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Adam Thompson on May 12, 2008 - 9:17am
In 2000, the World Health Organization ranked the US health care system 37th in the world despite spending more than any other country. In 2007, according to the US Census Bureau, the US ranked 42nd in life expectancy. If you are a person of color, a low-wage worker, non-English speaking, or live in a low-income community, the picture is much worse. For instance, the life expectancy for African-Americans is 73.3 years, five years shorter than it is for whites. For African-American men, it is 69.8 years, just above averages in Iran and Syria, but below Nicaragua and Morocco.
The groundbreaking, yet disturbing, 2002 report by the Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, showed what numerous other studies have found, that non-Hispanic whites in the US have easier and more access to health insurance and quality health care services than people of color, including African-Americans, Hispanics, and Asian-Americans. In the US, whether you can get quality health care when you need it is too often determined by your personal characteristics, your income and where you live. This creates health disparities where non-whites and non-English speaking individuals receive sub-par care and live shorter lives as a result.
In a just released report written by The Opportunity Agenda and Families USA, Identifying and Evaluating Equity Provisions in State Health Care Reform, researchers discuss how states are addressing health disparities and identify key measures that all state health care reform should include. While increased access to coverage will help all state residents, this is not enough to address the cultural, geographic and institutional barriers to quality health care faced by communities of color and low-income neighborhoods.
This Stateside Dispatch addresses what steps states can and are taking to reduce health disparities and achieve health equity. Fundamentally, the fix is more than universal coverage, it's about changing the system so that quality and affordable health care is provided to all US residents regardless of personal characteristics and circumstances.
Extent of the Problem and Causes of Health Disparities
White Americans have easier and more access to quality health care than people of color. This problem, however, is much more than being insured or uninsured, although non-Hispanic whites do have the lowest rate of uninsured, at 13% of the white US population. The highest uninsured rate is in the Hispanic community, at 36%. For even those with health insurance, people of color are more likely to receive sub-par care, have worse outcomes and are less likely to receive routine or necessary care than whites.
- The infant death rate for white Americans is 5.7 deaths per 1,000 live births. For African-Americans, it is a staggering 13.6, more than double. Not surprisingly, almost 89% of white mothers have access to prenatal care, while only 76.5% of African-American mothers have similar access.
- Similar disparities occur in death rates between whites and African-Americans. While 817 whites die per 100,000 people, that number jumps to 1,066 African-Americans per 100,000 people.
- Diabetes deaths by race show the extent of disparities in US health care. Per 100,000 people, 48 African-Americans die from complications caused by diabetes. This compares to just over 22 deaths among whites. Similar disparities occur in deaths from stroke.
Health disparities result in heightened concerns among affected communities: Not surprisingly, low-income Americans and people of color are more worried about their health care than whites are. 59% of Americans with incomes below $20,000 are very worried, while only 25% of Americans with incomes of $50,000 or higher report being worried about their health care. What is equally, if not more, striking is that while 6 in 10 people of color say they are very worried about their care, fewer than 3 in 10 whites are similarly worried.
Factors Leading to Health Disparities: The causes of health disparities are many. They are complex, systemic, personal and reflect the racial, class, and ethnic tensions that have for so long shaped American society and culture. Factors include:
- inadequate access, or proximity, to quality health care services in lower-income communities and communities of color;
- lack of racial and ethnic diversity in the health care workforce and cultural competency among providers;
- higher uninsured rates for people of color;
- inadequate public support for providers serving low-income communities, such as community health centers and safety net hospitals; and,
- low health literacy and limited English proficiency.
There are also broader societal issues leading to health disparities, or disparate health status across racial, ethnic, class and gender lines. These include environmental factors, like lead-based paint in older and low-income houses, inadequate access to parks and recreation for physical activity, smog in inner cities, and access to healthy foods. For instance, substandard housing conditions lead to increased diabetes risk among African-Americans, even after adjusting for other factors. And, a recent New York Timesarticle detailing the loss of supermarkets in many New York City neighborhoods, reported that low-income communities and communities of color are being especially hurt, resulting in inadequate access to healthy and affordable food.
