Disparities

COVERAGE: Poor and Uninsured Wait for Lung Cancer Treatment (And We Don't Mean In Canada)

Joanne Kenen — Tue, 03 Nov 2009 16:57:00 -0500

We get really tired of hearing foes of health reform go on and on about waiting lists in Canada and how it's rationing... And how nobody in the United States lacks care because they can always go to the emergency room. We know that yes, people in other wealthy industrialized countries sometimes wait for elective procedures, but here in the United States people -- particularly the poor and the underserved or the uninsured -- do plenty of waiting and postponing even when lives are at stake. (And how many people do you know who get cancer diagnosis, surgery, chemo, radiation and follow up care in their local ER?)

The American Cancer Society has made the point during the health care debate that uninsured and underinsured people get diagnosed later and die sooner. A new study in the Journal of Thoracic Oncology (which we read about on Health News Daily) found that the length of time a newly diagnosed lung cancer patient has to wait for treatment depends in part on whether they are treated at a public (safety net) or private hospital, whether they are insured, their age, and their race.

Researchers at the University of Texas Southwestern Medical Center analyzed data on 482 patients diagnosed with non-small cell lung cancer. They found that 59 percent of patients treated at a public hospital had advanced (stage 3) lung cancer, compared with 37 percent of patients treated at a private hospital. They also found differences in patient populations at public and private hospitals in terms of age, race and socioeconomic status. This is a lethal disease, and earlier detection can't always save lives. But the prognosis by stage three is pretty grim.

"This study demonstrates that in a contemporary U.S. health-care system, intervals among suspicion, diagnosis and treatment vary widely and are predominately associated with system variables such as insurance and hospital type," said study author Dr. David E. Gerber. "An organized and timely approach to subsequent diagnostic and therapeutic measures may benefit these individuals and reduce this health-care disparity."

Disparities are very complicated and the health reform legislation won't wipe them out overnight, although it will help. But health reform will address a lot of the life and death inequities about coverage -- who gets timely care and who does the waiting.

QUALITY: Health Reform Will Work To Eliminate Health Disparities

Meredith Hughes — Wed, 19 Aug 2009 14:47:00 -0400

With so much ruckus over what's in the House health reform bill, what's not actually in the bill and what imaginary horrors it will bring about , we'd like to highlight a feature not getting much attention -- namely a push to reduce or eliminate health disparities.

Here are some of the highlights from the House Tri-Committee bill, HR 3200:

Medicare will reimburse for "culturally and linguistically appropriate services" to promote access for Medicare beneficiaries with limited English proficiency. (NOTE: This is not a codeword for covering illegal immigrants, as some foes of reform have contended).
Reducing health disparities would be an explicit goal in the HHS Secretary's national priorities for quality improvement in health care.
The Secretary of HHS and the Institute of Medicine would look at how providers utilize cultural and linguistic support services, design a demonstration program to pay for these services, and study the impact on reducing health disparities.
Establish a CDC grant program for community-based prevention and wellness. Significantly, "At least 50% of these funds must be spent on implementing services whose primary purpose is to reduce health disparities."

Many health advocates are excited about these provisions in the bill. Last week, our Health Policy Program Director, Dr. Len Nichols, discussed them at an event held by The National Partnership for Action to End Health Disparities.

To combat health disparities, we need to start by acknowledging and understanding them -- and making their reduction a high priority in legislation. It is a central part of access equity, and it's germane to quality of care. Our reformed health care system should not tolerate disparities.

What kind of problem do health disparities present? The IoM in its 2002 study, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, found that all other things being equal -- insurance status, income, age, and severity of conditions -- medical treatment varied by race. This means that racial and ethnic minorities are more likely to stay sick even when they seek care. They don't get the same quality of care, they are less likely to have health insurance coverage, or they have limited or substandard coverage -- the kind that leaves them with bank-breaking deductibles when they do get sick. No single factor explains this phenomenon, but patient attitudes, provider biases, and unconscious stereotypes all play a role.

