Eliminating Health Disparities

In 2000, the World Health Organization ranked the U.S. health care system 37th in the world despite spending more than any other country. This year, according to the U.S. Census Bureau, the U.S. is 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 White Americans. 

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 also found: White Americans have easier and more access to quality health care than people of color, including African-Americans, Hispanics, and Asian-Americans. In the U.S., 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.

This Dispatch deals with health disparities and what steps can and are being taken by states to reduce them 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 U.S. residents regardless of personal characteristics and circumstances.

More Resources

Valuing Families

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 Whites do have the lowest rate of uninsured, at 11% of the White U.S. population. The highest uninsured rate is in the Latino community, at 33%. For even those with health insurance, people of color are more likely to receive sub-par care, experience worse outcomes and are less likely to receive routine or necessary care than whites. 

The Kaiser Family Foundation's state health facts website includes a section on health status. Glaring disparities include:

• 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 U.S. 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 White Americans 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 physical access to quality health care services in lower income communities and communities of color; lack of racial and ethnic diversity in the health care workforce; lack of 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; low health literacy; and limited English proficiency. In addition to lack of physical access to quality health care, environmental factors lead to health disparities.  For instance, substandard housing conditions lead to increased diabetes risk among African-Americans, even after adjusting for other factors.

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. Recent events in Los Angeles bear this out.

Just last week, the federal Centers for Medicare and Medicaid Services decided to revoke $200 million in annual fundingto the embattled Martin Luther King  Jr.-Harbor Hospital, which has been an important symbol for African Americans since the racial tensions of the 1960's and serves one of Los Angeles County's lowest-income communities. The hospital, which lost its accreditation in 2005 after repeatedly failing to meet minimum standards for patient care, most recently made headlines in May 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 U.S. residents. 

Similarly, a report by The Opportunity Agenda about health disparities in New York State found that health care resources are inadequately distributed across New York 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, Latino and Asian Americans.

More Resources

Valuing Families

Strategies to Eliminate Disparities

As states continue to move toward comprehensive and universal health care reform, initiatives must include concrete steps to eliminate health disparities; achieving universal health care is only part of the answer. The Center for Health Equity Research and Promotion identifies key strategies for eliminating disparities. Along with improving the environments of people affected by health disparities, they are: (1) broadening access to quality health care and (2) increasing the cultural competency of health care providers.

Broadening Access to Quality Health Care:

A May 2007 Commonwealth Fund report comparing the performance of the fragmented U.S. health care system to systems in 5 other countries - Australia, Canada, Germany, New Zealand, and the UK - found the U.S.'s lack of a universal health care system to be the leading factor for its failure to achieve better health outcomes than these countries.  The U.S. came in dead last in comparisons of patient safety, efficiency, equity, and, of course, access. 

Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical home." It is not surprising, therefore, that the U.S. substantially under-performs other countries on measures of access to care and equity in health care between populations with above-average and below-average incomes.

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 White Americans, even when socioeconomic factors are accounted for, and increased use of these services could save 100,000 lives in the U.S. each year. 

Paying for Medical Homes: A barrier to providing access to medical homes is that primary care doctors are seldom reimbursed for coordinating care with specialists, being available after hours or by e-mail, or investing in health information technology. To promote medical homes, 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. 
Monthly payments to primary care practitioners for each patient in their care can be increased, with varying levels to account for patient needs and risk.  These payments would pay for coordinating health care among other practitioners, health information technology and be tied to reaching benchmarks.  Other expenses, tests, and screenings would still be reimbursed as they currently are.  States can lead in reimbursing for medical homes through Medicaid and other public or public/private programs.

Community Health Centers: As discussed, communities of color and low-income communities in the U.S. 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.

Chronic Care Management and Data Collection: 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 in 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 only to 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.

Cultural Competency:

Little knowledge of how to deal with patients from diverse sociocultural backgrounds or provider stereotyping of patients leads to lower quality of care. Language barriers can lead to longer stays and delays in receiving necessary or emergency care. Fostering a culturally competent health care system that reflects and serves the diversity of America must be a priority for health care reform.  Steps include:

Reducing Language Barriers: Mistrust, dissatisfaction, medication and correct-dosage mistakes, patient falls or injuries during treatment, skin breakdowns, and equipment problems - patients with Limited English Proficiency (LEP) are 19% more likely to suffer an adverse event 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 concordence 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. Because people of color are more likely to work in underserved communities, these programs support workforce diversity.

States Mandating 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. State initiatives include legislation that sets 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 licensed or re-licensed 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 required 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.   

More Resources

Valuing Families

Massachusetts - A Case Study for Building Coalitions and Advancing Policies to Eliminate Health Disparities

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 are important, 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).

After a series of meetings and brainstorming, the coalition developed House-2234, An Act Eliminating Racial and Ethnic Health Disparities in the Commonwealth. The bill centers around creation of a Health Equity Office which would coordinate the many programs and projects working to eliminate disparities, across the state.  In addition to the Office of Health Equity, the bill's measures include: several grant programs to support community agencies, hire community health workers, and fund community-based research; data collection coordination; health literacy promotion; promote diversity in the health care workforce; creation of an environmental health index to identify communities with high rate of death and illness; and a chronic disease management program improving wellness education.

Although the legislation is still in committee and the work of the DAN is on-going, 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.

More Resources

Valuing Families

Other State Initiatives

Colorado legislators this year enacted SB 242, sponsored by State Sen. Peter Groff (D), 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. Importantly, it also creates a grant program to support community-based efforts.  Grants will go to supporting 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. 

Michigan, similarly, has been working to reduce disparities through its Health Disparities Reduction Program. Four primary strategies include the following:

1. Funding has been made available to 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.
2. In 2005, the state required Medicaid managed care organizations 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.
3. The state launched efforts to analyze plans' data across racial categories to identify disparities and develop programs to reduce them.
4. Michigan's Department of Community Health, Health Disparity Reduction and Minority Health has developed a strategic framework for reducing racial and ethnic disparities in the state.

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.  

More Resources

Valuing Families

Conclusion

In order to achieve quality and affordable health care for all, health care 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, coordinating public and private programs that target disparities, 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.

Health disparities reflect and perpetuate the inequity and injustice that permeates American society. Eliminating health disparities will help create equal opportunity for all Americans in all sectors of our society.