[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
ADDRESSING DISPARITIES IN HEALTH AND
HEALTHCARE: ISSUES OF REFORM
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON WAYS AND MEANS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
JUNE 10, 2008
__________
Serial No. 110-86
__________
Printed for the use of the Committee on Ways and Means
----------
U.S. GOVERNMENT PRINTING OFFICE
47-453 PDF WASHINGTON : 2009
For sale by the Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800;
DC area (202) 512-1800 Fax: (202) 512-2104 Mail: Stop IDCC,
Washington, DC 20402-0001
COMMITTEE ON WAYS AND MEANS
CHARLES B. RANGEL, New York, Chairman
FORTNEY PETE STARK, California JIM MCCRERY, Louisiana
SANDER M. LEVIN, Michigan WALLY HERGER, California
JIM MCDERMOTT, Washington DAVE CAMP, Michigan
JOHN LEWIS, Georgia JIM RAMSTAD, Minnesota
RICHARD E. NEAL, Massachusetts SAM JOHNSON, Texas
MICHAEL R. MCNULTY, New York PHIL ENGLISH, Pennsylvania
JOHN S. TANNER, Tennessee JERRY WELLER, Illinois
XAVIER BECERRA, California KENNY HULSHOF, Missouri
LLOYD DOGGETT, Texas RON LEWIS, Kentucky
EARL POMEROY, North Dakota KEVIN BRADY, Texas
STEPHANIE TUBBS JONES, Ohio THOMAS M. REYNOLDS, New York
MIKE THOMPSON, California PAUL RYAN, Wisconsin
JOHN B. LARSON, Connecticut ERIC CANTOR, Virginia
RAHM EMANUEL, Illinois JOHN LINDER, Georgia
EARL BLUMENAUER, Oregon DEVIN NUNES, California
RON KIND, Wisconsin PAT TIBERI, Ohio
BILL PASCRELL, JR., New Jersey JON PORTER, Nevada
SHELLEY BERKLEY, Nevada
JOSEPH CROWLEY, New York
CHRIS VAN HOLLEN, Maryland
KENDRICK MEEK, Florida
ALLYSON Y. SCHWARTZ, Pennsylvania
ARTUR DAVIS, Alabama
Janice Mays, Chief Counsel and Staff Director
Brett Loper, Minority Staff Director
______
SUBCOMMITTEE ON HEALTH
FORTNEY PETE STARK, California, Chairman
LLOYD DOGGETT, Texas DAVE CAMP, Michigan
MIKE THOMPSON, California SAM JOHNSON, Texas
RAHM EMANUEL, Illinois JIM RAMSTAD, Minnesota
XAVIER BECERRA, California PHIL ENGLISH, Pennsylvania
EARL POMEROY, North Dakota KENNY HULSHOF, Missouri
STEPHANIE TUBBS JONES, Ohio
RON KIND, Wisconsin
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Ways and Means are also published
in electronic form. The printed hearing record remains the official
version. Because electronic submissions are used to prepare both
printed and electronic versions of the hearing record, the process of
converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
Page
WITNESSES
The Honorable Donna M. Christensen, Delegate to Congress from the
United States Virgin Islands................................... 7
The Honorable Hilda L. Solis, Representative in Congress from the
State of California............................................ 16
The Honorable Madeleine Z. Bordallo, Delegate to Congress from
Guam........................................................... 21
The Honorable Jerry Moran, a Representative in Congress from the
State of Kansas................................................ 26
Marsha Lillie-Blanton, DrPH, Senior Advisor on Race, Ethnicity
and Healthcare, Kaiser Family Foundation....................... 39
Mohammad Akhter, M.D., MPH, Executive Director, National Medical
Association.................................................... 44
Deeana Jang, J.D., Policy Director, Asian & Pacific Islander
American Health Forum.......................................... 50
Anthony B. Iton, M.D., J.D., MPH, Director of Public Health &
Health Officer, Alameda County, California..................... 58
Sally Satel, M.D., Resident Scholar, American Enterprise
Institute...................................................... 65
Michael A. Rodriguez, M.D., MPH, Associate Professor and Vice
Chair of Research, UCLA, Department of Family Medicine......... 69
SUBMISSIONS FOR THE RECORD
The Honorable Hilda L. Solis, Statement.......................... 87
America's Health Insurance Plans, Statement...................... 94
American College of Physicians, Statement........................ 97
American Dental Education Association, Statement................. 100
American Dental Hygienists' Association, Statement............... 103
American Hospital Association, Statement......................... 109
Glenn Flores, M.D., Statement.................................... 111
National Black Nurses Association, Statement..................... 118
National Business Group on Health, Statement..................... 121
National Council of Urban Indian Health, Statement............... 122
Papa Ola Lokahi, Statement....................................... 126
Special Olympics International, Statement........................ 129
ADDRESSING DISPARITIES IN HEALTH AND
HEALTHCARE: ISSUES OF REFORM
----------
TUESDAY, JUNE 10, 2008
U.S. House of Representatives,
Committee on Ways and Means,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to call, at 10:07 a.m., in
room 1100, Longworth House Office Building, Hon. Fortney Pete
Stark [Chairman of the Subcommittee] presiding.
[The advisory announcing the hearing follows:]
ADVISORY
FROM THE
COMMITTEE
ON WAYS
AND
MEANS
SUBCOMMITTEE ON HEALTH
CONTACT: (202) 225-3943
FOR IMMEDIATE RELEASE
June 03, 2008
HL-26
Addressing Disparities in Health and
Healthcare: Issues for Reform
House Ways and Means Health Subcommittee Chairman Pete Stark (D-CA)
announced today that the Subcommittee on Health will hold a hearing on
disparities in health and access to care as part of the on-going health
reform hearing series. The hearing will take place at 10:00 a.m. on
Tuesday, June 10, 2008, in the main committee hearing room, 1100
Longworth House Office Building.
In view of the limited time available to hear witnesses, oral
testimony at this hearing will be from invited witnesses only. However,
any individual or organization not scheduled for an oral appearance may
submit a written statement for consideration by the Committee and for
inclusion in the printed record of the hearing.
BACKGROUND:
Over the years, numerous studies and reports have documented the
disparities that exist in health and access to healthcare for women and
racial and ethnic minorities in the United States. Despite research on
the causes of these differences, disparities persist in access to care,
quality of care, health outcomes, and prevalence of certain diseases
for particular subpopulations. A host of socioeconomic factors such as
place of residence, income, education, and insurance status contribute
to this troubling problem.
Though isolating the precise impact of gender, race, and ethnicity
is difficult, lack of health insurance coverage is undeniably one of
the most important barriers affecting access to care and the resulting
disparities that exist today. A 2007 report published by the Agency for
Healthcare Research and Quality (AHRQ) found that uninsured individuals
were six times more likely than insured individuals to be without a
usual source of care and nearly four times as likely to be without a
usual source of care for financial reasons\1\
---------------------------------------------------------------------------
\1\ http://www.ahrq.gov/qual/nhdr07/nhdr07.pdf
---------------------------------------------------------------------------
However, even when people have insurance coverage, both public and
private, disparities remain. The House-passed CHAMP Act, H.R. 3162,
attempted to improve the understanding of and address some root causes
of the persistent disparities in the Medicare population by improving
data collection across the program, increasing access to culturally and
linguistically appropriate care, and instituting several demonstration
projects to address issues affecting vulnerable beneficiary subgroups.
In announcing the hearing Chairman Stark said, ``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.''
FOCUS OF THE HEARING:
The hearing will focus on issues related to health disparities and
disparities in access to care, as well as possible solutions to address
these issues.
DETAILS FOR SUBMISSION OF WRITTEN COMMENTS:
Please Note: Any person(s) and/or organization(s) wishing to submit
for the hearing record must follow the appropriate link on the hearing
page of the Committee website and complete the informational forms.
From the Committee homepage, http://waysandmeans.house.gov/, select
``110th Congress'' from the menu entitled, ``Committee Hearings''
(http://waysandmeans.house.gov/Hearings.asp?congress=18). Select the
hearing for which you would like to submit, and click on the link
entitled, ``Click here to provide a submission for the record.'' Follow
the online instructions, completing all informational forms and
clicking ``submit''. Attach your submission as a Word or WordPerfect
document, in compliance with the formatting requirements listed below,
by close of business Tuesday, June 24, 2008. Finally, please note that
due to the change in House mail policy, the U.S. Capitol Police will
refuse sealed-package deliveries to all House Office Buildings. For
questions, or if you encounter technical problems, please call (202)
225-1721.
FORMATTING REQUIREMENTS:
The Committee relies on electronic submissions for printing the
official hearing record. As always, submissions will be included in the
record according to the discretion of the Committee. The Committee will
not alter the content of your submission, but we reserve the right to
format it according to our guidelines. Any submission provided to the
Committee by a witness, any supplementary materials submitted for the
printed record, and any written comments in response to a request for
written comments must conform to the guidelines listed below. Any
submission or supplementary item not in compliance with these
guidelines will not be printed, but will be maintained in the Committee
files for review and use by the Committee.
1. All submissions and supplementary materials must be provided in
Word or WordPerfect format and MUST NOT exceed a total of 10 pages,
including attachments. Witnesses and submitters are advised that the
Committee relies on electronic submissions for printing the official
hearing record.
2. Copies of whole documents submitted as exhibit material will not
be accepted for printing. Instead, exhibit material should be
referenced and quoted or paraphrased. All exhibit material not meeting
these specifications will be maintained in the Committee files for
review and use by the Committee.
3. All submissions must include a list of all clients, persons,
and/or organizations on whose behalf the witness appears. A
supplemental sheet must accompany each submission listing the name,
company, address, telephone and fax numbers of each witness.
Note: All Committee advisories and news releases are available on
the World Wide Web at http://waysandmeans.house.gov/.
The Committee seeks to make its facilities accessible to persons
with disabilities. If you are in need of special accommodations, please
call 202-225-1721 or 202-226-3411 TTD/TTY in advance of the event (four
business days notice is requested). Questions with regard to special
accommodation needs in general (including availability of Committee
materials in alternative formats) may be directed to the Committee as
noted above.
Chairman STARK. If our guests can find seats, we will
commence the hearing, the third in the series dealing with
issues that we may face in healthcare reform in the next
Congress; and I welcome our colleagues from the Congressional
Black Caucus, the Hispanic Caucus, the Asian Pacific American
Caucus and the Rural Caucus, I presume.
The purpose of the hearing is to learn more about
healthcare disparities, and there are still some people that
question whether these disparities exist. Hurricane Katrina
established that we have a two-tiered healthcare system, if
anybody else didn't believe that, one for those who are healthy
and well-insured and have money and one for everybody else.
Without Katrina, it is clear on a daily basis that minority
populations are disproportionately represented in the second
tier of everyone else.
We could do better; and, as we gear up for health reform,
we should try and craft solutions that reduce and hopefully
eliminate healthcare disparities. We must do more than simply
cover everyone. We should ensure access and the receipt of
healthcare to be determined by one's healthcare needs and not
their ability to pay, their place of residence or their skin
color.
We have to look at the role that Medicare has played in
reducing disparities among the elderly and the general
population and know that universal coverage is a necessary step
toward eliminating health disparities.
Before Medicare, minorities age 75 or over had an average
of 4.8 doctor visits a year compared to 7.5 for their white
counterparts. By 71, minority beneficiaries saw doctors at a
rate comparable to the rest of the United States, and Medicare
helped integrate the healthcare system as a whole which was
previously segregated, thereby improving access.
Just as a sidebar, there is absolutely no mention in
Medicare, either when you sign up for it or in the records we
keep, that deals with race and ethnicity. That may be a
problem. But it is an absolutely color, race, religion-blind
system that basically everyone over 65, I would say,
participate. Interesting to study that.
There are other economic factors that drive disparities.
Good health insurance is the single-most-important variable,
one affecting access; and the most important thing we can do to
reduce disparities is to get everyone covered. However, we
shouldn't stop there. Data from public and private programs
show that disparities persist even when coverage is available,
which is a reasonable doubt--I have lost my pages here.
Just last week, the Robert Wood Johnson Foundation released
new research showing that the quality of care and health
outcomes does vary dramatically depending on race; and that is
not acceptable. Last year's CHAMP Act included a number of
provisions to combat these problems in Medicare, and I am
pleased to see that Chairman Bachus may have included some of
these provisions in the legislation that will be before the
Senate this week.
But there is more to be done. We will hear from our
colleagues, from the Congressional Black Caucus, the
Congressional Hispanic Caucus, the Asian Pacific Caucus; and we
will discuss these issues generally with a mention of the
provisions of H.R. 3014, the Health Equity and Accountability
Act, that are, at least those provisions, under our
jurisdiction and a discussion of the CHAMP Act's disparity
provisions, which are still pending in the Senate.
The witnesses on the second panel will give us a broad
overview of health and healthcare disparities and offer
promising approaches to address them. The panel includes health
services research experts and those with firsthand experience
as physicians and administrators. Again, I want to thank the
witnesses today.
And I want to add one other comment for this panel and the
subsequent panels, and the Members of this Subcommittee I think
have heard me suggest this often. We don't--and I don't--let's
just say as a matter of my policy, to the extent that I can
direct the policy on this Committee--try to make decisions in
this Committee that will affect various procedures, drugs or
dollar payments for specific procedures.
We have MedPAC. We have CMS with experts. We aren't expert.
Most of the procedures and drugs we can't pronounce or spell,
and we don't have any idea what they do. And if we once started
to say, okay, Doc, we are going to pay X dollars for this
procedure, the line outside our office doors would go around
the block three times for other doctors wanting to get the
price of their procedures raised or manufacturers of exotic new
equipment wanting us to include it in Medicare. I think you,
our colleagues in the House and the public are better served by
our defaulting to professionals to advise us and for us to deal
with broader payment structures to the providers.
Because there will be discussions of--for example, I think
it is known that African Americans have a higher rate of
diabetes. I am not sure this Committee should get into the
issue of whether we should pay more for certain diabetic
procedures or not. I think the fact that we--if we recognize
that and can ask the public insurance companies, who are the
only ones we have any control over, to take that into account
and ask for studies, that is about as far as we go. And I just
wanted to add that as kind of a limitation that I think we have
in our jurisdiction.
Mr. Camp, would you like to address the panel?
Mr. CAMP. Yes. Thank you, Mr. Chairman; and I also want to
welcome all of our witnesses and thank them for coming. I look
forward to hearing your testimony today.
It is an unfortunate fact in this country that some people
don't have health insurance, and in previous hearings we have
talked about who these people are. And today we will hear
testimony about why some people have better access to quality
care than others, and we will find discrepancies and treatments
and outcomes do exist amongst certain populations. This
morning, several factors will be dissected and their role in
contributing to health disparities will be discussed.
The Robert Wood Johnson Foundation released a study last
week that examined geographical and racial disparities within
the Medicare Program. This study found that, on a variety of
quality indices, African Americans are less likely to receive
recommended care than whites within a given region. However,
the most striking disparities are found when comparing results
across States.
For example, 72 percent of African American women in
Medicare in Massachusetts received mammograms, while just 48
percent received them in California. Also, in all but two
States, African American diabetics are less likely than whites
to receive annual hemoglobin testing. But 88 percent of African
Americans in Massachusetts received the screening, compared to
just 66 percent of those living in Colorado.
It is clear having health insurance, even Medicare, will
not solve the disparities that exist within the healthcare
system.
We also need to address the variations in medical practice
and spending. In the time remaining, I do want to emphasize one
contributor that I believe should not be overlooked, and that
is a person's geographic location. I want to highlight this
area because I represent a large rural district. I routinely
hear from constituents with difficulty obtaining needed
healthcare because of a dwindling number of healthcare
providers in their communities. For those with chronic
conditions, it can be an incredible burden to follow prescribed
treatment plans when specialists are not local or are unable to
travel to see their patient in their home. Health disparities
as they relate to race and ethnicity are very important, and I
wanted to bring attention to the fact that disparities exist
across rural areas as well.
I thank the chairman for calling this important hearing,
and I look forward to working with him in a bipartisan manner
to address these critical issues.
Thank you. I yield back.
Mrs. JONES. Mr. Chairman?
Chairman STARK. Yes, Mrs. Tubbs-Jones.
Mrs. JONES. I would like unanimous consent to make a
statement, please.
Chairman STARK. Absolutely. Who would dare object to that
request?
Mrs. JONES. I don't know, Mr. Chairman. I knew you
wouldn't, though. That is why I love you.
Thank you. Mr. Chairman----
Mr. CAMP. Me neither.
Mrs. JONES. A short one.
I just want to, first of all, thank you for hosting this
hearing. Throughout the time that I have been on this
Committee, it has been an issue that has been very, very
important to me and more important to--as important to my
predecessor, Honorable Congressman Louis Stokes. I stand on his
shoulders trying to make sure that we continue to address the
issue of health disparities.
I won't try to go into a diatribe or anything like that.
There are a lot of issues that we must focus on in order for us
to assure that people, regardless of their race, color, sex,
religion, et cetera, et cetera, have access to healthcare. And
it is clear with all the studies that have been presented that,
even with the same kind of healthcare coverage, there is a
disparity in the access to that care, no matter where you
compare throughout the country; and we have to be careful to
compare Massachusetts with the rest of the world in terms of
the delivery of healthcare.
I thank you so very much for focusing on this issue, and I
appreciate the opportunity for my colleagues who have a lot of
experience and background in the area to be able to address
you. Thank you very much, Mr. Chairman.
Chairman STARK. If there are no other statements, I am
going to recognize the four Members before us and from left to
right. The first will be the Honorable Donna M. Christensen, a
delegate to the Congress from the United States Virgin Islands,
a physician and a Member. She will be followed by the Honorable
Hilda Solis from the wonderful State of California; Madeleine
Bordallo, a delegate from Guam; and Jerry Moran, a
representative from the State of Kansas, who seemed to have
avoided tornadoes in this last week and everybody else got
them. Right?
So, Donna, if you would like to lead off, and we will just
go down the line. The light will go on for 5 minutes. Without
objection, your prepared testimony will appear in the record in
its entirety; and we will get a chance after--you want to
summarize your statements or expand on them--to find out more
from you during the inquiry period.
Donna, proceed.
STATEMENT OF THE HON. DONNA M. CHRISTENSEN, A DELEGATE TO
CONGRESS FROM THE TERRITORY OF THE VIRGIN ISLANDS
Mrs. Christensen. Thank you. Good morning, Chairman Stark,
Ranking Member and Members of the Subcommittee.
This is a historic and very important hearing on an issue
of grave concern; and on behalf of my colleagues in the
TriCaucus, some of whom you will hear from this morning, who
have been seeking a hearing on this issue for a long time and
the millions of racial and ethnic minorities who are in poorer
health because of these disparities, I sincerely thank and
applaud you for this hearing. And I also want to thank my
colleague, Congresswoman Stephanie Tubbs-Jones, for her
leadership as well.
The central core of my testimony today, which is very much
abbreviated, is that health disparity elimination must be an
integral component of healthcare reform. And I also wanted to
make sure that the Subcommittee understands that the poor
health outcomes of minorities adversely impacts not just ours
but the health of everyone else in this country. It is also the
racial and ethnic health disparities, infant and maternal
mortality, to name just two, in African Americans, that are
responsible for our embarrassingly dismally national health
indicators compared to other countries in the world. Closing
these and other gaps will improve healthcare for everyone in
the country, improve our world standing and also reduce the
cost of healthcare. We therefore owe it to our fellow
Americans, all of them, to eliminate the racial, ethnic, rural
and gender health disparities that have plagued this country
for too long.
This hearing is a good first step. Passing the disparities
provisions of CHAMP would be another. And while the great
success achieved with the passage of CHAMP in the House was
unfortunately short-lived, it nonetheless started a process
that brought us here today where racial and ethnic health
disparities are front and center in the work of this very
important Subcommittee.
And before I turn to the three provisions of H.R. 3014, it
is also important to underscore that health or the lack of it
does not occur in a vacuum and to recognize the important roles
that the lack of universal coverage and the social determinants
of health play.
This bill, the healthcare Equity and Accountability Act
which the TriCaucus has introduced in the last three
Congresses, was developed with broad input both on and off the
Hill and with a comprehensive approach. Additionally, it tracks
key recommendations of the Institute of Medicine report on
equal treatment.
It is our position that H.R. 3014, introduced by my
colleague Congresswoman Solis, even though many of the
provisions are not under the purview of the Subcommittee,
should be the foundation upon which healthcare reform meets the
health and healthcare challenges of millions of racial and
ethnic minorities, women and rural populations.
The first issue I want to raise from the bill is the need
for health workforce diversity. At the outset, let me say that
the only way to truly achieve cultural and linguistic
competency in healthcare is to increase and dramatically so the
number of minority health providers at all levels.
Studies indicate that racial and ethnic minority healthcare
providers are more likely to serve racial and ethnic minorities
and other underserved communities. Additionally, providers of
the same background are more likely to be able to bridge the
gaps and the dynamics of the patient-provider relationship,
which translates into more trust and better outcomes.
Because of poor policy and budget priorities, racial and
ethnic minority providers are grossly underrepresented across
all aspects of the U.S. healthcare system. Together, African
Americans, Hispanic Americans, Asians and American Indians make
up only 9 percent of our nurses, 6 percent of our physicians
and 5 percent of our dentists; and racial and ethnic minorities
make up less than 10 percent of baccalaureate nursing, 8.6
percent of dental school and only 4.2 percent of medical school
faculties.
So the larger healthcare reform dialog must address these
severe deficiencies. Without diversity within our Nation's
healthcare system, millions of innocent, hard-working Americans
will continue to suffer poorer health outcomes and a lower
quality of life and be at risk for premature, preventible
death. Hopefully, in the next panel or in the question period,
the issue of disparate treatment of providers in communities of
color by CMS will be raised as well as the need for incentives
to providers serving in high-health-disparity communities.
The next issue is accountability. Critical to the health
disparity elimination and also to healthcare reform is
establishing accountability and evaluation as well as
coordination of effort in the elimination of health
disparities. The Health Equity and Accountability Act in that
bill would not only work to strengthen and expand existing
entities, such as the Office of Minority Health at the
Department of Health and Human Services and the National Center
on Minority Health and Health Disparities Research at NIH, but
we also propose the creation of offices of minority health
within CMS and FDA and to create an Office of Health
Disparities in the Office of Civil Rights at the Department.
These offices would help to ensure that Federal efforts and
Federal resources are better coordinated and more effective.
Third, I want to address the need for community centered
and comprehensive approaches to eliminating health disparities.
Our proposal for health empowerment zones, which enjoyed broad
and strong support in the health advocacy community, should
resonate in this Committee which created health economic
empowerment zones. They are included in H.R. 3014 as well as in
a stand-alone bill. These zones leverage expertise at the
community level as well as existing resources across all
Federal agencies to implement health disparity elimination
plans developed by the impacted communities with technical
assistance provided by the Department. Fully engaging the
community is essential. Not doing so is what I believe the
chief reason that prior efforts have been unsuccessful.
In closing, no discussion on health disparities before this
Subcommittee would be complete without including health
disparity elimination within the Medicare population, including
the health and quality of healthcare for those with end-stage
renal disease, a disease that has a disproportionate impact on
African Americans.
Additionally, while my position agrees with that stated by
the chairman earlier and remains that it is not good policy to
legislate medical practice, as the Subcommittee and the
Committee decides to move forward with proposed legislation I
urge doing so with provisions that acknowledge the differences
between small and large dialysis facilities and that factors
like race, ethnicity and geography affect the needs of many
patients.
In this case, one size does not fit all; and so we hope
that whatever approach you take would allow for the case-by-
case adjustments necessary to preserve the health and wellness
of the millions of Americans, a disproportionate number of
which are African American as well as other racial and ethnic
minorities and members of rural communities.
In closing, I want to again thank Chairman Rangel, Mr.
Stark, Ranking Member Camp and everyone else who made this
hearing possible.
Chairman STARK. Donna, thank you very much.
[The prepared statement of Mrs. Christensen follows:]
Statement of The Honorable Donna M. Christensen, Delegate to Congress
from the United States Virgin Islands
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman STARK. Hilda Solis.
STATEMENT OF THE HON. HILDA L. SOLIS, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
Ms. SOLIS. Thank you, Mr. Chairman and Ranking Member Camp
and my colleagues. I want to thank you for inviting me here to
present what we believe is one of the most important healthcare
access issues of our time.
Chairman Stark, you especially are to be commended for your
leadership in bringing the attention here to the Congress to
discuss healthcare disparities in communities of color; and I
am pleased to be here along the side of two very hard-working
Members of Congress that have been working on this issue for a
number of years, Donna Christensen and, of course, Ms.
Bordallo.
I am proud to serve as Chair of the Congressional Hispanic
Caucus Taskforce on Health and the Environment and as a Member
of the Energy and Commerce Committee on the Health
Subcommittee.
Although there have not been any hearings on healthcare
disparity since 2000, we know that communities across the
country have worked on these issues for many years.
Unfortunately, our most vulnerable underserved populations are
left behind in health policy.
Latinos, you know, are the fastest-growing ethnic minority
population in the country. We make up 14 percent of the
population, more than 42 million people across this country.
Thirty-four percent of Latinos are uninsured. According to a
study of 2007, the National healthcare Disparities Report,
Latinos fared worse than non-Hispanic whites for core
measurements on healthcare access and quality.
The growing diversity of our country means that patients
encounter barriers to receiving optimal healthcare services.
Currently, nearly 52 million people, or more than 19 percent of
the U.S. population, speak also a language other than English
at home. And in my district in East Los Angeles and the San
Gabriel Valley, about 60 percent of the population there are
Latino, and approximately 20 percent are Asian Pacific
Islander. Sixty-eight percent speak a language other than
English at their home.
Cultural and linguistic barriers contribute to reduced
quality of care, adverse healthcare outcomes and increased
racial and ethnic disparities. Just as an example, limited
English proficient individuals are less likely to understand
their medication instructions, less likely to use primary and
preventive care, and more likely to seek care in an emergency
room.
This is also why I support funding for outreach efforts by
persons such as community health workers. In our community,
they are known as promotoras. Community healthcare workers are
known to work and help enroll underserved populations in health
insurance programs and engage in health promotion and
prevention. Through their efforts, they can help reduce the
burden of asthma, diabetes, HIV and AIDS awareness in many
communities of color.
Given the existing health inequities of our healthcare
system, we produced H.R. 3014, the Health Equity and
Accountability Act. Among other things, the legislation would
create a Medicare demonstration project examining access to
care, costs and health outcomes for all beneficiaries. I am
proud that we have the support of more than 100 Members of
Congress and more than 300 organizations.
And I would like to ask the Committee if I could submit
this letter for the record.
Chairman STARK. Without objection.
[The information follows:]
******** COMMITTEE INSERT ********
Ms. SOLIS. Several provisions of H.R. 3014 have been
referred to this Committee. And I stated in my letter addressed
to Chairman Rangel and Ranking Member McCrery on October 23,
2007, I am eager to work with each and every one of you on
these provisions. Improving access to health insurance,
including Medicare, is a key part of reducing inequities in our
healthcare system. However, efforts that only address access to
insurance are not the solution for our ills.
The Institute of Medicare found large disparities among
Medicare beneficiaries. Spanish speakers, as an example,
enrolled in Medicare managed care plans have more difficulties
with provided communication and timeliness of care when
compared to non-Spanish speakers.
I believe Medicare, as the leading purchaser of healthcare,
has the opportunity and responsibility to reduce racial and
ethnic health disparities; and I am pleased that some of H.R.
3014's provisions were included in the CHAMP Act of 2007. We
worked very hard to try to bridge the gap between these
disparities.
I have urged the inclusion of provisions in legislation
last fall that would improve low-income Medicare beneficiaries'
access to services and reduced disparities within Medicare. And
on June 4, 2008, I led a letter from the Congressional Hispanic
Caucus asking for inclusion of the same provisions in the
Medicare package recently developed by the Senate Finance
Committee. I would like to also insert that letter for the
record with your permission, Mr. Chairman.
Chairman STARK. Without objection.
[The information follows:]
******** COMMITTEE INSERT ********
Ms. SOLIS. I strongly support the Medicare demonstration
project to improve communication between providers and limited
English proficient seniors, a study on Medicare patients for
language services, an Institute of Medicine report on the
impact of language services on the health of limited English
proficient beneficiaries and a report on Medicare compliance
with national standards on culturally and linguistically
appropriate services.
I also believe all the culturally and linguistically
appropriate standards should be adopted by Medicare and other
healthcare organizations, and I am pleased that Senator Baucus
recently introduced a Medicare package which includes some of
those provisions which are necessary to reduce these healthcare
disparities.
In closing, I would like to take the opportunity to note
that our health is the product of our social determinants of
health, including income, race, education, environment and
geography. It is my hope that the Congress and future leaders
will consider how policies impact our health particularly the
health of vulnerable communities of color, and we will be able
to hopefully implement such measures as H.R. 3014 to improve
the quality of healthcare and decrease those inequities that
exist in this disparate treatment.
I thank you again for having this hearing, and I commend
the Members of this Subcommittee.
I yield back the balance of my time.
Chairman STARK. Thank you very much.
[The prepared statement of Ms. Solis follows:]
Prepared Statement of The Honorable Hilda L. Solis,
Representative in Congress from the State of California
Chairman Stark, Ranking Member Camp, and my colleagues, thank you
for inviting me to testify about the inequities of our healthcare
system. Chairman Stark, I would especially like to commend you for your
leadership in bringing attention to disparities in health for
communities of color.
I am pleased to be here today with Representatives Christensen and
Bordallo. We represent the Congressional Hispanic, Black, and Asian
Pacific American Caucuses, known collectively as the TriCaucus.
As the Chair of the Congressional Hispanic Caucus Task Force on
Health and the Environment and as a Member of the Energy and Commerce
Subcommittee on Health, I am working to improve the health of all
individuals, particular communities of color. Latinos are the fastest-
growing racial/ethnic group in the United States. We make up 14 percent
of the population, which is more than 42 million people across the
nation, yet we also suffer from the highest uninsured rates in the
country. According to data released by the Census Bureau in 2007, 34.1
percent of Latinos (more than 15 million) are uninsured, compared with
20.5 percent of African Americans, 15.5 percent of Asian/Pacific
Islanders, and 10.8 percent of non-Hispanic Whites.
As we move forward toward national health reform, we must not leave
behind our most vulnerable and underserved populations. Unfortunately,
current programs do leave behind our most vulnerable and underserved
populations.