Linguistic and cultural barriers can frustrate patients and doctors. Not all doctors are great at breaking down medical jargon into terms their patients can understand -- even when both speak the same language. Even for skilled translators, it can be daunting to communicate the complexities of medical diagnosis, treatments and follow up procedures. Doctor and patient should be able to work as a team to accomplish mutual goals for patient care. That means, too, the ability to understand and communicate a patient's values and goals of care. The linguistic and cultural support services provided by health reform legislation will help.

As we've mentioned previously, a recent Health and Human Services study found that racial and ethnic minorities face higher rates of disease, especially chronic disease such as cancer, diabetes, or HIV. Of the approximately 46 million uninsured, about half are poor and one-third suffer from chronic disease, according to healthreform.gov. For more detailed statistics on health disparities, check out the group health profiles on the Office of Minority Health website or the Kaiser Family Foundation's statehealthfacts.org.

The challenges of health disparities deserves our attention. We've written frequently about how it is morally unacceptable for hard-working American to be sicker, die younger, and receive poorer care than his or her fellow Americans because they lack insurance. We cannot allow our fellow Americans to suffer from such problems more frequently simply because they are a member of a racial or ethnic minority.

If we want to eliminate health disparities, we must commit to an honest dialogue. Race, inequality, and discrimination are complex subjects that can be difficult to discuss, but they cannot be glossed over or ignored. Honest dialogue includes discussions about eating and exercising habits, possible incentives, as well as community-enhancing investments in access to fresh foods and walking-friendly physical environments. (The Robert Wood Johnson Foundation's Commission to Build a Healthier America has done a lot of work on healthy neighborhoods, and we've written about it several times, including here.)

As Americans, we have to commit to solving this problem on all levels -- in both the private and public sector, and especially in our communities. The provisions in the House health reform bill are a good step forward, but they alone aren't going to solve the problem of health disparities.

QUALITY: Health Reform That Works for Women and Families

Meredith Hughes — Fri, 19 Jun 2009 13:16:00 -0400

Everyone has a stake in the health care reform debate. As the National Partnership for Women & Families pointed out in a recent issue brief, the stakes are particularly high for women.

Women face difficulties accessing and affording care. Recently, reports by both the White House and the Kaiser Family Foundation shed light on women's health disparities. Women are often the primary health care decision makers for their families, so they experience first-hand the strain brought on by problems in the current system. According to a recent poll by Consumer Reports, 76 percent of women support or strongly support health reform that would give all uninsured Americans access to affordable, quality health care.

The National Partnership has a number of policy suggestions to relieve the strain the health care system places on women and families. Here are some highlights:

Affordability. During the past decade, health care costs have risen faster than wages. This is a problem for women, since they utilize care more frequently than men but, on average, have lower incomes. The Partnership suggests the federal government should provide tax credits to help low- and middle-income families purchase health insurance and establish out-of-pocket payment caps to ensure no individuals or families are paying more than 10 percent of their income for coverage. Medicaid should be expanded to cover families with incomes at 150 percent of the federal poverty level and childless low-income adults. Individual mandates should be implemented with a public information campaign and a progressive penalty structure that does not place unfair strain on low-income individuals.

Choice and Cost. According to the National Partnership, women are more likely to work for or own small businesses. Small businesses are less able to afford health insurance for their employees, especially during troubled economic times. Currently, private insurers are legally permitted to deny women coverage or raise premiums based on age, gender, or health status. The National Partnership calls for guaranteed coverage for everyone, regardless of pre-existing conditions, and a limitation on age and lifestyle rating for premiums.

Coverage. Women need regular check-ups and screening for reproductive health cancers, during and beyond their reproductive years. A comprehensive coverage package should provide women with maternity care, well-woman and well-child visits, cancer screening, and reproductive health services.

Quality. Even when insurance status, income, age and health condition are considered, women and minorities tend to receive poorer quality care. The National Partnership calls for patient-focused delivery system reform that emphasizes coordinated care, patient choice, and routine assessments to continually improve quality and eliminate disparities.

Successful health care reform should alleviate the burden placed on women and families by the current system. The health needs of women, children, and families are not competing needs in health care reform, but are instead all aspects of a comprehensive solution that works for everyone.

