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!...

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

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.

Disappearing Food

Rising rents are not only displacing New York residents but their food as well.  As the New York Times reports, the city of eight million now has just over 550 moderately sized supermarkets, defined as at least 10,000 square feet.

The dearth of easily available fresh food isn't confined to poor communities but these areas are disproportionately affected.  A Health Department study from last year specifically compared the Upper East Side with Harlem finding a vast disparity in access to healthy foods.  Harlem has twice as many bodegas, or corner stores, than the Upper East Side but these stores typically offer less healthy food.  Only three percent of Harlem bodegas even sell leafy green vegetables.  Expanding to other food options, 16 percent of Harlem restaurants serve fast food compared to only four percent on the Upper East Side.

Predictably, the result is Harlem residents are three to four times as likely to be obese or have diabetes.  Yesterday's NYT article features an excellent citywide map (see below) showing the correlation of low supermarket density and incidences of diabetes.  Pay particular attention to the Bronx and the intersection of Queens and Brooklyn.

You're Invited to a Hill Briefing on CERD and Health Inequality

Here's an event that folks interested in health equity and human rights might want to attend ...

Congressional Briefing on Health Inequality and the Convention on the Elimination of All Forms of Racial Discrimination (CERD)

The U.S. government recently filed a required periodic report to the United Nations on the nation's progress toward the elimination of racial discrimination. The report cited progress in many areas, including health and health care. The U.N. CERD Committee agreed with some aspects of the report but noted that the United States has failed to recognize and remedy instances where facially-neutral policies contribute to inequality in health and health care.

To address these issues, several dozen non-governmental organizations and individual scholars, under the leadership of the Poverty and Race Research Action Council, prepared a "shadow" report, Unequal Health Outcomes in the United States (available at http://www.prrac.org/pdf/CERDhealthEnvironmentReport.pdf), that illustrates instances of non-compliance with CERD in the right to health, health care access, and treatment, and outlines steps to correct them.

You are invited to a special briefing with some of the collaborators on this report to learn of the extent of racial inequality in health and environmental health, their causes, and actions that government can take to address them. This panel discussion, moderated by Brian Smedley of The Opportunity Agenda, will feature presentations from Katrina Anderson of the Center for Reproductive Rights, Steve Hitov of the National Health Law Program, Rea Pañares of Families USA, and Philip Tegeler of the Poverty and Race Research Action Council, and will take place on April 24 from 1:30pm - 3:00pm in room HC-8 of the Capitol. To RSVP for the briefing, please call or email Kara Forsyth of the Raben Group at (202) 223-2848 or KForsyth@rabengroup.com. All are invited, but seating is limited and priority will be giving to Congressional staff and members.

Unnatural Causes: Is Inequality Making Us Sick?

The United States is a vastly unequal country, not just in terms of income and wealth, but also in terms of access to opportunity - some communities have it, some don't.  And it turns out this inequality of opportunity hurts not just the poor or people of color who face a legacy of discrimination, but everyone in our society. That’s because inequality literally harms our health – people at every descending step of the socioeconomic ladder have worse health than those just one rung above, and societies characterized by high levels of inequality have poorer health than those that are more equal. 

Public health scholars have known this for quite some time. But now a new, powerful documentary series by California Newsreel promises to inform a far broader audience of the pernicious effects of inequality on health. This series, “Unnatural Causes,” is airing on PBS stations around the country, and tells the stories of real people – some poor, some middle class, some well-off – and how their access to opportunity affects not only their health, but the health of others in their communities. It shows how, for example, the health of nearly every resident of a small town in Western Michigan declined when a major factory closed, relocating the plant to Mexico where the company could pay workers wages one-tenth of those earned by the Michigan workers. It shows how subtle, persistent racism and social deprivation can lead to a higher incidence of low birth weight babies among black women. And it shows how a Pacific Island community’s health was compromised when the U.S. government uprooted it, disrupting traditional health and nutritional practices.

Cynics might suggest that inequality is a natural phenomena – some people are “winners,” others “losers” in a competition for resources. Or that attempts to solve – or even raise awareness of – these problems are un-American, and can lead only to radical strategies such as the redistribution of resources.

But addressing inequality doesn’t take a revolution. We can begin by asking ourselves what kind of country we want to be. If we believe – as most Americans do – that the United States should be a place where everyone has a fair chance to achieve their full potential, then we can focus on achievable policy solutions. These include things like providing access to high-quality early child education programs for all children, reforming school financing to equalize the quality of education in K through 12^th grade, and reducing financial barriers to college. We should also support living wage policies, so that no one who works full-time is forced to live in poverty, and expand the Earned Income Tax Credit program. We should provide job training so that more people can participate in high-growth jobs, such as in the technology industry. We should invest in affordable housing and fix the nation’s crumbling infrastructure. We should support housing mobility programs, so that people in low-opportunity communities can move to better neighborhoods, and invest in jobs and schools in low-opportunity communities so that they become attractive places to live and work.

These are but some of the ways to restore opportunity and improve our health. It doesn’t take a revolution – just a reconciling of our beliefs with our actions.