Communities of color often suffer from higher rates of death and
disease. The Agency for Healthcare Research and Quality's 2007 National
Healthcare Disparities Report (NHDR) finds that ``Overall, disparities
in quality and access for minority groups and poor populaitons have not
been reduced since the first NHDR.'' According to the 2007 NHDR,
Latinos fared worse than non-Hispanic Whites for seven of eight core
measurements of healthcare access and for 23 or 38 core report measures
of quality.
The growing diversity of our country means that many patients
encounter barriers to receiving optimal healthcare. By 2050, it is
projected that members of racial or ethnic ``minority'' groups will
together account for almost half of the U.S. population. Currently,
nearly 52 million people, or more than 19 percent of the U.S.
population, speak a language other than English at home. There are also
a substantial number of individuals who are not proficient in the
English language. According to the 2006 American Community Survey,
almost 11 million U.S. citizens speak English less than very well.
I have seen firsthand the growing diversity in our nation. In my
district in East Los Angeles and the San Gabriel Valley, more than 60
percent of my constituents are Latino, and approximately 20 percent of
individuals are of Asian Pacific Islander descent. Sixty-eight percent
of families speak a language other than English at home.
For these communities, culture and language play vital roles in the
provider and patient relationship. Culture can define how healthcare
information received, interpreted, and acted upon by patients.
Communication barriers, such as the lack of langauge services, between
patients and providers contribute to reduced quality of care, adverse
health outcomes, and increased racial and ethnic disparities. Such
barriers can lead to lower patient adherence to medications and
decreased participation in healthcare decision making. A study by the
Access Project based at Brandeis University, titled ``What a Difference
an Interpreter Can Make,'' indicates that more than 25 percent of
limited English proficient individuals who needed but did not get an
interpreter reported that they did not understand their medication
instructions. Non-English speaking patients are also less likely to use
primary and preventive care and are more likely to seek care in
emergency rooms.
Given the existing health inequities of our healthcare system, I
introduced H.R. 3014, the Health Equity and Accountability Act with the
support of my TriCaucus colleagues. I am proud that we now have the
support of more than 100 Members of Congress. In addition, we also have
a letter of support from more than 300 organizations. I would ask that
this letter be inserted into the record.
This legislation, which we introduced in past years, is based on
many of the Institute of Medicine's recommendations from Unequal
Treatment: Confronting Racial and Ethnic Disparities in Healthcare.
This legislation would require Federal agencies to improve access for
individuals with limited English proficiency and create a Medicare
demonstration project examining access to care, costs, and health
outcomes for beneficiaries. Several provisions of H.R.3014 have been
referred to this Committee and I as stated in a letter addressed to
Chairman Rangel and Ranking Member McCrery on October 23, 2007, I am
eager to work with you to enact these provisions.
Improving access to health insurance, including Medicare, is a key
part of reducing inequities in health. However, efforts that only
address access to insurance are inadequate, as evidenced by continuing
disparities seen within the Medicare population. The Institute of
Medicare found marked disparities among Medicare beneficiaries, even
after adjusting for socioeconomic differences. According to the 2007
National Healthcare Disparities Report, among Medicare patients,
Latinos and Native Americans are least likely to receive all
recommended care for heart failure. In addition, an April 2008 article
published in Health Services Research found that Spanish speakers
enrolled in Medicare managed care plans have more difficulties with
provider communication and timeliness of care when compared to non-
Spanish speakers.
On August 11, 2000, the President signed Executive Order 13166,
``Improving Access to Services for Persons with Limited English
Proficiency.'' This Executive Order requires Federal agencies to
examine the services they provide, identify any need for services to
LEP individuals, and develop and implement a system to provide those
services so LEP persons can have meaningful access to them.
I believe that Medicare, as a leading purchaser of healthcare, has
the opportunity and responsibility to reduce racial and ethnic health
disparities. Consequently, I am pleased that some of H.R. 3014's
provisions were included in H.R. 3162, the Children's Health and
Medicare Protection Act (CHAMP) of 2007. I and many of my colleagues
worked hard to pass the CHAMP Act and to protect provisions related to
the reduction of disparities. Unfortunately, the Senate failed to take
up the Medicare provisions.
This past December, before another short-term Medicare physician
fix bill was enacted, I urged the inclusion of provisions that would
improve low-income Medicare beneficiaries' access to services. On June
4, 2008, I also led a letter from the Congressional Hispanic Caucus
asking for the inclusion of the same provisions in the Medicare package
recently developed by the Senate Finance Committee. I would like to
insert this letter into the record.
I also strongly support a Medicare demonstration protect to improve
communication between providers and limited English proficient seniors,
a study on Medicare payments for language services, an Institute of
Medicine report on the impact of language services on the health of
Limited English Proficient beneficiaries, and a report on Medicare
compliance with national standards on Culturally and Linguistically
Appropriate Services (CLAS).
The CLAS standards, some of which are mandates for health
organizations that receive Federal funding, were developed by the U.S.
Department of Health and Human Services' (HHS) Office of Minority
Health. They are intended for adoption by healthcare organizations and
represent a way to improve access to healthcare for minorities, reduce
inequities, and improve quality of care. I strongly believe that all of
the CLAS standards should be adopted by Medicare and other health
organizations. I am pleased that several of these provisions were
included in S. 3101, the Medicare Improvements for Patients and
Providers Act, which was recently introduced by Senator Baucus.
In closing, I would like to take the opportunity to note that our
health is the product of our social determinants of health, including
income, race, education, environment and geography. Housing,
transportation, education, energy, and agricultural policies all impact
our health, although most Americans think only of our healthcare system
when we speak about health.
Our current healthcare system is not the sole reason why racial and
ethnic populations experience higher rates of death and illness. Given
this Committee's jurisdiction, I kept my remarks limited to changes to
our healthcare system. However, it is my hope that this Congress and
future leaders will consider how seemingly-unrelated policies impact
our health, particularly the health of vulnerable communities of color.
Thank you again for inviting me to testify before you
today.
Chairman STARK. And the Honorable Madeleine Bordallo from
Guam, would you like to proceed?
Ms. BORDALLO. Good morning again.
Chairman STARK. Would you pull the microphone right up
close. Thanks.
STATEMENT OF THE HON. MADELEINE Z. BORDALLO, A DELEGATE TO
CONGRESS FROM THE TERRITORY OF GUAM
Ms. BORDALLO. Good morning, and thank you, Chairman Stark
and Ranking Member Camp, for the opportunity to testify on
behalf of the Congressional Asian Pacific American Caucus.
Asian and Pacific Islander Americans are one of the
fastest-growing populations in our country today. Over the last
18 years, the APIA community has more than doubled from 7
million to over 15 million individuals.
A significant number of Americans face challenges on a
daily basis, but these challenges are unequally borne across
the spectrum of our ethnically diverse country. Asian and
Pacific Islander Americans, like Latino Americans and African
Americans, struggle with overcoming the additional obstacle of
disparities.
The sheer diversity in language and culture within the
greater Asian and Pacific Islander American community presents
its own challenges. Asian and Pacific Islander Americans
encompass 49 ethnic groups and over 100 individual and distinct
languages and cultures.
The common needs of our minority communities have led to
the introduction of H.R. 3014, the Health Equity and
Accountability Act. H.R. 3014, as you will hear today, is the
product of collaboration between the Congressional Black
Caucus, the Congressional Hispanic Caucus and the Congressional
Asian Pacific American Caucus. It is a bill, Mr. Chairman, to
comprehensively address the pressing issues resulting in and
contributing today to identified healthcare disparities faced
by the communities of color all across our country, whether it
be in Indian country, in border communities, the inner cities
or in the offshore territories.
This bill, which has now been introduced in three
consecutive Congresses, demands this Subcommittee's attention
and deserves your consideration. Its provisions have been
scrutinized by the medical, health professional and academic
communities.
My colleagues have touched upon different areas of H.R.
3014 in their testimony this morning. I will address the data
collection title of the bill.
Today, there is a serious absence of up-to-date medical
data on minorities. Because of its diversity, the data gap for
the APIA community is more glaring and consequential. Right
now, if you search for diabetes information on the Centers for
Disease Control and Prevention Web site, for example, you will
find only data characterized for black, white and Hispanic or
nonwhite. The fact sheet prepared by the CDC states that
African Americans, Hispanic/Latino Americans, American Indians
and some Asian Americans and native Hawaiians or other Pacific
Islanders are at particularly high risk for type 2 diabetes and
its complications but that the total prevalence of diabetes,
both diagnosed and undiagnosed diabetes, is not available for
Asian Americans or Pacific Islanders. And this, simply put, is
disturbing and it needs correction.
Although this one example is drawn from an agency that is
not under the direct jurisdiction of this Committee, it
nonetheless aptly illustrates the information gap for
minorities, particularly for the APIA community. We as a
Congress simply cannot address or rightly aim to overcome the
health challenges facing our citizens if we do not even know
what they are or have some sound measure of the extent of their
impact.
Equally disconcerting is the fact that it has now been over
a decade since the Office of Management and Budget established
new standards for the collection of Federal data on race and
ethnic identification, yet their full adoption and
implementation by certain Federal agencies remains outstanding.
The Social Security Administration, for example, has made no
revisions to its Social Security Card application to take into
account the new standards. The OMB race and ethnic developed
categories are by no means impossible to implement. Without the
use of these standards, we are left with inconsistency in
application; and sound public policy cannot be shaped without
solid data.
Our caucus, CAPAC, believes that further disaggregation
beyond the OMB standards established 10 years ago is warranted
today to accurately reflect the diversity of the APIA
community. However, we know this step cannot logically be taken
or fully pursued into the spirit of the 1997 changes that are
adhered to by our own Federal Government. Therefore, compliance
with the 1997 standards and additional collection of data on
primary language is a priority, both of which are required by
H.R. 3014 and Subtitle D of the CHAMP Act. So we ask that you
exercise due oversight to ensure compliance.
Apart from a compliance with these standards are other data
collection priorities. Both H.R. 3014 and the CHAMP Act, for
example, strengthen data collection and analysis by requiring
that the data be collected from the parent or legal guardian of
minors and reported to the Centers for Medicare and Medicaid
Services and other agencies for proper analysis.
My final point today is to underscore my other colleague's
statements relative to cultural and linguistic competencies in
healthcare. This is vital for the APIA community. Roughly a
third of Asian and Pacific Islander Americans live in
linguistic isolation. Seventy percent of Cambodians, 68 percent
of Laotians, 61 percent of Vietnamese, 52 percent of Koreans,
51 percent of Chinese, 39 percent of Tongans and 22 percent of
Samoans are classified as limited English proficient. These
barriers, Mr. Chairman, have severe effects on healthcare
access, such as patients' ability to understand diagnoses, to
understand prescription directions. People have and will
continue to die as a result of misinformation or
mistranslation.
It is for these concerns and the others that we urge your
attention to focus on H.R. 3014. Health disparities for Asian
and Pacific Islander Americans are very real, and people are
suffering every day from these disparities.
I want to thank you, Mr. Chairman, for the opportunity to
testify on this important issue. We look forward to working
with you and other Members of the Committee on Ways and Means.
Thank you.
Chairman STARK. Thank you for your efforts on this issue. I
appreciate it.
[The prepared statement of Ms. Bordallo follows:]
Prepared Statement of The Honorable Madeleine Z. Bordallo,
Delegate to Congress from Guam
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman STARK. Jerry Moran, our colleague from the great
State of Kansas, would you like to proceed?
STATEMENT OF THE HON. JERRY MORAN, A REPRESENTATIVE IN CONGRESS
FROM THE STATE OF KANSAS
Mr. MORAN. Mr. Chairman, thank you very much. Thank you and
Mr. Camp for including me in the invitation today.
I represent a congressional district that is nearly 60,000
square miles, 69 counties. The largest community has a
population of about 45,000 people, what by all standards would
be considered a very rural district. I think, in regard to
districts like that across the country, we have a number of
factors that come together to create significant disparities in
the availability and affordability of healthcare.
Age, our population is very senior. Income, we are often--
as rural citizens, our income levels are lower. Distance, the
ability to travel to access healthcare. Financial, most
healthcare providers make more money serving patients in a
wealthier, younger and more urban environment.
Many of the items that my colleagues have indicated in
regard to ethnicity and minority issues also are found in many
rural districts across the country; and for much of the time
that I have been in Congress, I have co-chaired with my
colleague from North Dakota, Mr. Pomeroy, the Rural Healthcare
Coalition, which, incidentally, has many issues in common with
urban, particularly core center of city, communities across the
country.
In addition to that, I have chaired the Healthcare
Subcommittee in regard to Veterans Affairs in which, for
example, in my congressional district there is no VA hospital
and so access even to a government program, the VA, becomes
very difficult.
Residents--in fact, I might just highlight some of those
issues. Residents in rural Kansas have virtually no access to
public transportation. Therefore, the ability to access
healthcare before one becomes very sick is limited. Our
population is very rural, and elderly are likely to have
chronic diseases and yet 10 to 20 percent less likely to
receive the recommended pre-screenings, preventative screenings
or checkups.
Rural residents tend to be poorer. On the average, per
capita income in rural areas of the country is more than $7,000
lower than in urban areas and nearly 24 percent of children in
rural America live in poverty.
Higher rates of uninsurance are found in rural communities.
In the southwest part of my congressional district, which is,
in many ways, very Hispanic, 16.8 percent of the citizens lack
healthcare coverage.
Healthcare professional shortage areas, as defined by the
Department of Health and Human Services, 25 percent of all
Kansas counties have a Federal physician shortage area. Of the
2,157 health professional shortage areas, those are in rural
areas, as compared to 910 in urban areas.
It is hard to keep infrastructure in place. Fortunately for
us in rural America, critical access hospitals have been a
saving feature for access to healthcare for many across rural
America. But, having said that, those hospitals face
difficulties in reimbursement and face a tremendous challenge
in keeping their doors open.
Medicare payments to rural hospitals and physicians are
significantly less than those to their urban counterparts; and,
in fact, more than 470 rural hospitals have closed in the last
25 years. Medicare utilization is high in rural districts. In
fact, Smith County Hospital along my Nebraska border, 8 out of
every 10 patients admitted to the hospital are Medicare
beneficiaries.
EMS is simply we sometimes forget about. And I often find
myself talking to my constituents about hospitals in
particular, and I am reminded that many of my counties have no
hospital at all. The only services that they have immediate
access to--or at least one hopes immediate access to--is
emergency medical services, and yet statistics indicate that
the response time in a rural community is 8 minutes less than
response time in an urban area. And many, if not most all, of
our emergency service providers are volunteers. In many
communities those volunteers are now in their sixties,
seventies and eighties; and there is virtually no one in their
twenties and thirties and forties to serve as EMS providers.
Community pharmacy is something that I hope this Committee
will consider. Many consequences fell from the Part D
prescription drug benefit that was provided by Congress. But,
again, community pharmacy is an important component of
providing healthcare in rural communities; and yet 7 of my
counties have no community pharmacy, 32 counties have only one
pharmacist, and adequate reimbursement for our pharmacies are
an important component and timely reimbursement as well.
Nursing home, home healthcare, access to durable medical
equipment all face significant challenges in rural America.
And, finally, I would say that it is difficult to recruit
and retain healthcare professionals, nurses, doctors. At the
moment, critical shortages of dental providers and almost no
mental health services are available in most rural communities.
So as we look at ways that we can try to eliminate
disparity, I would indicate that, along with the items that my
colleagues have pointed out related to race and ethnicity, we
face many of the similar challenges in rural communities across
the country.
I thank the chairman and the Ranking Member for inviting me
to testify, and I would be happy to respond to any questions.
[The prepared statement of Mr. Moran follows:]
Prepared Statement of The Honorable Jerry Moran,
A Representative in Congress from the State of Kansas
I. Disparities in the rural healthcare system
Rural Kansas residents have greater transportation
difficulties reaching healthcare providers, often traveling great
distances to reach a doctor or hospital. There are very few public
transportation systems and so many folks wait until they are very sick
before they access the healthcare system.
Rural Kansans have a higher percentage of elderly likely
to have chronic diseases like heart disease and diabetes, but they are
10-20% less likely to receive recommended preventive screenings or
check-ups.
In addition, rural residents tend to be poorer. On the
average, per capita income is $7,417 lower than in urban areas, and
rural Americans are more likely to live below the poverty level. Nearly
24% of rural children live in poverty.
Higher rates of uninsurance are also found among rural
communities. In 2001, the Southwestern region of Kansas had the highest
proportion of uninsured at 16.8%. It is also in these rural regions
where we find higher rates of delayed entry or too few prenatal care
check-ups for pregnant women. Rural residents strain the capacity of
rural hospitals when hospital emergency rooms are used inappropriately
as a substitute for a medical home.
There are 2,157 Health Professional Shortage Areas
(HPSA's) in rural and frontier areas of all states and U.S. territories
compared to 910 in urban areas. 25% of all Kansas counties have federal
physician shortage area designation for primary medical and all of
there are rural counties.
II. It is hard to keep the Healthcare infrastructure in place
Having access to a local hospital and their services is
important
There are 75 hospitals in the First District of Kansas, many of them being
Critical Access Hospitals (25 beds or less). They allow people the ability
to access local care when they are sick and are the cornerstone to the
rural healthcare delivery system.
One challenge to keeping the doors open is that there is less volume than
in many urban settings. In addition, Medicare payments to rural hospitals
and physicians are dramatically less than those to their urban counterparts
for equivalent services. This correlates closely with the fact that more
than 470 rural hospitals have closed in the past 25 years.
Many rural hospitals have higher Medicare utilization rates than their
urban counterparts. In my district, Smith County Hospital, over 8 out of
every 10 hospital admissions were from Medicare beneficiaries.
EMS providers face big challenges. There are higher rates
of death and serious injury accidents in rural versus urban areas. One
reason for this is that in rural areas, prolonged delays can occur
between a crash, the call for EMS, and the arrival of an EMS provider.
Many of these delays are related to increased travel distances in rural
areas and personnel distribution across the response area.
National average response times from motor vehicle accident to EMS arrival
in rural areas was 18 minutes, or eight minutes greater than in urban
areas.
Keeping the additional healthcare services and players in
business is important as well.
Community Pharmacies are on the front lines of the healthcare delivery
service. Currently, there are 7 counties in Kansas that have no drug store
and 32 counties have only one available.
It is important that we are adequately reimbursing pharmacies for the
Medicaid prescriptions that they are filling and it is important that we
pass legislation to ensure that they are reimbursed in a timely manner.
Nursing homes, Home Healthcare and access to durable medical equipment is
also very important to rural residents.
III. It is difficult to recruit Healthcare Personnel
It is extremely difficult to recruit healthcare
professionals to places where doctors are few and access to major
metropolitan hospitals requires hours of travel. According to the U.S.
Department of Health and Human Services, while a quarter of the
population lives in rural areas, only 10 percent of physicians practice
there.
Kansas has 234 physicians specializing in the specialty of obstetrics. Only
59 have practices located outside the large urban counties and in fact,
only 21 are available in the entire western \1/2\ of the state.
One lifesaving program has been the J-1 Visa Waiver program. The J-1 Visa
Waiver program provides opportunities for graduates of foreign medical
schools, who have trained in U.S. medical residency programs on the J-1
cultural exchange visa, to stay in the United States if they serve for
three years in an area that has a health professional shortage. These
designated health professional shortage areas can occur in rural areas as
well as urban areas.
Kansas has been able to recruit 98 physicians to work in underserved areas
and with underserved populations since 2002 through the J-1 Visa Waiver
program.
Additionally, the lack of mental health and dental
services continues to be a significant problem in most counties in
Kansas. The 2005 Health Professional Underserved Areas Report shows
that only nine counties in Kansas have adequate numbers of mental
health professionals (1 psychiatrist for 30,000 population) and only
twenty counties have adequate numbers of dental professionals (1
dentist for 5,000).
Anywhere from 57 to 90 percent of first responders in
rural areas are volunteers
Chairman STARK. Well, I thank all of our colleagues for
joining us.
Dr. Christensen, it was a year ago I think you testified
before us on the end stage renal disease issue, and we agreed
then that any changes in the dialysis reimbursement must not be
a one-size-fits-all. And we think this last bill had the
requisite flexibility to respond to individual patient needs.
Modernizing that system is even more critical today because
of the perverse incentives of the current system which has
encouraged unusual dosing of Epogen and has put many patients'
health at risk. So I hope we will work together on this issue,
and I hope that the Senate puts the patient needs ahead of
industry profits. I think we will have some time to review that
again.
Congresswoman Solis, you brought up an issue on disparities
that--and I think several of you have touched on this--that it
is just not a coverage issue. It goes to access, that we find
disparities among the Medicare population, which is a uniform
coverage. Even if you adjust for social economic status, we
could use your community as an example. Do you want to just
expand on why addressing disparities transcends access and
insurance and the other moves that we might make to correct
that?
Ms. SOLIS. Well, I think one of the issues is that our
healthcare system for many, many years has looked typically at
majority population in terms of how that service delivery is
provided. Just recently, you see some innovative, you know,
footnotes by, for example, researchers through the Kaiser
Foundation who realized that you can actually save a lot more
money if you start to tailor the services to better fit and
better suit the population at hand; and what we are finding is
that we do have to do much more in providing incentives for our
university medical schools, for example, to recruit and retain
individuals from rural America, from inner city America who are
reflective of the populations that are faced with these chronic
illnesses. I think it says a lot when you do bring people who
are much more familiar with individuals that they would serve,
that there is much more ability to be able to break down those
barriers of communication, understand culturally the
differences that are unique to different populations.
I think that my colleague, Ms. Bordallo, evidently gave us
some very good facts in terms of even the differences in the
API community, Tagalog, Filipino, Mandarin, all the various
different groups that need to have a different perhaps
interpreter or type of service that is available to them.
I know that we have been reluctant in the last few years in
the Office of Civil Rights to actually push for better outcomes
in terms of what our healthcare hospitals and our centers are
providing. I don't think that is a negative. I think that that
is something that we should continue to work toward.
Mrs. Christensen. Chairman Stark, may I add?
Chairman STARK. Sure.
Mrs. Christensen. I just wanted to again call your
attention to the IOM report on equal treatment of a few years
ago, and the hundreds of articles that were reported on there
and have been reported since that also point to discrimination
within the healthcare system. So that individuals who have full
insurance and present themselves either private or public
within that system, everything else being equal except for race
and maybe language, did not receive the same kind of diagnostic
evaluation or if that diagnostic evaluation is done are not
offered the same level of treatment and care.
Chairman STARK. I don't think you would find anybody who
would disagree with that. And I think what we have to look
forward or look for with all of your help is, from our
standpoint, what can the Federal Government do, not what Blue
Cross or Aetna or the private plans, over whom we have little
jurisdiction. But what can we do as a Federal Ggovernment to
change that.
And, Congresswoman Bordallo, you talked about better data.
And it has been--what--11, 12 years since OMB published their
standards for the collection of data; and we are still not
doing it. Do you think that it is urgent and that we can do it
without getting into discrimination questions, collect more
data in our Social Security system so that we at least can
begin to look at the numbers and see what is happening? Do you
support that?
Ms. BORDALLO. Yes. Yes, Mr. Chairman, in answer to your
question. Because I represent the Asian Pacific area, which is
the fastest-growing; and we have so many different ethnic
groups, 49, perhaps more. And, yes, I would say that this would
be a priority, to gather the data before we can even have any
understanding of what the situation is or how many people are
affected.
Chairman STARK. Thank you.
Jerry, you are an outlier as far as topics go, because I
really hadn't anticipated dealing with the rural issue. But it
is one that this Committee, to my knowledge, in 20, 25 years
has dealt with the issue in two ways. One, we have always known
as a political fact of life that whatever we do to aid rural
America through the Medicare system will be doubled or tripled
on the Senate side when it gets there; and we have to resolve
it in conference. And so we have always accepted that and
always look forward to our colleagues in the other body
correcting whatever inadequacies we might provide.
But let me point out a couple of things and let you comment
on them.
You did mention, you know, 470 rural hospitals have closed
in the past 25 years. That is my tenure both in the minority
and majority on this Committee. But if you look at it, that is
less than 15 hospitals a year, and we have never had a year
when 20 hospitals have closed. So maybe three-quarters of them
are rural. Out of 6,000 hospitals, that ain't bad. And we
usually figure, as I have always said, that most of the cause
of closing rural hospitals is because the doctor died or moved
out of town.
And what I would like to think as times change and Mr.
Pomeroy comes--I don't think he has any big towns in his State.
But, I mean, you haven't seen little cities until you have gone
to North Dakota.
But what I have noticed is that the clinics begin to take
on more procedures and that transportation may be a solution.
Because a 10- or 20-bed hospital just can't support the kind of
care that you want when you are faced with a cancer or a
cardiac problem. You are going to drive the 100 or 200 miles or
get flown in a helicopter. And I think that is what you and I
would want.
So my sense is that how--and I don't know whether you would
agree with this. Politically, it is impossible to stand by and
watch a hospital close on your watch. We recognize that.
We wrote in this Committee the peach and each act, which
more or less said here is how a 10-bed hospital can get off-
stage with the local politicians. We will make it a long-term
care facility or an outreach facility somehow, quite frankly,
to give political cover to people who may have to encourage
their residents to take a longer trip to get them more
sophisticated medical care, data, electronic data, if we had
that more broadly, so it was available, teleconferencing, all
of those things.
And I would hope that, if you don't find that offensive,
that you would continue to support whatever efforts we can make
to kind of modernize, if you will, the rural system and--
because I do agree that we can help with the visa issue, and I
think that that will help us with diversity. And I have no
objection to that. So I hope that you will continue to be
involved in this issue, because I would hate to see Mr. Pomeroy
have to carry the whole ball all by himself.
Thanks for your testimony.
Any comment?
Mr. MORAN. As much as I admire and respect Mr. Pomeroy, I
would like to say that he and I work closely together, and I
have been to some of his communities. In fact, we took----
Chairman STARK. I am not sure you both voted the same way
on the agriculture bill this year.
Mr. MORAN. We did not vote the same way on the ag bill or,
more surprising, nor did we vote the same way on the
prescription drug benefit.
But Mr. Pomeroy and I had the CMS administrator in my
district and his State several years ago, Mr. Skully. And,
incidentally, it was an interesting experience in my mind to
listen to Mr. Skully see for the first time a critical access
hospital. Here is the person who is in charge of the CMS
program responsible for Medicare and Medicaid services and yet
had not at that time ever seen a critical access hospital. His
reaction was very foretelling to me, which was, Congressman,
they deliver great quality healthcare here, don't they, but
there are no frills, are there?
And, to your point, I think that is what we are
anticipating. And it is the way we live our lives in much of
rural America, is there are no frills. That is what our
critical access, our small, less-than-25-bed hospitals provide,
is basic services; and our ability to attract other healthcare
professionals I think is dependent upon having that hospital
there.
So while Mr. Pomeroy and I are very active in renewal of
the J-1 visa, the Conrad 30 program, our ability to utilize the
program--and I appreciate what my colleague said about
attracting physicians into medical schools who have diverse
backgrounds, in our case, a rural background. We have
discovered that the best shot we have at getting a doctor to a
rural community in Kansas is that they grew up in a rural
community in Kansas or someplace. But what we discover is they
go off to medical school, and they marry someone who likes
restaurants and shopping, and even the hunting and fishing that
we have becomes less appealing when the spouse has different
ideas.
So the point I would perhaps differ with you, Mr. Chairman,
on is that those--particularly those critical access hospitals,
yes, they are not there to provide every service imaginable;
and we need regional medical centers and specialized hospitals
in which a transportation system will allow rural residents,
patients to be transported to receive that kind of care. But
for the very basics, including just emergency room coverage and
our ability to keep physicians and other healthcare providers
in communities, those small hospitals are critical.
Chairman STARK. Thank you very much.
Mr. Camp, would you like inquire?
Mr. CAMP. Thank you, Mr. Chairman.
Thank you all for testifying.
Dr. Christensen, thank you for your leadership on end stage
renal disease and dialysis.
I am interested in, Congresswoman Solis, your comment about
a demonstration project to improve communication between
providers and limited English proficient seniors. Is CMS doing
any of that, are you aware, currently?
Ms. SOLIS. From what I have learned, there hasn't really
been an adequate growth in terms of funding these kinds of
efforts. I think maybe in the last 2 or 3 years you have seen
some movement but not enough where we can actually even enforce
the current codes in the law that say that we are required to
provide better access services to those patients that have
cultural linguistic, linguistic barriers. So I think that we
still have a ways to go, and I would hope we could work with
you and the Committee to see that we get support for that.
Mr. CAMP. All right. Thank you.
And, Congresswoman Bordallo, you mentioned a data gap; and
we have seen that in all areas. We just had a hearing the other
day on HSAs, and we are using data from the first year the
program was enacted to try to draw our conclusions about where
HSAs are today, even though much of the growth occurred well
after the first year of implementation.
So there is a real data gap. There is a lag in health data
all across the spectrum. I think we have difficulties in
getting access to the right kinds of information. So I think
that is something that we need to really work on particularly,
and we are almost in 2009, making decisions for 2009 and 2010.
To not know even the last couple of years is a very difficult
thing.
Mr. Moran, you mentioned many of the disparities between
rural and urban areas. One of the things I didn't hear you
mention was the disparities in reimbursement; and we have long
talked about this in this Committee about the difference
between many of the large urban areas like Miami, for example,
and just about anywhere else in the country in terms of the
reimbursement rates.
Do you think that is a factor in some of the disparate
health services and treatment available to rural Americans?
Mr. MORAN. Absolutely, Mr. Camp. A question that you know
the answer to and that you and I agree totally on it.
In regard to our ability to attract and retain
professionals, reimbursement is a significant component of that
inability. If you are a physician that wants to make more
money, you will choose to live in an area in which your
Medicare and Medicaid components of your practice are less than
most rural areas of the country.
Reimbursement of hospitals. Even the cost-based
reimbursement that occurs in regard to a critical access
hospital is not true of cost-based reimbursement.
And I remember my first year in Congress, 1997, we had the
Balanced Budget Act. One of its premises was that we could
reduce the amount of reimbursement for Medicare providers in an
effort to balance the budget. Noble goal of balancing the
budget. But when 80, 90 percent of your patient load are
Medicare patients in a hospital, you have no place to turn,
with perhaps the exception of raising property taxes to keep
your hospital doors open.
So in each of these instances, the reimbursement rate, the
disparity between rural and urban, the geographic factor that
occurs in the physician reimbursement, there is an actual
geographic component of the reimbursement a physician receives
under the belief that it is less expensive to live and practice
medicine in a rural community. I don't know that the facts
would bear that premise out.
