 I want to thank UTSA for hosting us today. It's great to be here on this campus. And thank President Ricardo Arumo. Thank you very much for hosting us. I also want to thank Burt Marshall with Blue Cross Blue Shield and others who helped make this event possible. Albert Carzales, Elvira Yacaz, and James Perego. Thank you very much for all your help with this. We have one more event in this health series we're doing with Blue Cross Blue Shield. It's November 1st at Rice University at the Baker Institute. So if you're ready for a road trip, please join us over there. Also all of our events including the August 27th health event we did, today's event and the Baker Institute one, will be, the video will be available online on our site, TexasTribune.org, in the next day or so. So if you missed anything, you want to go back and review, check there. If you enjoy events like this, please consider joining us in Austin at the end of the month for the Texas Tribune Festival. This is what we call Woodstock for Wonks. So it's nine tracks, three days, about 150 speakers, as well as walking tours of the Watergate Papers at the Ransom Center, the Texas State Cemetery, and even maybe a UT marching band making an appearance. So tickets for that are available. The prices go up tomorrow. So if you want to get your tickets today is a good day for it. It's $160 now. Tomorrow it goes up to $195. Speaking of joining the Tribune, if you're not a member of the Texas Tribune, please see Natalie Chote at the table out in the lobby. She'll be glad to tell you all about us. We're a non-profit, non-partisan news organization, and we rely on members like you to make events like this possible. Other things are, if you have your cell phones, please make sure they're on silent. So your folks calling you don't disrupt the program. But if you are tweeting or taking pictures, please use the hashtag TRIBLIVE for this. We'd love to do that and get people out here to see what we're doing. The format today is we're going to have one hour of discussion that Becca will moderate and then 15 to 20 minutes of questions from the audience at the end. So with all that done, I'd like to turn it over to Becca Aronson, my colleague at the Tribune who's moderating today's panel. Hi, everyone. Thank you for joining us today. And I hope to see you later this month at our festival. Today we're going to be talking about the future of Latino health care. As you probably know, within the next decade, Texas is likely to become a majority Hispanic state. And already 50% of our youth are Hispanic. So this is going to have a really big impact on health care. And here to talk with us today are Dr. Estaman Lopez, the regional president of the San Antonio region for Blue Cross Blue Shield. He oversees 310,000 members and is dual certified in internal medicine and pediatrics. We also have Dr. Amelie Ramirez. She is a professor and director of the Institute for Health Promotion Research at the UT Health Science Center here in San Antonio. She has 30 years of experience researching Latino health care, such as genetic predispositions to cancer and disease prevention. Also we have Democratic state senator, Leticia Vanipute, who has two decades of experience serving in our state legislature and is also a pharmacist here in San Antonio. So before we talk about the future, let's start with the present. What are some of the health disparities that particularly affect the Latino community now? And why are these problems more prevalent within this community? Actually, I'd like to address that. We just completed a study through our Institute for Health Promotion Research looking at the 38 counties in South Texas and the two top concerns that we have are obesity and diabetes. And South Texas rates were higher than the rest of Texas and higher than the nation. So this is a reflection and as you well know, the further south we go, the larger the Hispanic population. And one of the things I'm concerned about is that oftentimes not all Latino populations are represented in some of the data that we have available nationally, but at the same time I keep reminding people that two-thirds of that population are Mexican-Americans. So these are some things that we really need to be looking at and developing programs that really began to address this issue. And recently there was a study on what makes a city healthy and it's having more green spaces, it's really encouraging activities for families to be involved, getting the health care community involved in creating these kinds of changes. Then we also have unique cancers that are impacting our population, such as cervical cancer, but then we have liver, stomach, and gallbladder cancers. We don't have really good treatments available for those and those are on the rise. Again, they're higher in South Texas compared to Texas and compared to the nation. So these are things that are all related to obesity as well, so that we really need to take a more concerted effort in that area. Absolutely. I'm so pleased to be here on the west side of San Antonio. I started my career 10 years ago down the street at the Texas Diabetes Institute. And of course in that practice that I had 10 years ago we saw disproportionate amount of comorbidities with folks with diabetes. And it's true today that the comorbidities and the death rate within the Latino population are disproportionate from the non-Latino population or specifically the Anglo population in the state of Texas and across the country. And to Dr. Ramirez's points, two-thirds of Latinos in the nation are of Mexican descent. And so specifically here in South Texas we have to focus on the needs of this population to be able to close that gap with disproportionate comorbidity and death specifically with regards to diabetes specifically with regards to obesity and the various cancers. Even though the overall cancer rate among Latinos is low we want to continue that positive trend but we're seeing some very disturbing trends with regards to obesity related cancers. So why is obesity and diabetes, why are these diseases more prevalent in Latino communities and other demographics? One of the things that we're seeing are really lower socioeconomic levels, less access to health insurance, less access to preventive care, and lower education. And we find that individuals who tend to have a lower education less than high school are more likely to be obese nationwide. And this is recently in a report that came out in obesity. And so these are kinds of environmental areas where we need to change and we need to really think more proactively about how can our communities create more walking spaces, more parks and recreations for our kids to come out and play. Well I think what I'm most alarmed at is how public policy and the lack of insurance really increases those mortality numbers and particularly the morbidity, the bad outcomes. When Latinos are the highest group with no insurance, that preventive care which is accessible in, for example, non-Hispanic whites that things would be taken care of early on are not available. And so while I understand the statistics and yes, it is diabetes, it is obesity, it is... that is a very alarming problem. The fact that Latinas contract cervical cancer at twice the rate than non-Hispanic white women is very alarming and maybe there is that correlation. But I also know if you don't have any money to go get your yearly pap smear, if the state has cut off basic access to the women's health program, if you're on Medicaid and we're one of the very few states that cuts off Medicaid 60 days postpartum. 60 days after the birth of the baby. That access is critical to help prevent some of those problems. So I don't want to just blame it on my folks. I still practice pharmacy. I was working there yesterday at Davila Pharmacy. Not too far away from here. Less than about three minutes from here. And I think it's wrong for us to blame a lifestyle or the diet on the blame of the Latino population when in fact our main problem are poverty and lack of insurance. So let's talk a little bit more about this lack of insurance. Many people know Texas is the highest rate of uninsured information. But among the Latino community even though they're currently only about 40% of our population total, they're about 60% of uninsured. So they do make up the largest demographic group of uninsured. So what impact this has on the amount of access to health services? If I may, 60% is a huge percentage of uninsured. 