QUALITY: Report Highlights Relationship Between Gender, Race, Ethnicity and Health Disparities

Meredith Hughes — Fri, 12 Jun 2009 13:50:00 -0400

Previously, we've discussed health disparities and barriers to care American women face. We've looked at health disparities facing racial and ethnic minorities. At an event this week, the Kaiser Family Foundation put these issues, literally, on the map. The report, Putting Women's Health Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level, examines the relationship between gender, race, ethnicity, and health on a state-by-state and national basis.

The report looked at three dimensions of indicators:

Health Status, such as overall wellness, and chronic or mental illness.
Access and Utilization, such as coverage and regular check-ups.
Social Determinants, such as income and education.

Though all women experience some level of difficulty with health disparities, the report found women of color were worse off than white women on almost all health indicators.

The report compares the state averages to the national data. Few states were consistently better or worse than the national average. Across all three dimensions, only Georgia, Maryland and Virginia were better than average on all three. Montana, South Dakota, Indiana, Arkansas, Louisiana, and Mississippi were worse than average on all three dimensions.

Different racial and ethnic populations each face a different set of challenges. According to the report:

Hispanic women had consistent difficulties with access to and utilization of care
Black women had the worst rates for indicators of health and social determinants
Asian American, Native Hawaiian and Other Pacific Islander women had lower rates of preventative screenings (for example, 34 percent had not had a recent mammogram, in comparison to only 25 percent of white women)
White women generally had higher rates of smoking, cancer mortality and psychological distress.

The report contains a wealth of information (although not all the policy implications have been analyzed). For more details, check out Kaiser's Women's Health Disparities on statehealthfacts.org, which features an interactive map. To see the human face of these statistics, the video Women at Risk: A View from the Safety Net documents a day at the Arlington Free Health Clinic in Virginia, where women, many of whom are recently unemployed, seek care. As Agency for Healthcare Research and Quality director Carolyn Clancy stated at the Kaiser event, most data on health care access and quality has a brief time lag, so it is likely that the current economic recession has worsened the disparities.

In her closing remarks at the Kaiser event, Marsha Lillie-Blanton, the foundation's senior adviser on Race, Ethnicity, and Health Care, emphasized the significance of women's health in society. The challenges faced by women, especially racial and ethnic minorities, are the same challenges faced by the families, children, and communities that women support. The persistency of these health disparities stem, in part, from a lack of knowledge about the nature of the problem, and about potential policy solutions. This reports is a step forward in understanding the nature of health disparities, but it is up to policymakers to take on disparities as an aspect of comprehensive health reform.

Though disparities reflect long-standing societal inequalities, Lillie-Blanton stated that we should work towards a future where health and access to care are no longer defined by racial, ethnic, and economic divides. "States doing better than average give us confidence about what is achievable now," she added.

QUALITY: More Likely to Get Sick, Less Likely to Have Access to Care

Meredith Hughes — Wed, 10 Jun 2009 16:09:00 -0400

More evidence about the health care crisis facing poor people and minorities. Health and Human Services Secretary Kathleen Sebelius this week released a report, Health Disparities: A Case for Closing the Gap, examining widespread and worrisome disparities. Low-income Americans and racial and ethnic minorities experience higher rates of disease, face more barriers to accessing care, and often lack access to routine or preventative care.

Chronic disease is a particularly big problem. In general, minority populations are more likely than white populations to experience obesity, cancer, diabetes, or HIV. While about 39 percent of the general population suffers from chronic disease, the rate for African Americans is 48 percent. Seven out of 10 African Americans between the ages of 18 and 64 are overweight or obese. They are also more likely than other racial or ethnic groups develop cancer or be HIV infected.

Access is also a problem. Low-income people and minorities are much less likely have insurance. Of the approximately 46 million uninsured, about half are poor and one-third suffer from chronic disease. Even for those with access to care, the care is less consistent. Disjointed, inconsistent care frequently leads to poorer health, and for those with chronic disease, a lack of routine care and prevention can lead to costly emergency room visits and more serious health problems. Low-income Americans are three times less likely to have a consistent source of medical care.

Minorities are less likely to receive routine screening for cancer. That means when the disease is finally detected, it is in a more advanced and often fatal stage. Low-income women are 26 percent less likely to have a mammogram. Vietnamese women are about half as likely to get routine pap smear for early detection of cervical cancer—and Hispanic and Vietnamese women experience cervical cancer at twice the rate of white women. The White House addressed the health care problems faced by women in an earlier report, Roadblocks to Health Care.

