The State of Opportunity

Local Progress in Tackling Health Disparities

Earlier this month the Atlas Project at the Dartmouth Institute for Health Policy and Clinical Practice released a report documenting the state of health inequalities in the United States.  The report (which was previously mentioned in a post on The State of Opportunity blog) titled “Disparities in Health and Health Care among Medicare Beneficiaries” can be accessed here. 

The report calls attention to the fact that health care reform is not only about expanding insurance coverage and improving efficiency standards for health spending – it is also about addressing the unequal access to and the quality of health care in the U.S.  As the Dartmouth report articulates, health disparities are widespread and extensive.  There are higher rates of obesity and smoking among African Americans than there are among whites; this leads to blacks experiencing higher rates of diabetes and cardiovascular disease than whites do.  Blacks have poorer access to primary and specialty care, and this limits their ability to manage any chronic illnesses they might have.  Blacks also have poorer access to advanced surgical solutions, and are more likely to face unfavorable, last resort treatments like leg amputation for diabetes.

Monday Health Blog Roundup

•    This past week there have been a number of news articles on HIV and the racial disparities among those who are infected.  The Washington Post reported that the number of young homosexual men diagnosed with HIV has risen 12%.  The largest increase of 15% was among young African American men (compared to a 9% increase among young white men):

Previous studies have found that gay black men on average have fewer sex partners, are less likely to use drugs and are no more likely to have unprotected intercourse than gay white men. Consequently, their higher rate of infection does not appear to arise from riskier behavior.

Instead, it reflects the higher prevalence of HIV -- as well as syphilis and gonorrhea, which increase a person's susceptibility to HIV -- in the black population.

Despite this negative news of increasing health disparities between whites and African Americans, there was also a positive step in the battle against HIV.  According to the New York Times, the New York City Health Department has announced a three year plan to give an HIV test to everyone living in the Bronx:

While Manhattan has long been the epicenter of the AIDS epidemic in New York, with the highest incidence of both AIDS and H.I.V., the virus that causes it, the Bronx, with its poorer population, has far more deaths from the disease. Public health officials attribute this to people not getting tested until it is too late to treat the virus effectively, thus turning a disease that can now be managed with medication into a death sentence.

Though the story does not mention the demographic population of the Bronx, 35.6% of Bronx residents are African American, a much larger percentage than the percentage of African American Manhattanites (who make up only 17.4% of the borough’s population).  Expanding HIV testing in the Bronx is an important part of combating the racial disparities among those with HIV and helping end the upward trend of HIV rates among young African Americans. 

•    The Kaiser Health Disparities Report has a story on a House bill to reduce allowable lead levels in paint.  The bill, which just unanimously passed the House Financial Services Committee, aims to lower the number of children exposed to lead-based paint (many of whom are poor, minority children who live in older homes):

According to bill sponsor Rep. Keith Ellison (D-Minn.) and other lawmakers, despite a 1992 law that restricted the use of lead-based paint in houses, hundreds of thousands of children are exposed to excessive levels of lead, which can cause brain damage and other serious health problems.

•    The HealthBeat blog has a posting on how progressives should incorporate cost control into their discussion of health care reform.  Without cost control on the agenda of health care reform, it will be difficult to bring Americans who are most concerned with rising costs of health care on board:

That is why I believe that progressives must begin talking about the high cost of care, and how we need to wring the waste out of the system to make truly effective, high quality care affordable for everyone. Don’t let the conservatives dominate the debate about spending. If they do, they’ll take the conversation in the wrong direction.

The Opportunity Agenda believes that addressing the issue of cost is crucial to a fruitful, productive discussion on health care reform. For example, 52% of American workers do not enroll in employer insurance plans because they are too costly.  Premiums for family coverage have increased by 59% since 2000.  Decreasing these costs, in addition to addressing the problems of unequal access and unequal quality, is absolutely necessary in order to reform the health care system in the U.S.  To learn more, take a look at The Opportunity Agenda fact sheet, Health Care and Opportunity.