6.2 million uninsured in the state of Texas and 60% of those folks are Latino. That's why things like the Affordable Care Act play such an important role within the Latino community because the Latinos are the most benefit in terms of access to care at an affordable price. I think that's, if we're talking about the future, that's part of the solution of getting folks the care that they need. I still practice and I practice in the emergency department. And I see so many Latino patients I practice on the southwest side of town at Southwest General and I practice down in the Rio Grande Valley in Edinburgh. And the bulk of my patients are Latinos and over and over I see folks that I may diagnose in the emergency department and diagnose with a cancer or something similar and sending them home with no good follow-up because they don't have insurance to get access to the oncologist and sometimes there's some challenges with the safety net within the communities that they live. So the lack of insurance is part of the problem but now with the Affordable Care Act and with implementation and open enrollment beginning October 1st it's an opportunity to deal with that issue and getting the information out to Latinos in our communities across the state is so important. The other thing is the Affordable Care Act is a wonderful opportunity but we need to get our community enrolled. We need to educate them about what it is, what it's going to offer and the importance of coming in for preventive screening because if you just mentioned our population is used to more urgent care because they haven't had the insurance so we really need this concerted effort of public education informing them of what it is and the importance of it because they're still going to come in for that urgent care and that's what they're used to so it's going to take a while to change and we need to start early. I think one of the most disappointing policy decisions for our state was the Governor's decision not to take advantage of the expansion of Medicaid under the Affordable Care Act. On the low side our state numbers indicate about maybe 950,000 working adults would have been covered in that. On the high side Kaiser tells us Kaiser Permanente tells us that it's probably closer to 1.7 million working adults. What the Affordable Care Act did in its passage was saying that any adults with a family of four under the 138 percentile of poverty and people say well what does that mean? If you make 32,499 dollars a year there are so many Latino families that fit in that category and they are working that those folks would be covered by Medicaid expansion and really it's a misnomer to say it's a Medicaid expansion in fact so many states are going to the private market and enrolling those technical Medicaid expansion programs in the private market. What that decision did was very very difficult under the Affordable Care Act especially for Latinos who are working and who lacked that healthcare insurance. It is going to be difficult for our Latino population who also are small business owners because of the passage of the Affordable Care Act that was mandatory states had to expand it. The Supreme Court decision said they gave the states the ability to say no. Texas one of the few states that is saying no to that at a real cost I think to the people and to the Latino population you know it's no surprise that 20 some odd chambers of commerce throughout the state wrote resolutions to the legislature in favor of our hospital association and many of the groups because they understand the economics of this but what it means for Latino families is to have the security of knowing that you would have the ability to have a family doctor. That decision leaves us in the hole and affects Latino families more than any other policy decision that the state could have taken is to deny that healthcare coverage for at least a million working adults 60 some odd percent of those Latinos and at a cost to the state you know Medicaid gives us a match rate but this would have been for every dollar the state puts in $9 in federal funds and that's after the first three years feds would pick it up totally so basically our numbers were that the state could have spent $51 million to draw down $4 billion dollars in healthcare the majority of that would have gone to cover Latino working adults. Actually the Urban Institute I think had a study that showed 22% of Latinos won't be able to get health insurance some of the affordable care act because we didn't expand Medicaid you know this goes back to how they're actually accessing care right now I mean what are you seeing in the delivery of care to the Hispanic and Latino community now in terms of health insurance how do they access care? One of the places that they go to the emergency departments where I see them emergency departments a great place to get life-saving care if you're having a heart attack or stroke or some type of event like that but it's not a great place to get your diabetes managed or your hypertension managed or your cholesterol managed why because you're going to see a different doctor every time there's no good continuity of care so having access to a regular provider and again I'll come back to the affordable care act for the folks that will qualify for the affordable care act and to Dr. Ramirez's point getting the information out to them is so very important one of the things that we're doing is we have a grassroots campaign called We Cover Texas and in Spanish it's a Segurato Salud. It's a way that we are as an insurance company getting information out in a non-biased fashion we're not branding it to the Blue Cross Blue Shield logo it's going to benefit the insurers because we're going to get information out and they're going to pick the insurance that best meets their needs so I think having public-private partnerships or private partnerships with community organizations which we're doing across the state is so important in order to get the information out to the population. The other point I want to make is to Senator Vandeput's point it's not just about diet and lifestyle because when we look at the traditional Latino diet when we look at first immigrant like my parents who came from Mexico they tend to be healthier and as they assimilate we start seeing the challenges with health and so it really is as they start getting a more western diet or Americanized diet that we start seeing those challenges with obesity and things to that effect but you know my mother worked 8 hours a day she came home and cooked a full meal from scratch. I probably ate more burgers in a year than I ate in my entire childhood or more pizza in a year than I ate in my entire childhood as an adult and that is one of the things we want to continue to foster some of the challenges that we face in the communities that we're in are food deserts, areas where they don't have access, unsafe neighborhoods where they can't walk to a grocery store neighborhoods without sidewalks to Senator Vandeput's point earlier I think the issue is very complex and as we look at the demographics of our, for instance our physician community in the state we make up around 8.5% of the physicians in the state of Texas where 38% of the population for the last 10 years physicians have accounted for 10% of the medical students every year for the last 10 years have been Latino and that's kept steady so it really has increased with the percentage of our population I mean that's an important point not having Hispanic doctors to care for Latino patients because what are some of the cultural differences in the way the Latino community approaches healthcare just in general that Westernized doctors might understand when they're trying to communicate with that patient about what's going on with their health. One of the biggest problems obviously is the language barriers and just feeling comfortable with a person who looks like them and who speaks their language they're more likely to come and feel more comfortable there and to come back for repeated care and right now our system is still somewhat fragmented in that area you know we'll pull a nurse or we'll pull somebody else to help with translation services versus having more active translation services available but I wanted to go back to an earlier point when I see cancer patients come through our cancer centers