Lobbying for her community: Looking for a paradigm shift

Training more Hispanic doctors is key to helping patients overcome cultural, linguistic and economic barriers to quality care, the National Hispanic Medical Assn. president says.

By Kevin B. O’Reilly — Posted Sept. 11, 2006

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She was the first person in her Mexican-American family to leave home for a four-year university. But as a girl, Elena V. Rios, MD, MPH, had even bigger dreams. While working as a candy striper at the Southern California hospital where her mother was a nurse, Dr. Rios realized she wanted to be involved in medicine -- ultimately leading her to medical school. After seeing vast disparities in care during her internal medicine residencies in San Jose, Calif., and East Los Angeles, Dr. Rios' commitment to improving Hispanic health through policy and organizational work was reaffirmed.

Her career path ultimately led her to launch the National Hispanic Medical Assn. in 1994. The group has a $2 million budget, about 1,000 members and is on the AMA Minority Affairs Consortium Governing Council. She's been the group's full-time president and CEO since 1998.

AMNews reporter Kevin B. O'Reilly recently spoke with Dr. Rios about the barriers to care Hispanics face and what can be done to reduce them.

AMNews: What are the challenges Hispanic patients face that contribute to disparities in health care ?

Dr. Rios: Hispanics proportionally have the worst record for all access indicators, whether it's financial, like insurance status, or nonfinancial, such as trust in your doctor and having a regular source of care. Part of the problem is that growing numbers of Hispanics come from other countries and arrive with different values, don't trust the system and don't know how to apply for different types of programs.

Then we have a system itself that's unresponsive to the needs of a different culture. And, of course, there are major barriers in language, especially among older or first-generation Hispanic immigrants. When you talk about insurance, the problem is compounded. There are application forms to qualify, and language becomes a barrier. When it comes to Medicaid and [State Children's Health Insurance Programs], too often Hispanics just don't know about them. Lastly, the jobs Hispanics have for the most part are in the retail industry or the service industry -- the hotels, the restaurants, the fast-food -- and small businesses that can't afford to offer insurance, or if they do, it's with high co-pays that many people can't afford.

AMNews: What role can Hispanic physicians play in improving Hispanics' access to quality health care?

Dr. Rios: They're a natural connection to Hispanic patients. They don't have a lot of time, so there have to be ways to help the doctor -- tools that are developed that are targeted to Hispanic patients, like videos in the waiting room. It's a trusting source of information to educate Hispanic patients through doctors' offices.

In terms of being a spokesperson and being a leader, we're determined to build a more proactive Hispanic work force in terms of being change agents, meeting with congressmen and so on. Those are catalysts for change. We've got to have people at different levels of power and influence, and [NHMA] is about helping to make the change happen through these connectors.

AMNews: There's been a lot of attention paid to the idea of training physicians to competently care for patients from different backgrounds. How do you assess progress in that area?

Dr. Rios: The medical schools have accepted that idea, and they're pushing forward with more creative curricula, but they're not doing enough, and there's still a long way to go. There are now monitoring and tracking systems, but what's needed is an evaluation of the impact and the change in the behavior of young residents, the future doctors and nurses.

That said, there's a real understanding now of the need to diversify medical education and especially the work force. It's a problem that's persisted in that greater diversity of the physician work force hasn't happened. Nobody thought about how fast the demographic changes would happen in the '80s and '90s. Who'd have known that Hispanics would surpass African-Americans in total population -- 14% now, and a projected one out of four Americans by 2050 -- but that Hispanic medical students would stay at the same 6% or 7%? We won't ever catch up unless there's a strong paradigm shift in the country.

AMNews: Is organized medicine doing enough to help diversify the physician work force?

Dr. Rios: It's pretty evident that it's not the responsibility of one sector. The federal government has made a good effort, but it's not been enough. The profession itself, not just the medical schools, but the AMA, along with its partner minority medical associations, all need to consider how they can institute programs to recruit the next generation of doctors. Then the private sector needs to get more involved -- the health plans, the HMOs have never been asked to put a penny into the pipeline to get minority students to consider medicine. ...

We need to do something extraordinary. We now have the Hispanic medical, dental and nurses associations, but that's only happened in the last 10 years. It will be the professions getting together with the private sector to start putting some money into diversity in medical education that's going to be the real change. Every grammar school student should be able to see a firefighter, a police officer and a doctor. For a young kid to see a Hispanic doctor, that's how they'll figure out they, too, can do it. It's going to have to be a more comprehensive approach.