Communities of Color Lack Equal Access to Quality Care: A leading cause of health disparities is location - where you live determines the quality of care you receive and people of color lack equal access to quality services. A Commonwealth Fund supported study in Archives of Internal Medicine shows that people of color are more likely to receive care in lower-performing hospitals. Events in Los Angeles in 2007 bear this out.
Last summer, the federal Centers for Medicare and Medicaid Services decided to revoke $200 million in annual funding to the embattled Martin Luther King Jr.-Harbor Hospital, which serves one of Los Angeles County's lowest-income communities. The hospital, which was subsequently closed, lost its accreditation in 2005 after repeatedly failing to meet minimum standards for patient care. In May of 2007, the hospital made headlines when a 43-year-old woman died on the floor of the emergency room lobby vomiting blood and "writhing in pain" for 45 minutes. According to news reports, staff ignored her, except for a janitor who cleaned up the blood as she vomited. This is a stark example of the differing levels of quality of care available to US residents.
Similarly, a report by The Opportunity Agenda concerning health disparities in New York State found that health care resources are inadequately distributed across New York's diverse communities, leaving many neighborhoods with the most health needs - disproportionately low-income and communities of color - with the least health care resources. Key findings, include:
- Almost 60% of New York zip codes lack adequate access to primary care physicians who accept Medicaid patients and one-quarter of New York City residents lack a primary care doctor, leaving them without a medical home and health care that helps them be and stay healthy.
- Low-income communities and communities of color in New York City have the fewest OB/GYN providers; and, not coincidentally, the highest percentage of babies born with low birth weight.
- Two-thirds of recent hospital closures and downsizing in New York City affected hospitals that served mostly people of color, African- Americans, Latinos and Asian-Americans.
The Health Care Gender Gap
In a similar focus on gender disparities in health care, the National Women's Law Center (NWLC) published two companion reports, Women and Health Coverage: The Affordability Gap and A Framework for Moving Forward, which document both the particular difficulties women face in accessing quality and affordable health care and the existence of disparities among women across racial, ethnic, and income lines, as well as evaluates health care reform strategies as they impact women's health care needs.
As the NWLC reports in The Affordability Gap, although women are more likely to be insured than men, women face unique challenges obtaining insurance and face greater challenges affording care even with insurance. The reasons are many: women earn lower wages and have more difficulty affording coverage and cost-sharing; women are less likely to have access to employer-sponsored insurance; and, women are more likely to be covered through their spouse's insurance, creating health insecurity and instability. And, yet, the health needs of women are much different than men, which exacerbate challenges in securing coverage. Women need more health care than men yet face higher out-of-pocket costs as a share of their income, leading more women to avoid needed health care because of cost than men.
And, yet, as detailed in A Framework for Moving Forward, many proposals on the table today, particularly those from the Right, do not directly address the specific needs that women face - for comprehensive and affordable coverage. For example, Association Health Plans would permit small businesses to purchase coverage across state lines, potentially creating more options for women working in small businesses. However, such proposals allow insurers to get around state benefit mandates and AHPs could deny coverage to businesses with large percentages of women employees. Health Savings Accounts are paired with high deductibles, which pose a greater barrier to health care for women than they do for men, who typically have fewer health needs yet higher incomes.
Furthermore, in Making the Grade on Women's Health, a national and state-by-state report card, the NWLC shows that women's health is deteriorating and we are falling further behind in addressing women's health care needs. According to the NWLC, only three of 27 benchmarks have been met - percentages of women achieving regular mammograms, annual dental visits and screenings for colorectal cancer. A key finding is that women need better access to affordable and comprehensive health insurance in order to get necessary care. The racial and ethnic disparities already cited in this Dispatch are similar among women of different races and ethnicities. While a staggering 38% of Hispanic women and 23% of African-American women do not have coverage, 17% of white women are uninsured, a lower but still concerning statistic in its own right.
