By Erin Prather Associate Editor, Texas Medicine Meet Jimmy Reyes Jr. He's 20 years old and was born in Raymondville, the grandson of Mexican immigrants who came to Texas to find work. Jimmy is a hardworking guy who holds down two jobs. He's a construction worker by day and a convenience store clerk by night. Neither job provides health insurance. That's too bad, because at 5'11" and 315 pounds, Jimmy is headed toward diabetes and other health problems associated with obesity. So are his three brothers, his sister, and their children. Now meet Steve Murdock, PhD. He doesn't know Jimmy Reyes Jr. personally, but as the state demographer he's paid to forecast the future. And although the Jimmy Reyes you just met is not real, he represents what Dr. Murdock says could be a lot of people in Texas if current population and health trends continue. Director of the Texas State Data Center at The University of Texas at San Antonio, Dr. Murdock studies the characteristics of human populations to provide estimates that may be used to plan upcoming public policy. His first and foremost prediction is that the Texas of today is the United States of tomorrow. "What I tell people is if you want to know the future look of the country that your children and grandchildren will live in, just look around at this state," he said.

With regard to medicine and how demographic changes will affect physicians and their patients, Dr. Murdock identifies three developing factors that will drastically alter the future of Texas health care: more people, older people, and more Hispanics.

To start, the state population continues to grow rapidly. According to Dr. Murdock, the Texas population grew to 20,851,820 in the 1990s. This kept Texas the nation's second most populous state behind California.

He attributes the population growth primarily to a "natural increase." More people are being born in Texas than are dying.

"We live in a rapidly growing state that will keep on having rapid growth as the population adds about 200,000 persons per year, all due to natural increase. In fact, in the 1990s, if no one had moved to Texas from another state or from another country, we would still have been the third fastest growing state (in numerical terms) in the nation, simply from our natural increase," Dr. Murdock explained.

The Texas-Mexico border, the area along the central corridor along Interstate 35 from Dallas to San Antonio, and the Houston-Galveston region experienced the largest population growth. The slowest growth occurred in the Panhandle, West Texas, and the Beaumont-Port Arthur areas.

Continued migration from other states and other countries is another factor boosting the state's population.

Based on various scenarios involving different migration rates, Dr. Murdock predicts that the overall state population will maintain, if not increase, its current growth trends. The population is projected to be between 24.2 million and 25.9 million by 2010, and 35 million to 50.6 million by 2040. One scenario calculates that the state's population in 2040 could be 24.2 percent Anglo, 7.9 percent black, 59.1 percent Hispanic, and 8.8 percent members of other ethnic groups.

Gray Power
Dr. Murdock's forecast of an older population could be called the graying of Texas. Like the rest of the United States, the number of people over age 65 in Texas is beginning to surge. Demographers have long warned about the effects of "baby boomers" entering their 60s. Dr. Murdock predicts there will be more than 8 million Texans over 60 by 2040, while the 85-plus population will reach 831,000. Eventually, elder Texans will make up almost one quarter (23 percent) of the total state population.

Because most elders require additional health procedures and resources, the predicted increase of older Texans will obviously place a greater demand on overall medical services.

A report in the March 19, 2003, issue of the Journal of the American Medical Association (JAMA) says older adults are affected disproportionately by chronic diseases, which contribute to an increase in health and long-term care costs.

Additionally, costs per capita for people over 65 in the United States are three to five times greater than costs for those under 65.

For Texas, Dr. Murdock estimates the total days of hospital care and associated costs for people aged 65-74 and 75 and older will increase from 4.6 million days and $12.8 million in 2000 to 17.9 million days and $50.6 million by 2040.

That prediction assumes migration will remain at the same level it was in the 1990s.

This does not surprise Leslie L. Cortes, MD, of Austin, president-elect of the Texas Geriatrics Society.

"The elderly use a disproportioned amount of health care dollars. If you double that population, you increase the total dollar burden, and that impact is going to be significant. There are already family practice and internal medicine physicians whose main patient base is over age 60. This will only become more prevalent as the 'baby boomers' age," he said.

Despite the warning of an aging population, various reports show the current health care system will not be capable of handling the influx of elders.

According to Medical Never-Never Land, a report by the Alliance for Aging Research, there is a gap between what primary care physicians know and what they should know to treat older patients.

And, although physicians will see more diseases that specifically affect the elderly, a survey conducted by the Merck Institute of Aging & Health found that only half of physicians surveyed believe their colleagues could adequately treat a number of common geriatric conditions (e.g., falls, memory loss, and incontinence).

The Never-Never Land report also recommends that physicians understand the logic, goals, and some of the techniques of good geriatric care to provide the best possible treatment for their older patients. One proposal calls for health care professionals to take a team approach to elderly care, as elders often have several chronic conditions simultaneously that require more than one specialist.
JAMA also says public health agencies and community organizations should expand their traditional scope from infectious diseases and maternal and child health to include health promotion in older adults.

Beth Stalvey, PhD, MPH, senior gerontologist at the Texas Department of Aging and Disability Services, supports these suggestions.

"It is beneficial for health care professionals to receive some sort of training to treat this specific age group," she said. "There are biological, age-related, and functional differences in an older person that need to be treated differently than a younger person."

Dr. Stalvey says medication is just one example. "There have been numerous occurrences of an elder being given too high a dose of medication because it was not taken into account that an older body metabolizes medicine differently than a younger person. With proper training and communication among specialists, these types of medication mistakes can be prevented."