there's lots of gaps in their care you know these are individuals with very devastating diseases and sometimes they get care links sometimes they don't you know and they're constantly in and out of what they qualify for and so utilizing patient navigation services is something that we have found very effective and helping them stay connected so they can get consistent care because as soon as they you know become unqualified for a type of health services they've got to go through all the paperwork all over again and helping you know having someone to help them navigate that system is critical. I think what's really different growing up in San Antonio and on San Antonio's west side I owned a pharmacy in San Antonio's west side and I still work as a pharmacist is understanding I think what is the biggest cultural difference is that healthcare decisions for Latinos are not individually made they are made with the family if you are talking to Senor Rodriguez one of my patients and I just use that as an example and you're visiting with him about the diabetes and compliance unless you have Mrs. Rodriguez in the room that's not going to work because she controls the household she controls what he eats and I think it's a very big cultural difference giving an example when I had a pharmacy the pharmaceutical representatives would come in and you know I had doctors offices and the waiting rooms were out and they thought oh my gosh what great business because there would be 35 people in the waiting rooms there's only 5 patients but you understand when Walita goes to the doctor I mean it's the daughter-in-law and you really have to understand because it's all about the conversation and about the prevention and I think that having someone who not only understands the language but understands the culture you get much better outcomes and unless you know that that's why our program are so strong and are very effective and that's why it's going to be very important in any roll out of the exchanges of the Affordable Care Act that the people that are actually giving the information understand who really makes the decisions in the household and I mean to this point you know what do you do to change our healthcare system to both you know be more understanding of these kind of cultural differences the way that might improve it for everyone and improve it specifically for the Latino community in the way that they can access care I mean I can give you an example from our company Blue Cross Blue Shield we hire bilingual bicultural customer service advocates that work with individual members we're hiring bilingual bicultural nurses we have folks at all levels of the company and we have initiatives in place specifically to address the needs of the Latino community not just from a language issue not just from the pamphlets that we develop but to how we may work with them over the phone making sure that the information is culturally relevant to the population that we're serving and it might be culturally relevant in a way for south Texas maybe a little bit different from how we manage folks in Illinois where there may be a larger Puerto Rican population for instance the health disparities aren't just Latino health disparities but they're health disparities within our community so for instance we may not have an issue with asthma with Mexican Americans but Puerto Ricans a huge percentage of Puerto Ricans have asthma and complications with that so we need to address the various groups within our organization and as an insurance company we acknowledge that we're doing research internally to focus specifically on Latino health the fact that I'm here as a regional president in San Antonio is a testament to the fact that we're really wanting to address Latinos in a way that's culturally relevant in this part of the state I just wanted to support that and we need to start it from the moment they enter into the clinic all the way through their last visit and then the continuity of care the referrals, the follow-ups that are needed they need a lot of assistance throughout the process because it's really intimidating if you're coming in with a very serious health problem in terms of how to deal with that and how to, you know, and as Senator Vanderpute said, you know, you bring your family and everybody's listening to a different piece of it and helping and make the next decision for you but we need to be really clear about what steps they need to take and then the follow-up care that they need as well and you kind of mentioned the be covered campaign many people do not understand the Affordable Care Act, whether you support it or you don't, it's a very complicated law right now and, you know, come up to where people are going to be trying to enroll and get health care and I get questions all the time, where do I go what do I do I mean, how are we really going to educate people on what options are available if right now all they know is to go to the emergency room and have health insurance I think, you know, the be covered campaign is a start and having a consistent message from a reliable source is important and that's why the be covered campaign is a grassroots organization that isn't coming from the top down but really disseminating the information with organizations that are ready in those communities and are trusted sources all we're doing is providing the information to those folks so that they can provide it in a way that's culturally relevant and competent obviously our campaign is going to be in English is in English and in Spanish so it's very important but when we have 42% of the population across the country that thinks that the Affordable Care Act is overturned we have huge challenges we have to start from from 0, 89% of Latinos want more information about the Affordable Care Act we're here to provide that information and it's one of many sources out there but we want to be a Texas relevant source and I think that's why getting the information out locally is so important disappointing I think for us besides not taking advantage of the Medicaid expansion is as you know Texas decided not to run its own exchange in the marketplace which folks will start to begin to be enrolled October 1st for coverage that starts in January we are going to be under the federal exchange and as such we do have a limited number of navigator grants that came to our communities and really working with those folks that got the grants but what I am seeing is so many grassroots organizations business organizations healthcare groups not for profit grassroots that are so concerned that our state did not take advantage of what was I think the good points of the Affordable Care Act that they themselves have formed these great coalitions and I was speaking to a legislator that really you know their state took advantage of everything and their state is doing the exchange and they're worried because of the grassroots type of involvement I think because of our lack of our state government becoming engaged in this folks are really going to get out there in the local communities they're already knocking on doors in communities in Texas trying to explain to people and you really have to explain it in real simple terms because there is a lot of controversy and so the way that I always start out when folks ask me whether I'm at the pharmacy or at the grocery store about the Affordable Care Act as I said do you believe that every family ought to have a family doctor and if they say yes and I say well then you're going to love the Affordable Care Act now if you don't believe that every family in this country deserves a family doctor you're not going to like it at all but once they understand that and understand our situation in Texas they are ready to try to seek a way to get coverage for their family it's having to go through the different portals it's not knowing and it's really what they see and hear about the controversy not understanding that part of it only a very little part of it was turned down by the the Supreme Court and that the working ability the tenants of the act are really going to have to come at least in our state with the very local communities and grassroots in the federal government because the state has basically abdicated its role, its responsibility and I think it was a great error but it is what it is in politics and so it's up to our local communities and to the folks who really understand