To address these issues - women, in general, earn less and have more difficulty affording health care - reform must consider the unique challenges women face as a gender, as well as the unique challenges faced by women of color. To that end, the National Women's Law Center has launched a new initiative and website, Reform Matters: Making Real Progress for Women and Health Care, a new initiative encouraging women to be "active and vocal advocates in the fight for progressive health care reform" and providing key tools and strategies for them to do so.
Strategies to Eliminate Disparities
As states continue to move comprehensive health care reform and move towards quality health care for all, reform must include concrete steps to eliminate health disparities; achieving universal coverage is only part of the answer. In Identifying and Evaluating Equity Provisions in State Health Care Reform, The Opportunity Agenda and Families USA examine health care reform efforts in five influential states - California, Illinois, Massachusetts, Pennsylvania, and Washington - and evaluate how well they are addressing the unique needs of specific groups.
The report did identify significant missed opportunities to achieving equity in health care, including:
- no state plans achieved truly universal coverage or access;
- many vulnerable groups are not eligible for new state expansions, including single and childless adults, undocumented immigrants, and some legal immigrants;
- "community-empowerment strategies" are uncommon - where policies seek to strengthen community input and allocate resources more deliberately; and,
- only Washington State has sought to strengthen Certificate of Need -- a regulatory process that requires hospitals and other health care facilities to obtain state approval before offering certain new or expanded services -- by linking it to a "statewide health-resources strategy" for addressing disparities and ensure distribution of services.
From their analysis, The Opportunity Agenda and Families USA identified six broad strategies to make health care more equitable. These strategies are:
Improving access to health care - limiting barriers such as insurance cost-sharing for low-income populations, reduce cultural and linguistic barriers.
Improving the quality of care- instituting pay for performance, measuring performance, provider quality report cards, and collecting data to shed light on disparities and inform policy.
Empowering patients - supporting patient education, health literacy, training and reimbursement of community health workers to help empower patients to take more control of their health and health care.
Improving the state health care infrastructure - a lack of insurance is compounded by a lack of resources in low income communities and communities of color. States can invest in health care institutions serving underserved communities, improve incentives for providers to practice in underserved communities and require cultural competency training.
Improving state program and policy infrastructure - gaining community input in decisions concerning allocation of resources will better align resources, establishing state offices of minority health, and strengthening Certificate of Need programs that regulate new hospital construction.
Adopting or strengthening policies to address social and community-level determinants of health - reducing social and economic gaps across racial, ethnic, and income lines in education, housing, criminal justice, environmental policy and other areas will help reduce health care disparities and achieve equity. State agencies should be coordinated and actively work to ensure policies and programs do not adversely impact the health of residents across demographic factors.
Policy Options to Reduce Health Care Disparity
Despite these challenges, states are taking a leading role in working to eliminate health disparities. A growing emphasis on cultural competency training for providers and ensuring interpretive services is helping to empower patients to take more control of their health needs. Recent state initiatives to ensure coordination among state agencies and the development of long-term plans to identify and eliminate disparities are improving the health care infrastructure and shedding light on the needs of underserved populations. While more needs to be done, the growing awareness of health disparities will help result in greater adoption of many key policy options described below.
Access to Health Care
- Coverage Expansions: As we've written previously, there are a number of ways to increase access to health coverage. These include raising income eligibility limits for Medicaid, the State Children's Health Insurance Program and public/private expansions that provide sliding-scale premium subsidies. As The Opportunity Agenda and Families USA stress, coverage expansions need to be designed in ways that do not include costly co-pays or other financial barriers to accessing care.
- Access to "Medical Homes": Having a medical home, often a primary care setting where one's health care needs are looked after and care is coordinated, can reduce or eliminate health disparities. Patients with a medical home are more likely to get reminders to receive preventive care, such as screenings for cholesterol, breast cancer and prostate cancer. A recent study from Partnership for Prevention shows that use of key preventive services by people of color is disproportionately lower than whites, even when socio-economic factors are accounted for, and increased use of these services could save 100,000 lives in the US each year. To promote medical homes, as the Commonwealth Fund reports, states need to reform primary care reimbursement by measuring and rewarding medical homes, testing care delivery models and maximizing the potential of health information technology.
