By DIANNE SOLÍS / The Dallas Morning News and JUDITH TORREA / Al Día
 
María and Eusebio García, factory and grocery workers, straddle two medical systems – one Mexican and cheap, another American and costly.

That health care hybrid provides dentistry and flu medicine in Monterrey, Mexico, and heart surgeries in the United States for their 8-year-old daughter, Amy. With a combined income of just over $45,000, the Duncanville residents now make too much money to qualify their two daughters and one son for Texas' medical insurance program for children.

"If you don't do it this way, how?" asks Mrs. García, a naturalized U.S. citizen, as she fingers a packet of ampicillin from Mexico.

Consider the Garcías survivors of America's health care crisis. The family is part of a huge American demographic swell: Hispanics who lack health insurance or are underinsured. About one in three Latinos in the United States lacks such insurance – the highest rate of any racial and ethnic group.

Insurance companies, mindful of the expected growth in the Latino population, are beginning to take notice. They're providing such services as health care promoters, Web sites and dedicated hotlines in Spanish.

But other insurers remain surprisingly indifferent. In the meantime, health care costs for Hispanics have continued to rise. In 2002, the costs jumped nearly 10 percent, representing the largest increase in more than a decade.

To be sure, the high cost of insurance is affecting all Americans. About 43.6 million people in the United States, or about 15 percent of the population, were uninsured in 2002, according to the U.S. Census Bureau.

But Latinos are hardest hit for a variety of reasons, experts say. Lower incomes aggravate the problem. Many tend to work for smaller companies that are less likely to offer insurance.

With such a large number of foreign-born Latinos – fully 40 percent – there are language issues and health care customs that make seeking catastrophic care, rather than preventive care, the norm, some experts say.

Another problem is that the product selection is just wrong, says Dr. David E. Hayes-Bautista, professor of medicine and director of the Center for the Study of Latino Health at the University of California at Los Angeles. The health care industry is where the food industry was 20 years ago, Dr. Hayes-Bautista says.

"There's an awareness that there is a growing population out there that can grow further, but they still aren't sure whether they will switch from ketchup to salsa," he says.

Focusing on prevention

For example, Blue Cross Blue Shield of Texas and UnitedHealthCare Group don't operate Spanish-language Web sites. Lumenos Inc. has one Spanish-speaking customer agent, a spokeswoman for the company says. And Lumenos and Blue Cross Blue Shield translate certain materials into Spanish.
Others have been more aggressive.

Aetna Inc. recently launched a health education program in Spanish, says spokeswoman Margaret Jarvis.

At Aetna, the nation's second-largest health insurance company, product changes for the Latino community include the use of promotoras, or health care promoters, a common practice in Mexico.

In addition, Aetna funds community health care education programs through its foundation.

On a recent Thursday morning, the foundation money was at work in the basement health clinic of the Grace United Methodist Church in Old East Dallas, where patients began arriving a full hour before the clinic doors opened. The facility overflowed with patients whose conditions were so severe that it seemed more like a hospital emergency room.

Among them was a 75-year-old man who had advanced diabetes. Sitting in a metal chair looking exhausted, the blind man was supported by a cane, two daughters and a boisterous grandchild.

"We're the daughters, and we are trying to take care of him," says one daughter, who asked that her family's identities not be disclosed because they are undocumented immigrants.

Nearby, Silvia Gallegos, the diabetes program coordinator for the Dallas Concilio of Hispanic Service Organizations, explained to the crowd where to find classes on controlling diabetes, a disease especially prevalent among Latinos. The diabetes program is funded by Aetna.

Preventing disease is paramount, says Celia Carbajal, Aetna's director of emerging markets for the Southwest and western United States. "We need to educate them, especially the Mexican immigrants, that in America, the health care system is based on prevention," Ms. Carbajal says. "It is a dual system, and they need to do their part."

Aetna also has a 24-hour dedicated hotline for the Spanish-speaking, as well as the capability to provide clients with phone assistance in more than a dozen other languages. Its DocFind feature provides consumers with information on which medical providers speak Spanish.