how beneficial it could be for our Latino families to be able for the first time to enroll and get a health care product at a reasonable rate that protects their family and as Senator Vanderpute and Dr. Lopez have said it needs to be in a culturally appropriate and culturally relevant way it needs to be easy to understand and it is going to take this door-to-door approach to make it happen I mean a lot of, you know a lot of the focus in our previous legislative sessions has been about producing the cost of our Medicaid program not expanding it you know, fraud prevention and things like that which, you know, there are some impressions of our Medicaid program in the state that certain lawmakers have that guide their decisions on these issues particularly in Tyler programs and can you guys speak to the utility of what these programs are actually used for and kind of the way in which they might be misrepresented in some cases or In my prior role in joining Blue Cross Blue Shield I was the program director and medical director for the Texas Medicaid Wellness Program so I had an opportunity to be all across the state in both doctors' offices and in patients' homes I did not see any fraud when I was across the state the people that we visited needed to be on Medicaid and needed to have the resources that we were providing through that program I can't I can't comment on what the legislators may think about Medicaid, I can only comment about my experience within the program and those folks who I dealt with truly needed it from a Latino perspective 50% of Latino children across the country are on CHIP or Medicaid. It's a huge percentage so it's a very important aspect of how folks in the Latino community receive care and a lot of it is just perception at least when I visit with my colleagues they're gaining the system I'll give you a real example that happened here in San Antonio I was with my sister my sister and her husband have adopted six children at Child Protective Services those adopted children have healthcare under the Medicaid program my sister and her husband my sister left her job and is a full-time mom adopted these six kids one is a four-set siblings I went with her to the doctor checkup and my sister drives a big suburban I mean you have to without many kids and you know they're okay financially he's a preacher at one of the mega churches here we were leaving the doctor's office and a person came up and said I'm going to report you and you're having that car and you're having that purse and I saw you, you had Medicaid how horrible for the children to witness that they have Medicaid because it's the policy of our state that we want to encourage people to adopt and if they would have to be responsible for all the healthcare I just quickly got the kids in the car and my sister was just in tears you never know people's circumstances perception but unless people understand that adopted children are still on Medicaid and people in the foster care system are on Medicaid they have this perception because they saw our drive in this big car that's what's wrong you don't know people's situation and what would we do without good people in this state adopting children in our foster care I was I was livid and angry I didn't want to open my mouth because I thought I don't need to traumatize the children anymore but I think it's things like that and then they call their legislators I just saw somebody with this and I just saw somebody using food and maybe it is that perception so what I believe is that when you really need to focus on those very few either practitioners providers in the system that may be gaining the system we've got algorithms in our payment logs now that they can really identify somebody who's seen too many patients a day or they're building a normal I mean you know that they should go after that and really investigate rather than spend the millions that we're spending now just to placate this perception of well there's so much broad in the system I believe like Dr. Lupus I mean human nature is what it is and in any industry you're going to have some bad players go after them we can really do that in a very focused way rather than put it on the whole population I think we work if we just work smarter instead of the way that we're doing now we're throwing out the broad nets with a gotcha mentality particularly for our providers it would be a much more effective system I mean children with SSI benefits receive Medicaid and they do that because they would max out their insurance otherwise and so they would exceed their yearly maximum or lifetime maximum so that's another population that receives Medicaid and those parents may be very affluent so since you know Texas isn't taking advantage of being a formal cat and the way that you guys have been talking about by expanding Medicaid adults under the 100% of the federal poverty line won't qualify for insurance under that law so what do other organizations in the health care community need to be doing or what are they doing already to change the way that we pay for care if they're not insured or to improve the way that people can access care for the Latino community from an insurance standpoint it's important to provide plans that are affordable so I know from Blue Cross Blue Shield perspective that's one of the things that we're doing in addition there still remains the safety nets that are here in the state I believe Senator Vanity can speak more to that well our safety net has always been and our health care providers here and our policy wonks know when we say dish payments they're disproportionate share payments to hospitals for uncompensated care the federal government which sends these was putting those on the decline and rightly so because under the Affordable Care Act there'd be no need for a lot of uncompensated care when people are covered well in states particularly that like ours that didn't take advantage of that expansion those dish payments are reducing to hospitals meanwhile the payments that we thought would happen because this population of at least no a million were supposed to be covered by the Medicaid expansion are not so there is a disconnect because of the way the law was written but mainly because of the poor policy decisions from the state that was the safety net for a lot of the hospitals as for the safety net in our communities our federally qualified health care clinics particularly in San Antonio in our area here Bear County Hospital District rather than how folks come to the hospital they really have done something extremely sensible over the last 15 years which is to put the primary care clinics out in different quadrants of the community therefore doing that primary care to folks and they've got some stuff on a sliding scale so that way they don't show up at the ER those are the types of things it's our local communities our local faith-based groups that really have filled this hole for the safety net they can't continue to do it they cannot continue to do it more and more often we see these providers that have been working in their communities have to shut their doors without I think the expansion without that coverage and with the reduced payments folks I think we're headed for a real crisis unless we figure out in the next two to three years how to mash our state policy differences with what the federal law is and our reimbursement systems I support that 100% I kind of call it the quilt that's kind of frail we've been doing pretty good but it's going to tear pretty soon because the type of support systems that we have are stretched to the max there are people that continue to need more health care and more catastrophic care it's once you're diagnosed with cancer it's just not the treatments, it's the recovery it's your quality of life and how to get back into the work settings so we have a lot of number of issues from prevention all the way through survivorship that we need to be looking at so you were talking about navigators that help people go through this system Texas is kind of trying to innovate in this arena with the 1115 waiver which is the grant that we've gotten from the federal government to set up some different innovative programs in the way that we deliver care do you guys have any examples of the way in which hospitals or clinics are really changing up the way that they guide patients or help them access care that we might look towards as a future