Mr. CAMP. All right. Thank you all very much.
Thank you, Mr. Chairman.
Chairman STARK. Thank you.
Mr. Doggett, would you like to inquire?
Mr. DOGGETT. Thank you, Mr. Chairman; and thanks to each of
our witnesses. Congresswoman Solis, could you expand on the
role that you believe Medicare can play in addressing the
disparities that you have described?
Ms. SOLIS. Well, I think one of the issues that--actually,
there are several items that I would touch on. And one is, of
course, the lack of adequate healthcare professionals that are
coming into the healthcare system, number one. We do have a
shortage in our labor force there, and we have to really
incentivize our teaching hospitals to identify individuals and
even those that come from different countries who are qualified
in giving them the ability to come and work here. I think that
that is one way of addressing it.
I think also providing incentives so that people will work
in rural, low-income or underserved communities. We face the
same problems that rural America does when you see a low
reimbursement rate. You see doctors in East Los Angeles and I
am sure in the State of Texas where you find Latino doctors who
will now refuse to take on any more Medicare/Medicaid patients
because of the lack of low reimbursement. Even for those
professional doctors that specialize in special treatment,
orthopedic surgeons, we are also finding hip replacement, those
kinds of things that we see occurring much more in our
community, individuals are very far and few, maybe 1 to 10,000
a population, one specialty doctor for a population of 10,000.
That is wrong.
We need to do more also to make sure that we fully utilize
those public clinics. In our districts, for example, in Los
Angeles we don't have access to many of those bigger hospitals,
community hospitals. Much in our county have been closed down.
So we rely very heavily on the public hospital community
centers there that provide assistance.
But to really do more--how can I say--extensive outreach to
help identify treatment opportunities and prevention and
education and to make sure that we have lay people that are
fully trained this can provide that assistance in an atmosphere
that is well received and that people will feel trustful of----
You know, there is a big issue now in our community with
this whole immigration debate and why people sometimes won't
even access healthcare because of fear that they may be somehow
detained or denied healthcare when in fact they are eligible
for this aid.
So I think that we have a long way to go; and there is
multiple, multiple things that we can do, including beefing up
our research institutions to do more specialized review in
terms of why it is that there is a higher propensity of Latinas
to have breast cancer, why it is we see an increasing number of
teenage pregnancy amongst Latinas, what are the cohorts in our
community so that we can provide prevention so that at the end
of the day we don't end up having to pay for this accumulation
of costs at our emergency hospital or trauma unit when the
services could have been provided maybe, you know, a year ago
in a more comfortable, informative manner. So there is many,
many things that we can do.
I know that this Committee is very, very strongly
supportive of some of the reforms we are talking about; and I
would hope that we can challenge our Presidential candidates to
adopt the discussions that we are having here today, because I
really think this is the most burning issue of our time.
Mr. DOGGETT. One of the things that is at the top of the
list is to see that our healthcare professionals reflect the
population as a whole and that we have, especially in the
medical specialties, a more diverse workforce that is aware and
sensitive to these problems.
You made mention also to the term promotoras. I have met
with some of the young women in south Texas that do that work,
some of the very problems that you were referring to, breast
cancer, teenage pregnancy. How would you use them and what--it
is a demonstration project you referred to under CHAMP one
might use them. What role would they play in this process?
RPTS HUGILL
DCMN MAGMER
Ms. SOLIS. Well, they would be kind of the first
responders, so to speak, out in the community that have a
better map or design of what is taking place in their
community, in their neighborhood; and they are trained
individuals that typically will meet with the core group of
families--typically in this case they may be females--and
they'll talk about--and it's not just for one gender. They'll
talk about how to go about prevention, what signs to look for
for any diseases. There's a higher rate of asthma in the
community. They can talk about what needs to be done to care
for the family, the child, but also to help enlist these
individuals on knowing what services are currently available so
we don't duplicate our efforts but we are more strategic also
in a figure which program they can conceivably apply for. And I
think that's our biggest test right now, that people get so
overwhelmed with paperwork and not understanding which program
fits their particular need.
So individuals in the promotoras program and even in the
State of California where there are 1,200 promotoras right now
and they're not all publicly funded, those efforts have shown
very, very positive outcomes in terms of decreasing the amount
of money that we could provide in terms of prevention and at
the end of the day have more money to do more outreach and
enrollment in some of these very important programs like the
SCHIP program that are very helpful in our communities,
especially in the State of Texas.
Mr. DOGGETT. Thank you.
Thank you, Mr. Chairman.
Chairman STARK. Mr. Thompson, would you like to inquire?
Mr. Pomeroy, would you like to inquire?
Mr. POMEROY. I would, Mr. Chairman.
First of all, I would like to commend this most superb
panel. I think we are all used to member panels, and they put
in their kind of constituent-provided or interest-provided
talking points, and that is about the end of it. It is clear
that each of the panel members has demonstrated a lot of
knowledge that I would say is approaching policy expertise in
these areas, and I really do commend them.
It has been my pleasure to serve with Mr. Moran as co-Chair
of the Rural Healthcare Coalition, and I look forward to
continuing working with him on rural issues. I think that he
has advanced a number of issues that I completely agree with
his take on them.
I want to, rather than ask questions of the panel, put into
the record, Mr. Chairman, a group that is largely rural based
but presents health disparities toward a minority population as
profound, I believe, as any and that is the Native American and
Alaska Native populations. The American Indian and Alaska
Natives born today have a life expectancy of 2.4 years less
than the general population. We have decreased the infant
mortality rate with Native American children 64 percent during
the years '72 to '99, and that's a tremendous achievement, but
they still die at a rate of 10 per 1,000, which is 24 percent
higher than other populations.
Of all of the disparity indices relative to Native
Americans, to me the most stunning is mortality rates for
specific causes compared to general population. Tuberculosis,
Native Americans die at a 500 percent greater rate. Alcoholism,
638 percent greater rate. Diabetes mellitus impacting Native
American mortality, in other words, the death rate for Indians
dying of diabetes, 291 percent greater than the normal
population. Unintentional injuries, 215 percent. Pneumonia and
flu, 67 percent higher mortality. Gastrointestinal, 38 to 40
percent. Heart disease, 20 percent.
One of the more humiliating moments in my congressional
service came when I went to an Indian reservation to talk about
the great news of providing diabetes testing strips under
Medicare. Having made my little presentation, I asked, by the
way, what is the longevity rate here on the reservation? For
males, it was 63 years. They were dying 2 years on average
before they became even Medicare eligible. We see 73 percent of
American Indians and Alaska Natives residing in health
professional shortage areas, 90 doctors per 100,000 compared to
229 per 100,000 across the general population.
Mr. Chairman, I would like to submit in the record my
statement as well as two documents, Indian Health Service Facts
on Indian Health Disparities and a document prepared by the
Center for Rural Health in North Dakota on health disparities.
I did not want to take panel time. I think it's important for
this Committee to hear from other Members not on the Committee,
but I do want this in the record on health disparities.
Chairman STARK. Without objection.
[The information follows:]
******** COMMITTEE INSERT ********
Mr. POMEROY. Thank you; and I yield back, Mr. Chairman.
Chairman STARK. Mr. Becerra, would you like to inquire?
Mr. BECERRA. Thank you, Mr. Chairman, and double thank you
for holding this hearing. Many of us have believed that for
many years we should have had an opportunity to discuss this
issue further, and I want to thank you very much for your
interest and your commitment to having this issue raised and
hopefully addressed in the near future.
To our panelists, thank you very much for your testimony. I
think each and every one of you point out the reason why we
need to move on this for any number of reasons. Whether it's
race, ethnicity, geography, we have to take all those things
into account.
And a special thanks to Congresswoman Solis for her active
involvement not only in the Congressional Hispanic Caucus but
back in California on the issues of healthcare over the years.
To me, I find something very stunning, and one of our
witnesses, Dr. Michael Rodriguez, will I suspect testify to
this a little later on, but three-quarters of physicians, when
they are treating people who are limited in their English
understanding, three-quarters of family physicians use family
members to do interpretation, translation. Now I have got to
tell you that maybe if you want directions on how to get to the
monument a few miles away or how to get to the cinema to go see
a great movie it's okay to have your family member translate
for you. But when it's the issue of what medication you should
take or whether you should have an amputation, having a family
member doing the translation services for you I think is one of
the biggest mistakes we make with regard to healthcare.
And when you take into account that the Civil Rights Act--
Title VI of the Civil Rights Act actually mandates that
healthcare providers that are receiving Federal funds provide
meaningful access to all of their programs and activities to
people who have limited English proficiency, you wonder what's
going on. The Civil Rights Act says you are required to provide
these services if you are taking Federal dollars. Yet, at the
same time, you have a Medicare Program that doesn't reimburse
providers to try to provide these interpretation services.
Dr. Rodriguez will probably testify on these. It's in his
written testimony that the average cost to provide these
interpretation services, competent interpretation services,
professional interpretation services would probably add about
$4 to a medical visit, 4 bucks to save an amputated leg or to
make sure you are taking about your prescription medication
correctly.
And perhaps more to the point and the reason why I think
this hearing, Mr. Chairman, is so important is that the issue
of trust for a lot of these patients who, whether it is because
they are low income or a racial or ethnic minority or language
challenged, don't receive the best medical assistance.
Sometimes they leave the hospital with less than a good
experience.
The problem with that in my encounters and my experience
shows me is that that means you have people who are less
confident in their medical providers and those professionals
that are telling them what to do with their lives and their
health. And if you are less willing to accept the word of a
physician because you didn't have a good outcome or a good
encounter, there is a very good chance that you are not going
to trust what that physician is telling you when it comes to
some perhaps lifesaving treatment or service. And so to
undermine the trust that we would have between the provider,
the doctor, and the patient to me is perhaps one of the
greatest sins that we commit in allowing disparities to occur;
and so I think it is critical that we begin to address this
issue. And I want to thank my colleagues for their excellent
testimony in bringing to light the different disparities and
the types of solutions that we can devise to try to address
this.
And with that, Mr. Chairman, I will yield back the balance
of my time.
Chairman STARK. Thank you.
Mrs. Tubbs-Jones, would you like to inquire?
Mrs. JONES. Thank you, Mr. Chairman.
I want to thank all of my colleagues for appearing.
Unfortunately, it seems like I end up at the end of the list,
and I am not saying I was discriminated against. I am just
saying I am at the end of the list, and all the people I want
to ask questions of, unfortunately, had to leave. So I am going
to ask my question and answer my question.
Chairman STARK. It is difficult for me to understand how a
person so young could have risen to such seniority on this
Committee.
Mrs. JONES. I know. It is because of the way the process
operates. I won't talk about that about that now.
I'm joking.
All kidding aside, Mr. Moran, my colleague, your discussion
has specifically been focused on urban and rural disparities.
Can you shed any light on the disparities that occur in your
congressional district as a result of race?
Mr. MORAN. Yes, in the sense that I represent a very
Hispanic district, at least in comparison to other
congressional districts in the Midwest, and what I would point
out is the importance of community health clinics in meeting
the needs not only of individuals with low incomes but
particularly individuals with low incomes in the minority
population.
In southwest Kansas, where the largest proportion of
Hispanics reside, United Methodist Ministries is a community
healthcare provider that provides medical services to that
community. It is significant, it is important, and even in
rural America somewhat contrary to the stereotype. Our
population is very diverse.
Mrs. JONES. What percentage Hispanic is it?
Mr. MORAN. Eleven percent Hispanic.
Mrs. JONES. Your congressional district.
Mr. MORAN. Yes.
Mrs. JONES. And what is your district again?
Mr. MORAN. It is the First District of Kansas, which is
every community in Kansas that you have never heard of.
Mrs. JONES. You don't know that.
Mr. MORAN. I don't know that.
Mrs. JONES. There you go.
Mr. MORAN. I am stereotyping in this case. But it is
everything except Wichita, Kansas City, and Topeka.
Mrs. JONES. Okay. Thanks a lot.
I would have focused much of my questions to my colleague,
Donna Christensen, because it is my job as the African American
Member of this Committee to focus on issues that focus around
the African American community, and I want to quickly just read
kind of questions and answers that I would have asked Dr.
Christensen were she still here.
One of those was the source of growth in stage renal
disease in racial and ethnic minority communities; and it
includes a spike in conditions such as diabetes, hypertension
and a variety of socioeconomic factors. It can also be
attributed to a lack of access to care and lack of coverage.
Effective programs or tools or strategies to reduce the
disproportionate number or burden of ESRD, or end-stage renal
disease, in these communities can include access to care and
health insurance coverage, education about diabetes and
hypertension prevention, national policies that recognize the
diverse needs of the end-stage renal disease population.
And one of the reasons I focus on this is because of the
disproportionate number of people in my own community that I
have seen have amputations as a result of end-stage renal
disease. And to see a person lose limbs in the course as a
result of that disease is devastating and to know that there
are opportunities within our healthcare community to reduce
some of that are significant.
I had an opportunity just the other day to speak with a
physician who specializes in vascular surgery to attempt to
reduce the number of amputations that occur in that community.
I would have had a conversation with Dr. Christensen around
efforts to address the issue of overprescription of Epogen and
how do we address that and how we are looking at bundling and
what impact that has on our community. And the reason we focus
on that is because we don't want people to have the perception
that physicians are overprescribing, but, on the other hand, we
don't want to say we don't want to be involved in legislating a
medical practice. That should be left to physicians and
prescribers of prescriptions.
I do want to focus in on for a moment a recent American
Journal of Kidney Disease report dated April, 2008, that
indicates that when the travel time for dialysis increases from
1 to 15 minutes to 15 to 60 minutes, mortality increases by 20
percent.
Additionally, if you look in areas with high numbers of
smaller facilities, they also happen to be areas in which high
proportions of African Americans are treated. If these
facilities are closed because of a flawed payment system,
African Americans with ESRD would face greater travel times to
other dialysis facilities and thus would face greater risk for
mortality.
I see I am out of time; and again I want to thank my Chair
for hosting this Committee around healthcare disparities,
racial and ethnic healthcare disparities. You can see that it
is a topic that deserves much more time and much more
attention. But we have an opportunity to address additional
things such as cultural problems within the healthcare delivery
service, access, and on and on and on.
I thank you, Mr. Chairman, for the opportunity to present
in this area. I want to again thank my colleagues for taking
the time to come before the Committee, and I look forward to
the second panel where we will have a further opportunity to
address some of these issues.
Chairman STARK. I thank you all, those that have been able
to stay. I know that Congresswoman Christensen had a
Subcommittee to Chair, and Ms. Bordallo had other appointments.
So I appreciate your taking the time and patience to be with us
this morning. Thanks very much.
Mr. MORAN. Thank you, Mr. Chairman, for allowing this
outlier.
Ms. SOLIS. Thank you, Mr. Chairman.
Chairman STARK. I would like to ask our second panel to
come on up to the witness table. And I won't go through each
biography in the interest of time, but many of our witnesses
have come from around the country, and they have considerable
experience and expertise.
But I have to especially welcome Dr. Anthony Iton, who
comes from my district in Alameda, California. He is the
Alameda County Health Officer and has devoted his career to
working on these issues before us today.
Just to give you a sense of Dr. Iton's qualifications, he
has a medical degree from Johns Hopkins. He's board certified
in internal medicine and preventative health. He has a law
degree and a master's in public health from the University of
California at Berkley. He is a member of the California Bar.
And we just feel fortunate having him serve my constituents.
And I want to, as I say, welcome the other witnesses, all
of who have outstanding credentials. They just aren't lucky
enough to live in the 13th Congressional District of
California.
And I am going to call on you as best I can read your names
from here. We have, as best I can pronounce these--I am going
to just through the list--Dr. Lillie-Blanton, Dr. Akhter, Dr.
Jang, Dr. Iton we know, Dr. Satel, and Dr. Rodriguez.
Chairman STARK. Dr. Lillie-Blanton, would you like to lead
off?
STATEMENT OF MARSHA LILLIE-BLANTON, DR.P.H., SENIOR ADVISOR ON
RACE, ETHNICITY AND HEALTHCARE, KAISER FAMILY FOUNDATION
Ms. LILLIE-BLANTON. Thank you, Mr. Chairman and Members of
the Subcommittee on Health, for the opportunity to testimony on
the issue of racial disparities in health and in healthcare.
I am Marsh Lillie-Blanton, Senior Advisor on Race,
Ethnicity and Healthcare at the Kaiser Family Foundation and
also an associate research professor in the George Washington
University School of Public Health and Health Services.
In the past half century, the United States has made
remarkable progress in improving the health of all Americans,
including Americans of color. We also have seen tremendous
gains in access to medical care since the mid-1960s. Medicaid
and Medicare, along with the enforcement of the 1964 Civil
Rights Act, deserve much of the credit for improved access. Yet
disparities in health persist and our health system provides
inadequate care for some and excludes millions of others.
My testimony today focuses on the role of health insurance
in reducing disparities in healthcare and in health status, two
distinct but related challenges. Although the causes of health
disparities are complex and result from multiple interrelated
factors, differentials in access and in quality contribute to
these disparities.
The landmark IOM report, Unequal Treatment, provided
compelling evidence that racial disparities in care persist.
The extent to which medical care contributes to health outcomes
may be relatively small when the outcome is defined as overall
population mortality. However, the effects of medical care are
immeasurable for individuals with specific health problems such
as asthma or heart disease or who may need the guidance from
the health system to help change personal behaviors.
However, addressing healthcare disparities is important for
reasons far beyond their impact on health outcomes. The racial
divides in the U.S., whether in education, employment, or
healthcare, reflect the Achilles heel of this Nation. Healing
the wounds that separate this Nation is important if we are to
move forward as one Nation.
The U.S. was founded on ideals of equality of opportunity,
and continuing efforts to realize those goals are warranted
throughout all sectors of society. In the health system,
assuring that individuals with similar healthcare needs are
similarly treated is a basic matter of fairness.
Health insurance coverage provides the final means to
access care in the U.S. Of the 47 million non-elderly Americans
uninsured in 2006, approximately half, 24 million, are people
of color. While younger adults are more likely than older
adults to be uninsured, older adults, especially the nearly
elderly, are a particularly vulnerable group because health
problems increase with age.
The consequences of being uninsured can be serious. When
compared with the insured, the uninsured are less likely to
have a regular doctor and are more likely to be hospitalized
for preventable conditions. Uninsured adults across racial
ethnic groups are at least twice as likely as the insured to go
without a doctor visit in the past year.
A recently completed study panel of the National Academy of
Social Insurance concluded that racial disparities exist not
only among the privately insured but also among Medicare
beneficiaries in fee-for-service and managed care. One study
cited in the report analyzed HEDIS measures for beneficiaries
enrolled in Medicare managed plans. The study found that the
white/black gap narrowed for seven of the nine HEDIS measures
but was not eliminated in any category, and it widened for two
measures.
One of the most important tools for tracking disparities in
access and quality of care is the annual National Healthcare
Disparities Report. The 2007 report found that there was either
no change or a worsening of disparities in quality on more than
half of the 16 indicators tracked over time across all racial
ethnic groups. In other words, healthcare disparities in the
last 5 years are not getting any smaller.
Race and ethnicity clearly matters in our healthcare
system, but so do other many other factors such as the
geographic availability of health services or the language
capability of the providers. The wealth of evidence, however,
that insurance makes a difference in opening the door to the
health system suggests that reducing the number of uninsured
would be one effective step in reducing racial and ethnic
disparities in care.
Racial disparities among persons who are insured, however,
are an indication that expansions in coverage, though
necessary, are not sufficient. Efforts therefore are needed to
increase the knowledge base of what works and then apply that
knowledge to help close the gap in the quality of care.
I appreciate the opportunity to testify before the
Committee today and welcome your questions. Thank you.
Chairman STARK. Thank you.
[The prepared statement of Ms. Lillie-Blanton follows:]
Prepared Statement of Marsha Lillie-Blanton, DrPH, Senior Advisor on
Race, Ethnicity and Healthcare, Kaiser Family Foundation
Mr. Chairman and Members of the Subcommittee on Health, thank you
for the opportunity to testify on the issue of racial disparities in
health and healthcare. I am Marsha Lillie-Blanton, Senior Advisor on
Race, Ethnicity, and Healthcare at the Kaiser Family Foundation, and
also an Associate Research Professor in the George Washington
University School of Public Health and Health Services.
Today, 1 in 3 Americans self-identify as either Hispanic/Latino,
African American/Black, American Indian/Alaska Native, Asian American,
or Native Hawaiian or Pacific Islander. By 2050, half of the U.S.
population will be a person of color (Figure 1). This demographic shift
in the population suggests that there are economic as well as health
consequences of our failure to eliminate longstanding disparities in
health status and in access to healthcare.
In the past half century, the United States has made remarkable
progress in improving the health of all Americans, including Americans
of color. We also have seen tremendous gains in access to medical care
since the mid-1960s. Medicaid and Medicare, along with the enforcement
of the 1964 Civil Rights Act, deserve much of the credit for improved
access among low-income families, the elderly, and the disabled. Yet
disparities in the health of the U.S. population persist and our health
system inadequately cares for some and excludes millions of others.
My testimony today focuses on the role of health insurance in
reducing disparities in healthcare and in health status, two distinct
but related challenges. Disparities in healthcare--whether in insurance
coverage, access, or quality of care--are one of many factors producing
inequalities in health status in the U.S. Eliminating disparities in
health among segments of the population (e.g., by race/ethnicity,
education, income, gender, geographic location) was one of two
overarching goals of Healthy People 2010, the Federal Government's
blueprint for what it wanted to achieve in health by the end of this
decade.
Let me begin with several examples of the urgency of these goals
with two examples reflecting longstanding disparities, and one
reflecting a more recent occurrence of a pattern of excess burden of
disease that is unacceptable in a nation with the economic resources
and technological know-how of the U.S. (Figures 2-4).
A baby born to a Native American woman with a high school
degree is almost twice as likely to die during the first year of life
as a baby born to a Hispanic woman with the same years of education
(9.2 vs. 5.3 per 1000 live births)
A Black man earning less than $10,000 has a life
expectancy at age 25 that is 3 years less than a White man earning the
same income; and
The rate of new AIDS cases among adults/adolescents is 3
times higher among Hispanics (26 per 100,000) than the rate among
Whites (7 per 100,000).
Although the causes of health disparities are complex and result
from multiple interrelated factors (some individual and some societal),
differentials in access to care and in the quality of care contribute
to these health disparities. Access to quality care matters. The extent
to which medical care contributes to health outcomes may be relatively
small when overall population mortality is the measure of health
outcome (McGinnis et al 2002); however, the effects of medical care can
be immeasurable for individuals with specific health problems such as
asthma or heart disease or who need the guidance of the health system
to help change personal behaviors. Nonetheless, efforts to address
healthcare disparities are important for reasons far beyond their
impact on health outcomes.
Why Addressing Healthcare Disparities is Important
The racial divides in the United States--whether in education,
employment or healthcare--reflect the Achilles heel of this nation.
Healing the wounds that separate this nation is important if we are to
move forward as one nation. The U.S. was founded on ideals of equality
of opportunity and continuing efforts to realize those goals are
warranted throughout all sectors of society. In the health system,
assuring that individuals with similar healthcare needs are similarly
treated is a basic matter of fairness.
The landmark IOM report, Unequal Treatment, provided compelling
evidence that racial disparities in care persist. However, national
surveys continue to show that a sizable share of the population is
unaware that all Americans don't receive the same access to medical
care (Figure 5). Some of the disbelief is rooted in concerns about the
quality of the evidence on racial disparities (i.e., whether the
problem is real or largely explained by socio-economic differences in
the population).
About five years ago, the Foundation working in partnership with a
number of physician groups launched a campaign ``Why The Difference''
in an effort to increase awareness of healthcare disparities and
ultimately encourage efforts to address them. We learned that the
disbelief about whether a problem exists also extended to physicians.
As such, a major component of the initiative was a thorough review of
studies on racial differences in the care of patients with heart
disease. We drilled down to the best studies designed to control for
differences in heart disease severity, as well as socioeconomic status.
The review, undertaken with the American College of Cardiology
Foundation and Association of Black Cardiologists, provided credible
evidence of lower rates of diagnostic and revascularization procedures
for at least one of the minority groups under study in eight out of ten
studies. This finding held true whether reviewing all studies meeting
criteria for the review, the subset of studies defined as the most
methodologically rigorous or that analyzed only clinical data (Figure
6). A number of efforts are now underway to improve the quality of
cardiac care and reduce disparities in care, including one funded by
the Robert Wood Johnson Foundation that is showing evidence of success.
The Role of Insurance in Racial Disparities in Care
Health insurance coverage provides the financial means to access
care in the U.S. Whether or not one has health insurance or adequate
insurance for their medical needs is linked to a number of factors
including age, employment, state of residence, and even race/ethnicity.
Of the 47 million nonelderly Americans uninsured in 2006,
approximately half--24 million--are people of color (Figure 7). While
younger adults are more likely than older adults to be uninsured, older
adults, especially the near-elderly (adults age 55-64) are a
particularly vulnerable group because health problems increase with
age. A racial disparity in coverage also exists among Americans ages
55-64. For example, in 2006, 23 percent of American Indian/Alaska
Natives and 19 percent of African Americans ages 55-64 were uninsured,
as compared with 10 percent of Whites in that age group (Figure 8).
This disparity has consequences for Medicare costs since many of the
uninsured in this age group will have unmet needs for medical care upon
entering Medicare at age 65.
Insurance matters for adults of all ages. Uninsured adults across
racial/ethnic groups are at least twice at likely as the insured to go
without a doctor visit in the past year (Figure 9). Among Hispanic
adults, for example, 21 percent of the insured had no doctor visit in
the past year as compared with 53 percent of the uninsured. Numerous
studies show that the consequences of being uninsured can be serious.
When compared with the insured, the uninsured are less likely to have a
regular doctor, and are more likely to be hospitalized for preventable
conditions.
Medicare provides insurance coverage for virtually all persons ages
65 and older and for 7 million younger adults with permanent
disabilities who qualify for Social Security. However, racial/ethnic
differences in supplemental coverage among Medicare beneficiaries also
can affect differentials in care. An estimated 18 percent of African
Americans compared to 11 percent of Latinos and 11 percent of White
Medicare beneficiaries lack supplemental coverage to fill in the gaps
and pay for services not covered by Medicare (Figure 10). In addition,
because Medicare beneficiaries of color are disproportionately low-
income, they are more likely than Whites to have supplemental coverage
from Medicaid and thus are greatly affected by federal-state Medicaid
policies that influence access to care. Without insurance or adequate
insurance coverage, access to medical care suffers and can ultimately
compromise one's health.
In a review of multiple studies on the contribution of health
insurance to racial disparities in care, health insurance was found to
be the single largest factor explaining racial disparities in whether
an individual had a regular source of medical care (Lillie-Blanton &
Hoffman 2005). For example, one study in that review found that health
insurance explained approximately 42 percent of the access disparity
between African Americans and Whites, and about 20 percent of the
access disparity between Hispanics and Whites in having a regular
source of medical care (Figure 11), a well recognized measure of one's
ability to obtain access to timely and quality care.
Disparities in Care Among the Insured
Although the uninsured are clearly the most vulnerable for getting
less than adequate care, disparities in access and in quality of care
exist even among the insured. Evidence of racial/ethnic disparities in
care among individuals who are similarly insured is particularly
disturbing.
The National Academy of Social Insurance recently completed a study
panel on Medicare and racial disparities (NASI 2006). After a review of
the research, the panel concluded that racial disparities exist not
only among the privately insured but also among Medicare beneficiaries
in fee-for-service and managed care. One study cited in the report
analyzed Healthcare Effectiveness Data Information Set (HEDIS) measures
for elderly White and Black beneficiaries enrolled in Medicare managed
care plans between 1997 to 2003 (Trivedi et al 2005). The study found
that the White-Black gap narrowed for seven of nine HEDIS measures but
was not eliminated in any category, and it widened for two measures:
glucose control among patients with diabetes and cholesterol control
among patients with heart conditions. Another study of Medicare
patients with breast, colorectal, lung, and prostate cancers shows that
disparities persist in treatment of these conditions as well (Gross et
al 2008).
Evidence from the Medicare program also provides a positive example
of how expansion in insurance coverage can diminish healthcare
disparities (Daumit and Powe 2001). A nationwide study found that the
racial disparity in cardiac procedure use among patients with chronic
renal disease--a group at high risk for heart disease--was sharply
reduced after patients qualified for Medicare (Figure 12). African
American men and women were a third as likely as White men (the study
reference group) to receive catheterization, angioplasty, and bypass
surgery before enrolling in Medicare. After enrolling in Medicare and
entering into a comprehensive system of care, there was no difference
in cardiac procedure use between African American women and White men.
For African American men, however, the disparity persisted. In other
words, insurance coverage reduced the disparity for both population
groups, and eliminated it for one population group.
Tools for Tracking Changes in Healthcare Disparities
One of the most important tools for tracking disparities in access
and quality of care is the annual National Healthcare Disparities
Report (NHDR), which examines differences in patterns of care across
different segments of the population. The 2007 NHDR shows that
disparities between racial/ethnic groups continue to exist for a number
of conditions and services and that progress in reducing disparities
has been modest at best. The NHDR found that there was either no change
or worsening of disparities in quality on more than half (57%-69%) of
the 16 indicators tracked over time for the four racial/ethnic groups
of color compared to Whites (Figure 13).
It is important to note, however, that of the 42 quality indicators
included in the 2007 NHDR, data on only 16 indicators were available to
track over time for all racial/ethnic and income groups. Increasing our
knowledge on healthcare disparities and effective interventions will
require routinely collecting, analyzing, and reporting on data on
healthcare use across population demographic characteristics such race/
ethnicity, income and education. These efforts are needed to benchmark
and track our healthcare system's performance in serving all Americans,
regardless of their background characteristics or where they live.
Race and Coverage Matter, but so do Other Factors
Race and ethnicity clearly matter in our health system, but so do
many other factors--such as the geographic availability of health
services or the language capability of the provider. We live in a
society that remains highly residentially segregated by race/ ethnicity
and by income. People of color tend to live in close proximity to each
other and people of limited financial means and those of great wealth
tend to live in the same neighborhoods. As a result, education,
employment, and healthcare opportunities tend to cluster along those
divides. This reality complicates our ability to neatly define the
causes of the problems or their solutions.