AMNews: In 2000, the Dept. of Health and Human Services Office of Civil Rights began requiring that any physician who accepts Medicaid patients pay for interpreter services for patients with limited English proficiency. The rules have been loosened since then but are still controversial among doctors who see it as an unfunded mandate. What's your take on the issue?

Dr. Rios: The trend is to support language services and reimbursement policies to the extent that the institution or the government can come up with creative ways of financing them. ... Rather than just continuing the status quo, we need to look at how to address language barriers in health care. We're headed in the right direction, but we need many more creative minds coming together to solve this problem.

This is about system change. Medical care in this country needs to be able to respond to its patients no matter where they come from or what language they speak. It's part of quality care.

AMNews: What's your take on the new federal requirement that Medicaid patients not already enrolled prove that they are U.S. citizens to qualify for benefits?

Dr. Rios: It's ridiculous, an example of lack of vision. Medicaid is a program for the poor, and poor people don't have money to go buy a passport. There are a lot of people in this country who weren't born in hospitals or who don't have birth certificates. ... The golden rule of medicine is "do no harm." This is an example of a very harmful provision of a federal bill.

AMNews: It appears that the Health Careers Opportunity Program and the Centers of Excellence program are in danger of being defunded by Congress. What do those programs do and what's the latest news?

Dr. Rios: HCOP is the longest-running program that recruits ethnic, racial minorities and other disadvantaged groups into medicine. It's a development program that funds recruitment and academic skill-building initiatives and helps students who don't have the financial wherewithal to get into medical schools.

It was funded at $33 million in fiscal year 2005 and has been cut down to zero on the House side, $4 million on the Senate side for fiscal year 2007. COE has funded medical schools aimed at minorities, and the House and Senate have proposed cutting its budget from $33 million to $12 million.

For all intents and purposes, both programs have the same fate, given the huge pressures in the federal budget process.

Everybody knows that the HHS budget won't be discussed until after the election because of the amount of discretionary funding there. So we're doing a letter-writing campaign and have scheduled a congressional briefing Sept. 28 featuring the four minority congressional caucuses [black, Hispanic, Asian and Native American] to raise awareness on this issue.

AMNews: You've talked about the impact Hispanic physicians can have on their patients and in the community. Do you ever regret your decision to move directly into policy and organizational work instead of practice?

Dr. Rios: I do have second thoughts about it. I realize that with all that training, I probably should have! I also realize the importance of the work I'm doing, and I really like what I do. I'm trying to impact the health of whole populations, not just one individual patient at a time.

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Elena V. Rios, MD, MPH

Title: President and CEO, National Hispanic Medical Assn.

Education: MD, UCLA School of Medicine; MPH, University of California School of Public Health

Age: 51

Hometown: Washington, D.C.

Experience: Served as adviser for Regional and Minority Women's Health for the U.S. Dept. of Health and Human Services Office on Women's Health from November 1994 to October 1998. Also did policy research for the California Office of Statewide Health Planning and Development and was an outreach coordinator for President Clinton's National Health Care Reform Task Force.

Best part of the job: Connecting powerful policy-makers with individuals who have dedicated their lives to improving health care in Hispanic communities.

Worst part of the job: Not having enough time in the day.

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Hispanic physician pipeline

The latest U.S. Census Bureau estimates Hispanics as 14% of the population and projects they'll make up more than 25% of the population by 2050. But their presence in medical school and the physician work force has not kept pace.

Status Number of
of total
Applicants 2,708 7.2%
Acceptees 1,325 7.3%
Enrollees 1,269 7.4%
Graduates 936 5.9%
Licensed physicians 27,935 3.2%

Source: Assn. of American Medical Colleges (does not include figures for osteopathic students); AMA

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Growing disparities

A federal study shows a wide gap between Hispanics and whites when it comes to access and quality of health care. The government assessed 40 measures to determine how often each ethnic group faced worsening disparities as compared with whites.

Hispanics 59%
American Indians/Alaska Natives 50%
Asians 48%
Blacks 42%

Source: Agency for Healthcare Research and Quality, "2005 National Healthcare Disparities Report"

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