These disparities are only growing worse in the current economic crisis, underscoring the importance of health reform that is affordable, accessible, and emphasizes comprehensive, preventative care for everyone. Recently, the Kaiser Family Foundation has taken a look at state and national health disparities in terms of gender, race, and ethnicity. We'll post on the briefing, Putting Women's Health Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level, later this week. As Secretary Sebelius said in a press release,

Minorities and low income Americans are more likely to be sick and less likely to get the care they need...These disparities have plagued our health system and our country for too long. Now, it's time for Democrats and Republicans to come together to pass reforms this year that help reduce disparities and give all Americans the care they need and deserve.

COVERAGE: Women Pay More, Get Less, in Health Care

Meredith Hughes — Wed, 13 May 2009 19:33:00 -0400

We've noted the disparities in cost and coverage that women face in the health insurance marketplace before. The Department of Health and Human Services and the White House are taking notice too. Their report Roadblocks to Health Care: Why the Current Health Insurance System does not Work for Women highlights some worrisome statistics about women and health care.

Women often have a more difficult time finding health care coverage through an employer. Only 52 percent of women, as opposed to 73 percent of men, are employed full-time. Of those women, only 48 percent are able to get employer-sponsored health coverage, versus 57 percent of men. Women are twice as likely to be on a spouse's plan, and single women are two times more likely to be uninsured than married women.

Purchasing health care coverage on the individual market is also problematic for women. The anti-discrimination laws that protect women with employer-sponsored coverage do not apply to the individual market—so women pay premiums based on pre-existing health conditions, age, and gender. Not only is maternity excluded from coverage in most individual plans, women are generally charged more for coverage during their reproductive years. For example, a 22-year-old woman can be charged 1.5 times more in premiums than a 22-year-old man, all other factors constant. In some states, women can also be denied coverage if they have been victims of domestic violence.

In total, about 21 million women and girls are uninsured. The lack of access to care providers is a significant problem as women need routine screenings such as pap smears and mammograms. The report said that women are more likely to have such chronic conditions as joint pain, headaches, or psychological distress—and they are more likely to struggle to get access to that care. Nationwide, 52 percent of women report delaying or avoiding care because of cost concerns, while only 39 percent of men had the same problem. Nearly half of women who do seek care report problems paying their bills, and one-third had to use up their savings, go into debt, or give up basic necessities to pay medical bills.

"We know that the status quo just isn't working," Health and Human Services Secretary Kathleen Sebelius said in an online statement about the report. "All Americans are suffering under the current system, but women are paying a particularly heavy price."

HEALTH REFORM: Hard Times in Rural America

Paul Testa — Fri, 08 May 2009 20:08:00 -0400

Our nation's health care crisis affects all Americans in different ways. A new report from the Department of Health and Human Services details the health care challenges faced by the some 50 million people living in rural America.

Hard Times in the Heartlands is an excellent collection of resources for understanding what hits home for rural Americans. The report makes several key points.

First, the report notes that the economic downturn has struck rural America especially hard. Rural areas are losing jobs at faster rates than the rest of the economy. Now, nearly one in five (8.5 million) of our nation's uninsured live in rural areas.

Farming plays a central role in the rural economy and more than 80 percent of the farms in the U.S. are run by a sole proprietor. This creates a unique situation in which nearly a third of all farmers purchase health insurance on the individual market–compared to just 8 percent nationally. Without the benefits of the large group market, these individuals face higher premiums, increased cost-sharing, and a greater likelihood of being denied coverage because of their health status or a pre-existing condition. On average, rural residents pay 40 percent of their health costs out-of-pocket with one in five spending more than $1,000 out-of-pocket.

Access to care is also an issue. Shortages of both primary care and specialists are particularly acute in rural America. There are half as many specialists per 100,000 residents in rural areas compared with urban areas, and a third as many psychiatrists.

The issues of access, coverage, and affordability conspire to accentuate disparities between rural and urban populations. Rural Americans are more likely to have chronic conditions like obesity and hypertension, but less likely to receive the recommended care and preventive screenings for conditions like diabetes and breast cancer.