The wealth of evidence, however, that insurance makes a difference
in opening the door to the health system suggests that reducing the
number of uninsured would be one effective first step in reducing
racial/ethnic disparities in care. African Americans, Latinos, Native
Americans, and some Asian and Pacific Islander Americans are
disproportionately uninsured, and thus will face greater financial
burden in obtaining access to care. Racial disparities among persons
who are insured, however, are an indication that expansions in
coverage, though necessary, are not sufficient. Efforts are needed to
increase the knowledge base of what works and then apply that knowledge
to help close the gap. Finally, collecting data to better track
performance measures on our health system is important to monitor our
progress in reducing disparities in care.
I appreciate the opportunity to testify before the
Committee today and welcome your questions. Thank you.
Chairman STARK. Dr. Akhter, who is the Director of the
National Medical Association, we are happy to have you here and
look forward to your testimony.
STATEMENT OF MOHAMMAD AKHTER, M.D., MPH, EXECUTIVE DIRECTOR,
NATIONAL MEDICAL ASSOCIATION
Dr. AKHTER. Thank you, Mr. Chairman and Members of the
Committee. It is honor to testify before you on this very
important subject not only to our community but to our Nation.
National Medical Association's 30,000 physicians provide
every single day services to the minority community, so what I
am about to tell you is the reality on the ground.
The first and most important contributing factor to the
disparities is lack of affordable care. When the healthcare is
not available, one out of three Hispanics and one out of four
African Americans have no access to care. When the care is not
available, they can't access the care in a timely manner. Then
a small problem becomes a big problem. Like in our Nation's
capital, a child who couldn't get dental care, the dental
abscess became the brain abscess and the child died. And there
are many examples like this. So access to care becomes the
number one issue for our minority communities.
Even when we do have health insurance, people have
difficulty getting the access because there are not many
providers in those communities. Why would a provider open his
office in a community where every third person coming in is
uninsured or has no ability to pay? And so when there is no
provider or very few providers, people are having difficulty
getting care, even for Medicare patients.
Fifty percent of the Medicare patients in a study done by
Hopkins shows they have difficulty finding a general
practitioner to be taking care of their diabetes, their
hypertension; and 81 percent of the patients have no access to
mental health services. So, without these services, it really
becomes very, very hard.
So in areas of our country when people do have insurance
and people do have access, they usually receive poor quality
care in the minority communities. And one big reason for
receiving poor quality care is a lack of coordination between
the providers. Most minority patients with multiple chronic
conditions have many doctors and many providers. They don't
talk to each other.
So in this one study by Hopkins, 32 percent of the patients
got conflicting medical advice from their providers. Twenty-
five percent of the time they had to have duplicate tests done,
and another 25 percent of the time they got wrong prescriptions
or conflicting prescriptions. So no wonder 71 percent of
Hispanics and over 50 percent of African Americans are
dissatisfied with the care they receive when they go to get the
care.
Mr. Chairman and Members of the Committee, the system is
broken. We need to fix the system.
And when everything is available--the people have
insurance, they have access to care, there are great
institutions--the culturally competent care is not available.
The language problem, low literacy rates, the communication
between the doctor or the provider and the patient is not very
good, so the treatment plan that's developed is not followed by
the patient appropriately. So, as a result, despite our
spending a lot of money in the healthcare delivery system, we
continue to have these disparities.
And finally, Mr. President, when the system was put in
place in the last century, in our Nation life expectancy was
around 50 years, and most our people were of European descent.
So the system put in place was for the sick care system or the
acute care system. It has served us very well over the years.
But now our Nation has changed. Our population has grown
older. Our society has become multicultural, multiethnic, and a
bigger problem for our society is the chronic care, management
of care. Seventy-five percent of the problem is management of
chronic care. That is where the disparities come in. This acute
care system is not designed to do deal with chronic care
problems. So we need to transform the system from a sick care
system to a healthcare system that includes prevention, disease
management that is patient centered and is affordable.
Mr. Chairman, I know you've been very interested in this
issue and the Members of the Committee, but really truly to
address this issue not only we need to follow through on the
TriCaucus bill but we also need to transform our healthcare
delivery system so it could meet the needs of our population as
it exists today and as it will be in the future.
I thank you very much for the opportunity today, Mr.
Chairman, to testify before you.
Chairman STARK. Thank you, Doctor.
[The prepared statement of Dr. Akhter follows:]
Prepared Statement of Mohammad Akhter, M.D., MPH,
Executive Director, National Medical Association
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Chairman STARK. I guess it's Ms. Jang, who is the Policy
Director of the Asian and Pacific Islander American Health
Forum. Would you like to enlighten us, please?
STATEMENT OF DEEANA JANG, J.D., POLICY DIRECTOR, ASIAN AND
PACIFIC ISLANDER AMERICAN HEALTH FORUM
Ms. JANG. Thank you. I guess I am a doctor, because I have
a J.D.
But I want to thank you Chairman Stark, Ranking Member Camp
and Members of the House Ways and Means Subcommittee on Health
for inviting me to testify on disparities in health and
healthcare and for your leadership on healthcare reform,
especially your efforts to address health equity.
The Asian and Pacific Islander American Health Forum is a
national advocacy organization dedicated to improving the
health and well-being of Asian Americans and Pacific Islander
communities through policy, programs, and research. My
testimony this morning will discuss the disparities in
healthcare coverage, health status, access to care, and quality
of care for Asian Americans and Pacific Islanders. I will end
by discussing some important policy proposals included in the
House-passed CHAMP Act and H.R. 3014, the TriCaucus-sponsored
health equity legislation.
Earlier today, Ms. Bordallo discussed the heterogeneity of
Asian American and Pacific Islander communities in terms of
ethnicities, languages spoken, culture, and socioeconomic
status. As a group, Asian Americans and Pacific Islanders are
more likely to be uninsured than nonHispanic whites. Specific
Asian American and Pacific Islander groups face extremely high
rates of uninsurance. For example, 24 percent of Native
Hawaiians and Pacific Islanders and 31 percent of Korean
Americans are uninsured.
The sources of insurance also varies greatly between Asian
American and Pacific Islander subgroups. Southeast Asians have
higher incidents of poor and near poor and are more likely to
rely on Medicaid and the State Children's Health Insurance
Program. Koreans, who are more likely to work in their own
small businesses, are less likely to have employer-sponsored
health coverage.
Any healthcare reform coverage that includes employer
mandates must take into consideration the need for affordable
health coverage for small business owners, and expanding public
programs to cover more low-income individuals will also result
in expanded coverage for Asian Americans and Pacific Islanders.
While health insurance coverage is an important predictor
of access to healthcare in our communities, uninsured Asian
Americans were more than four times as likely as insured Asian
Americans to lack a usual source of care. However, disparities
and access to care remain, regardless of healthcare coverage.
Factors such as language and cultural barriers prevent many
Asian Americans and Pacific Islanders from accessing quality
care. For example, cancer is the leading cause of death among
Asian Americans; yet Asian Americans were significantly less
likely to receive preventative services such as cancer
screenings or cholesterol checks or counseling about smoke
cessation, diet, weight, exercise, and mental health.
There are two important strategies included in the CHAMP
Act and H.R. 3014 that I want to highlight that should be
included in any efforts to reform healthcare. First of all,
standardizing the collection, analysis and reporting of data on
race, ethnicity, and primary language in an accurate and
appropriate manner and, secondly, ensuring that effective
communication takes place between provider and patient through
the provision of competent language assistance.
Accurate, timely disaggregated data by race, ethnicity, and
primary language on Asian Americans and Pacific Islanders and
other racial and ethnic minorities are vital to developing and
monitoring programs and policies aimed at improving health
equity. Medicare data has provided a rich source of information
about these populations and the disparities in health and
healthcare among Medicare beneficiaries.
You have heard about the Robert Wood Johnson study that was
mentioned earlier, but there has also been a recent study that
found that, although there were variations related to geography
and socioeconomic status overall, Asian Medicare beneficiaries
were less likely than whites to receive mammography and
colorectoral cancer screening and all three diabetic services.
And while there have been some improvements in the quality
of data collected on race and ethnicity, there remains much
more to be done. For example, the improvement in the data on
race, ethnicity, and primary language in the Medicare system.
The problem is that Medicare's data comes from the Social
Security Administration, and this data is collected at the time
that someone applies for a Social Security number. The problem
is that the way that data is collected has not been updated to
conform with the OMB revised standards in 1997 on the
collection of race and ethnicity.
The second problem is the Enumeration at Birth process.
That doesn't provide data on race and ethnicity.
And, finally, 12 percent of Medicare beneficiaries are
enrolled by Medicare health plans that are not required to
collect or report data on race, ethnicity, or primary language.
Finally, in terms of language access, almost all health
providers are obligated by the Civil Rights Act to provide
language assistance, but we need more technical assistance and
resources to pay for it. So while the Centers for Medicare and
Medicaid Services has clarified that language services are
reimbursable in the Medicaid and SCHIP program, no such
reimbursement is specifically available in the Medicare
Program. And although Medicare health plans are required to
provide the language services, most of them are passing those
obligations on to their contractor providers without any
reimbursement or resources to help them do that. So we support
the provisions in the CHAMP Act that will call for a study and
evaluations and demonstration projects to assure that high-
quality language assistance is provided in a cost-effective
manner with incentives for providers to use it.
I thank you for the invitation, again, to testify. There is
more data and details in my written statement, and I would be
happy to answer any questions.
Chairman STARK. Thank you very much.
[The prepared statement of Ms. Jang follows:]
Prepared Statement of Deeana Jang, J.D., Policy Director,
Asian & Pacific Islander American Health Forum
Thank you, Chairman Stark, Ranking Member Camp, and Members of the
House Ways and Means Subcommittee on Health, for inviting me to testify
on disparities in health and healthcare. I also want to thank Chairman
Stark and Members of this Subcommittee for your leadership on
healthcare reform and for your efforts to address health equity within
the context of reform.
The Asian and Pacific Islander American Health Forum, or ``Health
Forum,'' is a national advocacy organization dedicated to improving the
health and well-being of Asian American and Pacific Islander (AA and
PI) communities through policy, programs, and research. We advocate on
health issues that impact AA and PI communities, provide community-
based technical assistance and training to address chronic diseases,
HIV/AIDS, and domestic violence in AA and PI communities, and convene
regional and national conferences on AA and PI health.
Healthcare reform, or expanding access to healthcare for uninsured
and underinsured Asian Americans and Pacific Islanders (AAs and PIs),
is one of five major policy priorities for the Health Forum. But, as
you'll see from my testimony, even with health coverage, disparities in
health and healthcare persist in our communities. My testimony will
also cover some of the unique factors that make it difficult for AAs
and PIs to access quality healthcare; such as disparities in health
coverage due to poverty, and a significant percentage who work in or
own small businesses and barriers due to language and culture.
Disparities in Health Coverage among AAs and PIs
As a group, Asian Americans and Pacific Islanders are more likely
to be uninsured than non-Hispanic whites. Specific AA and PI groups
face extremely high rates of uninsurance: from 2004-2006, 24 percent of
Native Hawaiians and Pacific Islanders and 31 percent of Korean
Americans were uninsured.\1\
---------------------------------------------------------------------------
\1\ Kaiser Family Foundation and Asian & Pacific Islander American
Health Forum, Health Status, Coverage, and Access to Care for Asian and
Native Hawaiian and Pacific Islander Americans (Washington, DC: April
2008).
---------------------------------------------------------------------------
The high rate of uninsurance in several Asian American communities
is related to their employment in small businesses that do not offer
health insurance benefits. For example, more than half of Korean
Americans work in businesses with less than 25 employees. Yet, only
half of employees in such firms are provided coverage through their
employer. As a result, Korean Americans have one of the lowest rates of
employer-sponsored health coverage among AAs and PIs, 49 percent,
compared to South Asians who have the highest rate at 75 percent.\2\ By
providing small businesses with affordable options, healthcare reform
efforts could significantly lower the number of uninsured AAs and PIs.
---------------------------------------------------------------------------
\2\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
Public programs such as Medicaid and SCHIP also play an important
role in reducing uninsurance in AA and PI communities. Gains in
coverage by these programs, between 1997 and 2004-2006, helped protect
AAs and PIs from declines in job-based coverage. This helped decrease
the number of uninsured AAs and PIs from 21 percent to 19 percent over
that same period.\3\ An expansion of public programs through healthcare
reform efforts is critical for individuals who do not have access to
affordable coverage through an employer or the private market.
---------------------------------------------------------------------------
\3\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
Coverage of AAs and PIs in public programs grew in part due to
federal and state efforts over the last decade to reduce barriers faced
by minority and immigrant communities. Many AAs and PIs qualify for
public programs but remain uninsured because of language and cultural
barriers in the enrollment process, misinformation about eligibility,
and other family hardships such as food and housing insecurity. There
are others who do not qualify even if they are low-income and legal
immigrants. Since 1996, legal immigrants in low-income families have
been barred from receiving Medicaid or SCHIP during their first five
years in this country, even if they meet all other requirements for the
programs. Citizens of the Republic of the Marshall Islands (RMI), the
Federated States of Micronesia (FSM), and the Republic of Palau are
ineligible for public programs as well, even though they are allowed to
work and travel in the U.S.
To address these disparities in coverage, many states developed
strategies to help enroll individuals with limited English proficiency
in Medicaid and SCHIP.\4\ States also took additional steps to simplify
enrollment and renewal procedures for children.\5\ And, nearly half of
states have continued to provide coverage for legal immigrants during
their first five years in the country through state-funded programs.\6\
Ensuring that similar solutions are enacted through healthcare reform
would help eliminate the health insurance disparities faced by AA and
PI communities.
---------------------------------------------------------------------------
\4\ M. Youdelman, J. Perkins and J. Brooks, Providing Language
Services in State and Local Health-Related Benefits Offices: Examples
from the Field, (New York: The Commonwealth Fund, January 2007).
\5\ Kaiser Family Foundation, Health Coverage for Children and
Families in Medicaid and SCHIP: State Efforts Face New Hurdles: A 50
State Update on Eligibility Rules, Enrollment and Renewal Procedures,
and Cost Sharing Practices in Medicaid and SCHIP in 2008, (Washington,
DC: January 2008).
\6\ L. Ku, Reducing Disparities in Health Coverage for Legal
Immigrant Children and Pregnant Women, (Washington, DC: Center on
Budget and Policy Priorities, April 2007).
---------------------------------------------------------------------------
Disparities in Access to Care
Health insurance coverage is an important predictor of access to
healthcare in AA and PI communities. From 2004 to 2006, uninsured Asian
Americans were more than 4 times as likely as insured Asian Americans
to lack a usual source of care.\7\
---------------------------------------------------------------------------
\7\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
However, disparities in access to care remain regardless of health
coverage. Nonelderly AAs and PIs were more likely to lack a usual
source of care than non-Hispanic Whites (18 percent vs. 14 percent).\8\
Similarly, 52 percent of nonelderly uninsured AAs and PIs lacked a
usual source of care, compared to 46 percent of non-Hispanic uninsured
Whites. Factors such as language and cultural barriers prevent many AAs
and PIs from accessing quality care.
---------------------------------------------------------------------------
\8\ Kaiser Family Foundation, op. cit.
---------------------------------------------------------------------------
Disparities in Quality of Care
Findings from the Commonwealth Fund's 2001 Healthcare Quality
Survey concluded that Asian Americans experience poor access to quality
care on a range of measures.'' \9\ Asian Americans reported greater
communication difficulties and lower levels of satisfaction during
their healthcare visits.\10\ They were also ``the least likely to feel
that their doctor understands their background and values, to have
confidence in their doctor, and to be as involved in decision-making as
they would like to be.'' \11\
---------------------------------------------------------------------------
\9\ K. Collins, D. Hughes, M. Doty, B. Ives, J. Edwards, and K.
Tenney, Diverse Communities, Common Concerns: Assessing Healthcare
Quality for Minority Americans: Findings from the Commonwealth Fund
2001 Healthcare Quality Survey, (New York: The Commonwealth Fund, March
2002).
\10\ Collins et al, Diverse Communities, Common Concerns, 2002.
\11\ Collins et al, Diverse Communities, Common Concerns, 2002.
---------------------------------------------------------------------------
Despite having higher rates of certain health conditions, many AAs
and PIs do not receive the recommended levels of prevention,
counseling, or care they need. The 2001 and 2006 Healthcare Quality
Surveys revealed that Asian Americans were significantly less likely to
receive preventive services such as cancer screenings or cholesterol
checks, or counseling about smoking cessation, diet, weight, exercise,
and mental health.\12\ Less than half of Asian Americans with chronic
conditions received the care they needed to manage their
conditions.\13\
---------------------------------------------------------------------------
\12\ Collins et al, Diverse Communities, Common Concerns, 2002. A.
Beal, M. Doty, S. Hernandez, K. Shea, and K. Davis, Closing the Divide:
How Medical Homes Promote Equity in Healthcare,'' (New York: The
Commonwealth Fund, June 2007).
\13\ Beal et al, Closing the Divide, 2007.
---------------------------------------------------------------------------
Disparities in Health Outcomes and Disease Prevalence
The lack of health coverage, limited access to healthcare, and the
lack of culturally and linguistically competent services can manifest
in harmful, and even fatal ways:
Cancer deaths are increasing at a faster rate among AAs
and PIs than any other racial and ethnic population. For example, the
risk of death for Asian American women with breast cancer is 1.5 to 1.7
times higher than that for white women.\14\ This is due in part to the
relatively low screening rates and late stage diagnoses that occur
among AA and PI women.
---------------------------------------------------------------------------
\14\ C. Chappell, ``Healthcare Needs of Asian American Women,''
Issues, Concerns, and Responsive Human and Civil Rights Advocacy: Asian
American Women, Second Edition, Chapter 5, pages 101-120, 2007.
---------------------------------------------------------------------------
Although statistics on the overall prevalence of diabetes
in AA and PI communities are unavailable, it is the fifth leading cause
of death among AAs and PIs. In Hawaii, AAs and PIs aged 20 and over are
more than 2 times as likely to have diagnosed diabetes as whites after
adjusting for population age differences. In California, Asian
Americans are 1.5 times as likely to have diagnosed diabetes as non-
Hispanic whites. Despite the importance of managing diabetes, nearly
half of AA and PI adults with diabetes in California had not received a
foot exam in the past year, compared with less than 30 percent of
Whites and African Americans.\15\
---------------------------------------------------------------------------
\15\ Centers for Disease Control and Prevention, National Diabetes
Fact Sheet, United States, 2005.
---------------------------------------------------------------------------
Asian American women aged 15-24 and over 65 have the
highest suicide rates across all racial and ethnic groups.\16\
Furthermore, Asian American girls have the highest rates of depression
across both race/ethnicity and gender.\17\ The U.S. Surgeon General
noted in 2001 that nearly half of AAs and PIs have problems accessing
mental health services because of the lack of providers with
appropriate language skills.\18\
---------------------------------------------------------------------------
\16\ Centers for Disease Control and Prevention, ``Deaths: Leading
Causes for 2001,'' National Vital Statistics Reports, 52(9), 1-86,
2003.
\17\ National Center for Health Statistics, ``Health, United
States, 2003,'' (Hyattsville, MD: U.S. Public Health Service, 2003).
\18\ U.S. Surgeon General. 2001. Mental Health: Culture, Race, and
Ethnicity. A Supplement to Mental Health: A Report of the Surgeon
General. Washington, DC: U.S. Department of Health and Human Services.
---------------------------------------------------------------------------
Strategies to address disparities in coverage, access and quality
There are two important strategies included in Subtitle D of H.R.
3162, the Children's Health and Medicare Protection Act of 2007 (CHAMP
Act) that should be included in healthcare reform initiatives to
address disparities in coverage, access and quality:
1. Standardizing the collection, analysis and reporting of data on
race, ethnicity and primary language in an accurate and appropriate
manner.
2. Ensuring that effective communication takes place between
provider and patient through the provision of competent language
assistance.
Importance of collection of data on race, ethnicity and primary
language
Accurate, timely, disaggregated data by race, ethnicity, and
primary language on Asian Americans and Pacific Islanders are vital to
developing and monitoring programs and policies aimed at improving
health equity.
In 1999, Congress requested that the Institute of Medicine (IOM)
assess the extent of health disparities; explore factors that may
contribute to inequities in care; and recommend policies and practices
to eliminate them. Its report, ``Unequal Treatment: Confronting Racial
and Ethnic Disparities in Healthcare,'' found significant disparities
in the quality of health services received by minorities--even when
insurance status, income, age, and severity of condition were
comparable. The IOM study further revealed that minorities are less
likely to be given appropriate cardiac medications, undergo bypass
surgery, and receive kidney dialysis or transplants. Sadly, they are
also more likely to receive last-resort procedures, such as lower limb
amputations for diabetes. Subsequent research suggests that these
disparities continue to this day for both minorities and women. For
example, a recent study released by the Robert Wood Johnson Foundation
found that the rate of leg amputation is four times greater in African
American Medicare beneficiaries than in whites.\19\
---------------------------------------------------------------------------
\19\ E. Fisher, D. Goodman, and A. Chandra, Disparities in Health
and Healthcare among Medicare Beneficiaries: A Brief Report of the
Dartmouth Atlas Project, The Robert Wood Johnson Foundation, June 2008.
---------------------------------------------------------------------------
To help close the disparity gap, the IOM recommended that the
Federal Government: (1) collect and report data on healthcare access
and utilization by patients' race, ethnicity, and socioeconomic status;
(2) include measures of disparities in performance measures; and, (3)
monitor progress toward the elimination of healthcare disparities. In
2001, the Commonwealth Fund went a step further by recommending that
quality measurement and reporting tools, such as the Health Plan
Employer Data and Information Set collect and report health data by
race, ethnicity, and primary language. However, no comprehensive action
has been taken on these recommendations; it is long overdue.
A recent study published in Health Affairs found that, although
there were some variations related to geography and socioeconomic
status, overall, Asian Medicare beneficiaries were less likely than
whites to receive mammography and colorectoral cancer screening
services and all three diabetic services.\20\ The National Healthcare
Disparities Report in 2006 found that Asians receive lower quality of
care compared with whites for one-third of the core measures tracked in
the report, and for 75 percent of those measures, the gaps in quality
were not improving over time.\21\
---------------------------------------------------------------------------
\20\ E. Moy, L. Greenberg, and A. Borsky, Community Variation:
Disparities in Healthcare Quality Between Asian and White Medicare
Beneficiaries, Health Affairs, Vol. 27, No. 2, March/April 2008.
\21\ Agency for Healthcare Research and Quality, 2006 National
Healthcare Disparities Report, December 2006.
---------------------------------------------------------------------------
Medicare data has provided a rich source of information about
racial, ethnic, and socioeconomic disparities in health and healthcare
among Medicare beneficiaries. And while there have been some
improvements in the quality of data collected on race and ethnicity,
there remain much more that needs to be done to improve the quality and
accuracy of data. For example, an analysis of 2002 Medicare
administrative data show that only 52 percent of Asian beneficiaries
and 33 percent of both Hispanic and American Indian/Alaska Native
beneficiaries were identified correctly.\22\
---------------------------------------------------------------------------
\22\ A. McBean, Improving Medicare's Data on Race and Ethnicity,
Medicare Brief, No. 15, National Academy of Social Insurance, October
2006.
---------------------------------------------------------------------------
Medicare's data on race and ethnicity come from Social Security's
administrative records and are collected on a consistent basis when an
individual applies for a Social Security number. The way the data is
collected was not (and has not been) updated when the Office of
Management and Budget revised the standards for collection of race and
ethnicity data in 1997. In addition, since the late 1980's, most
applications for Social Security numbers are made through the
Enumeration at Birth process, and questions regarding race and
ethnicity are not included. Finally, 12 percent of Medicare
beneficiaries are enrolled by Medicare health plans that are not
required to collect or report data on race, ethnicity or primary
language.\23\
---------------------------------------------------------------------------
\23\ A. McBean, op. cit.
---------------------------------------------------------------------------
APIAHF is part of the Out of Many, One (OMO) Data Task Force, a
coalition of advocates working to eliminate racial and ethnic health
disparities. At the request of OMO, the Congressional Tri-Caucus has
sent a letter to the Social Security Administration requesting
information on the status of its efforts to improve data collection on
race, ethnicity and primary language. OMO and APIAHF are also
supporting language in pending Medicare legislation in the Senate to
grant authority to the Secretary of Health and Human Services to
require Medicare plans and providers to report race, ethnicity, and
gender-specific data as part of the quality measures they are currently
required to collect and report. Such provisions would help identify and
eliminate disparities in the quality of health services that minorities
and women enrolled in the program receive.
The provisions included in Subtitle D of H.R. 3162, the Children's
Health and Medicare Protection Act of 2007 (CHAMP Act) will
substantially improve the collection of data on race, ethnicity and
primary language. Specifically, we support:
Collection of data on race, ethnicity, and primary
language of each applicant for and recipient of Medicare benefits in
conformity with the 1997 revised OMB standards and further
disaggregation, where practicable, for additional population groups.
Development of standards for collection of data on
primary language spoken and written of Medicare beneficiaries.
Technical assistance for health information technology
improvements that will facilitate collection and analysis of racial,
ethnic and primary language data; improving methods for collection and
analysis of smaller populations and ethnic subgroups within the minimum
OMB standards; and educating healthcare organizations, providers and
health plans to raise awareness that collecting and reporting data on
race, ethnicity and primary language are essential to eliminate
disparities and is legal; and providing for the revision of the
existing HIPAA claims-related code set to require collection of data on
race and ethnicity and to provide a code set for the collection of
primary language data.
Identification of appropriate quality measures to monitor
for disparities and to develop new quality measures related to racial
and ethnic disparities in health and healthcare.
We also support the provision in H.R. 3014, the Health Equity and
Accountability Act of 2007, that requires the Social Security
Administration to collect data on the race, ethnicity, and primary
language of all applicants for social security numbers or benefits.
Ensuring that effective communication takes place between provider and
patient through the provision of competent language assistance.
Language barriers can reduce access to healthcare, jeopardize the
quality of care, lower patient satisfaction and adherence, increase the
risk of medical errors and lead to other adverse outcomes. More than a
third of Asian Americans and 12 percent of Pacific Islanders speak
English less than very well. The rate of limited English proficiency is
even higher for specific groups: more than half of Vietnamese, Hmong,
Cambodian, Laotian, Bangladeshi, and Taiwanese are limited English
proficient. Research indicates that the use of trained interpreters and
especially the use of language concordant health providers can improve
access to and quality of care for persons with limited English
proficiency.\24\ Research also shows that Medicare beneficiaries who
are limited English proficient in English are less likely than those
who are proficient in English to have access to a consistent source of
care and less likely to receive important preventive care, including
cancer screening tests.\25\ However, more research is needed to
determine the impact of language services on the health and healthcare
of limited English proficient populations. We support the provision in
H.R. 3162 that requires the Secretary of HHS to arrange for the
Institute of Medicine to conduct a study of the effects of providing
language access services on quality of healthcare, access to care and
reduced medical error.
---------------------------------------------------------------------------
\24\ Green, A., et al. ``Interpreter services, language
concordance, and healthcare quality. Experiences of Asian Americans
with limited English proficiency.'' J Gen Intern Med. 20(11):1050-6,
Nov. 2005. Flores, G. ``The impact of medical interpreter services on
the quality of healthcare: a systematic review.'' Med Care Res Rev.
62(3):255-99, June 2005. Ngo-Metzger, Q. ``Providing high-quality care
for limited English proficient patients: the importance of language
concordance and interpreter use.'' J Gen Intern Med. 22 (Suppl 2):324-
30. Nov. 2007.
\25\ N. Ponce, L. Ku, W. Cunningham, and E. Brown, Language
Barriers to Healthcare Access Among Medicare Beneficiaries, Inquiry,
Spring 2006.
---------------------------------------------------------------------------
Medicare programs should be ensuring that meaningful access to
enrollment and healthcare services is provided for persons with
limited English proficiency.
Under Title VI of the Civil Rights Act of 1964, all recipients of
Federal financial assistance are required to provide meaningful access
to its programs, services and activities, including those that are not
directly Federally funded, to persons with limited English proficiency.
Not all Medicare programs are considered Federal financial assistance.
While Medicare Part A providers are considered recipients of Federal
financial assistance, providers (e.g. individual physicians, who only
receive Medicare Part B and no other form of Federal financial
assistance, e.g. Medicaid) are not obligated to comply with federal
civil rights law.\26\ This has caused some confusion as new Medicare
programs have been initiated with a mixture of Part A and Part B funds,
e.g. Part C, and other sources so that determining whether participants
in some Medicare programs are required to comply has become more
complex. We support the provision in H.R. 3162 to require the HHS
Inspector General to prepare and publish a report on the extent to
which Medicare providers and plans are complying with Title VI and are
providing culturally and linguistically appropriate services as
described in the Office of Minority Health's Culturally and
Linguistically Appropriate Services Standards in healthcare. In
addition, we support requiring all Medicare providers to comply with
Federal civil rights laws. This provision is included in Title I of
H.R. 3014.
---------------------------------------------------------------------------
\26\ U.S. Department of Health and Human Services, Office for Civil
Rights, Guidance to Federal Financial Assistance Recipients Regarding
Title VI Prohibition Against National Origin Discrimination Affecting
Limited English Proficient Persons, 68 Fed. Reg. 47311, August 8, 2003.
---------------------------------------------------------------------------
Furthermore, Executive Order 13166 requires that all Federal
agencies develop plans to ensure that programs conducted by the Federal
Government are accessible to persons with limited English
proficiency.\27\ Therefore, outreach and enrollment in the Medicare
program conducted by the Centers for Medicare and Medicaid Services
(CMS) should be accessible for persons with limited English
proficiency. We are concerned that while CMS translated much of the
outreach materials for enrollment in the Medicare Part D program, there
remain issues of inaccessibility to telephone assistance and enrollment
materials. We are also concerned that Medicare informational materials,
applications and beneficiary notices are not available in languages
other than English and Spanish.
---------------------------------------------------------------------------
\27\ Improving Access to Services for Persons with Limited English
Proficiency, 65 Fed. Reg. 50121, August 16, 2000.
---------------------------------------------------------------------------
The Federal Government needs to provide reimbursement for the cost of
language assistance and provide technical assistance to
providers to ensure that high quality and effective language
assistance is available in a timely manner.
Although CMS has clarified that states can get federal matching
funds for the provision of language services in its Medicaid and State
Children's Health Insurance Programs, language services are currently
not specifically reimbursable by the Medicare program. Although the
regulations for Medicare Advantage require managed care plans to
``ensure that services are provided in a culturally competent manner to
all enrollees, including those with limited English proficiency or
reading skills, and diverse cultural and ethnic backgrounds,'' \28\ it
is unclear whether and how Medicare Advantage plans are paying for
language services and if they need or should have additional payments.