example we've certainly have found in some of the research studies that we've done that if you have a patient navigator in a cancer center you can reduce the time from the time of diagnosis to get them into timely treatment and then follow up and it's really been critical again to cover those holes where particularly if they didn't have health insurance they were bilingual as mentioned earlier they come from the community they understand the community and really help them to go through the systems I'm really proud just got two 1115 waivers dealing with diabetes education and prevention so Dr. Schenckler is here from the health department so I'm really excited about those two initiatives coming to San Antonio so and what are those going to be doing in terms of trying to change the way that we do outreach or prevention for diabetes? Correct and educating them, bringing them in for prevention getting them connected with their clinics having a home-based site where they can get the care I think one of the most promising things and this was actually something that the state supported, okay let me repeat that this is something actually that the state supported was for newborns and particularly for new parents the type of follow up after they leave the hospital particularly for what they would deem at risk young moms women who are not married folks who are under a certain indicator of poverty, they may not make it on the medicator, they may be on Medicaid but let's face it they're going to be cut off in 60 days postpartum those types of programs where you have that home visitation I think is using that navigator that source of information to our families and I think it has shown great success when we've had those programs and I think one of those I think is absolutely great and a wonderful decision but what I think people are not focusing on is given our poverty stats given our disparity and this was even before the obesity about our rates of diabetes prevalence I mean this happened before the obesity epidemic it's not just obesity it's certainly it's been complicated by that I don't think there's been enough focus on the Latino family health resiliency there are so many things I mean if you look at some of the indicators and where they are they should be doing way more what we should focus on besides trying to alleviate some of the comorbidities I mean there are some great health statistics that we have why we're so resilient you know even if Latinas don't get as much prenatal care we tend to have healthier babies that's resiliency something's happening within the family those are the things that we also need to concentrate on as we build this Latino health and when you think about it how important is it to Latinos to have health the other cultures and stuff when you do a brindisa toast cheers ours salute the health is the most important thing that you value besides your family and your faith it's salute it is the basis of what represents that family unity and the ability to succeed but if you are in a system and you live in a neighborhood and you have a job that doesn't offer you the ability to have health insurance then you're left with the maze of trying to go to this place over here to get this little service or this little place to get this service and I can tell you how really important it is for women San Fernando Cathedral has a health fair every year here in San Antonio they have a mammography machine there are women that line up at 5am just to be able to get that mammogram there are 60 women in line really almost at sunrise because that's the only place that they know they're going to be able to get a free mammogram that tells you something about the need for this comprehensive type of care I mean McAllen for example down in the Rio Grande Valley got a lot of national attention because although they're one of the most obese cities in the nation they're also one of the happiest and that speaks to what you were saying about how family and culture plays into health outcomes what are some of the lessons that Texas should bring in as they become a majority Hispanic state and incorporate into our health care system that might improve care for many people I think one of the things we tend to as you mentioned earlier is that we criticize our diet a lot and it's really not so much the diet it's the proportions that we eat and so forth and I think San Antonio has a great opportunity of working with the Culinary Institute of the Americas here who are focusing on Latin foods and how to promote the good side it was saying because we need to really focus on what is good and we have a program called Salud America that's focusing on reversing Latino childhood obesity and we're really trying to promote what are people doing in the communities that's the right thing and how they're making and focusing on the positive things that are going across our nation so that other communities can replicate them as well but it is that resiliency of the family of coming together in that unity but it's being bombarded by marketing you know we have more billboards in our Latino communities than we do in non-Hispanic whites that are promoting unhealthy foods we have fewer food deserts as we were saying we have more food deserts there we have our corner stores that aren't offering fresh foods and vegetables we have fewer grocery stores that do offer the positive things so we need to bring this into our community and it's going to take a huge community effort to make that happen but we can make it I always say the farmers markets for example we have some of the best produce in south Texas why don't we have more farmers markets that was also one of the key things that made a healthy city was the amount of farmers markets they have and I said well you just got to be careful that when we buy our bananas at the farmers market they may right by the time you get them into the car because of the heat here but you know we do need to think of different ways of making those produce available to our families from the insurance why is there anything that you know the state can be doing to change the way once someone has insurance they're trying to get it to incorporate some of the social as I mentioned earlier what we're doing is really focusing on the Latino community in a holistic way so making sure that we're addressing Latinos not just as individuals but we recognize that it's a family unit that is so important and when you address the Latino member you're addressing the Latino family and so both Senator Vaniput and Dr. Ramirez as points you have to think of Latino health not just individually but how the decisions are made within the family how food is cooked in the family what safety issues folks may worry about and additionally the issue is so much larger than you know is there grocery stores in the neighborhood or is it cheaper to go to a fast food place and get and feed the family for a more affordable price than to buy fruits and vegetables and those are some of the challenges that our communities face but from an insurance perspective making sure that our programs are in place that aren't just bilingual I mean you can put a pamphlet out in Spanish but that that bilingual pamphlet or that person on the phone knows how to address the Latino community in a culturally sensitive way I think one of the things that is something that we have not touched on is school health policy our children are in the school really for a much longer time and closer to that environment than they are at home the school nutrition lunch program and now thanks to my colleague Senator Eddie Lucio all of the school lunch programs will also now have the benefit of the breakfast programs those types of programs where you have breakfast, you have a nutritious lunch and the school policies with regard to physical activity and PE and what we call the walking school bus rather than a school bus that picks the kids up to have an organized policy where parents or grandparents have this walking bus that picks up kids along the way to promote physical activity but I'm going to tell you I fought a colleague in the Senate, Jane Nelson when the new curriculums were going to be adopted this past year they were going to eliminate the PE requirement in high school and we said absolutely not have you seen our rates so I think our schools and particularly we know that people live in communities are school districts who are