•    For a touch of humor, check out a recent posting on Disease Management Care Blog.  Along with a YouTube video of Canned Heat’s “Let’s Work Together” there are new lyrics encouraging all to work together to reform health care in the U.S.:

Together we'll stand
Divided we'll fall
we need more data
the… cash flows will stall
let’s work together
Come on, come on
let’s work together
Now now people….
Because together we will stand
Every doc, all the vendors and Plans!...

Thursday Immigration Blog Roundup

•    Last week, The Opportunity Agenda's Immigration Blog Roundup linked to an Of América posting about the Guantanamo-like treatment of individuals held at ICE detention facilities.  The latest Breakthrough video titled “Death by Detention” documents individuals’ stories of their horrific experiences at these facilities.  The video has been posted on numerous pro-migrant blogs, including Standing FIRM.

•    Immigration News Daily has posted an editorial titled “No Getting Around the Wall.”  The editorial, which originally appeared in La Opinión, condemns the Supreme Court for refusing to hear a challenge to the Department of Homeland Security decision to build a wall along the U.S.-Mexico border.  Numerous Arizona environmental organizations have claimed that the DHS ignored 36 environmental protection laws in deciding to construct the wall:

Once again, as in the case of the "mismatch letters" and other similar actions, the Bush Administration is trying to improvise an immigration policy without taking into account the consequences triggered, the rights violated, or the injustices committed.

Building a wall along the border is bad policy. As long as it continues, the courts have the responsibility to stop the abuse of authority that stems from its implementation.

•    Wednesday’s Immigration Equality Blog posting calls attention to a USA Today story describing how U.S. citizens are suing the DHS after they were detained and interrogated by ICE workers.  The plaintiffs in the suit claim that they were subject to racial profiling and that ICE officials violated workers rights in the process of detaining people.  One immigrant worker, Jesus Garcia, was thrown in jail because of the ICE agents’ “mistake”:

ICE agents went to Jesus Garcia's home on April 16 in conjunction with a raid on a nearby Pilgrim's Pride poultry processing plant, where he worked marinating chicken meat. Garcia, from Mexico, has been a legal permanent resident for a year and a half. When about 10 ICE agents and local sheriff's deputies knocked on his door, they told him he was using the wrong Social Security number, says his wife, Olivia Garcia, a U.S. citizen.

Though Garcia showed the agents his green card, they handcuffed him and jailed him. He was released a day and a half later after agents told him he wasn't the person they wanted, he says. He had spent the night in jail. "He said it was pretty bad," Olivia says. "People were crying and screaming."

•    A story that appeared in Medical News Today and was initially reported by the Ventura County Star examines California Governor Arnold Schwarzenegger’s decision to save $87 million in the state’s Medicaid program (“Medi-Cal”) by cutting funding for health care services to approximately 91,000 immigrants each month:

Immigration advocates say the cuts would prevent patients from obtaining preventive care, thus increasing emergency department visits and costs. State Assembly and Senate budget committees have voted against the proposals and other Medi-Cal changes, but state officials say they will continue to push for the cuts.

Monday Health Blog Roundup

•    An Associated Press story that appeared in numerous publications last week discussed the American Medical Association’s position on a tobacco bill currently before Congress.  The bill would, among other things, ban flavors in cigarettes.  Marketing campaigns for flavored cigarettes (such as mint, clove and vanilla cigarettes) usually target young people, and by banning the use of these flavors, Congress hopes to decrease smoking among youths.  However, the AMA is supporting the menthol exemption that the tobacco industry pushed.  African-American smokers typically prefer menthol-flavored cigarettes, and menthol cigarette advertising campaigns have traditionally targeted black communities.  The AMA has been criticized for supporting the exemption, since it leaves African-American smokers subject to manipulative marketing strategies:

Menthol cigarettes such as Kool were marketed during the 1960s in advertising campaigns targeting urban blacks, according to the National African American Tobacco Prevention Network. That group withdrew its support from the tobacco control bill last month over the menthol exemption and found allies in the former health secretaries.

The exemption harms the black community, said Robert McCaffree of the American College of Chest Physicians, the group that introduced the AMA proposal.