Most managed care plans pass on the requirement to their contracted
providers without specific funding or incentives. So while the managed
care plans may have contractually agreed to provide language
assistance, their payment policies may in fact create a disincentive
for providers to participate and use language services.
---------------------------------------------------------------------------
\28\ 42 C.F.R. 422.112(a)(8).
---------------------------------------------------------------------------
Healthcare providers from across the country have reported
inadequate funding of language services to be a major barrier to LEP
individuals' access to healthcare and a serious threat to the quality
of the care they receive.
63% of hospitals encounter patients with LEP daily or
weekly; an additional 17% encounter LEP patients at least monthly.
65% of internal medicine physicians have active patients
who are LEP.
Almost every major health organization (including the AMA, AHA,
ANA, AAP, AAFP, ACP, ANA, APHA, APA, NACHC, NAPH, NASW, NMA and NHMA),
supports government payments for language services as necessary to
ensuring quality healthcare. Over 75 organizations have endorsed the
Language Services in Healthcare Statement of Principles which supports
funding mechanisms to ensure language services are available where and
when they are needed.
The American College of Physicians recommends that
Medicare should pay for the added expense of language services and the
additional time in providing clinical care.
The American Hospital Association stated that resources
should be targeted to improving language services for all patients with
LEP.
According to a recent article in Pediatrics, discussing
results from a survey of pediatricians supported by the American
Association of Pediatrics, reimbursement for language services is
associated with greater use of professional interpreters.
We recognize that determining the best methodology and structure to
provide reimbursement in the Medicare program is complex given the
payment structure of the various providers, including in--and out-
patient hospital care, physician care and managed care. Therefore, the
approach taken by H.R. 3162 to support a study and demonstration
projects to examine the ways that Medicare should develop payment
systems for language services is necessary to determine the most
efficient, cost-effective way to ensure the provision of language
services that includes incentives for providers and that result in
effective communication between providers and LEP persons. The National
Health Law Program together with the Center on Budget and Policy
Priorities has already taken a preliminary look at this issue and we
urge HHS to consider their report on ``Paying for Language Services in
Medicare: Preliminary Options and Recommendations,'' October 2006. The
major recommendations from the report are:
Offer grants to hospitals, schools that train health
professionals and community groups to increase the recruitment and
training of bilingual and multilingual medical interpreters and
clinicians.
To improve language services in physician settings,
provide Medicare reimbursements to in-person interpreters and develop a
system of federal contracts for telephone interpretation firms.
Improve monitoring and oversight of existing requirements
to provide language services in Medicare managed care.
Exempt language services from Medicare cost-sharing
requirements.
Barriers to participation in Federal healthcare programs must be
removed for immigrants and other noncitizens
In order to ensure coverage and access to healthcare for all,
federal programs including Medicare, Medicaid and the State Children's
Health Insurance Program (SCHIP) must remove barriers to eligibility
for immigrants and other noncitizens.
We support the provisions in the CHAMP Act and H.R. 3014 to allow
states to cover lawfully residing immigrant children and pregnant women
in SCHIP and Medicaid. H.R. 3014 also provides eligibility for Medicaid
and SCHIP for citizens of RMI, FSM and the Republic of Palau. In
addition, other barriers such as excessive citizenship documentation
must be repealed. We support these provisions in H.R 3162 and H.R. 3014
as well.
Conclusion
We look forward to working with Congress and the new Administration
to achieve our mutual goals of guaranteed, affordable, high quality
care that is truly accessible and equitable to all.
BOARD OF DIRECTORS
2008
Executive Committee
Fatima Angeles, MPH
Chairperson
Ho Luong Tran, MD, MPH
President/Chief Executive Officer
Dexter Louie, MD, JD, MPA
Treasurer
Janice Louie, RD, BSPH, MA
Secretary
Rea Panares, MHS
Vincent Hau, MD, PhD
Senator Mee Moua
Joyce O'Brien, MPH
Sela Panapasa, PhD
Wilson Wang, MD, MPA, MPH
Headquarters:
450 Sutter Street
Suite 600
San Francisco CA 94108
Main 415-954-9988
Fax 415-954-9999
www.apiahf.org
Washington D.C. Office:
1828 L Street N.W.
Suite 802
Washington, D.C. 20036
Main 202-466-7772
Fax 202-466-6444
National Advocates for
Asian American,
Native Hawaiian &
Pacific Islander Health
Chairman STARK. Dr. Iton, would you like to testify,
please?
STATEMENT OF ANTHONY B. ITON, M.D., J.D., MPH, DIRECTOR OF
PUBLIC HEALTH AND HEALTH OFFICER, ALAMEDA COUNTY, CALIFORNIA
Dr. ITON. Good morning, Committee and certainly, Chairman
Stark, as a practicing internist for the past 20 years, I have
been very familiar with the Stark rules I and II, and it is an
honor to be from a county that is represented by you and the
leadership that you have shown in the Medicare Program.
Good morning, Ranking Member Camp and Members Becerra and
Jones.
My name is Dr. Tony Iton. I am the Health Officer and
Director of the Alameda County Public Health Department. I am a
board-certified physician and an attorney, and I work in a
department that serves about 1\1/2\ million people and have
about 170,000 uninsured people in my county. Our combined
agency expenditures are about $1 billion a year in healthcare.
I recently had the privilege to participate in the creation
of a multi-part PBS television documentary entitled Unnatural
Causes: Is Inequality Making Us Sick? In concert with the
national airing of that documentary series, my health
department released a report on the preventable root causes of
health disparities. We entitled our report Life and Death From
Unnatural Causes: Health and Social Inequity in Alameda County,
and with your permission, Chairman Stark, I would like to
submit that report for the record.
Chairman STARK. Without objection.
[The information follows:]
******** COMMITTEE INSERT ********
Dr. ITON. My testimony is largely based on research and
data that appear in both the television series and the report
as well as upon the experience of providing public health and
healthcare services for the 1.5 million residents of Alameda
County.
Now, the focus of this hearing is healthcare disparities in
the Medicare system. My particular input will be on the
evidence that, while access to healthcare is a critical
contributor to overall health status, the healthcare system by
itself cannot successfully reduce health disparities and that
unless greater attention is paid to public health approaches to
reducing health and social inequity the Medicare system will be
bankrupt due to the inexorable burden of chronic disease.
I also try to address several false dichotomies and myths
that are regularly entertained in policy discussions focused on
health and health disparities.
I will endeavor to make the following four points in my
testimony: One is that health does not equal healthcare; two is
that health disparities do not equal healthcare disparities;
three, health disparities are worsening and are overwhelmingly
driven by chronic disease; and, four, chronic disease is
preventable.
I also hope to touch on some of the false dichotomies
related to the conflict between universal access and community
based prevention and the notion of individual responsibility
versus social responsibility. And, finally, if I have enough
time--I doubt that I will--I would like to address the issue of
the immigrant health paradox and the myth that immigrants are
draining our healthcare system.
So, to start with, health does not equal heath care. Most
people who live long and healthy lives in this country--many of
us represented on this panel and in this room--do so without
much assistance from the U.S. healthcare system. In fact, a
reasonable goal of most Americans is to live a life that allows
us to avoid hospitalization, emergency room visits and even our
physician's office except for routine, clinical, and
preventative screening services.
The best strategy for doing this is to avoid acquiring a
chronic disease. According to CDC, the medical care costs of
people with chronic diseases in this country account for 75
percent of the Nation's $2 trillion medical care costs. Chronic
diseases are the cause of seven of every ten American deaths,
and the prevalence of chronic disease in the community is a
primary driver of the demand for healthcare services.
As a healthcare program administrator, I live with the
reality of the so-called 80/20 rule, which refers to the fact
that 80 percent of healthcare costs are driven by 20 percent of
the population. Relatively modest shifts in the overall chronic
disease burden in that 20 percent can have dramatic effects on
healthcare costs and utilization. Thus, the overall health of a
community is not primarily shaped by access to healthcare.
Instead, access to healthcare serves to remediate and repair
the damage that the healthcare system is presented with as the
result of the overall prevalence of chronic disease in a
community.
Now, get me right here. Healthcare access matters, and this
is one of the first false dichotomies. To argue that the
overall community health status is not primarily controlled by
access to healthcare is not equivalent to arguing that access
to healthcare plays no role in shaping overall community
health. We know about the consequences of lacking access to
healthcare, and I am not going to repeat them here because we
have many people on this panel and this Committee has heard
this before. And we know certainly that access to healthcare
reduces the chronic stress of poverty in many communities.
Simply by reducing the specter of personal bankruptcy
associated with catastrophic medical illness, universal access
to healthcare will ease the chronic stress of being working
poor in this country. It also reduces job lock, which is the
fear of leaving your job when you have a pre-existing illness
due to the fact that you are afraid that you will not be able
to get insurance in your next job.
Healthcare disparities do not equal health disparities.
Healthcare disparities are the result of a healthcare system
that lacks accountability for health outcomes and lacks
transparency regarding the selection and application of
treatment regimes. Therefore, any policy initiatives that serve
to increase accountability and transparency of the Medicare
system will create pressure on the healthcare system to reduce
differential treatment by race/ethnicity.
A particularly critical accountability and transparency
measure, and is referenced in the CHAMP Act, is the collection
of data on race, ethnicity, and primary language of
beneficiaries. Such data allows health systems researchers and
healthcare quality improvement practitioners to identify
systematic biases in provider and system behavior and thereby
adjust and correct their performances.
Now, health disparities are differences in health status
and outcomes that occur largely independent of the health
system and consequently are much broader in scope and impact
than healthcare disparities.
In my county, Alameda County, we have mapped health
disparities geographically using geographic information systems
and have demonstrated geographic patterns of disease and death
distribution that correlate closely with the distribution of
other important health protective resources such as
opportunities for employment, recreation, health, high-quality
education, and living-wage income.
These strong correlations suggest that health disparities
are substantially structural in nature and can be ameliorated
by facilitating better access to proven health protective
resources and opportunities for low-income communities and
including rural communities regardless of race but with a
particular focus on those communities that have a
disproportionate concentration of African Americans, Native
Americans, Latinos, and Pacific Islanders. The health status of
these particular groups is demonstrably worse than other race/
ethnic populations in terms of chronic disease, particularly
around obesity, diabetes, and portend worsening outcomes for
the larger population in America. And in many ways these
populations represent canaries in our coal mine; and the
vulnerability due to racial discrimination, low income, poor
education, environmental pollution make these populations more
prone to the impacts of larger disease-generating social trends
that will ultimately seep into the larger population.
I see that my time has run out. I would like to make the
point and hopefully in questioning we can discuss the issue of
false dichotomies around individual responsibility versus
community responsibility and address the myth that immigrants
are somehow bleeding our healthcare system. That is patently
false. Immigrants have in many cases in Alameda County and
elsewhere much lower utilization of healthcare services than
native-born or American-born populations and relatively good
health status given the levels of poverty. So I am happy to
address that issue if it comes up in the questioning.
Thank you.
Chairman STARK. Thank you.
[The prepared statement of Dr. Iton follows:]
Prepared Statement of Anthony B. Iton, M.D., J.D., MPH,
Director of Public Health & Health Officer, Alameda County, California
Good morning Chairman Stark and Members of the Subcommittee on
Health, thank you for the opportunity to testify today on addressing
disparities in health and healthcare. My name is Dr. Anthony Iton,
Director and Health Officer, Alameda County Public Health Department. I
will keep my comments brief and concise. A copy of my written testimony
will be submitted for the record. I am a dually board certified
physician, an attorney and the Director of a large local public health
department in Northern California. Approximately 11% or 170,000 people
in my county are uninsured.\1\ Our county runs three public hospitals,
several outpatient health clinics and funds healthcare services for the
uninsured at several other community-based health clinics. In addition
we manage a large clinical mental health and substance abuse program as
well as providing a broad array of public health and environmental
health services. The combined cost of these county-provided services is
about $1 billion dollars per year.
---------------------------------------------------------------------------
\1\ California Health Interview Survey 2007.
---------------------------------------------------------------------------
Recently, I had the privilege to participate in the creation of a
multi-part PBS television documentary entitled Unnatural Causes: Is
Inequality Making Us Sick. In concert with the national airing of that
documentary series, my health department released a report on the
preventable root causes of health disparities entitled Life and Death
From Unnatural Causes: Health and Social Inequity in Alameda County. My
testimony is largely based on research and data that appear in both the
television series and the report as well as upon the experience of
providing public health and healthcare services to the 1.5 million
residents of Alameda County.
The focus of this hearing is healthcare disparities in the Medicare
system. My particular input will be on the evidence that while access
to healthcare is a critical contributor to overall health status, the
healthcare system, by itself, cannot successfully reduce health
disparities and that unless greater attention is paid to public health
approaches to reducing health and social inequity, the Medicare system
will be bankrupted due to the inexorable burden of chronic disease. I
will also address several false dichotomies and myths that are
regularly entertained in policy discussions focused on health and
healthcare disparities. Good policymaking will endeavor to avoid the
trap of becoming locked into these unhelpful and simplistic dichotomies
and instead look for opportunities to create mutually reinforcing
strategies that simultaneously address several of the proximate and
root causes of health disparities. Preventive policies that address
root causes tend to be more cost-effective, sustainable, and socially
just.
I will endeavor to make the following points in my testimony:
Health % healthcare. Access to a high quality system of
affordable healthcare is an important human right and a necessary
strategy for improving health and quality of life and reducing health
disparities, but healthcare alone is not sufficient to ``produce''
health in populations.
Health disparities % healthcare disparities. Healthcare
disparities are a subset of health disparities and can only be reduced
by increasing accountability and transparency within healthcare
delivery systems. However, the healthcare system cannot effectively
eliminate health disparities which are firmly rooted in larger social
inequities related to the historical legacy of discrimination by race,
class, gender, disability, and immigration status. These historical and
present injustices are only remediable by focused social policy
targeted at increasing opportunity across a broad range of policy
domains.
Health disparities are worsening and are overwhelmingly
driven by chronic disease.
Chronic disease is preventable.
Individual responsibility versus community responsibility
is a false dichotomy.
The Immigrant Health Paradox and the myth of immigrants
bleeding our healthcare systems.
This Committee has certainly heard testimony on numerous occasions
regarding the need for universal healthcare in this country. I strongly
support that view and consider universal access to a high quality and
affordable system of healthcare to be a fundamental human right.
Everyone of us should feel shame at our failure to achieve this basic
policy goal. However, universal access to medical care alone will not
eliminate the profound and worsening health disparities in the U.S.
because these health disparities are rooted in deeply entrenched social
inequity. Racial and ethnic health disparities are patterned on
profound race/ethnic disparities in income, employment, education, and
other critical social resources.
Health % Healthcare
Most people who live long and healthy lives in this country do so
without much assistance from the U.S. healthcare system. In fact, a
reasonable goal of most Americans is to live a life that allows us to
avoid hospitalization, emergency room visits, and even our physician's
office, except for routine clinical preventive services. The best
strategy for doing this is to avoid acquiring a chronic disease.
According to the CDC, the medical care costs of people with chronic
diseases account for more than 75% of the nation's $2 trillion medical
care costs. Chronic diseases, (primarily heart disease, stroke, cancer,
and diabetes), are the cause of seven of every 10 Americans deaths.
Chronic, disabling conditions cause major limitations in activity for
more than one of every 10 Americans, or 25 million people. The
prevalence of chronic disease in a community is a primary driver of the
demand for healthcare services.
As a healthcare program administrator, I live with the reality of
the so-called ``80/20 rule '' which refers to the fact that 80% of
healthcare costs are driven by 20% of the population. Relatively modest
shifts in the overall chronic disease burden of that 20% of the
population can have dramatic effects on healthcare costs and
utilization. In general, our reactive healthcare system is primarily
designed to mitigate the adverse consequences of chronic disease rather
than prevent the occurrence of chronic disease in the first place. Thus
the overall health of a community is not primarily shaped by access to
healthcare, instead, access to healthcare serves to remediate and
repair the damage that the healthcare system is presented with as a
result of the overall prevalence of chronic disease within the
community.
However, to argue that overall community health status is not
primarily controlled by access to healthcare is not equivalent to
arguing that access to healthcare plays no role in shaping overall
community health. This is the first false dichotomy that serves to
distract us from thoughtful policy solutions. Access to high quality
and prevention focused healthcare is not only a basic human right, but
this Committee has previously heard testimony from various individuals
and organizations regarding the overwhelming evidence of the
consequences of inadequate access to healthcare. These consequences
include delayed and foregone care, increases in expensive care
including emergency room visits and preventable hospitalizations,
decreased quality of life and decreased productivity, and premature
death.\2\ Above and beyond that, access to healthcare reduces the
chronic stress of poverty. Simply by reducing the specter of personal
bankruptcy associated with catastrophic medical illness, universal
access to healthcare will ease the chronic stress associated with being
working poor in this country. It will also reduce so-called ``job-
lock'' wherein people with pre-existing illness remain in sub-optimal
employment in order to maintain health benefits. Access to healthcare
is therefore necessary but not sufficient to eliminate persistent
racial/ethnic health disparities.
---------------------------------------------------------------------------
\2\ Kaiser Family Foundation. The Uninsured: A Primer.
---------------------------------------------------------------------------
Health Disparities % Healthcare Disparities
Just as health does not equal healthcare, healthcare disparities
are a subset of health disparities. Healthcare disparities are well-
documented and are the differential outcomes that patients achieve
after presenting to healthcare facilities. Healthcare disparities are
the result of a healthcare system that lacks accountability for health
outcomes and lacks transparency regarding the selection and application
of treatment regimens. Therefore any policy initiatives that serve to
increase the accountability and transparency of the Medicare system
will create pressure on the healthcare system to reduce differential
treatment by race/ethnicity. A particularly critical accountability and
transparency measure is the collection of data on race, ethnicity and
primary language of beneficiaries. Such data allows health systems
researchers and healthcare quality improvement practitioners to
identify systematic biases in provider and system behavior and thereby
adjust and correct their performance.
Health disparities are differences in health status and outcomes
that occur largely independent of the healthcare system and
consequently are much broader in scope and impact than healthcare
disparities. In Alameda County, we have mapped health disparities
geographically using geographic information system (GIS) technology and
have demonstrated geographic patterns of disease and death distribution
that correlate closely with the distribution of other important health-
protective resources such as opportunities for employment, recreation,
high quality education, and living wage income. These strong
correlations suggest that health disparities are substantially
structural in nature and can be ameliorated by facilitating better
access to proven health-protective resources and opportunities for low
income communities regardless of race, but with a particular focus on
those communities that have a disproportionate concentration of
African-Americans, Native Americans, some Latinos and Pacific
Islanders. The health status of these particular groups is demonstrably
worse than other race/ethnic populations and trends in obesity,
diabetes and chronic disease portend further worsening of health
outcomes in these groups. In many ways, these populations are the
``canaries in the coalmine'' for the rest of the U.S. population. The
vulnerability due to racial discrimination, past and present, low
income, poor education, environmental pollution, and geography, make
these populations more prone to the impacts of larger disease-
generating social trends that will ultimately seep into the larger
population. There is already some evidence for this phenomenon. CDC has
predicted for many years now that children born in the year 2000 will
have a 1 in 3 chance of developing diabetes in their lifetime. If that
child is African-American or Latino, the odds are 1 in 2. Recently
published research examining life expectancy for various regions across
the United States now demonstrates for the first time, declining life
expectancy in a cluster of counties in the Southeastern and lower mid-
Western part of the U.S.\3\ This unprecedented decline in lifespan can
largely be attributed to changing chronic disease prevalence. It does
not bode well for the overall health and productivity of the country.
---------------------------------------------------------------------------
\3\ The Reversal of Fortunes: Trends in County Mortality and Cross-
County Mortality in the United States. Ezzati, M. et al. PLos Medicine
April 2008, Volume 5, Issue 4, page 66.
---------------------------------------------------------------------------
Health Disparities are Worsening and are Largely Driven By Chronic
Disease Disparities
Economic studies estimate the forgone economic benefit associated
with the relatively poor health of less educated populations equates to
roughly 7.6% of U.S. GDP or approximately 1 trillion dollars.\4\ In
Alameda County and elsewhere in the U.S., racial/ethnic health
disparities in premature death, disability, and hospitalization are
overwhelmingly due to a disproportionate burden of chronic disease in
certain racial and ethnic populations, most notably, African-Americans,
Native Americans, and Pacific Islanders. Alameda County Public Health
Department has just released a report, entitled Life and Death From
Unnatural Causes\5\, which includes an analysis of over 400,000 death
certificates in Alameda County over a four decade period that indicates
that premature death is concentrated in certain geographic hotspots and
that the disparity in life expectancy between these communities and the
greater community is on the order of 11-15 years of life and
increasing. All but about one year of that disparity is attributable to
higher rates of chronic disease in these hotspot communities. Recent
national studies examining regional disparities in life expectancy in
the U.S. suggest that health insurance rates and health disparities are
not well correlated and that expanding health insurance coverage alone
would still leave huge disparities.\6\
---------------------------------------------------------------------------
\4\ Technical Report for Overcoming Obstacles to Health: Report
from the Robert Wood Johnson Foundation to the Commission to Build a
Healthier America: Economic Value of Improving the Health of
Disadvantaged Americans. William Dow, PhD.
University of California, Berkeley, Robert F. Schoeni, PhD,
University of Michigan
\5\ Life and Death From Unnatural Causes: Health and Social
Inequity in Alameda County. Executive Summary. www.acphd.org.
\6\ Eight Americas: Investigating Mortality Disparities across
Races, Counties, and Race-Counties in the United States. Murray, C., et
al.. PLos Medicine September 2006, Volume 3, Issue 9, page 250.
---------------------------------------------------------------------------
Chronic Disease is Very Amenable to Prevention
Chronic disease in a population is highly amenable to individual
and community-level prevention. The bulk of those preventive
strategies, particularly the community-level strategies, occur outside
of the healthcare system and are strongly influenced by social and
economic policies particularly policies shaping land-use, employment,
transportation, income, and education. California's experience with
tobacco control is arguably one of the clearest examples of the
benefits of primary prevention on health status, mortality and
healthcare costs. Between 1990 and 1998, California saved more than $3
billion in smoking-related healthcare costs. Through a comprehensive
and multi-faceted approach, California has been able to reduce the
prevalence of smoking by 33%. Accelerated declines have been
demonstrated in heart disease deaths and lung and bronchus cancer
incidence in California. These reductions in morbidity and mortality
are substantially greater than in the rest of the United States and
have been attributed to California's success in reducing smoking
rates.\7\ Similar prevention benefits could be achieved through
thoughtful and comprehensive primary prevention strategies targeted at
diabetes. Approaches that prioritized prevention in those populations
with the highest incidence of chronic disease would not only be cost-
saving and productivity-enhancing, but they would go a longer way
towards reducing health disparities, BEFORE people enter the healthcare
system. In his healthcare reform strategy for California, Governor
Schwartzenegger recognizes the critical role of community prevention
and the contribution of the environment, both physical and social, to
increasing the risk of chronic disease. The Governor's Community
Makeover Grants follow the basic model of California's globally-
renowned tobacco program by seeding multi-sectoral community
collaborations to promote physical activity, increase access to healthy
foods and address the root social and environmental causes of obesity
and other chronic disease precursors.
---------------------------------------------------------------------------
\7\ California Tobacco Control Update 2006. California Department
of Public Health, Tobacco Control Program. Available at: http://
www.cdph.ca.gov/programs/Tobacco/Pages/CTCPPublications.aspx.
---------------------------------------------------------------------------
Individual Responsibility vs. Community Responsibility
Smoking, consuming excessive alcohol, driving without a seatbelt
and engaging in risky sexual practices, when informed of the potential
consequences, are choices that individuals make. Similarly, skydiving,
race car driving, and competitive skiing are inherently risky
activities that can have potentially devastating health consequences.
In health, individual responsibility matters and individuals should be
held responsible for their choices and behaviors. However, many low
income populations are compelled by circumstances outside of their
control to live in neighborhoods with poor housing stock, lack of
recreational facilities and youth programming, poor schools, inadequate
transportation, high crime, concentrations of liquor stores and fast
food outlets, and numerous sources of environmental pollution. All of
these neighborhood environmental conditions are social consequences of
poverty in this country. All of these conditions have demonstrable
health consequences and have been implicated in the generation of
health disparities. In addition to the unique impact that each of these
health-injurious conditions has on individual health, the synergistic
and cumulative effect of these conditions over a lifetime is even more
profound and enduring. As demonstrated by research portrayed in the PBS
documentary Unnatural Causes, these neighborhood-level conditions
contribute directly to a high level of chronic stress among low-income
communities. The conscious and subconscious desire to relieve chronic
stress drives the desire for short term gratification such as that
provided by cigarettes, alcohol and unhealthy eating. In this way
social conditions constrain individual choices. Any of us subjected to
the unrelenting stress of being a paycheck away from homelessness, or
one uninsured hospitalization away from bankruptcy, or one bullet away
from losing a child would be more likely to smoke, drink to excess or
indulge in other manners of immediate gratification. Undoubtedly, many
people growing up and living in these environments choose not to smoke,
drink to excess or engage in other known health risks, however, the
constant burden of chronic stress in these communities is substantially
greater than that of more affluent communities and makes it more likely
that individuals will succumb to these stressors in low income
communities. The choices we make are shaped by the choices we have.
Keeping your child indoors away from the park may well save his life in
many American neighborhoods, including the one in which I work in
Oakland, California.
The social consequences of poverty are greatly influenced by
policies created by this Congress. In many low-income racially and
economically segregated neighborhoods, as well as many economically
deprived rural communities in this country, the social consequences of
poverty have become more severe. These consequences are not inevitable
or merely unfortunate, they are squarely within the control of
policymakers. So the notion of policies supporting individual
responsibility versus those focused on larger social responsibility is
another false dichotomy. We need to create social policies and health
policies that foster greater opportunities for all Americans to partake
of exercise, healthy eating, as well as reduce the stress of poverty by
reducing its social consequences. One obvious example is to create
universal access to a high quality and affordable system of healthcare.
Other strategies are more complex but eminently achievable and include
improving high school graduation rates, access to living wage
employment, and affordable housing. Improvements in all of these non-
health outcomes will improve health outcomes. If we are serious about
eliminating health disparities and preserving the solvency of the
Medicare system, we need to begin to recognize these social policies as
health policies.
The Immigrant Health Paradox
Immigrants to the U.S. are by and large healthier than American
born residents. They live longer, have less chronic disease, and use
less medical resources per capita than American born
residents.5,8 Over time as they acculturate and become more
American, they get sicker and acquire more disease and their health
profile begins to more closely resemble the American health profile. In
this way, America is not good for your health. It is unfair,
disingenuous and plainly wrong to lay the blame for the woes of our
healthcare system at the feet of immigrants.
---------------------------------------------------------------------------
\8\ Immigrants and Healthcare: Sources of Vulnerability. Derose,
K.P., et al. Health Affairs 26, no.5, (2007), 1258-1268.
---------------------------------------------------------------------------
Thank you for this opportunity to testify on the larger context of
health, healthcare and the root causes of health disparities. I invite
you to go to the website of Unnatural Causes (www.unnaturalcauses.org)
for a compelling overview of the role of social inequity in producing
and maintaining health disparities as well as the description of some
promising solutions.
Health Status, Health Insurance, and Healthcare Utilization
Patterns of Immigrant Black Men. Lucas, J.W., et al. American Journal
of Public Health. October 2003, Vol. 93, no. 10. page 1740-1747.
Chairman STARK. Dr. Satel, who is, if I didn't mention this
before, the Resident Scholar at the American Enterprise
Institute.
STATEMENT OF SALLY SATEL, M.D., RESIDENT SCHOLAR, AMERICAN
ENTERPRISE INSTITUTE
Dr. SATEL. Thank you, Mr. Chairman and Ranking Member Camp
and Representatives Jones and Becerra. I appreciate the
invitation to speak to you today.
I am a Resident Scholar at AEI, but I am here mainly
because I am the staff psychiatrist at the Oasis Drug Treatment
Clinic in Northeast Washington. So I speak to you mainly as a
clinician.
I reiterate what we have heard a lot of today that remedies
must go beyond access to care. Coverage is necessary. No
question about that. But it is not always sufficient. A good
many of our patients, for example, are on public insurance. But
they wait until a health crisis before they get care.
I saw a patient the other day who the week before had an
abscess on her hand from IV drug use. This is a methadone
clinic. She was instructed to get antibiotics from her local
doc, which she did have, but she didn't, and the next week she
came back with cellulitis and a fever and had to go to the
emergency room where she was admitted for IV antibiotics. But
she was a classic case of someone who had health insurance,
which is critical, and that it may not be enough.
So why do patients who have access to healthcare not
exploit it as much as they could or should? And how can systems
be more responsive to low-income patients by helping them
leverage the access that they do have? Three points to consider
in answering that.
The first is that a large element in fostering healthcare
seeking is establishing trust. The second is that, once
patients have sought care, it is very important they adhere to
the treatment regimens. And, ultimately, for both chronic
illness management and effective prevention, it is very
important that patients think in terms of a longer time horizon
to help keep their encounters with the healthcare system from
being driven by one crisis after the next.
What are some strategies that can help achieve these goals?
One is to establish continuity of care with the same provider.
Patients who see the same doctor from visit to visit will have
the opportunity to establish rapport with him or her, which in
turn will lead to better adherence with treatment regimens.
This is very important. In fact, a new study from an economist
at Columbia University found that increasing compliance could
reduce the black/white health mortality gap by at least two-
thirds. That is quite dramatic. And rapport, of course, enables
conscientiousness about self care: exercise, diet, risky
behaviors, smoking, alcohol and unprotected sex.
Another important way to achieve the goal of exploiting
access to care is to expand the average length of the doctor
visit. As you know, the average encounter is about 15 minutes.
There is almost no time in that period, especially if it is a
first visit or if the patient is in some sort of acute
distress, to also elicit his concerns, needs, values, and
preferences. These are key, but we need Medicaid codes expanded
to pay for what we call cognitive and evaluative services
because there really is no time for meaningful encounters.
In my clinic, oddly enough, I can spend as much time as
with patients as I want, but we don't take Medicare or
Medicaid. We have a very interesting consult pay system for the
poor and working poor.
