasonable to assumethat health plays a major role in Latino political behavior. However, this question hasbeen virtually ignored by scholars to this point interested in the Latino community. Weintend to shed some light on this topic by examining whether ethnicity impacts theattitudes of New Mexicans regarding health care across several dimensions. Specifically,we test the relationship between ethnicity and health policy salience by analyzing theextent to which Latinos indicate that health care is an important issue relative to otherpolicy areas (education, Iraq War etc.), and the extent to which Latinos believe providingaffordable health care is important relative to non-Latinos. We explore health policyattitudes further by exploring the potential impact of ethnicity on perceptions of who isresponsible for assuring everyone in New Mexico has access to health coverage, as wellas support for extending access to specific segments of the population, includingundocumented immigrants.We test these questions with a statewide survey of New Mexico residents focusedspecifically on health care and policy attitudes. Given the major disparities in health carewithin the state of New Mexico and the current health care reform efforts of the statelegislature there, New Mexico is an ideal locale for our investigation of the role ofethnicity in health care attitudes. We feel that this study provides a critical first steptowards understanding the relationship between Latinos and health care in the UnitedStates by allowing for a direct comparison between the attitudes of Latinos and nonLatino whites regarding health policy.The Salience of Health in New MexicoHealth care reform is currently a salient policy issue nationally and particularly sowithin the state of New Mexico. For example, several 2008 presidential candidates,including Senators Barack Obama (D-IL), Hillary Clinton (D-NY), and John Edwards(D-Va) are strong proponents of universal health care coverage, and incorporated thisissue in their respective presidential platforms. As early as 2006, Governor BillRichardson (D-NM), another early presidential candidate, proposed a plan that wouldinsure 59,000 low-income adults in New Mexico –about 15 percent of the population(Heil 2006). Health coverage reform is of particular importance to New Mexico, as thisstate has the second highest rate of uninsured adults and children (22%) in the nationRWJF Center Working Paper Series2008.WP002.Sanchez6

(Kaiser Family Foundation, 2007). Other studies suggest that the uninsured represent aneven greater portion of New Mexico residents when partial coverage is considered. Forexample the Mathematica policy report indicates that 185,000 (11%) New Mexicans areuninsured throughout the year, with approximately 46 percent of New Mexicans onlyhaving partial coverage--going without insurance coverage for part of the year (Chollet etal. 2007). The report also highlights how critical this policy issue is to the youth of thestate, as approximately 70 percent of children in the state were estimated to have lostinsurance coverage for at least part of the year in 2006.This uninsured trend has contributed to other negative health outcomes in the stateof New Mexico. Diabetes is particularly pervasive in New Mexico, as the state’s deathrate due to diabetes is higher than the national average. Approximately 1 of every 11 NewMexicans has diabetes, with diabetes treatment and prevention costing the state over 1billion annually (NM, D.O.H.). The impact of diabetes is particularly harsh for racial andethnic communities, with American Indians being three times more likely to have thedisease, and Latino and African Americans twice as likely as whites. Racial and ethnicdisparity within the state of New Mexico is unfortunately not confined to diabetes. Forexample a recent report completed by the New Mexico Department of Health entitled“Racial and Ethnic Health Disparities Report Card” (1997) found large disparities inobesity, prenatal care, motor vehicle death rates, and alcohol related deaths – wheredisparity rates for Latinos led to a C grade.As a result of these pervasive health issues within the state, Governor Richardsonmade health care reform the primary initiative of his ambitious 2008 legislative agenda.The largest substantive changes to the state’s current health care system included inRichardson’s plan are to require New Mexicans to have health insurance, and to requireemployers to contribute to a fund to help pay for it (Baker, 2008). In its regular 30-daysession that ended Feb. 14, 2008 the Legislature first gutted then killed Richardson’sreform plan due to budget considerations, strong opposition from the businesscommunity, and a general desire to conduct further study on the potential impact of theplan before enactment. Richardson has recently indicated that he plans to call a specialsession of the legislature over the summer of 2008 to achieve health care reform in NewMexico.Latino Public Opinion Toward Health PolicyRelative to Americans generally, we know very little about the political opinionsof the Latino community in the United States. This is a result of a general disinterest inthe attitudes and opinions of Latinos prior to the late 1980’s (de la Garza 1987). Althoughrecent advances in survey data with significant samples of Latinos has greatly improvedour knowledge of Latino public opinion, Latino’s attitudes toward health policy remainsunderstudied. This analysis is an effort to contribute to the growing knowledge of Latinopublic opinion by investigating whether the attitudes of Latinos regarding health carediffer in meaningful ways from non-Latino whites.RWJF Center Working Paper Series2008.WP002.Sanchez7

The first survey focused on the political attitudes of Latinos was not conducteduntil 1979, and that data only included Latinos of Mexican origin (Arce 1979). Despitethis obvious obstacle, scholars of Latino politics have generated some important insightsin the area of Latino public opinion. For example, research has indicated that Latinosgenerally support an activist government that protects minority civil rights and providesopportunities for individual citizens and minority groups (Martinez 2000). There is alsoevidence that Latinos are willing to pay higher taxes in order to provide for policies thatthey support. For example, the Latino National Political Survey (de la Garza et al. 19891990) indicated that 80 percent of Mexican Americans, 87 percent of Puerto Ricans, and89 percent of Cuban Americans support bilingual education, with