•    A recent posting on DMI Blog addresses the importance of making health equity a central focus of health care reform, particularly in the 2008 Presidential election.  If political leaders do not pay attention to the equality element of health care reform, the disparities in health care access and quality will not be dealt with:

It's a painful fact: people of color in the United States live sicker and die quicker--from the premature cradle to the early grave. According to the U.S. Department of Health and Human Services (DHHS), African Americans can still expect to live 6-10 fewer years than their white counterparts, and they have the highest rates of death due to diabetes; heart disease; and breast, lung, and colon cancer than any other ethnic group. The numbers are similarly grim for Latinos and other minority groups.

•    Yesterday’s posting on The Health Care Blog brings up the similarities between the U.S. health care system and the Dutch health care system, and the notion that the U.S. could learn from the Dutch in its health care reform efforts.

•    Another posting on The Health Care Blog mentions The Talking Cure, the “Healthy Conversations” project that the research organization Demos has launched.  The project is designed to engage stakeholders in and outside of the National Health Service and discuss how to improve health care in the UK.

•    Thursday’s New York Times had a story on a government proposal to facilitate improved access to prescription drugs for low-income Medicare beneficiaries.  The Bush Administration introduced the proposal as part of the settlement in a national class action lawsuit brought by people who are unable to get access to the drugs they need:

Under the proposed settlement, filed Thursday with the United States District Court in San Francisco, federal Medicare officials promised to speed up the process of providing extra help to low-income people, who now could qualify within days, rather than weeks or months.

60th Anniversary of the Universal Declaration of Human Rights

Yesterday was the 60th Anniversary of the Universal Declaration of Human Rights, a ground-breaking document initiated and championed by the United States and Eleanor Roosevelt.  Frank Knaack of the ACLU Human Rights Program writes about the significance of the Universal Declaration in the United States and where we are today in fulfilling the promise of "the foundation of the modern human rights system":

The UDHR laid the foundation for a system of rights which are universal, indivisible, and interdependent. The UDHR does not differentiate between civil and political rights on one side and economic, social, and cultural rights on the other. It realizes that in order to properly enjoy one set of rights, you must also be able to enjoy the other. As is often noted, one cannot properly exercise their right to vote, think, or live if they have no food, housing, or basic health services. It is from these principles that the modern human rights treaty system (international human rights law) was born.

[...]

While much of the focus on the human rights record of the U.S. government is in the context of foreign policy and the so called “war on terror,” including the rendition, torture, and indefinite detention of foreign nationals, and vis-à-vis its high rhetoric on spreading freedom and democracy throughout the globe, it is of equal importance to look at the state of human rights at home. From the government’s inadequate response in the wake of hurricanes  Katrina and Rita; to pervasive discrimination against racial minorities in the areas of education, housing, and criminal justice, including death penalty; to imposing life sentences without the possibility of parole on juveniles; to abhorrent conditions in immigration detention facilities, it is clear that the U.S. government has failed to abide by its international obligations.

While the struggle for universal human rights is far from over, there has been great improvement in the fight to bring human rights home. More and more non-governmental organizations (NGOs) and individual activists in the U.S. are utilizing the human rights framework in the domestic advocacy and litigation. At the latest session of the U.N. Committee on the Elimination of Racial  Discrimination (the treaty body that monitors state compliance with the Convention on the Elimination of All Forms of Racial Discrimination), there were more than 120 representatives from U.S.-based nongovernmental organizations (NGOs) in Geneva, Switzerland, who briefed the Committee members and provided additional information to counter the misrepresentations and omissions of the official U.S. government report on the state of racial discrimination in the U.S. This information, in turn, led the Committee to conclude that the U.S. should make sweeping reforms to policies affecting racial and ethnic minorities, women, indigenous people, and immigrants. The Committee’s recommendations garnered domestic and international media attention, and were followed by a three week official visit to the U.S. by the U.N.  Special Rapporteur on Racism. This visit by the Special Rapporteur further opened up opportunities for domestic NGOs to utilize the international human rights framework, as was evidenced by the successful public education and media outreach campaigns conducted by local NGOs throughout the US during this visit. As this shows, human rights advocacy has become an effective tool for social justice advocates in the U.S. to use to press for change and enhance the protection of basic human rights.