Also, we have to target adherence by recognizing that
chronic illness is actually quite a chore. Compliance can be
very difficult. Sociologist Linda Gottfredson put it very well
when she said ``chronic diseases are like jobs.'' She was
actually referring to diabetes, although it applies to other
chronic illnesses. There are duties to perform, glucose
testing, of course, for one, but it requires a regimen of
training to implement these tasks, continuously monitor one's
own physical signs, adjust food, exercise, medications and, as
someone mentioned, coordinate all the professionals that they
see: the internist, the surgeon, sadly, the nephrologist
because the diabetes has progressed to liver failure, the
nutritionist, and so on.
Type 2 diabetics in general find it very hard to believe
that they are truly sick until it is too late to avoid the
complications. Because if you don't feel sick, you often don't
act, especially when there are so many pressing daily realities
in your life. The focus on healthcare will recede into the
background.
I see this in my patients all the time, dealing with teen-
age kids gone astray, neighborhood crimes, taking care of
elderly relatives and, unlike the wealthier, who have their
share of personal and social problems, too, lack of resources
to buffer those setbacks.
Given these realities, I mentioned some of the ways we
could help patients exploit the access they do have. Some
others include, and these have been mentioned, outreach through
black churches, social clubs, work sites, patient navigators--
that can be very important; the idea is to give patients as
much control as they can--language services, dietary habits.
There is an article today in the New York Times about a
Harvard study showing that many physicians, even when they do
provide counseling, aren't attuned enough to the dietary habits
and cultural dispositions of their population. And so on.
So I will sum up by saying access to care is vital, of
course, but will not alone improve the health of minorities
low-income people as much as we would like because they are not
often in positions where they can exploit the care.
Thank you very much.
Chairman STARK. Thank you.
[The prepared statement of Dr. Satel follows:]
Prepared Statement of Sally Satel, M.D., Resident Scholar,
American Enterprise Institute
Dear Chairman Stark, Representative Camp and Members of the
Committee. My name is Sally Satel. I am a resident scholar at the
American Enterprise Institute, lecturer at Yale University School of
Medicine, and the staff psychiatrist at the Oasis Drug Treatment Clinic
in Northeast Washington D.C.
Thank you for the invitation to present my views on racial and
ethnic minority health status and the key principles upon which
remedies should be based.
Let me begin by noting that a number of realities are well-
established.\1\
---------------------------------------------------------------------------
\1\ For a comprehensive review see Klick J, Satel S. The Health
Disparities Myth (2006), AEI Press at http://www.aei.org/books/
bookID.847/book--detail.asp.
---------------------------------------------------------------------------
First, we know that differences in health status exist between
various ethnic and racial groups, and that there are often
discrepancies in indicated procedure rates across groups.
Second, we know that many of the factors linked to these discrepant
rates (e.g., access to care, geographical differences, good quality
care) are much more closely tied to socioeconomic (status), than to
race per se.\2\
---------------------------------------------------------------------------
\2\ Isaacs SL, Schroeder SA. Class--The Ignored Determinant of the
Nation's Health, New England Journal of Medicine 351 (2004): 1137--42;
Kawachi I, Daniels N, Robinson DE. Health Disparities by Race and
Class: Why Both Matter, Health Affairs 24 (2) (2005): 336.
---------------------------------------------------------------------------
Third, and most relevant to my comments today, we know that these
factors do not account for the full extent of discrepancy between
groups.
Thus, enhancing access to care and quality of care, though
essential steps toward improving health status among racial and ethnic
minorities must be vigorously fortified by other improvements that will
enable patients to benefit the most from the care they do receive (and
to need it less frequently and less intensively).
My remarks today will focus of those additional areas of need. To
effect these changes, healthcare systems and programs must have
flexibility to target local needs in creative ways.
Correlates of Health Differentials
Geography
Geographic residence often explains race-related differences in
treatment better than even income or education. Because healthcare
varies a great deal depending on where people live, and because blacks
are overrepresented in regions of the United States that are burdened
with poorer health facilities, disparities are destined to be, at least
in part, a function of residence. Researchers who fail to control for
location effects of low-income will misdiagnose the underlying causes
of many racial disparities in health.
Hospital Quality
An underlying cause of disparities may be that minority patients
are more likely to receive care in lower-performing hospitals.
Hospitals that treat greater numbers of minority patients generally
offer poorer quality service than those that treat fewer minorities.
Conversely, within hospitals, the quality of care is generally
comparable between whites and minorities when they are admitted for the
same reason or receive the same hospital procedure.
Quality of Physician
National physician survey data indicate that physicians in high-
minority practices depend more on low-paying Medicaid, receive lower
private insurance reimbursements, and have lower incomes. These
constrained resources help explain the greater quality-related
difficulties delivering care--such as coordination of care, ability to
spend adequate time with patients during office visits, and obtaining
specialty care--that relate directly to physicians' ability to function
as their patients' medical home.\3\
---------------------------------------------------------------------------
\3\ Reschovsky JD, O'Malley AS. Health Affairs (Web Exclusive,
April 2008), 27(3):222-231.
---------------------------------------------------------------------------
Beyond Access and Quality
Beyond the obvious need to expand access and enhance quality of
care, other factors demand attention if health differentials are to be
narrowed.
Establish continuity of care with same provider--Patients who see
the same doctor from visit to visit have the opportunity to establish a
rapport with him (which, in turn, will lead to better adherence with
treatment regiment and conscientiousness about self-care).\4\ Yet
African Americans are more likely than whites to rely on emergency room
care because they do not have a primary care physician.\5\ Other venues
of non-continuous care are community clinics and hospitals. (Note that
having Medicaid does not necessarily correlate with having a regular
source of care.)
---------------------------------------------------------------------------
\4\ Halbert C et al. Racial Differences in Trust in Healthcare
Providers Arch Gen Med 166 (2006):896-901.
\5\ Oster A, Bindman AB. Emergency department visits for ambulatory
care sensitive conditions: insights into preventable hospitalizations.
Med Care 41(2003): 198-207.
---------------------------------------------------------------------------
The Commonwealth Fund 2006 Healthcare Quality Survey finds that
when adults have health insurance coverage and a medical home--defined
as a healthcare setting that provides patients with timely, well-
organized care, and enhanced access to providers--racial and ethnic
disparities in access and quality are reduced or even eliminated.
Expand the average length of the doctor visit--One of the most
effective ways to enhance the doctor-patient relationship is for
doctors to spend sufficient time with each patient--more than the
standard fifteen minutes--to elicit patients' concerns, needs, values,
and preferences. We need to have Medicare codes expanded to pay for
cognitive, evaluative services--and pay more for them.
Foster health literacy--A patient's accurate understanding of the
nature of his illness and the purpose of various therapies is essential
to self-care and treatment adherence. An important new study from an
economist at Columbia University documented that differences in patient
self-management trigger a racial mortality gap even when access and
treatment for chronic heart failure are equalized. The authors estimate
that targeting compliance patterns could reduce the black-white
mortality gap by at least two-thirds.\6\
---------------------------------------------------------------------------
\6\ Simeonova, E. Doctors, Patients, and the Racial Mortality Gap:
What Are the Causes? Columbia University, November 2007 at http://
www.columbia.edu/es2085/research/jmpaper.pdf.
---------------------------------------------------------------------------
But compliance is difficult. Sociologist Linda Gottfredson puts it
well when she says that ``chronic diseases are like jobs.'' She focuses
on diabetes but her list of tasks that patients have to perform to
control and monitor their conditions can be generalized to other
chronic conditions such as moderate to serious asthma, hypertension,
renal failure, and chronic heart failure.
Set of duties to perform
Requires training
Implement appropriate regimen
Continuously monitor physical signs
Diagnose problems in timely manner
Adjust food, exercise, meds in timely and appropriate manner
Coordinate & communicate with others
Exercise independent judgment with only occasional
supervision from medical personnel. Efforts to control the condition
are often tiring, frustrating, and affects family life
Most Type 2 diabetics find it hard to believe they are truly sick
until it is too late to avoid the complications (pain, dysfunctional
eyesight, infections, etc). This is why following disease prevention
strategies is even more challenging for those with overwhelming
personal and family and occupational problems. Health recedes into the
background, surpassed by more pressing daily realities and stresses.
Common Sense Local Innovations
Educational modules that prepare and coach patients to
ask questions and present information about themselves to their doctors
are promising where implemented.
Grassroots outreach through black churches, social clubs,
and worksites
Patient ``navigators'' to help negotiate the system
Language services
Bonuses/incentives to get more good doctors into
distressed neighborhoods.
Clinic night hours: a great boon to patients with hourly-
wage employment who risk a loss of income, or even their jobs, by
taking time off from work for doctors' appointments.
Active pharmacists who issue reminders, provide education
to ensure patients grasp what they need to know; hotlines
A key element here is that these services need to be reimbursed.
Conclusion
Resolving health differentials between racial and ethnic groups
depends on improved access to care and quality of care. However, reform
in those areas alone will not be sufficient. Individuals need to be
able to exploit the care that is available to them. And the way to help
them achieve this is to target problems that stem from habits and
dispositions associated with life lived on the lower reaches of the
socioeconomic ladder. To tailor interventions most effectively,
healthcare systems need to have the flexibility to respond to specific
needs of individual communities.
Chairman STARK. Now Dr. Rodriguez, who is Associate
Professor and Vice Chair at UCLA Department of Family Medicine,
will inform us. Thank you.
STATEMENT OF MICHAEL A. RODRIGUEZ, M.D. MPH, ASSOCIATE
PROFESSOR AND VICE CHAIR OF RESEARCH, UCLA DEPARTMENT OF FAMILY
MEDICINE, LOS ANGELES, CALIFORNIA
Dr. RODRIGUEZ. Chairman Stark and distinguished
Subcommittee Members, thank you for inviting me to this
important hearing on health disparities and possible solutions
to address them.
I am a researcher, educator, and a practicing family
physician at UCLA; and the focus of my work is on addressing
health disparities and evaluating approaches to eliminate them.
It is a great honor for me to be part of this star-studded
panel of amazing choir singers, but, as the last singer, I will
try to keep my song short.
With minority Americans expected to comprise 50 percent of
the population by 2050, addressing their health needs is an
increasingly important public policy goal. Providing culturally
and linguistically appropriate services has the potential to
improve health outcomes, increase the efficiency of clinical
and support staff, and result in greater patient satisfaction.
A good colleague of mine at Harvard demonstrated through
research how practice policies to promote cultural competence
are associated with high-quality care for children with asthma.
As has been mentioned, it is well established that language
barriers contribute to health disparities. Approximately 55
million Americans speak a language other than English at home.
Half of these individuals report they speak English less than
very well, making them limited English proficient. More than 10
million children live in limited English proficiency
households. And, as was mentioned earlier, an inability to
communicate with your doctor not only creates a barrier to
accessing healthcare but undermines trust in the quality of
medical care that is being received and contributes to these
disparities in healthcare.
Patients with language barriers have worse access to
healthcare, lower rates of physician visits and preventative
services. Even when patients have access to care, if they have
language barriers, they have less follow-up care for their
chronic conditions, decreased comprehension of their diagnosis
or treatment, decreased satisfaction with care, and increased
medication complications. Language barriers have been found to
result in longer hospital stays, more medical errors, and lower
patient satisfaction.
Fortunately, the quality of medical care can be improved
through the use of trained interpreters or provision of care by
bilingual healthcare providers. They decrease medical clinician
errors, increase patient comprehension, and improve clinical
outcomes.
Unfortunately, as was mentioned, three-quarters of
physicians use family members as interpreters when working with
their limited English proficient patients. Barriers to the use
of interpreters include cost and convenience. The need--there
is a significant need to develop programs and policies to
promote the provision of adequate language services to this
rapidly growing limited English proficient population.
Research suggests that third-party reimbursement may
improve the use of trained interpreters and quality of care;
and an OMB study estimated that the overall cost of providing
language services would be modest, average $4 more per visit,
equivalent to 0.5 percent of the average cost per healthcare
visit, and less, far less, than the cost of the disparities.
There is a critical need to develop reimbursement policies
for interpretation. Testing alternative methods of delivering
linguistically appropriate services will enable us to provide
the best practices and vastly improve both access to and
quality of services to beneficiaries with limited English
proficiency.
A related issue is that, while the Congress passed this
Title VI of the Civil Rights Act 1964 to ensure that Federal
money is not used to support programs or activities that
discriminate on the basis of race, color, or national origin,
it is unclear to what extent recipients of Federal funds are
taking reasonable steps to ensure that patients with limited
English proficiency have meaningful access to programs and
activities.
The Department of Health and Human Services should take
steps to improve compliance and enforcement of its own Office
of Minority Health Culturally and Linguistically Appropriate
Services Standards. To improve quality, you need good policy
informed by good research and good data. Unfortunately, we lack
the data. Federal agencies should expand their work on data
collection. The absence of this timely, reliable, and valid
data is a limiting factor in measuring the progress of programs
and status for targeted populations.
States and health surveys and health facilities should be
mandated to collect data by race, ethnicity, and primary
language and conduct interviews and have materials in major
nonEnglish languages. Providers should also be required to
monitor selected process and outcome measures by race and
ethnicity.
As was mentioned by Dr. Satel, an increasing area that is
important has to do with processes and organizational responses
that may contribute to disparities, for example, continuity of
care which has been found to be low particularly in the
Medicare beneficiaries, many of whom have multiple chronic
health conditions. Fortunately, recent research has shown that
patient populations at risk for health disparities may
particularly benefit from accessible, coordinated,
comprehensive care delivered through the patient-centered
medical home. Therefore, there is a particular need to transfer
practices serving these populations and increase our efforts in
this promising area.
I thank the Committee for inviting me to be here today and
for its consideration of my testimony. I am grateful for your
commitment and for your concern for the improvement of the
health and well-being of all Americans.
Chairman STARK. Thank you, Doctor.
[The prepared statement of Dr. Rodriguez follows:]
Prepared Statement of Michael A. Rodriguez, M.D., MPH,
Associate Professor and Vice Chair of Research, UCLA,
Department of Family Medicine, Los Angeles, California
Chairman Stark and distinguished Subcommittee Members, thank you
for inviting me to this important hearing on health disparities and
possible solutions to address them. My name is Michael Rodriguez and I
am a researcher, educator, and practicing family physician at UCLA and
community clinics. A primary focus of my work is on addressing health
disparities and evaluating approaches to eliminate them.
My testimony today will address three areas: first, I will speak on
the importance of linguistically and culturally appropriate care;
second, the need for data collection by race, ethnicity and primary
language; and finally, the need for payment for language assistance
services as well as compliance with and enforcement of national
standards on culturally
BACKGROUND
A large body of literature has documented significant racial,
ethnic and language disparities in health and healthcare. Racial and
ethnic minorities have higher rates of disease, disability, and death
and tend to receive a lower quality of healthcare than nonminorities,
even when insurance status and income are taken into account. The fact
that racial/ethnic minorities in this country receive poorer quality
healthcare is undeniable and attributable to a range of patient,
clinician, practice, healthcare system, community and social factors.
The Institute of Medicine ``Unequal Treatment'' report provides
guidance for why and how we should address this issue and highlights
how eliminating racial/ethnic disparities in healthcare is an integral
part of improving the quality of our healthcare system, and the
healthcare of all Americans.
Many researchers and policy makers view racial and ethnic
healthcare disparities through the lens of quality improvement.
Improving quality through the components of patient safety, timely
response, and evidence-based, patient-centered care provides a
framework for eliminating disparities. Meeting the needs of the patient
population should be the focus of our efforts. As physicians we have a
professional and moral obligation to deliver the best possible quality
of care to everyone we see.
With minority Americans expected to comprise 50% of the population
by 2050, addressing their health needs is an increasingly important
public policy goal. Providing culturally and linguistically appropriate
services has the potential to improve health outcomes, increase the
efficiency of clinical and support staff and result in greater patient
satisfaction. Making sure that the healthcare provided to this diverse
population takes into account the linguistic and cultural needs is a
priority for health systems and policy makers. As such, a growing body
of laws and regulations seek to ensure that health systems respond to
these linguistic and cultural needs. Recent research by Lieu at Harvard
demonstrates how practice-site policies to promote cultural competence
are associated with higher quality care for children with asthma.
Because culture and language are vital factors in how healthcare
services are delivered and received, it is important that healthcare
professionals embrace the principles of cultural and linguistically
appropriate care. Cultural Competency Curriculum are being developed to
equip clinicians with the cultural and linguistic competencies that
will enable them to better treat the increasingly diverse U.S.
population.
DISPARITIES DUE TO LANGUAGE BARRIERS
It is well established that Language barriers contribute to health
disparities for limited English proficient (LEP) patients.
Approximately 55 million Americans speak a language other than English
at home. This is equivalent to one in five people in the United States.
Half of these individuals report they speak English less than ``very
well'' and these individuals are considered to be LEP. More than 10
million children live in have limited English proficiency households.
An inability to communicate with your doctor not only creates a barrier
to accessing healthcare but also undermines trust in the quality of
medical care received and contributes to disparities in healthcare.
Patients with language barriers have worse access to care and rate
their healthcare worse compared to English speakers, have less access
to a usual source of care, lower rates of physician visits and
preventive services. Even when patients have access to care if they
have language barriers they have less follow up care for chronic
conditions, decreased comprehension of their diagnosis or treatment,
decreased satisfaction with care and increased medication
complications. Language barriers have been found to result in longer
hospital stays, more medical errors and lower patient satisfaction.
Children in non-English primary language households also experience
worse outcomes. These children are more likely to be poor, overweight,
have suboptimal health but have higher risk of impaired access to
health.
Consider the following clinical scenario: An Asian speaking mother
brings her ill baby to an emergency room and cannot communicate with
the staff. The baby has a fever and is sent home with medicine for the
fever. Another Asian speaking mother brings her ill baby with similar
symptoms to an emergency room with Asian-speaking staff and the baby is
admitted with a diagnosis of appendicitis, is observed with worsening
abdominal guarding and has emergent surgery and her life is saved.
Title VI of the Civil rights act of 1964 mandates that healthcare
providers receiving federal funds provide ``meaningful access to their
programs and activities by LEP persons'' without cost to the patient.
Published reviews suggest that the quality of medical care is improved
through use of trained interpreters or provision of care by bilingual
healthcare providers. They decrease medication errors, increase patient
comprehension, and improve clinical outcomes. Three quarters of
physicians use family members as interpreters and less than half of
physicians use trained interpreters when working with their LEP
patients. Barriers to the use of trained interpreters include cost,
inconvenience, limited availability of trained interpreters. Given the
association of language barriers and compromised healthcare quality and
safety, there is a need to develop programs and policies to promote the
provision of adequate language services to the rapidly growing
population of LEP families.
Research suggests that third party reimbursement may improve use of
trained interpreters and quality of care and the overall cost of
providing language services may be modest. The Office of Management and
Budget estimated in 2002 that the cost of interpreter services for LEP
persons, when averaged over all types of visits, would average $4.04
more per visit, equivalent to 0.5% of the average cost per healthcare
visit and less than the cost of disparities.
LANGUAGE SOLUTIONS
Due to the barriers to using trained interpreters, we need to
develop and evaluate programs that will improve the medical delivery
systems of the future. Interpreter services should be developed for
bilingual staff, bilingual providers as well consultant interpreters
with certification and training programs. Spanish and other language
training for clinicians (including CME programs) and for medical
students should be supported significantly in targeted markets. There
is a critical need to develop reimbursement policies for these and new
interpretation technologies that are affordable, especially through
Medicare and Medicaid.
Language barriers place LEP patients at a disadvantage that can be
overcome by providing better linguistic access. Provision of
interpreter services or direct access to a provider can reduce
disparities in care for LEP patients. Although recipients of federal
funds are required to offer language services, Medicare does not
reimburse for these services. Testing alternative methods of delivering
culturally and linguistically appropriate services will enable Medicare
to apply best practices and vastly improve both access to and quality
of services to beneficiaries with limited English proficiency.
While congress passed Title VI of the Civil Rights Act of 1964 to
ensure that federal money is not used to support programs or activities
that discriminate on the basis of race, color, or national origin, it
is unclear to what extent recipients of federal funds are taking
reasonable steps to ensure that persons with limited English
proficiency have meaningful access to programs and activities. The
Department of Health and Human Services should take steps to improve
compliance and enforcement to its own Office of Minority Health
Culturally and Linguistically Appropriate Services (CLAS) Standards.
USING DATA COLLECTION TO DRIVE QUALITY
To improve quality, you need good policy informed by good research
based on good data. Federal agencies should expand their work on data
collection and disparities research. Without new knowledge with
community-based research, we may never advance beyond the disparities
that now exist in the healthcare system. Lack of data places policy
makers at risk of making inappropriate decisions that reflect a lack of
understanding of the mechanisms driving the increased burden of disease
and death as well and its impact. The absence of timely, reliable,
valid, and appropriate data is often a limiting factor in measuring
progress of programs and status of the targeted population. States and
health surveys and health facilities should be mandated to collect data
by race and ethnicity and language use and conduct interviews and have
materials in major non-English languages in order to develop a quality
healthcare system.
At a minimum, hospitals, health plans, and other providers should
be asked to maintain data on patients' race and ethnicity. Healthcare
organizations could also be required to provide training for their
staff in the delivery of culturally and linguistically appropriate
services. Finally, providers could be required to monitor selected
process and outcome measures by race and ethnicity. CMS can encourage
accrediting organizations to adopt such standards voluntarily, or it
can strengthen its own requirements. This will help to determine the
extent to which disparities exist. Collecting such data will help CMS
to establish baseline information about racial and ethnic disparities
within Medicare which will assist in the development of interventions
to address disparities and measure progress toward that goal.
A MEDICAL HOME
An increasing area of research to address disparities includes
examining differences in care processs and organizational responses
that may contribute to disparities. For example, continuity of care has
been found to be quite low, particularly for Medicare Beneficiaries--
many of whom have multiple chronic health conditions that benefit from
having a primary care physician. One Commonwealth study found that 35%
of Medicare beneficiaries' visits each year were with their assigned
physicians, and a third of beneficiaries changed their assigned
physician from year to year. If elderly people with multiple illnesses
cannot receive good care, other healthcare reforms may have less
impact.
Recent research has shown that patient populations at risk for
health disparities may particularly benefit from the accessible,
coordinated, comprehensive care delivered through the patient-centered
medical home; therefore there is a particular need to transform
practices serving these populations. While some of these medical home
concepts have already been applied in the U.S., they are often in large
pre-paid group practices or academic medical centers. Therefore a focus
on recruiting smaller physician practices where much of the care occurs
for Medicare beneficiaries is needed.
CONCLUSION
I thank the Committee for inviting me to be here today and for its
consideration of my testimony. I am grateful for your commitment and
for your concern for the improvement of the health and wellbeing of all
Americans.
REFERENCES
Office of Management and Budget, White House: ``Assessment of the
Total Benefits and Costs of Implementing Executive Order 13166:
Improving Access to Services for Persons with Limited English
Proficiency.'' HHS Office of Civil Rights, Guidance on Limited English
Proficiency.
Institute of Medicine, Unequal Treatment: Confronting Racial and
Ethnic Disparities in Healthcare (Washington, D.C.: National Academies
Press, 2003).
P.B. Bach and others, ``Racial Differences in the Treatment of
Early-Stage Lung Cancer,'' New England Journal of Medicine, vol. 341,
no. 16 (1999).
Tracy A. Lieu, Jonathan A. Finkelstein, Paula Lozano, Angela M.
Capra, Felicia W. Chi, Nancy Jensvold, Charles P. Quesenberry and
Harold J. Farber. Cultural Competence Policies and Other Predictors of
Asthma Care Quality for Medicaid-Insured Children. Pediatrics
2004;114;e102-e110
Chairman STARK. I will call on Mr. Becerra and see if he
would like to inquire.
Mr. BECERRA. Thank you, Mr. Chairman.
Welcome to you all. Thank you for your life's work and
certainly for your testimony today.
A personal greeting to an esteemed physician and good
friend, Dr. Rodriguez from UCLA.
And, Dr. Jang, I suspect you are like me, where my folks
also hoped that I would be a medical doctor and I sometimes
claim to be that doctor of law. If that doesn't satisfy them,
at least I did the next best thing. I married into the
profession. So, hopefully, you are close.
I want to just run a few things by all of you to see if you
might have a chance to comment.
In the House bill that passed last year that dealt with
Medicare and children's healthcare, the SCHIP program, we did a
number of things. I want to thank the chairman right now for
the work that he did in working with my staff, his staff and my
staff, working to include a number of provisions to deal with
these particular issues.
In the House-passed bill, the Children's Health and
Medicare Protection Act, the CHAMP Act, we included an
Inspector General study within HHS OIG, study to examine
whether the culturally and linguistically appropriate services,
the CLAS services, required by law are being enforced. We also
included a demonstration project on outreach to previously
uninsured Medicare beneficiaries. And just recently the Senate,
which introduced its similar legislation on Medicare, included
those two provisions as well in its bill, which is good.
Unfortunately, the Senate bill that was just recently
introduced did include a number of other provisions which
Chairman Stark and I worked very hard to include in the CHAMP
Act which did pass the House, which include a provision to
require the collection of ethnicity data for the Medicare fee-
for-service program.
And I mention this because, Dr. Jang, I think you
mentioned--in your testimony, you cited the Dartmouth Atlas
Project, which shows that real disparities between some of the
care that African Americans receive and whites. Unfortunately,
because Medicare relies on its administrative data to determine
race and ethnicity, if you think about it, that administrative
data is dependent on SSA, the Social Security Administration,
the SS-5 form. Well, Medicare beneficiaries today are 65 and
over. That means they certainly applied well before 1980 for
their Social Security number, which means back in those days
the only demographic that we took into account was either white
or black.
So that study, which pointed out some major disparities for
African Americans, could tell us nothing for Asian Americans
and Latinos and Native Americans because they were based on
these previous applications for a Social Security card and
number. Those different ethnicities and populations had to be
categorized as either ``other'' or ``unknown.'' So I guess a
lot of folks in this chamber, me included, would all be either
``other'' or ``unknowns'' when it comes to Medicare's ability
to track important data on disparity.
We put in the CHAMP Act, with the chairman's help, the
provision to require the collection of ethnicity data for
Medicare fee-for-service programs. Unfortunately, the Senate
has not included that.
We also included in the CHAMP Act a provision which would
provide funding for a demonstration project to provide paid
language services to Medicare beneficiaries, to Dr. Rodriguez's
point. Medicare providers say, well, it is really tough,
especially with the cuts that we are seeing these days in
Medicare reimbursement, to actually now increase fee-for-
services by providing translation by interpreter services. This
was a provision that would help fund that for a third party.
That, unfortunately, was not included in the Senate bill
recently introduced.
Another provision was a provision that required the
Institute of Medicine to report on the impact on Medicare
beneficiaries who need but do not get language access services.
That provision was not included in the Senate. It is in the
CHAMP Act.
And, finally, we include in the CHAMP Act a provision that
would require a study on the impact of managed care plans on
minority beneficiaries, because there is a great deal of talk
about whether managed care is good or bad for populations that
suffer from disparities.
RPTS MCKENZIE
DCMN HOFSTAD
Mr. BECERRA. And that provision, which did get included in
the CHAMP Act, was excluded in the Senate's bill.
And so I guess my question to you is, I think while the
House has done some remarkable work in trying to address the
disparities issue, are you at all doing any work with our
Senate colleagues to try to see if they can do a better job of
including these very modest proposals--because cost-wise, they
are very modest--these very modest proposal to make sure that
they are included in the Senate Medicare bill that is working
its way through the Senate?
And I know my time has expired, but if anyone has any
particular comments, Chairman, I would love to see if they
might have a chance. And Dr. Blanton might be the person who
probably works on this most.
Ms. LILLIE-BLANTON. Well, actually, I want to agree with
you that we need to do more data collection by race, by
ethnicity, by language services. Our population is changing
dramatically, and without the information to help us understand
the quality of care these people are getting, the access that
they get, it is impossible for us to know how much progress we
are making. So I just want to say that is critically important.
You also raised concerns about research and analysis. And I
think what we have to realize is that when we collect the data,
we have to analyze the data and we have to report on the data.
And unless we do both of the latter two, you will have data
collected that is just sitting there. And so it is important
for us to do further analysis to better understand how the
information that we have collected is being used.
Demonstration projects is one way of learning more, but
putting in place systems that can routinely monitor and assess
and evaluate is a way to structurally assure that we know what
is happening over time in our population. So in addition to
demonstration projects, the systematic analysis and assessment
is what is really needed.
We have moved to a whole new system of coverage and care
delivery with our managed care plans. And putting in place the
mechanisms for us to know how our beneficiaries in managed care
are faring in relation to the care they are receiving is just
as important as systems in place to know how are beneficiaries
in fee-for-service.
So I actually just want to agree with you and with the
provisions. But our organization is not one that actually is
involved in advocating and working with legislation, so we are
not involved directly. But there are others here on this body
who are, so they may want to speak to that issue.
Ms. JANG. I can speak to that, Congressman.
The Asian Pacific Islander American Health Forum is working
in coalition with a number of minority health organizations
under the auspices of ``Out of Many, One.'' And we have been
working together with the American Heart Association to
advocate for the inclusion in the Senate's Medicare bill of a
provision that gives the Secretary of HHS the authority to
mandate the collection of data on race, ethnicity and gender as
part of the quality measures that Medicare health plans have to
report on.
So we see that as a good step, giving the HHS--because we
do think that they do have the administrative authority to do
that. So we are hopeful that it has been included in the Senate
Medicare bill.
Chairman STARK. Thank you.
Mr. BECERRA. Thanks, Mr. Chairman.
Chairman STARK. Mr. Camp, would you like to inquire?
Mr. CAMP. Thank you, Mr. Chairman.
And, Dr. Blanton, I agree with you on data collection and
analysis. And you may have heard my comment to the other panel.
We often get requests to act on data that is 3 and 4 years out
of date. And you are correct, there is a dramatically changing
healthcare environment out there, and we often don't get that.
So I hope we can maybe improve that.
I had a question for Dr. Akhter. You mentioned about the
importance of coordinating care and the difference between
acute and chronic care, and that many seniors today have to
deal with multiple diseases, go to different facilities, have
different providers, doctors. And you say that this is
especially true of those--and I am quoting from your
testimony--of those seniors from minority populations, and
exacerbates rather than reduces disparities.
And we have about 8 million seniors, including about 1
million minorities, who have chosen to enroll in Medicare
Advantage that coordinates their care and helps manage their
chronic diseases and illnesses. Do you believe this type of
coordination would be helpful to greater minority populations
and especially those with chronic conditions?
Dr. AKHTER. Thank you, Mr. Camp. This is a very important
question.
Certainly, coordination will help, but we also need to
collect data to monitor to see what the effect is going to be.