primarily Title I who have primarily Latino students they are school health advisory councils which every school district has can play an important role in promoting policies that are at the school level that will really help the overall health not just of the Latino children but of the whole families that surround that for our communities, Latino communities define themselves by their schools and by their high schools that's how we define ourselves that and our churches and so that's what's really really important is our trustees the decision making at that level I think could add greatly maybe not in the state's purview but certainly under the decision making processes for local elected officials of the city county but particularly the schools I think we need to increase our active play places we need more parks and recreations but we need shared agreements with schools to let their communities utilize some instead of having these big fences coming up with opportunities for them to utilize it and as you were saying we need food and our schools reducing the vending machines and things like that and reducing the sugary drinks we need to encourage those water consumptions in our communities because our two-year-olds about 75% of our two-year-olds have already had a sugar bed verge by the time they're two and it costs the other night I was driving by Edison high school they put in lights it was 9 o'clock you couldn't get into the parking lot there were literally probably about 100 people walking the track that is wonderful for the community but the decision by the school board to actually have the lights on at night because who's going to walk in 100-degree rather during the middle of the day that community is utilizing that track those are the type of decisions and like I said I couldn't even get into the parking lot our mayor's fitness council here is really being very active in changing things around in San Antonio to make a lot of these things happen so we're really fortunate to have that so I'm going to open it up now to some questions from the audience so if anyone has anything they'd like to ask please step up to raise your hand we'll bring you a mic my name is Juan Mufacantu and I'm a community ambassador for the national psoriasis foundation it's very good to say about our Latino community when people don't have psoriasis okay we have kids we have elderly I have psoriasis I've had a stroke we don't talk about the core mobility and psoriasis one of the things you don't talk about is people with psoriasis because we're contagious we're you know we're mangy that's what they call us we're leprosos you know and we're not we're not treated in our communities not even in any place as human beings we're treated as people that shouldn't be here even the medical community we have abilities like cardiovascular obesity and you're talking about obesity people with psoriasis have a higher incidence we have a higher risk of developing all these illnesses but nobody cares about us when we want to talk about it when we say you know we're not contagious people look at us like you're not supposed to be here I walked into a restaurant one time and they said I don't know why they let her in here she shouldn't be she should be outside children are treated that way in school they're bullied in school I have a child I have a support group it's called my woman is said by limbo psoriasis group it's the first bilingual in the nation and nobody knows about it because nobody cares about psoriasis even though we're treated as the lowest of the low and for an illness that has been around 4,000 years nothing has been done about it yes I would like to ask what are you going to help us how are you going to help us to bring about better understanding of this illness I think one of the problems is with the Latino community but with it's not just the Latino community is that we tend to focus on those diseases or lifelong conditions that affect majority of the population the diabetes the high blood pressure and for diseases that are not have that high prevalence one that is getting I think and that ties into what you have mentioned with the psoriasis is the high incidence of lupus and the growing particularly in latinas I think there's been a lot of work on that because I would say where you are right now with your group and thank goodness empowering to have people at the grassroots say hey wait a minute there's this condition as well that's what happened with lupus and really the support groups for that there has been as you know the types of things with psoriasis with lupus because it's all autoimmune but I think it's not purposefully somebody sets out to discriminate it's the lack of information and it's the fear remember how communities responded 25 years ago to the first AIDS patients and children who were HIV positive in public schools think about it so I congratulate you for your work and yes we do need to do some work on those but I think what happens is that our policies tend to focus on those that affect the higher number we don't want psoriasis to affect but let me tell you my dad, my sister, my cousin it is an autoimmune and they have suffered as well and because of that I used to watch my dad in 100 degree weather wear long sleeve shirts because he didn't want to be embarrassed and he didn't want to embarrass us when we would go into a restaurant I'd like to thank I don't know I feel very proud to see elected people with research with this having heard what you say what do you need from the community so that we can have informed policy and leadership like yours and informed practice so that we can continue on the pathway of the time of change that the Affordable Care Act is allowing how far it's coming if I may one of the things that I'd love to see and I am seen in the community is local leadership having community leaders get behind the Affordable Care Act in terms of providing information to the folks that they in the communities that they live in that is so important to me as a physician and as a practitioner promoting going to the doctor and getting your preventative services not just when you feel unwell or when you feel sick but when you feel well to make sure that you can find those conditions at an early stage and treat them appropriately and Latinos get information about their health often from other Latinos in the community from tios and tias and from cousins and from mom and dad creating this grassroots movement for health within the Latino community both from the Affordable Care Act perspective getting information out to make sure that folks are getting the insurance that they need but also promoting health within the community is so very important I'd just like to echo that that we need to advocate within our members to be after city council and other political leaders for this change here in San Antonio we need more bike lanes we need to involve planning in other groups it's just not one group of individuals but it takes the whole community community leaders and the health care system to have this change occur and we really need to continue pushing that we need our parents and the PTAs to say we want better foods and schools we want to get rid of those sugary drinks those kinds of things in order to have that change occur I'm not going to be as diplomatic as these two great doctors here I'm going to use a four letter word vote until and I'm speaking at the state level the power of the Latinos is not reflected in their voting patterns and this is not just I'm not talking south Texas but we need to do more for registration and outreach but when Latinos are active at the ballot box and they vote for people who make decisions that will make decisions in the best interest of their communities then state policy will change none of my relatives in Mexico ever had I had insurance but I never used it I think that culture has come in the US with the Mexican government to our first generation my daughter works in Austin she's a nurse practitioner in those new clinics and she's telling me that not only there's no prevention it doesn't appear until it hurts I do the same I don't go to the dentist until it hurts my grandmother so that's that's the truth you think that because it doesn't hurt everything is going well like a car that's the philosophy so that is very dangerous I'm going to take care of myself really after I have the second child I really I thought I