The Opportunity Agenda is dedicated to bringing human rights home.  We are proud to work with coalitions such as the U.S. Human Rights Network and the Human Right to Health Capacity Building Collaborative to build the national, state, and local will to make human rights a real and effective tool for realizing American opportunity.

U.S. Human Rights Reports and Tools from The Opportunity Agenda:

• Human Rights in the U.S.: Opinion Research with Advocates, Journalists, and the General Public
• Unequal Health Outcomes in the United States: A Report to the U.N. Committee on the Elimination of Racial Discrimination
• Policy Brief: Healthcare, Opportunity, and Human Rights at Home

Monday Health Blog Roundup

•    Last week, Governor M. Jodi Rell signed legislation that established a “Commission on Health Equity” in the state of Connecticut.  The act is a crucial step forward in ensuring that all people in Connecticut have equal and appropriate access to health care.  It also explicitly recognizes that health is a human right:

Whereas the General Assembly finds that: 1) Equal enjoyment of the highest attainable standard of health is a human right and a priority of the state...

The Universal Health Care Foundation of Connecticut, an organization that works to achieve quality, affordable health care for every resident of Connecticut, applauded the Governor’s decision to sign the legislation.  Foundation President Juan A. Figueroa said in a statement (that can be accessed here):

The new commission represents an important first step toward addressing racial and ethnic health care disparities, a serious problem facing our state. Dismayingly, the health and health care trends of our state’s African American and Latino communities reflect a troubling national trend.  There is much work to be done here in Connecticut and throughout the nation.

•    The New York Times reported that a study conducted by researchers at Dartmouth University and released by The Robert Wood Johnson Foundation found that there are wide racial and geographic disparities in the treatment of Medicare beneficiaries.  Race and place of residence can have a significant impact on the level of care a patient receives:

For instance, the widest racial gaps in mammogram rates within a state were in California and Illinois, with a difference of 12 percentage points between the white rate and the black rate. But the country’s lowest rate for blacks — 48 percent in California — was 24 percentage points below the highest rate — 72 percent in Massachusetts. The statistics were for women ages 65 to 69 who received screening in 2004 or 2005.

In all but two states, black diabetics were less likely than whites to receive annual hemoglobin testing. But blacks in Colorado (66 percent) were far less likely to be screened than those in Massachusetts (88 percent).

The Robert Wood Johnson Foundation has committed $300 million to improve health care quality in regions across the United States.  Foundation President and CEO Risa Lavizzo Mourey said:

Despite having the most expensive health care system in the world, patients are subject to too many mistakes, too much miscommunication and too much inequity. As a result, too many Americans aren’t receiving the care they need and deserve. This unprecedented commitment of resources, expertise and training will turn proven practices for improving quality into real results in communities across America.

•    On June 15, an article that appeared in The Philadelphia Inquirer reported that health care for female veterans “lags behind” the care that male veterans receive at VA facilities.  The review of the facilities, which was conducted the Department of Veterans Affairs, found that there are clear needs for more equipment and more physicians trained in women’s care, as well as improved access to outpatient services for female veterans.

•    A recent posting on the Health Care Renewal Blog refers to a number of stories regarding the recent actions of UnitedHealth Group, the largest for-profit health insurance or managed care corporation in the U.S.  For example, the Hartford Courant recently reported that UHG had to refund $50 million to the small businesses in New York that it overcharged.  The Courant claims:

[Eric] Dinallo [the superintendent of the New York State Insurance Department] and New York Governor David A. Paterson said the settlement came about because insurers have the right to raise rates at will while regulators are empowered to review them only retrospectively. The agreement was reached after UnitedHealth's Oxford Health Insurance unit spent 70.6 percent of premium revenue on medical benefits in 2006, less than the 75 percent minimum.