- Cultural Competency Training for Medical Professionals: A 2006 report from the National Health Law Program discusses state efforts aimed at improving cultural competency education and training for health care professionals. Little knowledge of how to deal with patients from diverse socio-cultural backgrounds or provider stereotyping of patients can be mitigated through cultural competency education and physician reminders through electronic medical records. State initiatives include: legislation setting standards and expectations for providers and funding programs and initiatives that provide cultural competency training.
In 2005, New Jersey became the first state to enact a law, SB 144, to address the issue of equity in health care and cultural competency training of physicians. The law requires medical professionals to receive cultural competency training in order to receive a diploma from medical schools located in the state or to get license or re-license to practice in the state. Each medical school in New Jersey is required to provide this training.
California has taken several steps to ensure cultural competency across the state's health care infrastructure. In 2005, Assembly Bill 1195 requires mandatory continuing medical education courses to include cultural and linguistic courses. In the previous session, SB 853 was enacted requiring commercial health plans to ensure members' access to linguistic services and to report to state regulators steps being taken to improve the cultural competency of their services. Similarly, the state's Medicaid program, Medi-Cal, requires all health plans providing services for Medicaid patients to ensure their linguistic needs are met, including 24-hour access to interpretive services and documents in native languages.
- Elsewhere, Washington state enacted SB 6194 in 2006 requiring all medical education curricula in the state to include multicultural health training and awareness courses.
- Reducing Language Barriers: Mistrust, dissatisfaction, medication and correct-dosage mistakes, patient falls, injuries during treatment, skin breakdowns, equipment problems - patients with Limited English Proficiency (LEP) are 19% more likely to suffer from these kinds of adverse events than English-speaking patients (49% to 30%). Health system complexity can present barriers to patients with Limited English Proficiency, low health literacy, or little knowledge of Western health care. Hospitals can remove barriers by using multi-lingual signage, providing interpretive services, and making record of a patient's native language and communication needs.
- Increasing Workforce Diversity: The health care workforce is under-represented by people of color, yet people of color are more likely than white physicians to practice in federally designated underserved areas, to see patients of color and to accept Medicaid patients. As the Commonwealth Fund reports, racial concordance of patient and provider leads to greater participation in care and greater adherence to treatment.
- Minnesota enacted legislation to proactively recruit medical students in underserved areas. The University of Minnesota-Duluth uses a federal Area Health Education Center Program grant to run area health education center programs that recruit medical students in communities of color and raise awareness of medical careers.
- States can create incentive or loan repayment programs for medical students who work in medically underserved areas or loan. Because people of color are more likely to work in underserved communities, these programs support workforce diversity.
The Health Care Infrastructure
- States' Office of Health Equity: At least 35 states have a state office to address disparities. Pennsylvania recently established the Office of Health Equity to coordinate efforts and collaborate with other state agencies, academic institutions and community based groups to eliminate health disparities in the state.
Supporting the Safety Net and Community Health Centers: As discussed, communities of color and low-income communities in the US often lack adequate access to services. Working to fill the gap are community health centers, which have grown substantially over the past several years and serve a disproportionate percentage of non-white communities. To provide for medical homes and improve quality of care, Health Centers with dedicated chronic care management programs showed dramatically better quality of care than those without strong intervention programs - programs aimed at warding off disease and helping patients stay healthy.
Data Collection and Chronic Care Management: Patient registries as part of disease and chronic care management programs should include race, ethnicity and language, as well as medical conditions. These programs rely on strong communication both inside and outside of the traditional office visit. Providers should be able to effectively communicate with patients with limited English proficiency or limited health literacy. But data collection should not be limited to only disease management programs. To develop effective programs for eliminating disparities, accurate and timely data is essential. Some state data collection systems categorize all racial and ethnic groups as only black or white. As the Commonwealth Fund reports, the accepted categories for data collection are: American Indian or Alaska Native; Asian; black or African-American; Native Hawaiian or other Pacific Islander; white; and ethnic group: Hispanic or Latino.
