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The Surgeon General's T-O-D-O-S Report

Access to Health Care Preamble

The Hispanic/Latino population is composed of individuals and families of multiple national origins, some of which date back to the 1600's. The vast majority of Hispanics/Latinos live in large urban centers; however, included in this population are rural residents and migrant and seasonal workers, as well as those who are undocumented. Despite having the highest rate of labor force participation of all U.S. population groups, Hispanics/Latinos are the poorest minority group living in the United States today, and more than one-third of the population is uninsured. Not only do they lack accessible, affordable, available, affable, and portable health care, but they also are severely underrepresented in ownership of health-related enterprises.

Because of the great diversity of Hispanic/Latino populations, to address the needs of this group, national health reform must allow States to meet the national goals and standards of universal coverage and quality health care in creative and different ways. The Federal Government should facilitate any processes that allow States to select and craft their own administrative and insurance entities.


  1. Lack of comprehensive and portable health care coverage for Hispanics/Latinos.
  2. Underrepresentation of Hispanics/Latinos in leadership positions during critical phases of local, State, and national budgetary and programmatic planning activities.
  3. Lack of adequate and available health care service delivery systems and infrastructure to address primary, secondary, and tertiary health care needs of the diverse Hispanic/Latino population groups.
  4. Lack of accessible and adequate health care facilities because of financial and nonfinancial barriers in Hispanic/Latino communities.

Summary of Key Strategies

  1. Provide for Hispanic/Latino participation in the development and implementation of a national health care system that ensures universal access to all persons living in the United States, the Commonwealth of Puerto Rico, and U.S. territories.
  2. Increase Hispanic/Latino representation at all levels of the public health and health policy leadership pool and workforce.
  3. Ensure Hispanic/Latino participation in the planning, design, staffing, evaluation, and ownership of public health and health care infrastructure to ensure that it serves community needs.
  4. Eliminate all financial, cultural, language, age, belief, or gender barriers to health care.

Specific Strategies

Key audiences: Local, State, and Federal administrators and officials; Hispanic/Latino communities; and the media.

A. Provide Universal Health Care for All Americans

Develop a universal health care system that--

  • Is affordable, accessible, available, acceptable, affable, and portable.
  • Offers a basic package of services that includes health promotion and disease prevention.
  • Gives a choice of providers.
  • Allows for a regular source of such care and facilitates continuity of care.
  • Integrates systems of care: combines public health, community health, and private providers.
  • Strives for innovative health care financing that spreads the burden across all sectors of society.
  • Ensures coverage eligibility regardless of U.S. residency and employment status (does not exclude undocumented persons).
  • Offers easy enrollment and service procedures that facilitate participation.
  • Provides measures of cost containment, quality assurance, improved efficiency, and accountability to service recipients.
  • Allows service recipients and all providers, including "safety net providers," to participate in the governance of plans.
  • Offers rewards for providing services to undeserved and unserved populations.
  • Provides incentives for coverage of preventive services.
  • Enforces uniform procedures for reimbursement while recognizing differences by region and geography.
  • Provides outreach activities to increase awareness and use of available programs.
  • Is culturally competent and linguistically appropriate.
  • Addresses other needs specific to the Hispanic/Latino population (e.g., respite care, long-term care, transportation, child care, and other support services).
  • Does not exclude persons with preexisting illness and conditions.
  • Establishes health advocacy coalitions of public and private providers and consumers in Puerto Rico and in each State with significant Hispanic/Latino populations to review programs and develop recommendations annually.
  • Establishes a methodology for accurately estimating the cost of universal coverage.

Representation and Communication

  • Develop a mass media marketing plan that informs the public about how to gain access to and properly utilize health and related services. This plan should target Spanish-speaking and bilingual Hispanics, especially in areas where little or no information is available. (State and local)
  • Include Hispanic/Latino representation in the development of outreach and public information campaigns, including television, radio, and the print media.


  • Allow for cultural and regional differences in clinical and administrative measurements. What may be appropriate for one ethnic community or region may not be appropriate for others.
  • Make client surveys, chart pulls, and nonmedical content of care components of quality measurement.
  • Measure quality of care in terms of the bicultural and bilingual competency of staff. Capacity to serve in a culturally competent manner must be demonstrated. This competency should be addressed as part of any contracting process.
  • Emphasize preventive and primary services in quality measurement. Standardization of tracking and data systems is needed and should be oriented toward periodic and preventive care that is age-appropriate.
  • Include a cultural index of accessibility to care as part of quality measurements and requirements. Financial resources must be made available to those entities that need infrastructure development to meet this requirement.
  • Strengthen the public health capacity for surveillance, assurance, and policy and planning.
  • Develop plan coverage information in the language of the population and adapt it culturally as necessary. Member services should also have language-proficient representatives to serve individuals. Representatives should be required to provide outreach to job sites, social service centers, and other locations where these populations congregate.
  • Require health care plans to provide physicians and other providers who have a minimum of 24 hours of training in cultural competency.
  • Require States to develop certification components for interpreters to serve undeserved populations.