would be one big person who would help so why well I'm pretty dive-in-ing now but I'm about to take care of that too because I understand now the power the doctor told me this is one of the illnesses that you can stop but you can take this a lot of work and that's the problem my daughter sees patients 30 a day 15 minutes each that's all she's allowed and with extreme cases anything comes in there to that door and denial is the first thing that she has to deal with she sees newly born and 80 year old from cancer to mom nutrition whatever she says mom I'm speaking Spanish and explaining there's total denial no señorita I just ate this boiled chicken with vegetables with vegetables the last month or so and they are like but you gained 100 pounds so did you take your medication for a little just for a little bit because I started feeling well right away so they are very sick they don't take their medication but use it something very important I didn't think about it when I came here today but we are a subject of something very special but not prevention denial and then immediate cure with one bottle of medication and then we don't come back and then when we come back it's times worse and needs more cost so medication but constant understanding the culture explaining the results the other day I thought maybe we need to take pictures of the cancer patients that have lost an incident etc just like they did with the cigarette and show this is the way you are today and this is the way you are going to be you don't take care of yourself I finally was struck with that you know slap on my face that something is wrong I'm busy I cannot breathe well and sometimes I have blurry you know and you do that or you go to and I think I'm uneducated I have insurance and I fell into the same roof so imagine what happens when you don't have medication there's a lot of work because of our culture so so very well said and we confront that every single day you know we hear that why individuals didn't come in or why they end up in the emergency room and it is going to take this constant level of public education and information that's culturally relevant to get our community to begin to change you know by 2051 and three individuals children are going to be Latinos without childhood obesity today they're going to not they're not going to outlive their parents and they're going to live as they do they're going to have poor quality of life and whose responsibility is that but it's all our community we all have to be together if it's hard to go out and exercise you're not going to do it if you don't have the support groups to kind of motivate you you're not going to do it so we really need to change our perception and it's having more green spaces feeling safe when you're outside having more access to fresh fruits and vegetables are some of the key things that research is showing that we can change and we need to change we're 16% of the population of the United States we account for about 9% of the health care expenditures so we utilize health care services less than any other population by percentage those are things that we face as a physician I understand that I understand when Senora Ramirez comes in to see me that she's going to have all this baggage around her in terms of what her perceptions of care are and I have that because I'm Latino and I understand it and my parents are from Mexico but you're exactly correct I would start my office practice at 7.30 work through lunch and not leave until late at night seeing patients beyond my time frame because you require that intensive education and everyone in your staff has to educate the folks so we do face challenges from a cultural perspective that go down the generations close family member of mine born in the United States similar to me went to the doctor for preventative visit was found to be a family name that hadn't seen a doctor in about four or five years but I felt great and they found all these problems the problems were there you were just compensating for them so good that you went in and saw someone found them early and got the treatment that you needed to prevent something worse in the future and so these are some challenges and they're very real challenges and that is why having providers in the community is so very important and part of it is because of our lack of access to health insurance because of policies other organizations and other sectors really have taken up the slide and I'm going to talk about things like you wouldn't think that the housing authority and I know we've got a lot of this here are housing authorities that have folks who are in poverty who are struggling it is important for us to partner with the housing authority with the utility companies to put the message the salud to health and particularly I'm going to I always ask women to form those friendships our sisters to ask them have you gone for your yearly exam especially when you see our alarming rates cervical cancer and then find out why find and have the resources there are some places that you can getting of course more scarce with the women's health program and the oblivion I think of it even though we tried to put in some more money with it and even now with what happens is sometimes our health care providers get in the cross hairs of an unintended consequence for example the issue of termination of pregnancy and abortions really to exclude Planned Parenthood clinics when the majority of stuff that goes on at the clinics is your pap smear and your family planning and they're closing because of something political and but what's going to happen to the hundreds of thousands of women who don't have health care insurance that now that was their only source of low cost annual pap smears so sometimes those health care policies in and other parts of the state or city really impact particularly how women access their own health care and folks I think we're going to be at a crisis point for this you triple the what we're going to do we're going to educate expansion the destruction I think of our women's health care program the ancillary shots at Planned Parenthood where are women going to go in this state particularly women who are of limited means and women in the rural areas I mean very very difficult for our world and where do Latinos live they live in the city but huge amounts live in the rural areas I think we really are going to have to look comprehensively at that and maybe it's going to take those folks that we rely on the researchers and the statisticians we need good credible data we need that research and we need best practices on what works with limited resources how best to affect the outcomes of the health of our families and copy from other cities and other jurisdictions that may have a quantitative program that produces results my question is more of nuts and bolts concrete type question and I applaud your attention to being culturally confident the use of promotoras, trusted advocates etc but I recently heard in a presentation such as this that the enrollment form is pretty egregious that it's difficult they liken it to a FAFSA form and that it has tax implications and you know we're right around the corner from October 1 and I haven't seen this form what can we do to mobilize promotoras that we use in our community to become familiar with this form and to be efficient and effective in getting data out to the community and I'm really asking is the form in fact egregious and is there anything we can do to make it less so the form will have a lot of information that's required I think things that folks have to do to prepare for it is get their know what information they require so that's why they come to bcovertexas.org it will help prepare them for October 1 much has been spoken about the navigators and it's great to have a navigator grant here in San Antonio to have navigators but I don't think that's the end all you have a variety of different resources the navigators are one part of it other community organizations are going to be part of it and our population will need some level of quote navigation to get through the process the part that we haven't talked about are insurance agents and brokers they're going to be a big part of this as well and those folks can help individuals sign up for health insurance but I think it's going to be a larger group of folks I don't know that we're going to be able to change the form at