Latino health risks

Ms. Carbajal says some Latinos are less likely to have insurance because they are used to catastrophic care in their homelands. In other words, they only get care when they are sick.
"They find it very hard to pay $43 a month for something that they don't use," Ms. Carbajal says. "We tell them, 'Don't wait until you get sick, because it will cost you more, and it will tax your whole body.' "

At PacifiCare Health Systems Inc., the insurance provider targets the Latino community with a Spanish-language Web site and an interactive CD called Evalúe Su Salud. It allows the viewer to evaluate the health risks most common to Latinos: smoking, diabetes, heart disease and depression.

Forty bilingual customer service agents staff a consumer hotline. Through its foundation, PacifiCare launched a scholarship program for Spanish-speakers entering the health care field.

"We recognize how large the Hispanic population base is and want to better serve it and retain it," says Russell A. Bennett, vice president for Latino Health Solutions at PacifiCare. "And we want to acquire new members.

"It is not just that we have products for Hispanics," says Mr. Bennett, who lived in Mexico for 30 years. "We have begun the transformation of the entire company to serve Hispanics."

About 20 percent of PacifiCare's 3 million customers are Hispanic, and about 22 percent of PacifiCare's employees are Hispanic, Mr. Bennett notes.

Small-business woes

Large companies generally pick up bigger portions of health coverage, reducing monthly premiums to $150 to $200 for an employee, spouse and family. But that isn't true among small-business owners, who say they're being bloodied by health care costs that race far ahead of inflation.
That's caused many of the nation's 23 million small businesses to boost deductibles, co-payments and premiums. Some small businesses are now insuring their employees only.

Garry Castro, CEO of a trucking company called Logisticorp, is evaluating what he can afford to offer his workforce, which will soon expand to 65 people. A heart attack or problem pregnancy can spike the "risk factor" for an insurance company and eat into his operating budget for the year, Mr. Castro says.

"I can make an arbitrary decision that I am going to pay X percentage, then costs go up, and then I am impacted by $50,000," Mr. Castro says. "It is almost unaffordable for small companies to offer decent health care."

Restaurateur Tom Landis offers health insurance to the 50 employees at his Texadelphia restaurants. But some employees simply reject the $30 monthly premium because they can't see the immediate benefit, he says.

"When it comes down to someone making $15,000 or $18,000 a year, this is a huge issue," Mr. Landis says.

And a 2002 study by insurance and consulting firm Marsh & McLennan Cos. found that health coverage was offered by only 62 percent of employers with fewer than 50 employees, down from 66 percent the previous year.

The high costs

Felipe Korzenny has made a career of the art of marketing, especially to the Latino community.
But of health care, "costs are simply too high," says Mr. Korzenny, a communications professor at Florida State University. "That is why many Hispanic consumers go without insurance, or when they get sick, they go back to Mexico, or they go to a doc-in-the-box, or they go to an emergency room or a public assistance clinic."

Dallas resident Berta Vázquez has never had U.S. health insurance. Ironically, the 67-year-old works as a caretaker for an elderly man. On Wednesday, she was seeking medical attention at Parkland Hospital for joint pain that keeps her from sleeping at night.

"In the United States, you work so hard, and in the end you have nothing," she says. "If you start out poor, you stay poor."

Even if she had an opportunity to get insurance from her employer, she couldn't afford the monthly premiums because money is so tight, she says.

She now cares for her adult son, who injured his back on the job. An adult daughter has just moved in with her after losing a job because her own health problems led to work absences.

Meantime, the García family in Duncanville is weighing the options. The three children were dropped from the state Children's Health Insurance Program, known as CHIP. Nearly 100,000 children, or about a fifth of enrollees, have lost benefits in recent months.

Self-insurance is one option until Mrs. García can place the children on her insurance plan near the end of the year. But the Garcías say they can barely make ends meet now with their house and car payments and three children.

"I want stable insurance at a rate that is fair," she says. And she won't quit her job so the family could qualify for Medicaid, the federal insurance program for the poor.

"I want to work; I don't want to be lazy," Mrs. García says.

In the interim, Mrs. García carries with her a carefully folded, two-page medical history in Spanish and English about the efforts to repair her daughter's heart valve – in case of an accident. The doctor's narrative about Amy begins: "Amy has only one instead of two pumping chambers in the heart ..."