Provide a health benefit package that includes the following:

  • Primary care and preventive services, including mental health services, immunizations, periodic screening, health education, a full range of reproductive health services, comprehensive perinatal care, and outpatient medical care. (Local)
  • In-patient hospital care and alternatives to hospitalization, including skilled home health services. (State and local)
  • Emergency services, including emergency transportation. (Local)
  • Social services.
  • Dental services. (Local)
  • In-patient and out-patient drug and alcohol abuse prevention, treatment, and rehabilitation. (State and local)
  • In-patient and out-patient rehabilitation services (physical, occupational, and vocational therapy).
  • In-patient and out-patient mental health services.
  • Case management, including psychosocial support services.
  • Nutrition counseling.
  • Prescription drugs.
  • Vision and hearing services.
  • Long-term care and alternatives to long-term care, including case management, in-home support services, hospice, and adult day health care.
  • Transportation for health care visits.

Structure a financing package that distributes cost equitably according to ability to pay, stressing progressive financing schemes, cost-effective delivery systems, and infrastructure development for special populations:

  • Shared payment responsibility between employers and employees.
  • Government subsidies for small businesses.
  • Information safeguards for undocumented workers in an employment-based system.
  • Simultaneous reform of medical malpractice, the tort system, and workers' compensation.
  • Incorporation of Medicaid, CHAMPUS, and private and public employer-based health care payment systems, as needed.
  • Focus on progressive taxes with strong consideration of alcohol and tobacco taxes and with recognition that additional funds will be needed.
  • Consideration of equalization of reimbursement regardless of the individual.
  • Maintenance and equalization of efforts in terms of State government financial commitments.
  • Recognition of special financing needs of special populations.
  • Systemic incentives for cost-effective health care system approaches.
  • Conduct needs assessment of health coverage at the local level, where needed.
  • Increase the participation of representatives of diverse segments of the Hispanic/Latino population, including grassroots leaders, in decision-making processes regarding health care service delivery.
  • Standardize and streamline administrative forms required to be completed by patients and providers. Reallocate the saved human and fiscal resources to service delivery.
  • Enhance the health care infrastructure that services Hispanic/Latino populations. Funds should be earmarked specifically to develop local community-based primary care facilities and service network associations. The financial authority should fund community-based infrastructure development projects operated and managed by minority-owned and/or managed corporations and organizations.
  • Include "safety net" providers-- primary care clinics, traditional providers, and public health providers-- in the health care system. The system must have representative governance and community involvement.

Public-Private Partnerships

  • Direct the agencies within PHS to implement programs to foster establishment of public-private partnerships that improve and increase delivery of health care services for Hispanics/Latinos in all regions.


  • Support the development of community advisory boards to evaluate community grievances, provide feedback, address quality issues, and influence community empowerment. Secure funding to provide health leadership training at the grassroots level to ensure community empowerment.


  • Enact Federal legislation to include coverage for the uninsured and the undocumented as part of health care reform.
  • Provide a benefits package that is universal, whether the recipient gains access to care through employer-based coverage or is unemployed, undocumented, or a Medicaid recipient.
  • Enhance the health care infrastructure and provide funds for the construction of health facilities in Hispanic/Latino communities.
  • Reformulate the criteria for appointing physicians and other health providers to health professional shortage areas (HPSAs).
  • Create community-based health training centers that provide both training and job opportunities.
  • Reformulate the criteria for Federal designation of medically undeserved areas to accurately reflect the ethnic, demographic, and cultural characteristics of the communities served.
  • Fund pilot projects that explore alternative primary health care financing and delivery systems (analogous to Centers for Medicare and Medicaid Services's SHMO demonstrations).

B. Provide Accessible Health Care and Workmen's Compensation for the Farmworker Population

Farmworkers are the most underserved of all groups. Because 3 to 5 million of them are Hispanic/Latino, a special emphasis is required to address their health needs.


  • Foster and reward networking through technical assistance and remove bureaucratic barriers, such as categorical funding that limits care for patients with multiple needs because of separate tracking of services by fund source. All existing efforts to integrate and coordinate health, education, and social services should be mandated. (Federal)
  • Guarantee the participation of Medicaid-eligible farmworkers in the PHS329 program and identify alternate funding resources for others not eligible. Include case management as a mandatory reimbursable service for farmworkers. (State)
  • Require companies that hire migrant workers to provide access to health care facilities. (Federal)
  • Recognize that environmental factors -- such as nonexistent or inadequate housing, lack of alcohol and drug abuse programs and mental health services, and the failure of implementation of occupational and environmental regulations -- play a significant role in the health of the migrant farmworker, the family, and the community as a whole.


  • Provide funding for standardized data collection procedures and continuous analysis and reporting to provide a base for advocacy for future funding.


  • Provide funding for standardized data collection procedures and continuous analysis and reporting to provide a base for advocacy for future funding.


  • Federalize the Medicaid Program, eliminating the conflicting State eligibility criteria and varying reimbursement rates. Establish a national set-aside of funds to cover farmworkers. (Federal)
  • Under the PHS329 services, expand farmworker eligibility for Medicaid to all farmworkers. (State)
  • Establish national guidelines for farmworkers' coverage under the States' worker's compensation laws, thereby guaranteeing full and unrestricted access to rehabilitating and financial compensating services by those suffering accidents and diseases contracted in the performance of their jobs.

Include the following features in the demonstration projects:

  • Simplification of all farmworker eligibility processes.
  • Recertification of farmworkers on the basis of annual or semiannual income, not month-to- month earnings.
  • Recognition of all farmworkers' eligibility.
  • Clarification of payor reimbursement rates and eligibility standards, regardless of the origin of eligibility or site of service delivery.
  • Assurance of access to all primary care services on a timely basis.
  • Provision of funding for primary care research, including psychosocial and mental health services.

Table of Contents

Content Last Modified: 3/17/2006 2:41:00 PM
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