And, you know, data collection is a very important part of us
knowing what gets done, what gets measured that gets done. And
if we have a measuring tool that measures whether this
coordination is helping or whether we are just simply not doing
the coordination or doing the coordination to provide less
care, then it would not be very beneficial. So I----
Mr. CAMP. Do you think Medicare fee-for-service, which does
not coordinate care, will ever be able to resolve these
disparities that you mentioned are exacerbated by----
Dr. AKHTER. If we continue in this way, the way we have
been doing business in the past, it certainly will not. But I
think, again, coordination is important, but also monitoring is
important, so that we all have a transparency in the system
where we can all see what is being actually done on the ground.
Mr. CAMP. Thank you.
And I want to thank you all for your testimony today.
Dr. Satel, we have heard about the discrepancies that exist
in health outcomes in certain populations. And if two people
with the identical diagnosis but different races are admitted
to the same hospital for treatment, what has research told us
about their treatment and their recovery?
Dr. SATEL. Actually, the research is--some studies will
show that there are differences in the receipt of certain
services. Cardiac care has been one of the most incisively
examined ones. What is interesting, though, is the fact that
many of the studies, even though they saw a discrepancy in the
rate with which African Americans--most of the early work has
been done, really, black-white comparisons. Even though that
the African Americans were less likely to receive certain
procedures, mortality rates were similar. Not all studies found
that, but a lot of them did. That didn't say anything about
morbidity rates, but it said that mortality rates were--some of
them found either equal or actually lower for the African
Americans.
But the moral of that story is, as others have suggested,
is that we have to look as carefully at outcomes as we do at
the, you know, counting up of procedures. It is important to
know how often procedures are administered. We also have to
wonder are, perhaps, white people being overtreated because
they tend to be more litigious, and malpractice considerations,
that is something to think of.
It also raises another point that I would love to see more
ethnographic research. When we do see discrepancies, we are
left with trying to figure out what they are about. And often
they indicate something very subtle that we really can't pick
up from looking at databases in retrospect. We really want to
know, what did the physician tell the patient? What did the
patient truly understand? What were the preferences of the
patient? These kinds of considerations that are very, very
fine-tuned and don't emerge from big databases and really
does--I would love to see NIH fund that kind of work.
It is basically sociology, but that can be done in an
empirical and standardized way. And I think that would be a big
contribution to understanding the fine-grained explanations for
some of these differences.
Mr. CAMP. All right. Thank you.
And I guess to the extent we have received some testimony
on private-sector initiatives in the effort to eliminate
healthcare disparities, there are a number of those that are
taking place throughout the country as well.
But thank you all. I see my time has expired.
Chairman STARK. Mrs. Tubbs Jones, would you----
Mrs. JONES. Mr. Chairman, thank you very much.
And I want to thank all the witnesses for coming to this
historic hearing, focused on racial and ethnic disparities in
healthcare. I wish I had hours, and I don't. But there are two
or three things I do want to focus on.
And I want to ask you, Dr. Satel, do you know who Linda
Gottfredson is?
Dr. SATEL. A sociologist at the University of Delaware.
Mrs. JONES. And do you give credence to her research and
her comments?
Dr. SATEL. Oh, on this, as far as the way she framed the,
sort of, the comparison of having a chronic illness to almost
having a job?
Mrs. JONES. No, not that one. I have another one for you.
Dr. SATEL. Oh, I know what you are referring to.
Mrs. JONES. You know what I am referring to?
Dr. SATEL. I am pretty sure I do.
Mrs. JONES. Tell me.
Dr. SATEL. I suspect--well, she has done a lot of work on
IQ and race.
Mrs. JONES. And what has her work on IQ and race shown?
Dr. SATEL. Frankly, I didn't--that is not what I looked at.
I looked at the work she has been doing on education, diabetes
education and health literacy.
Mrs. JONES. Well, when you cite someone, you live with what
you like what they say and what you don't like about what they
say, don't you?
Dr. SATEL. Not necessarily.
Mrs. JONES. You give credence to them as--anyway, let me
not argue. Let me quote her for the record so that it is clear
that everybody understands who you rely upon.
Quote, ``Health scientists have noted that differences in
an individual's cognitive abilities may explain why some
patients receive better care than others. This theory suggests
that the variation of effective treatments may result from an
inner quality of reasoning capabilities among patients.
Patients with lower general reasoning abilities are less likely
to seek preventive care, to know signs and symptoms of disease,
and to adhere to treatment regimes.''
I personally, you know, think it is, like, code words. And
we go back to the problem with discrimination among racial and
ethnic minorities when we start talking about their cognitive
abilities.
I am not looking for an answer from you. I am merely
placing into the record a person whose statements you rely upon
to make your point.
I want to raise with you, however--you are a psychiatrist;
is that correct?
Dr. SATEL. Yes.
Mrs. JONES. Why haven't you talked at all about the issue
about psychiatry, A very necessary part of health treatment and
the disparities that exist among racial and ethnic minorities
having access to psychiatry, as part of your presentation
today?
Mrs. JONES. Right. Well, that is actually a place where--
when I mentioned the ethnographic approach, that is where it is
so important. Because there are so many cultural----
Mrs. JONES. No, I am asking you, why didn't you use that as
part of your testimony here today, to talk about that very
issue that you specialize in, psychiatry?
Dr. SATEL. Because I happen to--I just decided to take a
broader approach. But I could talk about psychiatry.
Mrs. JONES. Thank you.
Let me go on to someone else.
Dr. Blanton, first of all, good morning--good afternoon. It
is afternoon now.
Ms. LILLIE-BLANTON. Good afternoon.
Mrs. JONES. If there was one thing you could do, one, what
would you--let me stop for a moment.
To people who are listening to this hearing out in the
world and have not had a background or experience in healthcare
and would like to provide some testimony that would be of
assistance to the Committee, they gave me a convoluted way of
you doing this, which is go to house.gov, link to the Committee
on Ways and Means, link to this hearing, and send it in. But an
easier way is to send it to me at [email protected]. That is
[email protected]. Because I know there are others who would
want to have an opportunity to add something to our discussion.
And I am interested and I am sure the Committee is interested
in having additional information.
Back to you, Dr. Blanton.
Ms. LILLIE-BLANTON. You said if there was one thing I could
do?
Mrs. JONES. One piece of advice you would give us as
Members of this Health Committee.
Ms. LILLIE-BLANTON. If there was only one thing that could
be done, I would say we need to expand sources of coverage or
reduce the number of uninsured.
While we know insurance coverage is not the only thing that
makes a difference, we know that those who lack coverage face
financial barriers to care that affect not only their health
status but affect their ability to function in society, you
know, in terms of--you know, financially function in society,
with their jobs, with their families.
And so that would be the one thing, if there was only one
advice.
Mrs. JONES. Dr. Iton, can you for a moment address the
issue that there is some myth about healthcare disparities or
access to healthcare among races?
Dr. ITON. The data is overwhelming. There is absolutely no
credible argument that health disparities and healthcare
disparities don't exist. My argument has been that the linchpin
to understanding health and healthcare disparities is
understanding chronic disease and the distribution of chronic
disease throughout populations.
And I agree that the first thing we have to do is to get
everybody into a universal system of high-quality, affordable
healthcare. That is critical, and it is a matter of human
rights.
But the second thing is, we are not going to be able to
manage healthcare into the 21st century unless we get a handle
on chronic disease, because that will bankrupt our systems. And
we can do that. There is evidence of that. California has done
it around tobacco and has shown a substantial decrease in
tobacco-related heart disease, lung cancer, bronchus cancer,
and a decrease of about $3 billion in healthcare costs between
1990 and 1998. California has set an example for this. Other
States can do it. And we need to focus on obesity and diabetes
next.
Mrs. JONES. I thank all of you.
I am way out of time, Mr. Chairman. I thank you for this
extra minute or 2 for your testimony.
We, as Members of Congress, you know, we are viewed as
politicians. So when I start talking about healthcare
disparities, ``Well, you don't have any background; what do you
know?'' So I am glad to be able to have someone with some
background and some experience say and--what is the word--
second or testify to the fact that there are healthcare
disparities in America and how we need to address it.
Mr. Chairman, I thank you so much for the opportunity.
Chairman STARK. Thank you.
Mr. Johnson, would you like to inquire?
Mr. JOHNSON. Thank you, Mr. Chairman.
Ms. Blanton, you kind of got leaned on. I am going to ask
you, you have heard from other witnesses, or we have, today
that universal access to health coverage is important. However,
your testimony cites research that found health disparities
exist among different demographics, even in the Medicare
program.
Is that what you said?
Ms. LILLIE-BLANTON. Yes, that is correct.
Mr. JOHNSON. Could you please elaborate on your findings?
Since Medicare is a government-run entitlement program
universally accessible to individuals in this country age 65
and over or those otherwise disabled, that ought to give us
some insight. If you could discuss it, I would appreciate it.
Ms. LILLIE-BLANTON. Well, first of all, I think many of our
panelists have already talked about some of the other factors
that determine the access and the quality of care that people
have.
One, very importantly, is the availability of health
resources, whether it is physicians, whether it is other
provider groups. So if you are living in a neighborhood where
you don't have access to the providers or you don't have access
to the specialists, then you may not get the same care that
someone else has. If you are living in a community where
language barriers become an issue, you may not get the same
care that someone else----
Mr. JOHNSON. Well, I will tell you what, I just ran into a
situation in our hometown, which is full of hospitals, that
there were two of them that didn't--closer to us that didn't
have their emergency rooms open. And I don't know if that is
happening across the country or not. Are you aware of that
situation?
Ms. LILLIE-BLANTON. Well, I have not tracked whether or not
it has occurred at any increasing frequency, but it is a
reality. It is a fact that some hospitals are closing their
emergency rooms. And part of that has to do with emergent
patients, emergency patients who are uninsured and adding to
the costs. So it is a financial issue, but it is still an issue
that becomes a barrier to care for people, particularly in
emergency situations.
So I would say that both availability of providers becomes
a big issue and language becomes an issue. But there are still
other factors that affect disparities in care. And sometimes
the issue we really have a hard time understanding are just how
personal biases about who is deserving and more deserving or
less deserving of care for whatever reason. Sometimes it is
racial discrimination, sometimes it is discrimination because
of the condition that they are facing. Patients with mental
health problems, patients with other kinds of substance abuse
problems may have different access to care. So----
Mr. JOHNSON. Well, are you saying they categorize people
who are over 65, even though they are all on the same program?
Ms. LILLIE-BLANTON. Let me say that there are very subtle
ways where a bias about a patient may enter into the care
delivery system. And so it may not be overt biases. It could
just be judgments about the individual.
But in the research that has been done to look at the
factors, there probably is a broader systemic factors, such as
the availability of providers, that play a larger role. But you
still can't discount the interaction between a patient and a
provider as one of the factors that influences the quality of
care and their access to care.
Mr. JOHNSON. Thank you very much.
Thank you, Mr. Chairman. No further questions.
Chairman STARK. Well, the answer that I think Dr. Blanton
gave, as to what is the one thing we could do to begin the
process of reducing disparities, would be to do in whatever way
we are able to expand coverage to people that don't have
coverage.
I have always been under the assumption that to not have a
payment plan pretty much means, in this country, you are denied
access to medical care. You may be able to get it at the
eleventh hour in the emergency ward, but I think that I
wouldn't get much argument to say that if you don't have a
payment plan, you are not in the game.
I wanted to ask Dr. Iton, it has been discussed here, and
both referred to obliquely and directly, what I am going to
call the difference between race and class. My race is obvious.
I hope my class isn't that obvious.
But, Dr. Iton, what is more important in determining the
health of a senior citizen, their economic class, their
education level, where they live, or their race?
Dr. ITON. Well, I think that is one of those either/ors
that is sort of impossible to address, particularly with the
limited data we have on class.
We have done pretty extensive analyses of health
disparities according to race and income, you know, income
being sort of a crude estimate of socioeconomic status. And
when you stratify populations across incomes, you see very
clear correlations between length of life and income. The
poorer you are, the shorter your life is. The poorer you are,
the more chronic disease you are saddled with.
When you substratify that by race, you see an additional
burden imposed upon that stratification. That is pure race. In
other words, that wealthy African Americans have a higher rate
of chronic disease and health disparities than wealthy whites.
And these kinds of associations suggest that race and class
play an important role in mediating health disparities.
But one thing I would want to point out, though, is that
immigrants seem to fly against that general rule. And we find
that immigrants tend to, regardless of class, tend to have
better health outcomes than nonimmigrants. And that is, I
think, an important thing to try to understand, because there
are variables here that will play an important role in
designing how we approach the reduction and elimination of a
heavy burden of chronic disease in low-income populations.
I can expand on that further, but I just wanted to raise
that issue, because sometimes we lump things together in ways
that don't help the discussion. And understanding, for
instance, in California, how low-income Latino immigrants have
longer life expectancies than high-income whites is something
very important to understand in designing public health and
health policy.
Chairman STARK. Do you want to----
Mr. BECERRA. Sure.
Chairman STARK. Why don't I yield to my distinguished
friend.
Mr. BECERRA. Mr. Chairman, thank you.
Dr. Iton, it is a prescient observation that few know. But
the disturbing part of that is, if you extend the observation a
little further, you find that the longer the immigrant has been
here, or with the next generation of the children that followed
that first-generation immigrant, the outcomes start to mimic or
reflect those of the native-born population. So if you are
minority and poor and you are the son or daughter or the
granddaughter or grandson of an immigrant, then chances are you
are going to reflect more your peers who are native-born when
it comes to health outcomes than you do your parents, your
grandparents, who were poor but in better health.
So that is an unfortunate thing. It sort of flies contrary
to what you think, the longer you are here in America, the
worse your health gets.
Dr. ITON. Yes. We sometimes say that America is not good
for your health.
Mr. BECERRA. Yes, exactly.
Dr. ITON. And the evidence suggests that. And that is
important to understand, as well. Why does that happen? What is
it about becoming less of an immigrant and more of an American
that inures toward health behaviors and----
Mr. BECERRA. I think it is the lifestyle.
Dr. ITON. Exactly.
Mr. BECERRA. More smoking, more drinking, less exercise.
The more affluent you become, the less you need to do physical
labor. And you find a lot of these immigrants working very long
hours, don't have the money or the time to go out and drink or
smoke too much. And so it is--the fact that you have to live a
modest way keeps you pretty healthy.
And I suspect if you were in a rural area--I suspect if Mr.
Moran, Congressman Moran, were still here, he would probably
tell us that he finds that in a lot of parts of Kansas, a lot
of those folks who are still in rural America probably have
pretty decent health because they have to work so hard as well.
Dr. ITON. Well, we spend a lot of time in public health
trying to actually distill out what it is about that immigrant
health behaviors that we can actually spread to the larger
population, because we think immigrants teach us a lot about
health-protective behaviors.
Mr. BECERRA. Maybe we can tackle that immigration political
issue first.
Chairman STARK. I was going to ask Dr. Rodriguez to explain
to me why Los Angeles hasn't gone bankrupt, which is--the one
thing I have to say, Doctor, we have a marvelously diverse
county, as the doctor knows. I am now a minority in the county.
And we have a very liberal constituency, I might add. But where
they lose their liberal foundation in my town meetings is that
they are convinced that we are going to go bankrupt because of
undocumented residents in our community. And I get yelled at
every month at my town meetings and, I think, due to inaccurate
data, if there is any data. But it is a kind of xenophobia that
I haven't seen in a long time. And rarely can I say that I am
disappointed in my constituents. But in this one area, I have
been just terribly--I have been disappointed that they don't
take a better approach to that problem that we have.
I wanted to just establish a few things here. I suspect--I
am talking to the two JDs here, not the MDs, or the MD-JD
combination. But there is nothing illegal, is there, about
collecting data of either ethnicity or race when we collect it
for Medicare or public health records; is that correct?
Dr. ITON. It is correct, as far as I understand it.
Ms. JANG. Yes, that is correct. And, in fact, the Title 6
regulations require recipients of Federal financial assistance
to provide the Office for Civil Rights with the information
necessary to determine whether they are in compliance. And so,
therefore, recipients have an obligation to collect that
information.
Chairman STARK. Then I am going to ask Dr. Blanton just to
summarize as between Medicare, Medicare Advantage plans,
private fee-for-service plans. What kind of data collection do
we have? Do we have good data, sparse data? Can you kind of
summarize? And what should we do?
Ms. LILLIE-BLANTON. Right. Our data are very sparse,
especially on Medicare Advantage plans. In fact, we don't even
require the same collection of information from Medicare
Advantage plans as routinely are collected in other
administrative proceedings. And so we at least need to make
sure that we have comparable reporting for enrollees in fee-
for-service as we have in----
Chairman STARK. And what about in the Part D pharmaceutical
stuff?
Ms. LILLIE-BLANTON. Unfortunately, I am not----
Chairman STARK. Anybody know? I don't think we have very
good data on that.
Ms. LILLIE-BLANTON [continuing]. Requirements by race,
ethnicity. I know there are reporting requirements, but I am
not sure if the data required reporting specifically in Part D.
So I do think we need to improve on our administrative data
collection, at least for Medicare Advantage.
Chairman STARK. Okay. I agree. And, as I say, I hope that
we can proceed on a nonpartisan or bipartisan basis to begin at
least to collect more of the data. We should have been doing it
more thoroughly in Medicare. We don't do it at all in Social
Security. We do it pretty sparsely, I think, in Medicare. And I
don't know that we can do away with a lot of the arguments and
discussions if we can turn--if we can sort out the empirical
issues before us. And I think that that would be extremely
important for us.
Can you comment, Dr. Blanton, on how well the Medicare
Advantage plans, insofar as we know, have done in terms of
disparities versus fee-for-service, standard Medicare?
Ms. LILLIE-BLANTON. Well, only to the extent that there are
two studies that are cited that, you know, I think give us some
information. And from both of those studies--one that was by
Trivedi, who is now at Brown University but I think then was at
Harvard, and the other by Schneider. And both basically found
that disparities still exist even in the Medicare Advantage
program.
The study by Trivedi is fairly recent, in the sense that
they tracked over time. And that is the one that actually
looked at HEDIS measures and found that seven of the nine HEDIS
measures, there was a narrowing, but still the disparities
existed. And on two you actually had a widening. And the two
were very important, because one was glucose monitoring for
diabetics and the other was cholesterol monitoring for patients
with heart disease.
So there is some fairly recent evidence that performance in
Medicare Advantage plans has not resulted in eliminating
disparities.
The work by Schneider is probably cited even more, but it
is a little older data, but the findings are very similar. I
mean, they looked at breast cancer, they looked at diabetic,
eye exams, also looked at follow-up care after hospitalization.
And, you know, I think the potential exists for better
coordination, for better care. But I think what Dr. Akhter is
saying, you have to monitor it. It is not just a matter of
because the organizational structure there allows for better
coordination. There still has to be the monitoring to assure
that the kind of coordination and followthrough occurs, that
the organizational structure allows or would encourage to have.
Chairman STARK. Yeah, I have often felt that just to assign
people, say, as we have, to a managed care plan, we start
paying them, but we don't know if they ever show up. And
somehow I have always felt that I am happy to pay them, but I
think that they ought to somehow interact with the patient.
I am sorry, Dr. Satel, that you get this, but I can't help
but ask a couple of things. I was disturbed, to say the least.
And did any of you go to Harvard Medical School? No.
Dr. SATEL. Brown.
Chairman STARK. These guys at Harvard doing research who
were getting hundreds of thousands of dollars from the various
parts of PhRMA, which I thought was not very ethical.
Dr. SATEL. You can't leave psychiatry out of this.
Chairman STARK. Well, but then--no, no, but the other thing
then that troubled me--and that is what we are getting to--and
this comes closer to my home than I like, but the fact that we
are overmedicating and overdiagnosing children in the psych--
and, I mean, what I am seeing where my 6-year-old twins are
going to school, you know, half the class on meds? And I think,
``Holy smokes, Doc. They can't all be''--do you share my
concern that----
Dr. SATEL. Yes.
Chairman STARK [continuing]--that may have been created by
the makers of these drugs, who have been instructing your
colleagues at golfing outings and other--help me with that.
Dr. SATEL. That is a hard question about the interaction.
But it is--most psychiatrists, apparently except for the
physician at Harvard who was a large proponent of diagnosing
childhood bipolar and appeared by most accounts to have a
fairly low threshold for doing that and also a low threshold
for urging medication treatment, he----
Chairman STARK. But also for attention deficit, which is
one of the more common ones.
Dr. SATEL. Well, that can often overlap with bipolar or
appear to look like it. Yeah, these are difficult diagnostic
issues. And there has been a lot of concern among psychiatrists
that it is way overdiagnosed and way overprescribed.
An interesting subset of that concern, however--and this
has been well-documented--is that within this perhaps exuberant
tendency to prescribe and to diagnose is subsets of minority
children who may be underdiagnosed and undertreated. So it is a
paradox within that larger phenomenon.
Chairman STARK. Well, you have all been patient and kind.
And what you have really done is open yourself up for an awful
lot of extra work after this, when we and our staff ask you if
you will help us as we try to wind through. We are going to be
dealing with this issue next year, I am sure. And it is
important that we understand that just having an insurance plan
may not guarantee to every resident of this country the right
medical care or sufficient medical care.
But I think the witnesses have suggested to us that, as a
first step, we ought to make sure that at least they have
access and the money to pay for it, without which they are not
going to have access. And then we have a whole lot of subtle
differences that we have to deal with.
We really do appreciate your taking the effort to be heard
here. Are there any of you who have a last comment that you
would like to make to my colleagues?
Ms. Jones, would you like----
Mrs. JONES. For the record, there was some research done by
a researcher at Cleveland State University and Case Western
Reserve University and university hospitals around low-income
recipients of healthcare and the cultural impediments to the
receipt of that care. Unfortunately, as I sit here, I can't
think of the name of the researcher or the name of the report.
But if anybody is interested, please feel free to contact me. I
will get that information for you. It was very interesting
outcomes with regard to that whole issue of cultural
sensitivity and a lot of other issues that were barriers to
access to healthcare.
Chairman STARK. And the other suggestion that my friend,
Mr. Becerra, mentioned earlier, but for those of you who have
some relationship to advocacy groups or our colleagues on the
other side of the Capitol who need some encouragement, we
think, to do the right thing, and if you have a lot of extra
time and we don't have thunderstorms this afternoon, maybe you
can get over there and push them along a little bit toward what
we think has been a good job on a bipartisan basis that my
colleagues did here in the House over a year ago, or just a
year ago, when we did the CHAMP Act. And we would like to see
more of that survive.
And for those of you who are physicians, it isn't just the
fact that you might get a 10 percent cut, but there is also
more there that I think will help the entire country in the
delivery of medical care.
Thank you all for your patience and your participation.
The hearing is adjourned.
[Whereupon, at 12:43 p.m., the Subcommittee was adjourned.]
[Submissions for the Record follow:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Statement of America's Health Insurance Plans
I. INTRODUCTION
America's Health Insurance Plans (AHIP) is the national association
representing approximately 1,300 health insurance plans that provide
coverage to more than 200 million Americans. Our members offer a broad
range of health insurance products in the commercial marketplace and
also have demonstrated a strong commitment to participation in public
programs.
We thank the Subcommittee for holding this hearing on healthcare
disparities and we commend Congresswoman Hilda Solis and Delegate Donna
Christensen for introducing H.R. 3014, the ``Health Equity and
Accountability Act,'' as well as Congressman Jesse Jackson, Jr. for the
introduction of H.R. 3333, the ``Minority Health Improvement and Health
Disparity Elimination Act.'' We also applaud the Congressional
TriCaucus for its leadership in promoting a national dialogue on the
need for solutions to eliminate disparities in healthcare.
Our industry looks to the Agency for Healthcare Research and
Quality's (AHRQ) annual National Healthcare Disparities Report as an
important contributor to understanding continued gaps in care and our
nation's progress toward reducing racial and ethnic disparities. Health
insurance plans recognize that we serve an increasingly diverse
population and that this trend will continue over the next several
decades. In fact, by 2050, half of all Americans will be minorities.
This shift in the racial demographics of America poses significant
challenges to government, business, healthcare providers, and health
plans to ensure that we are reaching diverse communities and serving
them at their point of need. The health plan community is uniquely
situated to address this challenge with meaningful solutions.
Our statement focuses on two broad topics:
The importance of collecting data on race and
ethnicities, based on uniform standards and categories, to identify
disparities and develop programs that close the gaps in care; and
Initiatives our industry is pursuing to improve data
collection and eliminate disparities in healthcare.
II. DATA COLLECTION BASED ON UNIFORM STANDARDS
Health insurance plans are making significant contributions to this
debate in the area of data collection. Data are the fundamental
building blocks for: (1) identifying the differences in care
experienced by specific populations; (2) developing programs to address
these differences and ensure a higher standard of care; and (3)
increasing access to culturally and linguistically appropriate health
and wellness information, such as addressing language and
interpretation needs. Recognizing this opportunity, health insurance
plans are using the data that they are voluntarily collecting on race
and ethnicity to support culturally and linguistically appropriate
communications to members, to build wellness, prevention, and chronic
care programs that are relevant for specific race and ethnic groups,
and to implement or strengthen quality improvement efforts.
In 2003, we partnered with the Robert Wood Johnson Foundation
(RWJF) and commissioned a broad survey to evaluate the extent to which
health plans voluntarily collect or obtain data on their enrollees'
race, ethnicity, and primary language using both direct or indirect
methods. This allowed us to probe barriers to getting data, develop a
strategy, and implement programs. This original survey found that just
over half of enrollees were covered by organizations that collect or
obtain data on the race and ethnicity of their members.
Despite this early sign of progress, the survey findings also
identified major concerns as to why health plans choose not to collect
data on the race and ethnicity of members. Primarily, the answer is
that health insurance plans are concerned with how enrollees and
communities will react to this activity. These concerns have been
validated through AHIP focus groups with African Americans and
Hispanics/Latinos in 2005, and a consumer survey funded by the RWJF.
Focus group participants exhibited some willingness to answer questions
about race, ethnicity, and primary language if they were asked on a
voluntary basis, collected at the same time as other demographic
questions, and if the reasons for data collection were fully explained,
such as for quality improvement efforts.
In 2006, we partnered with RWJF to conduct a follow-up survey on
data collection and found that two-thirds of consumers receive their
health insurance coverage from an organization that collects data on
the race and ethnicity of members. This is a significant improvement
over the original 2003 study and an important step in eliminating
healthcare disparities. We are continuing our collaboration with RWJF
to conduct two additional surveys in 2008 and 2010 that move from
assessing the collection of data by health plans to identifying
strategies our member companies are utilizing to develop tailored
interventions that meet the needs of diverse populations. AHIP also
will be conducting health plan interviews to further explore challenges
and opportunities with data collection and successful strategies to
improve care through the use of these data.
Another significant concern is that there is no uniform method or
standardization in the categories used to collect data by race and
ethnicity. Instead, conflicting categories are used by various
government agencies, such as the Centers for Medicaid & Medicare
Services (CMS) and the Centers for Disease Control & Prevention (CDC),
even though it is widely recognized that the usefulness of data
collection efforts in identifying and reducing health disparities is
largely dependent on the accuracy and sharing of information. To
address this shortcoming, it is essential for public and private
stakeholders to work together to develop comprehensive standards that
will ensure uniformity of data categories for measuring progress in
reducing disparities across the entire healthcare sector.
AHIP, the National Health Plan Collaborative (NHPC), the Health
Research and Educational Trust (HRET), the RAND Corporation, and
several other public and private entities have stressed the need for
standardization of race and ethnicity data categories. Currently, the
NHPC is working with AHRQ and the HHS Office of Minority Health to
encourage a study committee convened by the IOM to identify best
practices for data collection and recommend the use of uniform data
categories for measuring and reporting quality of care across diverse
populations.
III. INITIATIVES BY HEALTH INSURANCE PLANS
AHIP's members have been working pro-actively through a number of
initiatives and partnerships to improve data collection and take steps
toward eliminating healthcare disparities.
Eleven major health insurers have formed a public-private
partnership--the National Health Plan Collaborative--that is working to
reduce racial and ethnic disparities and improve the overall quality of
care. This initiative, established in December 2004, is the first
national effort of its kind to move beyond research and actively test
possible solutions to inequalities in the delivery of healthcare
services.
From 2004 through 2006, a central goal of the Collaborative was to
test ways to improve the ability of health insurance plans to collect
and analyze data on race and ethnicity. Other top priorities included
developing methods of measuring improvement in the care of diabetes for
specific populations and testing interventions that have the potential
to improve healthcare quality for racially and ethnically diverse
populations.
During the current phase of this initiative, health plans are
looking at ways to standardize primary data collection, address
language access services, and create innovative programs that address
gaps in care. Looking forward, the Collaborative is focused on sharing
strategies and tools that prove successful in improving healthcare
quality with healthcare decision-makers and leaders, including other
health insurance plans serving commercial, Medicare, and Medicaid
populations. Ultimately, this needs to be an effort involving all
payors including public programs.
AHIP's Addressing Disparities in Health program was forged in 2003
through the leadership of our member organizations to highlight the
importance of designing quality improvement programs for populations of
different racial and ethnic needs. This program consists of:
Four regional workshops conducted across the country to
educate health plans and key stakeholders about the importance of data
collection, how to get leadership and community buy-in, and to provide
recommendations for collecting and analyzing data on race, ethnicity,
and primary language of their enrollees. Feedback from these trainings
resulted in the development of a data collection toolkit, Data as
Building Blocks for Change, for health plans interested in initiating
racial and ethnic data collection efforts and developing targeted
interventions.
Educational sessions with health plan communications
staff and other health plan professionals on cross-cultural
communication messaging that reinforces the need for cultural
sensitivity information for all populations.
Programs emphasizing an understanding of information
relevant to race, ethnicity, and culture and its significance to the
effective communication and delivery of health services. One key
strategy is to help healthcare professionals break down cultural
communication barriers through continuing medical education. AHIP, in
collaboration with the Manhattan Cross Cultural Group, has commissioned
a continuing medical education course that provides physicians with the
tools and skills to communicate more effectively with patients from
diverse backgrounds. To date, over 500 physicians have participated in
AHIP's cultural competency module that features a case study geared for
improving asthma care among African Americans. We will be expanding the
existing cultural competency training modules to new audiences such as
nurses, case managers, and non-clinical health professionals (e.g.,
health plan customer representatives). The clinical and non-clinical
modules will include a variety of case studies addressing chronic
conditions, such as hypertension and asthma, as well as how to better
serve diverse populations, such as individuals with limited English
proficiency.