Another problem is a lack of physicians and other health care professionals specifically trained in geriatrics.

A U.S. Center for Disease Control and Prevention (CDC) report, The State of Aging and Health in America 2004, says only a small proportion of practicing health care professionals have any formal geriatric training. Of the 650,000 practicing physicians in the United States, fewer than 9,000 are geriatricians. That equates to about 2.5 geriatricians per 10,000 elderly persons.

The CDC report also says there are not enough geriatric specialists to train others, and the majority of educational curricula do not require geriatric training. The agency reported that less than 3 percent of current medical students take any elective geriatric courses, and only 600 out of 10,000 medical school faculty list geriatrics as their primary specialty.

The CDC points out one encouraging note: In 2002, 92 percent of all residency programs in family medicine included geriatrics in their required curriculum.
But, it said, "the current Medicare system, with low reimbursement rates for geriatric primary care, may discourage young physicians from entering the field; these doctors are choosing more lucrative, procedure-driven specialties. Also, many physicians still see geriatrics as something 'extra' not 'essential,' despite the demographic imperative."

So it stands to reason that the current health care system is not prepared for a grayer America, much less a swelling percentage of older Texans.

A New Look
Texas also is beginning to experience a shift in the ethnicity of its younger populations. During the 1990s, the non-Anglo population grew much faster than the Anglo population. Texas now has the second largest Hispanic population, second largest African-American population, third largest Anglo population, and fourth largest "other" population (primarily Asian) compared with other states.

Currently, 60 percent of Texans under age 5 and 57 percent under 18 are non-Anglo.

Kenneth Shine, MD, executive vice chancellor for health affairs for The University of Texas System, says the growh of the state's Hispanic population is caused by immigration and the increasing number of Hispanics born in Texas.

"Even if you decreased the proportion of Hispanics who are immigrants, the birthrate among indigenous Hispanics means they will be increasing as both a percentage of the population and in absolute numbers," he said.

The CDC's Oct. 15, 2004, Morbidity and Mortality Weekly Report (MMWR) says Hispanics are underserved by the health care system, even though they are the largest minority group in the United States. The report also demonstrates that Hispanics bear a disproportionate burden of disease, injury, death, and disability when compared with Anglos.

Findings in the U.S. Department of Health and Human Services November 2000 report Healthy People 2010 reveal that Hispanics are almost twice as likely to die from diabetes as are Anglos and that the population also has higher rates of high blood pressure and obesity. Other ailments affecting the population include stroke, chronic liver disease and cirrhosis, HIV, and cancer.

With regards to immigration, the Dec. 15, 2004, issue of JAMA says that immigrants face more obstacles to quality health care and are less likely to receive preventative care than those born in the United States. An additional Oct. 15 MMWR report suggests that recent immigrants have an increased risk for chronic disease and injury. This could be attributed to their inability to speak English fluently, their unfamiliarity with the U.S. health care system, or their differing cultural attitudes about medicine.

The MMWR also found that Hispanics were less likely than Anglos to have health care coverage or access to medical services, which might contribute directly to their poorer health status and higher rates of morbidity and mortality.

A Bad Combination
The connection between coverage and access to care alarms Dr. Shine.
"Having health insurance is associated with having larger employers or industrial jobs. Many Hispanics typically work for small businesses that have a small number of employees and a disproportion of low-income jobs. This makes health insurance very difficult for them to attain," he said.

"Add in the population increase, and we are brewing what has appropriately been called a perfect storm. Fifteen percent of Anglos, who make up less than half of the Texas population, are uninsured. In comparison, 22 to 23 percent of African-Americans and about 38 percent of Hispanics are uninsured. These kinds of discrepancies are going to be really dangerous."

Dr. Shine adds that an Institute of Medicine report, Hidden Costs, Value Lost: Uninsurance in America, shows that 18,000 people die each year because of a lack of health insurance.

"It's also far more expensive to deal with an illness that has already developed than to prevent one," he said. "Having large numbers of uninsured people actually drives up health care costs. The overall population growth means health needs will continue to dramatically increase, but the ability to pay for them will keep on getting more and more difficult."

Both Drs. Murdock and Shine believe the socioeconomic gap between Anglos and non-Anglos must be closed.

Otherwise, Dr. Murdock says, "the changing population will cause Texas to become a poor state. One reason emphasis is placed on education is its tie to socioeconomic success. It is the best predictor of future income. In terms of reflecting the population, there needs to be an increase of minorities in different fields, including medicine."

It can be argued that improving health among African-Americans and Hispanics will begin a domino effect that will positively influence future population trends. The Oct. 15 MMWR says that if Hispanics continue to experience poorer health status than do Anglos, the expected demographic change will magnify the adverse economic, social, and health impacts of such disparities.

"Whether you have a healthy community determines the educational levels that people reach," Dr. Shine said. "Kids who have uncontrolled asthma don't learn very well in school. Likewise, the more educated people are, the better their health. It is important to understand that the relationship between education and health works in both directions.

"Clearly, the more physicians can do to treat and educate the population, the better life will be for future generations of Texans," he said.

Dr. Murdock's final words of advice: Physicians should learn to speak Spanish or hire employees who do. "If you don't have some Spanish speakers on staff, you are part of the past and not the future."

Erin Prather can be reached at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at erin.prather@texmed.org.