this point I mean that's a federal issue but dealing with the form that is in place and making sure folks have the information their financial information beforehand and work through the process with all the resources that will be available in the city good morning first of all thank you so much for this forum it's very enlightening and very good information I think one of the things that I just wanted to share with the panel and those in the room is that for us as housing providers as a housing authority health is a very health access and access to quality health is extremely important for the families that we serve just this week there was a report issued from the Institute for Children of Poverty and Homelessness the report basically says that there are numerous risk factors that lead to homelessness that low income families face among them of course family stability employment or under employment and health concerns lack of access to health was among really the more significant indicator so I think it speaks to why it's important for different groups to be involved it becomes a vicious cycle families don't have access to quality health it affects their ability to be able to work or to get to work it affects their ability to take care of their children and if we really want to break the cycle of poverty I think we need to look at this comprehensively so really I think my question is I know that we're all trying to more to ensure that the information gets to the families that we're serving but I do agree that I guess it's really a policy question it's a question of what are the priorities for our leaders for our state so I guess my question is what more can we do beyond stepping up and trying to get information out and raising awareness is there anything else that we can do within our communities to bring more attention to this issue I'll try to answer it I think having been involved as a pharmacist as a policymaker the coalition of groups that have come together because the state's not doing anything on the rollout of the exchanges that really led to the type of discussions with folks that never got around the same table before and I'm really pleased to see that and I understand that's happening in other communities as well but I think it's using every opportunity that we have in whatever we do and I see people in the education community, in the business community it is really an enlightened self-interest business community to understand what it would mean for them if they're employees, particularly the employees that have the lower end salaries to be able to to purchase a low cost plan on the market it is really, really important to use every interface as that opening for the discussion for knowledge I think that it's going to be tough it is complicated it's a lot of change in just a very short time and it's made more difficult by the controversies I mean, when you have state leadership and leadership that says their whole focus is shutting down Obamacare even at the expense of shutting down the federal government then that sends a very strong message to folks they dislike it what I keep trying to tell people in the Medicaid expansion and in everything is that I hope that the leadership in my state would come to a place where my local community is already and that's that they love the people who live in their communities more than they dislike this president or the affordable care act and to take the good parts of it and make it work and that any complex law is going to need the tweaking every law has its unintended consequences so for us to be able to get out the right information sometimes we need the right information right? it's a very complex law it's been made more difficult by the controversy but everyone would ever sector you're in to use that as an opportunity to interface with folks that may not know and then we've got to know who to direct them to we just had kind of an issue here is that our 211 hotline United Way they were first told that they couldn't help give out information about the exchanges okay this is the United Way hotline when people called and now we're trying to get the clarification that the state because they get state funds and we didn't want to help with the roll out of the exchange we're not helping but we've got to be able to at least give somebody a phone number and address of a place that they can get the information right? so my anger was not only does the state not want to implement but they don't want anybody using state dollars to even give information about it I mean how much do you hate the people that live in this state? I mean come on get over it it is absolutely about the health of the community and that's what I hope we focus on and every opportunity that you can do and particularly people here who are thought leaders who are on boards and commissions please bring it up one big opportunity that we have that we have not used that I think is in our coalition here is our faith-based communities if Latinos are or anything they are connected to their church they are connected to their faith-based organizations either that or their mother is and that's a great source to get out that information if I can add one more thing to that the title of our talk today was the future of Latino health and we painted a picture that seems a little bit grim but I have to believe that the future of Latino health is positive I mean we have these forms in place here today and to your point it's such a larger issue it is a policy issue it is a city-wide issue it is a regional issue and I recently worked with a group at Leadership San Antonio we were talking about diabetes and I think that folks need to understand we are 60 some percent of this county 60 percent of Bear County are Latinos and if we don't address the future of Latino health it is to our own demise why? because businesses won't come to San Antonio or to South Texas if their population is unhealthy there won't be tax revenue for the city or for the county it's such a big big issue that it is in all of our interest as Latinos and non-Latinos to make sure that we are addressing the issue of Latino health because it permeates all aspects of our society how our streets get paved and what revenues we have for the airport and how businesses get attracted to the city Toyota thought twice about coming to San Antonio because they saw the demographics and we have to change our demographics for our own survival for this part of the state and I think it is in the interest of every Latino and non-Latino in Bear County and in South Texas to make sure that we are creating a change so I have to believe that the future of Latino health is positive but in order to address the future we have to understand what the present is and what the past is so a new medical school in the rear grand valley that's a positive thing for Latino health we will have more Latino doctors and we will start addressing some of these issues and every step that we take along that path either in this forum or everyone in the audience is even brighter we need your voice we need to really advocate for these issues and the seven was just saying it's just not about health but it's education we still have one of the highest dropout rates here in South Texas we need to change that and we really want to be competitive in the future so bringing those things and we also need to value as Senator Vanderpute was saying that every life should be valued and that we really need to work hard we can't be silent anymore many times I'm on national committees in Washington and I'm going like where are the other Latinos here in this board we need more representations at all of these levels to reinforce what we're saying and I'm going what makes this different because I was here many years ago when we were only represented 6% of the US population and as Stevan said we are 16% and we're still not considered the majority population but they don't believe it so how are we going to create this change and it's only by hearing our voices and hearing about our needs that are really critical I just want to thank everyone for coming out and being here today I think we're going to continue this conversation but maybe outside of the panel thank you all for joining us and hopefully you can join us again later this month at the festival and we can keep talking about important health issues for our state thank you to everyone in the audience