•    Matthew Holt, blogger from The Health Care Blog and organizer of the Health 2.0 User-Generated Healthcare Conference, was recently interviewed on MDMG and gave his thoughts on the impact of Health 2.0:

The impact of the ability to search into other people’s experiences and match with cases online in these communities is going to be substantial. A doctor may see one or two of these cases in a lifetime, but there may be 20 or 30 or 1,000 of these people, and if you can put them all together in one group, it makes the information much easier to find.

GoogleHealth: Improving Access to Health Care, or Destroying People’s Privacy?

With the emergence of GoogleHealth and Microsoft HealthVault, many people have been speculating as to whether the ability of individuals to post their health records online will be beneficial or harmful.

For individuals who are interested in accessing their health records, there is a huge benefit to having them be available online: you can access them at a very low or no cost.  Through GoogleHealth, you can request your health records through any one of the GoogleHealth Partners.  Before this service was available, most people, particularly those who did not have easy access to a primary care physician, were forced to request records from their insurance companies.  Those who did not have insurance or a regular doctor were left with few options.  However, with GoogleHealth, all individuals have the ability to build their own health profile.  For those who did not have access to their health records, creating their own online profile makes the process much easier. 

GoogleHealth also enables you to search for physicians and hospitals online, and provides locations as well as directions for them.  This aspect of GoogleHealth could have the very positive effect of improving people’s access to primary care.  Depending on how many doctors and hospitals register with Google, many people could be able to find a health care provider in their area and have access to a service they might not have otherwise known about. 

As The Opportunity Agenda discusses in numerous reports, specifically Unequal Health Outcomes in the United States and Identifying and Evaluating Equity Provisions in State Health Care Reform, there is a significant and widespread problem of unequal access to health care in the U.S.  It is crucial that everyone, especially a website like Google that is able to reach so many people, commits to tackling this problem.  If Google can convince many primary care physicians and facilities, particularly those in deprived communities, to register on the website, then people will be able to find more health care facilities, not just the ones that are in their immediate area.  This could do a great deal to improve people's access to health care.

Six Years Later, Health Disparities by Race and Ethnicity Persist

Amidst the energy and momentum for health care reform in the United States, it is important to remember that getting an insurance card into everyone's wallet is not the same as guaranteeing equal access to quality health care.  Recent studies have shown that, in America, health is not just about having insurance or paying bills: it's also, unfortunately, about the color of your skin.

The Lancet, a journal of global medicine, published an article this last Saturday (free registration required) on persisting racial and ethnic disparities in health, six years following the groundbreaking Institute of Medicine study, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.  The Opportunity Agenda Research Director and primary editor of the 2002 IOM study, Brian Smedley, is quoted in the Lancet article:

“As the report's study director, I was pleased to see that Unequal Treatment prompted a sober discussion in health policy, academic, and political circles”, Brian Smedley, former senior programme officer at the US Institute of Medicine, wrote in a blog to mark the latest issue of the journal Health Affairs, which includes research on health disparities. “But ultimately the report failed to prompt passage of significant new federal legislation or spur the Department of Health and Human Services to adopt its core recommendations. As a result, little has been done, in my view, to systematically address the problem.”

Citing some of the papers in the latest issue of Health Affairs, called Disparities: Expanding the Focus [paid subscription required], he said that some of the most shocking health care gaps that were not documented when Unequal Treatment was published, were found in mental and oral health care. Meanwhile, the biggest gains in life expectancy occurred among the best-educated Americans.

Because of the failure of HHS to adopt recommendations to reduce disparities, and the stalling of major legislation in Congress to address disparities, many of the inequities identified half a dozen years ago are still prevalent.  In very real terms, this means that communities that often have the most need for quality health care are the ones that receive the least of such care. 

Monday Health Blog Roundup

•    The House Ways and Means Health Subcommittee is holding a meeting on disparities in health and health care in the United States.  The hearing will take place on Tuesday, June 10 at 10:00 am in the main committee hearing room, 1100 Longworth House Office Building.  Individuals not scheduled to give oral testimony at the hearing are able to submit a written report to the Committee.  Subcommittee Chairman Pete Stark (D-CA) said upon announcing the hearing:

While we can make a big dent in addressing disparities by getting everyone covered, we must recognize that these issues transcend access to coverage.  We must pay special attention to ensure access to care and good outcomes for everyone, regardless of race, gender, or ethnicity.