The heartland may be hurting, but their cries have not gone unheard. Already the stimulus funding for health IT and broadband connectivity should help ease some of the access problems in rural America. Proposals to create a new health insurance marketplace can help provide Americans, such as rural farmers, who purchase insurance on the individual market with more choices at lower costs.

Health reform must address the challenges of cost, coverage and quality shared by all Americans, but in a manner that reflects the diversity of America and adapts to needs of different populations.

QUALITY: Report Finds Link Between Education Level and Health in Adults

Meredith Hughes — Thu, 07 May 2009 19:36:00 -0400

So how's your health? And have you earned any good degrees lately?

American adults just aren't as healthy as they could be, a recent study by the Robert Wood Johnson Foundation Commission for a Healthier America found. Between 2005 and 2007, a little more than 45 percent of adults ages 25 to 74 reported being in less than very good health. And education levels seems to be a factor.

The study, Reaching America's Health Potential Among Adults: A State-by-State Look at Adult Health, found that the greatest indicator of health was education level. Nationally and on a state-by-state basis, people with higher levels of education were more likely to be healthy. Adults with a high school education were more likely to be unhealthy than college graduates. Adults who had not graduated from high school were more than three times more likely to be unhealthy than college graduates. The disparity between education level and health varied from state to state. Delaware was the best (only nine percent difference between overall adult health and overall health of adult college graduates) and California (with a nearly 20 percent difference) was the worst.

In addition to education, the other important indicators of adult health are household income level and race or ethnicity. While adults take primary responsibility for their own health, factors such as income, education level, and racial discrimination can combine to create significant environmental barriers and make it more difficult for adults to practice healthy habits. It is, for example, far more difficult to quit smoking if you are surrounded by advertising for cigarettes, and it is more difficult to get the recommended amount of physical activity if there aren't any recreational centers or safe places to walk in your neighborhood. This phenomenon is visible right here in DC, where noticeable health disparities in life expectancy exist between metro stops.

As the RWJF report demonstrates, people with knowledge and resources -- what we get through education -- can more easily access adequate care for themselves and their children, including heathy food, exercise, and regular doctor visits. The report also finds that Americans could, and should, be a lot healthier overall. When even those who have the resources to be healthier are missing the mark, it's time to take a step back and look at what's gone wrong. For health care reform to be successful, we need to change the way we think about our own health—not just fixing the problems in the system itself, but also creating a larger culture of prevention and wellness that will make all of us happier, healthier, and wealthier in the future.

HEALTH REFORM: Building A Healthier America

Paul Testa — Thu, 09 Apr 2009 21:52:00 -0400

Earlier this week, the Robert Wood Johnson Foundation's Commission to Build a Healthier America released a new report titled: "Beyond Health Care: New Directions to a Healthier America."

The first post we ever wrote for this blog was for the launch of the Commission to Build a Healthier America, which was created to "raise awareness of the factors beyond medical care that affect a person's health and recommend viable short- and long-term strategies to help improve the health of all Americans." They made their point brilliantly with a chart that looked like the D.C. metro-map showing the large variations in average lifespan in just a few miles between metro stops. Those disparities reflected differences in wealth, education and environment—in short, the social determinants of health beyond medical care. Over at RWJF's health reform blog, Jim Marks, a pediatrician and director of the RWJF's health group, elaborates:

What do we mean by, beyond medical care? There is a ton of evidence that shows where and how people live, where they go to school, how we go about the daily business of our lives—all of that has an effect on our health. And overall, these effects are HUGE. And the thing is, we tend to frame the daily business of living, and how it affects our health, solely as a matter of personal choice and personal responsibility.

Personal choice does play a role in my health and everyone's health. I can decide, for example, to have a bowl of ice cream for dessert instead of fruit. People can make choices about being physically active and avoiding risks like smoking.

But at the same time, many of us have fewer choices than others. If it's already hard to say no to the bowl of ice cream or the cheeseburger, how much harder is it if there's no grocery store with good produce or farmers' market in your area? If it's already hard to help your kids stay away from junk food, how much harder is it when schools are serving them unhealthy food and snacks—in effect teaching them that this is what they should eat?