Disparities Reduction Task Forces and Long-Term Planning
- As reported by The Opportunity Agenda and Families USA, Washington State in 2006 created the Governor's Interagency Coordinating Council on Health Disparities (SB 6197). The Council is charged with understanding how state policies perpetuate or help eliminate disparities and, at the request of a legislator or the Governor, conduct a "health impact review" to determine if a legislative or budgetary proposal will improve or worsen health disparities.
- Michigan, similarly, has been working to reduce disparities through its Health Disparities Reduction Program. Primary strategies are:
- Funding community-based organizations to target health conditions in specific groups. Tomorrow's Child targets infant mortality among African-Americans in Detroit, and the Arab-American and Chaldean Council targets cancers among Arabs in Dearborn and Detroit. Funding comes from state dollars and federal preventive health block grants.
- In 2005, the state required Medicaid managed care organizations (MMCO) to develop and implement programs to reduce health disparities. MMCOs held cultural competency workshops for high-volume providers and re-organized websites to be more navigable.
- The state launched efforts to analyze plans' data across racial categories to identify disparities and develop programs to reduce them.
- Colorado legislators in 2007 enacted SB 242, which charges the state's Office of Health Disparities with educating the public about health disparities and cultural competency, supporting local public health systems, promoting diversity in the health care workforce, and reducing language barriers. The legislation creates two bodies to monitor disparities, coordinate the state's response and develop strategies to eliminate disparities, and, importantly, creates a grant program to support community-based efforts. Grants will go to support prevention and early detection strategies and treatment for cancer, heart and lung disease, and diabetes. A recent study shows that eliminating disparities related to diabetes alone would save taxpayers in Colorado more than $80 million each year.
Building Momentum to Address Disparities - A Massachusetts Case Study
A June 2007 report from Families USA shows how comprehensive health care reform created an environment within which disparities advocates and local and state leaders in Massachusetts could increase media and public awareness of health disparities and move legislation to eliminate them.
The 2006 Massachusetts comprehensive health care reform created several bodies to monitor health disparities and advance steps to eliminate them. As Families USA reports, these steps were an important step, but advocates believed it was necessary to enact more substantive policies. Health Care for All, which played a lead role in passing the 2006 reform, led the creation of a broad coalition to address equity and justice in health policy, called the Disparities Action Network (DAN).
Recently, the Network achieved a key goal with the inclusion in budget negotiations of language creating an Office of Health Equity. As Health Care for All Massachusetts reports, the office would be charged with creating a health disparities report card with regional data and work with community health centers to eliminate disparities. Families USA identifies several lessons learned that disparities advocates in all states can take away, including:
- Heightened media and public attention to health care reform surrounding major legislation presents a wave for disparities advocates to ride, upon which they can increase awareness of health disparities and use the momentum to advance disparities legislation.
- A strong and diverse disparities coalition, including both disparities advocates and advocates for expansion, can coordinate the collective strength and outreach capability of these various groups to raise public awareness of disparities and advance their agenda through the public and the legislature.
- Policy is an important tool to reducing disparities, along with direct services. Disparities are a systemic problem and require systemic answers.
- The complexity of health disparities, which arise from socioeconomic, cultural and physical environmental conditions, requires program and policy solutions beyond just access and quality. Environmental and social determinants of disparities must be addressed.
In order to achieve quality and affordable health care for all, reform must include concrete steps to reduce health disparities. Ensuring access to coverage is only part of the answer. Leading states are reducing barriers to quality health care for people of color by requiring cultural competency training of medical professionals, recruiting a diverse workforce, eliminating language barriers in hospitals, collecting data to inform policies and providers, providing more funding to community health centers, and improving chronic disease management programs by making them more responsive to the needs of people of color as well as low-income and underserved communities.
Health disparities reflect and perpetuate the inequity and injustice that permeate American society. Eliminating health disparities will help create equal opportunity for all Americans in all sectors of our society.