The Opportunity Agenda has been extensively involved in researching health disparities in the U.S.  We collaborated with a number of organizations in publishing the CERD Working Group Report to the U.N. Committee on the Elimination of Racial Discrimination, titled “Unequal Health Outcomes in the United States.”  The report, which can be accessed here, details the extent of racial and ethnic disparities in health care treatment and access, the role of social and environmental determinants of health, and the responsibility of the state. 

In addition, The Commonwealth Fund issued a report, "Identifying and Evaluating Equity Provisions in State Health Care Reform," that was written by Brian Smedley and Betty Alvarez of The Opportunity Agenda along with Rea Panares, Cheryl Fish-Parcham, and Sara Adland from Families USA. The Report, which analyzes how recent state health care reforms have targeted health inequalities and disparities, can be accessed at The Commonwealth Fund website.

•    On June 3 The New York Times published an article discussing the recent Urban Institute study on the introduction of mandatory health coverage in Massachusetts.  The study, which was published in the Health Affairs and can be accessed here, found that Massachusetts was able to cut its uninsured population in half within the first year of instituting mandatory health coverage.  The study also found that Massachusetts made significant gains in expanding access to routine preventative care.  The NY Times analysis of the study emphasizes that:

Indeed, contrary to national trends, the share of residents receiving insurance through their employers increased in Massachusetts by nearly three percentage points from fall 2006 to fall 2007. Nationally, the percentages of employers that offer benefits and of workers who receive them have been sliding steadily throughout the decade.

•    A recent Trusted.MD posting titled Where Shall We Turn For Leadership in REAL Wellness?  contemplates the future of REAL Wellness in the U.S.  According to Trusted.MD , health and wellbeing education has seen more expansion and innovation in countries in Europe, as well as Brazil, Australia and Japan, than it has in the U.S.  Wellness education, which is an integral part of improving the quality of life of all Americans, is not focused on as much in the U.S. as it is in other countries.  Trusted.MD says:

The whole point of wellness should be to promote/facilitate and otherwise boost this mission - better life quality. Corporate wellness programming today, at least in the US, is weighed down with features designed to reduce company health insurance costs. These efforts are well and good and should be continued. However, expanded endeavors would follow if wellness were recognized as larger than a health concern. With a greater perspective and higher expectations, the orientation would not be limited to testing, monitoring, lecturing, pressuring or even coaching and mentoring.

"Brave New Laws" by Alan Jenkins at OurFuture.org

Check out The Opportunity Agenda Executive Director Alan Jenkins' new column, "Brave New Laws," at the Campaign for America's Future blog, Blog for Our Future.  Jenkins discusses the need for new, proactive laws that recognize what technological advances and scientific research have clearly demonstrated--that many Americans are still at risk of discrimination:

A growing body of research shows that, while old fashioned bigotry has declined, subconscious stereotypes and implicit biases continue to pose daunting barriers to equal treatment in health care, education, and the criminal justice system, among other sectors. Particularly compelling is the work of Harvard’s Project Implicit (https://implicit.harvard.edu/implicit/), which shows that we all carry around subconscious biases based on race, gender, religion, and other human characteristics that often influence our decisionmaking. The Institute of Medicine at the National Academies, among others, has found that such biases can influence health care and other decisions, including by professionals who have no conscious intention to discriminate.

Despite this established research, the courts have interpreted the Constitution’s Equal Protection Clause, as well as Title VI of the Civil Rights Act of 1964 (which bars racial discrimination in federally funded programs), to address only intentional efforts to harm people of a particular group. Because that reading fails to respond to the realities of modern exclusion, Congress should amend Title VI, and the next Administration should advocate a reading of the Constitution that embodies the Framers’ intention to eradicate discrimination, in its evolving forms, from our nation’s institutions.

Read the full column here.