Recognizing the shared responsibility of individuals and society to address this issue, the report identifies ways to encourage those choices that promote good health. Many of the recommendations focus on children—removing junk food from schools and ensuring kids are physically active for at least 30 minutes a day. One proposal calls on public-private partnerships to open grocery stores in communities without access to healthful foods. For example, Detroit, a city of 139 square miles, has just five full-service grocery stores. Maggie Mahar takes an extensive look at the report over at HealthBeat. We'd also suggest looking at the work Cass Sunstein and Richard Thaler have done on "nudges" or choice architecture, the way seemingly small, even arbitrary design decisions can have a large impact on the way we live and the actions we take. From smarter cafeterias, to providing vouchers for fruits and vegetables at farmers markets, they continue to document on Nudge blog, small changes that have the potential for big impact on the lives and health of individuals.

HEALTH CARE: Economic Crisis Worsens Racial and Ethnic Health Disparities

Kyle Noonan — Thu, 02 Apr 2009 12:32:00 -0400

The rising rates of unemployment and the growing numbers of uninsured people are exacerbating health disparities in low income and minority communities that already suffer from barriers to care and high rates of chronic disease. The Kaiser Family Foundation recently a hosted a webcast moderated by Cara James, Ph.D, the Foundation's Senior Policy Analyst on Race, Ethnicity, and Healthcare, to look at these all-too familiar patterns.

Howard University economist Dr. William Spriggs sketched out the economic backdrop. Nationally, the unemployment rate in February was 8.1 percent. For blacks, it's above 13 percent, and in Latino communities it ranges from 8 to 14 percent. Joblessness is a double-whammy, because it often means people also lose employer-sponsored health insurance. African-Americans are more likely to be on Medicaid, which is being squeezed in many states by the economic crisis (although the stimulus funds will help somewhat). African-Americans (even those with relatively high incomes) are being disproportionately hit by the mortgage and foreclosure crisis.

Adrienne Hahn, a senior attorney at Consumers Union, emphasized that we know that the uninsured get less care and suffer worse health outcomes (see the Moral Case for Reform on page 4). For African-American communities, already burdened by high rates of such conditions as diabetes, heart disease, and cancer, having a source of regular care to manage chronic disease is crucial. She said:

We know that minorities have higher rates of being uninsured. African-Americans, Latinos, and Asians have a higher propensity of being uninsured compared to whites. And we know that folks that are uninsured don't receive the same level of care as those that are insured. So, we're seeing them cutting back on care, reducing their medications, not visiting their providers more frequently, even for those folks who have chronic conditions.

Dr. Lauren Smith, the medical director of the Massachusetts Department of Public Health, pointed out how poverty shapes the environment and neighborhoods, which in turn create more obstacles to good public health.

The impact of social factors on the development of illness and the patterns of illness really is one that we are very aware of in the Department of Public Health and has well established in the literature in the terms of exposures to substandard housing, to differential rates of environmental air pollution and other kinds of exposures. The kinds of burdens of disease that low-income and minority folks carry with them before they even enter the healthcare system, even when they are insured.

Those things speak to the issues that the other panelists have raised in terms of what kind of neighborhood can you afford to be in, what kind of access to thingst hat promote health like physical activity in a safe environment, access to grocery stores. What's the proportion of liquor stores and fast food restaurants in your neighborhood? Advertisement for smoking and alcohol, those things are all what we would call the social factors that have a direct relationship both to the complex interplay of race and income in our communities.

So I would say that anything that has an adverse impact on the overall sort of social environment we know is going to ultimately have an impact on health because those social factors are such important drivers of health and well-being.

It's particularly worrying now, she said, when recession-driven budget cuts in her own state are affecting everything from tobacco prevention programs to services for the mentally retarded. And even though Massachusetts is the only state to have moved toward covering everybody, in really tough times like these even a $10 co-pay for a drug or doctor's visit can be tough to afford. And in the long run, it's not good health care, good policy, or good economics if people skimping on routine care or management of their conditions end up in the emergency room.

The speakers praised the funds for Medicaid and COBRA subsidies in the stimulus, as well as the Obama administration's expansion of the state children health insurance program. But they agreed that those steps were miniscule given the scope of the problem. The solution, they said, is comprehensive national health care reform that will meet the needs of all Americans, of all races and all incomes.