Health plan ``Models that Work'' to facilitate the
sharing of information on proven strategies for reducing disparities.
This clearinghouse will highlight a wide range of health plan
strategies for reaching out to culturally and ethnically diverse
populations that are at risk for certain medical conditions. This
initiative continues our industry's long tradition of sharing
information on effective models so these programs, or elements of them,
can be adapted for more widespread use and to benefit more people.
The industry's efforts are beginning to have an impact. In addition
to an increase in data collection, plans are analyzing these data to
determine where health disparities exist and implementing programs to
address gaps in the treatment of chronic conditions, adherence to
medications, and the use of preventive services and medical procedures.
To build upon this progress, we will be reaching out and working with
key stakeholders to increase patients' awareness about the utility of
data in improving health and healthcare.
IV. CONCLUSION
Looking forward, leadership from all stakeholders is the key to
eliminating disparities in healthcare. We all must come together in
recognizing that action on this priority is essential to improving
quality of care for all Americans.
While data collection and analysis are building blocks to
eliminating disparities, another very crucial component of our
challenge is to put the data to use in developing and implementing
programs to reduce disparities that are relevant to the specific
communities we serve. To meet this challenge, we need to break out of
silos and use our collective expertise to work collaboratively on
initiatives that will have a demonstrable impact in eliminating
disparities in healthcare and improving overall quality. We stand ready
to work with the Subcommittee and others to advance these important
priorities.
Statement of American College of Physicians
As the largest medical specialty society and the second largest
medical organization in the United States, the American College of
Physicians (ACP) is committed to eliminating disparities in healthcare
access and quality. ACP represents 125,000 doctors of internal
medicine, residents and medical students. The College is addressing
healthcare disparities in its public policy research, educational
initiatives and foundation activities. ACP applauds Chairman Pete Stark
for holding this hearing to improve understanding of the many factors
that contribute to health disparities, including access to care. The
College recognizes that addressing this issue is vital to improving the
health status of Americans and achieving a highly performing healthcare
system that is accessible to all.
Racial and ethnic disparities in healthcare are well-documented.
Addressing these inequities became a national movement with the
development of the Healthy People 2010 goals and objectives. In 2002 a
landmark report was released by the Institute of Medicine, Unequal
Treatment: Confronting Racial and Ethnic Disparities in Healthcare.
Since then, a significant amount of research has increased our
understanding of the scope and causes of disparities. Despite these
efforts, large gaps in access, quality of care and health outcomes
still persist. Earlier this year, the Agency for Healthcare Research
and Quality (AHRQ) released its annual National Healthcare Disparities
Report, which found that disparities in healthcare quality and access
have not decreased, and for many indicators, the gaps are expanding.
Specifically, the 2007 report notes that:
1. Blacks had a rate of new AIDS cases 10 times higher than
Whites.
2. Asian adults age 65 and older were 50% more likely than Whites
to lack immunization against pneumonia.
3. American Indians and Alaska Natives were twice as likely to
lack prenatal care in the first trimester, compared with
Whites.i
Timely access to appropriate healthcare is critical to improving
health outcomes. It is undeniable that uninsurance is a major barrier
to eliminating healthcare disparities. According to the AHRQ report,
individuals without health insurance fared worse than individuals with
private insurance on all access measures and almost 90% of quality
measures. Compared with the insured, the uninsured are about six times
as likely to lack a usual source of care and nearly three times as
likely not to get care as soon as wanted for illness or injury.
Unfortunately, the uninsured rates are high among many racial and
ethnic minorities. In 2006, 49% of Hispanics and 28% of African
Americans adults (ages 18 to 64) were uninsured, compared with 21% of
whites and 18% percent of Asian Americans.i The College
advocates that all Americans should have affordable health insurance
coverage to eliminate the financial barriers to accessing care.
---------------------------------------------------------------------------
\i\ Agency for Healthcare Research and Quality. 2007 National
Healthcare Disparities Report. Rockville, MD: U.S. Department of Health
and Human Services, Agency for Healthcare Research and Quality;
February 2008. AHRQ Pub. No. 08-0041.
---------------------------------------------------------------------------
The College also recognizes that disparities exist even among the
insured. It is for this reason that ACP is deeply committed to
improving access to care through a delivery model called the patient-
centered medical home. This team-based model of care, led by a personal
physician, provides continuous and coordinated care to maximize health
outcomes. Recent research has shown that many racial and ethnic
disparities related to access and quality are reduced or eliminated
when patients have a medical home. Among adults with a medical home,
Blacks and Hispanics were just as likely as Whites to receive
preventive care reminders, which have been proven to increase the rates
of routine preventive screenings.ii Ensuring all individuals
have a medical home will require restructuring of healthcare deliver
systems, including payment structures to support patient-centered care.
---------------------------------------------------------------------------
\ii\ Beal AC, Doty MM, Hernandez SE, Shea KK, and Davis K. Closing
the Divide: How Medical Homes Promote Equity in Healthcare: Results
From The Commonwealth Fund 2006 Healthcare Quality Survey, The
Commonwealth Fund, June 2007.
---------------------------------------------------------------------------
Effective patient-provider communication increases patient
understanding and is a critical component of patient-centered care.
Unfortunately, racial and ethnic minorities are more likely to report
poor communication with health providers than their White
counterparts.i Approximately 52 million Americans speak a
language other than English at home. Of these individuals, more than
half speak English less than ``very well'' and are considered limited
English proficient (LEP) patients.iii Language barriers can
result in the exchange of inaccurate or incomplete information, which
can affect access to and delivery of care and healthcare costs. LEP
patients disproportionately underutilize less costly preventive
care.iv However, when competent language services are
available, LEP individuals can communicate effectively with their
healthcare providers, improving their encounters and health outcomes. A
number of federal and state policies require healthcare providers who
receive federal funds to ensure access to services for patients with
LEP. However, often times these services are not being offered because
of time, costs, and availability of qualified interpreters.v
---------------------------------------------------------------------------
\iii\ U.S. Census Bureau. Language Spoken at Home for the
Population 5 Years and Over, Tbl B16004, data from 2005 American
Community Survey.
\iv\ AM. Doty. Hispanic Patients' Double Burden: Lack of Health
Insurance and Limited English. The Commonwealth Fund; February 2003.
\v\ American College of Physicians. Language Services for Patients
with Limited English Proficiency: Results of a National Survey of
Internal Medicine Physicians. Philadelphia: American College of
Physicians; 2006: Position Paper. (Available from American College of
Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106.)
Accessible at http://www.acponline.orgK/advocacy/where_we_stand/policy/
lep_paper.pdf.
---------------------------------------------------------------------------
An ACP survey found that the majority of practices represented by
internists that have LEP patients provide language services. However,
these services are limited and are typically provided by a bilingual
physician or staff member and hardly any practices rely on external
sources for language services or provide such services during off
hours. In addition, few physicians perceived a need for tools or
training to assist their practices in providing language
services.v A clearinghouse to provide translated documents
and patient education materials would be useful, but providing
reimbursement for the added costs of clinical time and language
services would be the most effective means of expanding the use of
language services.v
Language is just one aspect of an individual's culture that may
affect patient-provider communication, quality of the encounter and
patient outcome. Physicians and other healthcare providers must realize
the impact of culture on health status. There are many negative health
consequences that could result from ignoring culture, including missed
opportunities for screening because of a lack of familiarity with the
prevalence of conditions among certain minority groups; failure to take
into account differing cultural responses to prescription medication;
lack of knowledge about traditional remedies, leading to harmful drug
interactions; and diagnostic errors resulting from
miscommunication.vi Research has shown that quality
healthcare requires attention to differences in culture--the
``integrated pattern of human behavior that includes thoughts,
communications, actions, customs, beliefs, values and institutions of a
racial, ethnic, religious or social group.''vii
---------------------------------------------------------------------------
\vi\ Brach C, Fraser I. Can cultural competency reduce racial and
ethnic health disparities? A review and conceptual model. Med Care Res
Rev. 2000;57 Suppl 1:181-217.
\vii\ Betancourt JR, Green AR, Carillo JE. The Commonwealth Fund:
Cultural Competence in Healthcare: Emerging Frameworks and Practical
Approaches. New York: The Commonwealth Fund; October 2002.
---------------------------------------------------------------------------
Eliminating health disparities will require an adequate supply of
culturally-competent healthcare providers. Cultural competence in
healthcare has been defined as the ability of systems to provide care
to patients with diverse values, beliefs and behaviors, including
tailoring delivery to meet patients' social, cultural and linguistic
needs. Cultural competence techniques have been shown to effectively
change provider and patient behavior by improving communication,
increasing trust, improving racially or ethnically specific knowledge
of epidemiology and treatment efficacy, and expanding understanding of
patients' cultural behaviors and environment.viii
Accordingly, the College supports cultural competency training that is
incorporated in the training and development of all healthcare
providers, at all levels.ix
---------------------------------------------------------------------------
\viii\ Brach C, Fraser I. Reducing disparities through culturally
competent healthcare: an analysis of the business case. Quality
Management in Healthcare. 2002; 10:15-28.
\ix\ American College of Physicians. Racial and Ethnic Disparities
in Healthcare. Philadelphia: American College of Physicians; 2003:
Position Paper (Available from American College of Physicians, 190 N.
Independence Mall West, Philadelphia, PA 19106.)
---------------------------------------------------------------------------
A diverse workforce of health professionals is also an integral
part of eliminating disparities among racial and ethnic minorities.
ix-x Currently, many racial and ethnic minority groups are
poorly represented in the health professions, relative to their
proportion in the overall U.S. population. Increasing the diversity of
the healthcare workforce is a key to increasing access to care and
improving the quality of care for minorities. Minority staff, because
of shared cultural beliefs and common language, may improve
communication, create a more welcoming environment, and structure
health systems to better reflect the needs of minority communities.
Also, racial and ethnic minorities are more likely to serve in a
community of underrepresented individuals.xi-xii National
and local workforce policies are needed to:
---------------------------------------------------------------------------
\x\ Association of American Medical Colleges. Diversity in the
Physician Workforce: Facts & Figures 2006. Washington, D.C.:
Association of American Medical Colleges;
\xi\ Komaromy M, Grumbach K, Drake M, et al. The role of Black and
Hispanic physicians in providing healthcare for underserved
populations. NEJM.1996;334(2):1305-10.
\xii\ Stinson MH, Thurston NK. Racial matching among African-
American and Hispanic physicians and patients. J Human
Resources.2002;37(2):410-28.
Strengthen the education of racial and ethnic minorities
at all levels in the areas of math and science to create a larger pool
of qualified minority applicants for medical school.
Revitalize efforts to improve medical and health
professional school matriculation and graduation rates of minority
students. ACP supports the consideration of race and ethnicity in
determining admissions to institutions of higher education.
Expand programs that provide outreach to encourage
minority enrollment in medical and health professional schools.
Increase efforts to recruit and retain minority medical
school faculty.
Enhance funding for programs and initiatives that work to
increase the number of healthcare providers in minority communities.
Eliminating health disparities and improving quality of care
requires evidence-based policies and programs. Research to identify
sources of disparities, as well as effectiveness of initiatives
targeted to eliminate disparities, will necessitate the collection of
better data on race, ethnicity, and primary language using reliable and
standardized measurement tools. Unfortunately, inadequate data
continues to limit the analysis of health disparities.xiii
ACP supports efforts to improve collection of racial and ethnic
information within the healthcare system. ACP has supported legislative
efforts to eliminate disparities in healthcare, improve collection of
racial and ethnic data from Medicare participants and to incorporate
race, ethnicity, and primary language measures in quality improvement
projects. The College regards research to be a vital part of
identifying, monitoring, and addressing disparities in healthcare that
disadvantage racial/ethnic minorities.
---------------------------------------------------------------------------
\xiii\ Billheimer LT, Sisk JE. Collecting Adequate Data on Racial
and Ethnic Disparities in Health: The Challenges Continue. Health
Affiars. 2008; 27 (2):383-391.
---------------------------------------------------------------------------
Conclusion
The American College of Physicians appreciates the opportunity to
provide the Health Subcommittee with this summary of our views on
eliminating healthcare disparities. We recognize that health
disparities are multi-dimensional and will require comprehensive
efforts to eradicate the gaps that currently exist. We urge the
Subcommittee to continue to address this critically important issue.
Statement of the American Dental Education Association
The American Dental Education Association (ADEA) represents all
accredited dental schools, dental residency training programs and
allied dental programs in the United States, as well as the faculty,
dental residents, and dental and allied dental students at these
institutions.\1\ In these academic dental institutions (ADI) future
practitioners and re searchers gain their knowledge; the majority of
dental research is conducted; and significant dental care is provided.
---------------------------------------------------------------------------
\1\ There are 57 dental schools, 714 dental residency training
programs, 285 dental hygiene programs, 271 dental assisting programs
and 21 dental laboratory technology programs in the United States.
---------------------------------------------------------------------------
U.S. dental schools operate dental clinics and serve as safety net
providers. As such, they are the dental homes to a broad array of
vulnerable and underserved low-income patient populations, including
racially and ethnically diverse patients; elderly and homebound
individuals; migrants; mentally, medically or physically disabled
individuals; institutionalized individuals; HIV/AIDS patients; Medicaid
and State Children's Health Insurance Program (SCHIP) children; and
uninsured individuals.
In addition to providing oral health services to vulnerable and
underserved communities through clinics associated with dental schools,
ADEA has partnered with the Association of American Medical Colleges
(AAMC) to recruit and prepare underrepresented minority (URM) students
for the health professions. Building a diverse healthcare workforce,
which can better serve the needs of a culturally, ethnically, and
racially diverse population, is a critical step in addressing the oral
health disparities that now exist in both rural and urban communities.
Disparities in Oral Health
The first-ever U.S. Surgeon General's report found that there are
``profound and consequential oral health disparities within the
population,'' particularly among ``racial and ethnic minorities, rural
populations, individuals with disabilities, the homeless, immigrants,
migrant workers, the very young, and the frail elderly.'' \2\ These
disparities, the report asserts, have resulted in a ``silent epidemic
of dental and oral disease affecting the most vulnerable among us.''
This disturbing reality, in combination with the current shortage of
dental school faculty, the scarcity of underrepresented minority (URM)
dentists, and the need for targeted incentives to draw dentists to
practice in rural and underserved communities, makes the Subcommittee's
examination of health disparities timely and necessary.
---------------------------------------------------------------------------
\2\ U.S. Department of Health and Human Services. Oral health in
America: a report of the surgeon general. Rockville, MD: U.S.
Department of Health and Human Services, National Institute of Dental
and Craniofacial Research, National Institutes of Health, 2000.
---------------------------------------------------------------------------
The challenge facing policymakers and the dental community is not
only how to address the oral health disparities that exist in our
nation but also how to improve access to oral healthcare. According to
Delta Dental Plans Association and the National Association of Dental
Plans, 134 million American adults and children do not have dental
insurance. The lack of insurance is a significant barrier to receiving
needed preventive and restorative care. Having insurance, however, does
not guarantee quick access to dental care.
Despite concerted efforts by Congress and the dental community to
address issues affecting access to dental care, there has been little
substantive progress made since the untimely death of 12-year old
Deamonte Driver in February 2007. This Maryland boy died from an
infection caused by an abscessed tooth that spread to his brain. Timely
delivery of appropriate dental care at any point along the trajectory
from cavity to root canal to abscess could have saved Deamonte's life
and the state of Maryland nearly $250,000. This tragedy could have been
avoided if his Medicaid coverage had not lapsed and if he had had
better access to dental care. In this regard ADEA supports Congress'
continuing bipartisan effort to include a guaranteed dental benefit in
the bill to reauthorize the State Children's Health Insurance Program
(SCHIP). ADEA pledges to work for passage of this important legislation
in the 111th Congress.
U.S. Population and the Dental Workforce
The U.S. Bureau of Labor Statistics (BLS), which placed the number
of practicing dentists at 161,000 in 2006,\3\ projects a 9 percent
growth in the number of dentists through 2016. This rate would bring
the total number of practicing dentists to 176,000. The vast majority
of the professionally active dentists in the U.S. are White non-
Hispanic. At the present time the U.S. population is 303,375,763.\4\ At
the time of the last census, when there were 22 million fewer people,
the largest segment of the U.S. population was White (75 percent) but
an increasing percentage was minority with 35.3 million (13 percent)
Latino, and 34.6 million (12 percent) Black or African Americans.
---------------------------------------------------------------------------
\3\ U.S. Bureau of Labor Statistics, at: http://www.bls.gov/oco/
content/ocos072.stm, February 5, 2008.
\4\ U.S. Bureau of the Census, at: http://www.census.gov/
population/www/popclockus.html, February 5, 2008.
---------------------------------------------------------------------------
According to the U.S. Surgeon General, the ratio of dentists to the
total population has been steadily declining for the past 20 years, and
at that rate, by 2021, there will not be enough active dentists to care
for the population. The number of Dental Health Professions Shortage
Areas (D-HPSAs), designated by the U.S. Health Resources and Services
Administration (HRSA), has grown from 792 in 1993 to 3,527 in 2006. In
1993, HRSA estimated 1,400 dentists were needed in these areas; by
2006, the number grew to 9,164. Nearly 47 million people live in D-
HPSAs across the country. Although it is unknown how many of these
areas can financially support a dentist or attract a dentist by virtue
of their infrastructure or location, it is clear that more dentists are
needed in these areas.
The disproportionate burden of oral diseases and disorders
indicates that specific population groups are in greater need of oral
healthcare. Unfortunately, millions of Americans experience dental pain
daily and cannot afford to buy dental insurance or pay for dental care
out of pocket. Since few oral health problems in their early stages are
life-threatening, people often delay treatment for long periods of
time. Often, when they do seek care, it is in hospital emergency rooms
or other venues in the dental safety-net system, that is, academic
dental institutions clinics, community health centers, school-based
clinics, municipal clinics, etc. This system of care is inadequate to
effectively deal with the magnitude of the problem. Most ADI clinics
are filled to capacity and have long waiting lists.
Diversity in Dental Schools
The number of African American, Hispanic, and Native American
students in dental schools remains disproportionate to their numbers in
the U.S. population. In 2006, underrepresented minority (URM) students
comprised 12.4 percent of the applicants and 11.6 percent of first-year
enrollees. Asian/Pacific Islanders and whites comprised 69.7 percent of
applicants and 71.1 percent of first-year enrollees. The proportion of
URM students applying and enrolling in U.S. dental schools is far less
than the proportion of URMs in the communities served by the dental
school. For example, during the 2003-04 academic year, 7 percent of
dental students enrolled at the University of California Los Angeles
(UCLA) and the University of Southern California (USC) were Hispanic,
while 46.5 percent of the Los Angeles population was Hispanic. Also, in
2003-04, total African American enrollment at all U.S. dental schools
was 5.41 percent, while 12.8 percent of the U.S. population were black.
The proportion of URM dentists also remains significantly lower than
the proportion of URMs in the U.S. population. Currently, about 6.8
percent of professionally active dentists are URM, while 27.9 percent
of the U.S. population are URM. Increasing diversity in the dental
profession is vital to the future of the profession and it is central
to achieving optimal oral health for racial and ethnic minority groups,
which experience a higher level of oral health problems and have
limited access to dental care.
Response from Academic Dentistry
Recognizing that enrollment of underrepresented minorities (URM)
students has remained largely stagnant, the American Dental Education
Association has become actively engaged in supporting programs that
bolster underrepresented minority recruitment and retention into
dentistry and has partnered with foundations and others to make
progress:
The ``Pipeline, Profession, and Practice: Community-Based
Dental Education'' program sponsored by the Robert Wood Johnson
Foundation (RWJF). This program has also been supported by the
California Endowment and the W.K. Kellogg Foundation. The five-year
initiative launched in 2003 to help increase access to oral healthcare.
This program provided institutions with grants to link their schools to
communities in need of dental care and to boost their URM and low-
income (LI) student enrollment numbers. Dental Pipeline I successfully
concluded with 15 dental schools participating. Dental students and
residents in the program provided care to thousands of low-income
patients through partnerships with 237 community-based clinics.
The ``Summer Medical and Dental Education Program
(SMDEP),'' a collaborative program administered by ADEA and the
Association of American Medical Colleges (AAMC) and funded by the
Robert Wood Johnson Foundation-RWJF, offers freshman and sophomore
college students intensive and personalized medical and dental school
preparation. The program runs from summer 2006 through summer 2009 and
offers academic enrichment for disadvantaged undergraduate freshmen/
sophomores. Nearly 1,900 students have participated (333 dental and
1,564 medical). Seventy-one percent of the participants have been
women, 48 percent have been Black or African American, 21 percent have
been Hispanic or Latino, and 2 percent have been American Indian.
ADEA has received a grant from the Josiah Macy, Jr.
Foundation to increase the diversity of the dental workforce in the
United States. The grant funds the planning process to implement a
flexible seven-year dental curriculum, modeled after one currently used
in medicine, to prepare a new cadre of underrepresented minority and
low-income (URM/LI) students for the practice of dentistry. The program
aims to move toward the implementation of a seven-year curriculum that
will significantly increase the number of URM students that receive a
dental education and then enter the workforce as dental school
graduates.
Recommendations to Congress
There are several straightforward steps that Congress can take to
immediately address the oral health challenges we face. The American
Dental Education Association stands ready to work with Congress to
address oral health disparities and ameliorate access to dental care
problems. Specifically, ADEA recommends:
1. Strengthen and Improve Medicaid
Early intervention is the key to assuring that children have good
oral health. While children enrolled in Medicaid have a Federal
guarantee for access to dental services through the Early Periodic
Screening Diagnosis and Treatment program (EPSDT) \5\, accessing
services is often difficult due to low reimbursement rates and the
number of participating dentists. Unfortunately, millions of children
covered by Medicaid are not getting regular dental care. We urge
Congress to work with states to increase reimbursement rates and to
simplify and streamline the application, enrollment and recertification
process for Medicaid, and lessen the administrative burden associated
with this program.
---------------------------------------------------------------------------
\5\ Medicaid statutes, PL 101-239, Section 6403, require that
dental services for children shall at a minimum, include relief of pain
and infection, restoration of teeth, and maintenance of dental health.
Medicaid guarantees medically necessary services, including preventive
dental care, under its EPSDT provision.
---------------------------------------------------------------------------
2. Include Dental Guarantee in SCHIP
Congress can address oral health disparities and increase access to
dental care for vulnerable children covered by the State Children's
Health Insurance Program (SCHIP) by: 1) Establishing a federal
guarantee for dental coverage in SCHIP; 2) Developing a dental wrap-
around benefit in SCHIP; 3) Facilitating ongoing outreach efforts to
enroll all eligible children in SCHIP and Medicaid; and 4) Ensuring
reliable data reporting on dental care in SCHIP and Medicaid.
3. Restore Funding for Title VII Diversity Programs
The only federal programs whose goal it is to strengthen and
diversify the health professions are the Title VII Centers of
Excellence (COE) and Healthcareers Opportunity Program (HCOP). These
programs work in diverse communities to achieve this national goal. The
programs remain woefully under-funded after several years of
significant cuts. Congress should restore their funding at least to FY
2005 levels.
------------------------------------------------------------------------
Table 4: COE and HCOP Funding by FY
-------------------------------------------------------------------------
FY05 FY06 FY07 FY08
------------------------------------------------------------------------
COE $35 million $12 million $11.88 $12.77
million million
------------------------------------------------------------------------
HCOP $33 million $4 million $3.9 $9.8
million million
------------------------------------------------------------------------
The COE and HCOP programs assist institutions in developing a more
diverse applicant pool; establishing and strengthening the academic
performance of under-represented minority students enrolled in health
professions schools; improving institutional academic, research and
library capacity; and enhancing pipeline efforts to undergraduate and
pre-college students. Also, HCOP makes grants to community-based health
and educational entities to support student pipeline and other academic
activities.
4. Prioritize Dental Access in Rural Health Clinics
Rural communities across America rely on rural health clinics to
provide care to everyone, including those who are uninsured or
underinsured. Full-service community hospitals in rural areas are
safety net providers, offering basic health services but often oral
healthcare is unavailable. To improve the oral health status of rural
America, Congress should incentive rural health clinics to add
preventive and restorative dental services to the list of core services
they provide on-site or under arrangement.
Oral Healthcare and Reform
A sustained federal commitment is needed to meet the challenges
that oral health disparities and oral disease pose to our nation's
citizens, including children, the vulnerable and underrepresented
minorities. It is imperative that Congress address the growing needs in
educating and training health professionals, including dentists, to
meet the growing and diverse needs of the future. The American Dental
Education Association is eager to partner with Congress to develop and
implement a national oral health plan that eliminates oral health
disparities; guarantees access to dental care for everyone; bolsters
the nation's oral health infrastructure; and successfully addresses
academic and dental workforce shortages.
Consequently, oral healthcare coverage and access to affordable oral
health services must be included as integral components in any
proposal to reform the U.S. healthcare system.
Contacts: Myla Moss ([email protected]) at 289-7201 ext. 170 Deborah
Darcy ([email protected]) at 289-7201 ext. 163
Statement of American Dental Hygienists' Association
On behalf of the American Dental Hygienists' Association (ADHA),
thank you for the opportunity to submit testimony on ``Addressing
Disparities in Health and Healthcare: Issues for Reform.'' ADHA
applauds Subcommittee Chairman Stark for holding a hearing to examine
disparities in health and issues that will impact discussion on policy
efforts that seek to reform our healthcare system. This is a timely and
important issue and ADHA is pleased to participate in the dialogue
about disparities that impact the delivery of oral healthcare and ways
in which those disparities can be lessened or eliminated. Oral health
is a part of total health and the oral healthcare delivery system
requires reform along with the medical care delivery system.
ADHA is the largest national organization representing the
professional interests of more than 150,000 licensed dental hygienists
across the country. Dental hygienists are oral health professionals
licensed in each of the fifty states who are committed to improving the
nation's oral health, a fundamental part of overall health and general
well-being. In order to become licensed as a dental hygienist, an
individual must graduate from an accredited dental hygiene education
program and successfully complete a national written and a state or
regional clinical examination.
As an organization, ADHA has a fundamental commitment to better
oral healthcare for all people and advocates in support of oral health
programs for underserved populations. ADHA and its state associations
actively pursue efforts to increase the public's ability to access
preventive oral healthcare services.
Unfortunately, disparities in the delivery of healthcare services
tend to be even more pronounced within oral health. According to the
U.S. Surgeon General, over 108 million Americans lack dental
insurance--more than 2.5 times the number of Americans who lack medical
insurance. The May 2000 report, Oral Health in America: A Report of the
Surgeon General, brought to light the socioeconomic, regional, and
educational barriers that contribute to oral healthcare disparities.
The report also specifically noted that disparities are exacerbated by
the lack of community programs that provide needed oral healthcare
services.
The death of twelve-year old Deamonte Driver in 2007 from
complications of an abscessed tooth provided all of us with a tragic
reminder that lack of access to oral health services can have serious--
even fatal--consequences. Deamonte's death from a dental infection is
particularly heartbreaking because virtually all dental disease is
fully preventable. But, despite this proven prevention capacity, dental
caries (tooth decay) remains the single most common chronic disease of
childhood, five times more common than asthma. Dental caries--which is
an infectious transmissible disease--still affects more than half of
all children by second grade. Until the oral healthcare delivery system
is restructured to improve access to care, children will continue to
suffer needlessly from preventable dental disease.
Preventable dental disease disproportionately affects our Nation's
most vulnerable populations, including many children eligible for
Medicaid and the State Children's Health Insurance Program (SCHIP). The
current oral healthcare delivery system is simply not meeting America's
oral health needs, particularly the needs of Medicaid and SCHIP
children such as Deamonte Driver. As prevention specialists, dental
hygienists understand that recognizing the connection between oral
health and total health can prevent disease, treat problems while they
are still manageable, conserve critical healthcare dollars, and save
lives. While the practice of dental hygiene varies from state to state,
in the 26 states that allow patients to directly access dental hygiene
services, dental hygienists are able to work more readily in public
health settings--bringing patients otherwise disenfranchised from the
oral healthcare system into the pipeline for care.
As one of the fastest growing healthcare occupations in the
country, as identified by the Bureau of Labor Statistics (BLS), the
dental hygiene profession is well placed to significantly impact the
delivery of care in the U.S. BLS data indicates the number of dental
hygienists is expected to grow by more than 30 percent from 2006--2016.
The population of dentists is growing at a much slower rate and
according to the BLS; the growth of the profession is not anticipated
to keep pace with the need for dental care in coming years. Dental
hygienists are committed to working as part of a comprehensive
healthcare team in order to improve access to oral health services.
Indeed, one of ADHA's enunciated priorities is to ``work in partnership
with dentists to advance the oral health of patients.''
ADHA welcomes the opportunity to work with the Subcommittee and all
Members of Congress as well as the entire dental community and all
those who care about the nation's oral health to work towards solutions
to improve access to oral healthcare and ensure that all Americans have
access to oral healthcare providers in the future. Indeed, healthcare
reform efforts present an opportunity for ADHA to demonstrate its
commitment to partnership with organized dentistry as well as other
stakeholders in healthcare. Certainly, the elimination of healthcare
disparities will require a collective effort and will involve efforts
to reform and improve the current system.
U.S. Surgeon General Report on Oral Health in America Confirms that
Oral Health is a Fundamental Part of Overall Health
In May 2000, the U.S. Surgeon General issued Oral Health in
America: A Report of the Surgeon General. This landmark report confirms
that oral health is an integral part of total health and that good oral
health can be achieved. The Surgeon General's Report on Oral Health
challenges all of us--in both the public and private sectors--to
address the compelling evidence that not all Americans have achieved
the same level of oral health and well-being. The Report describes a
``silent epidemic'' of oral diseases, which affect our most vulnerable
citizens--poor children, the elderly and many members of racial and
ethnic minority groups.
Key findings enumerated in the Report include:
1. Oral diseases and disorders in and of themselves affect health
and well-being throughout life.
2. Safe and effective measures exist to prevent the most common
dental diseases: dental caries (tooth decay) and periodontal (gum)
diseases.
3. Lifestyle behaviors that affect general health such as tobacco
use, excessive alcohol use, and poor dietary choices affect oral and
craniofacial health.
4. There are profound and consequential oral health disparities
within the U.S. population.
5. More information is needed to improve America's oral health and
eliminate health disparities.
6. The mouth reflects general health and well-being.
7. Oral diseases and conditions are associated with other health
problems.
8. Scientific research is key to further reduction in the burden of
diseases and disorders that affect the face, mouth and teeth.
U.S. Surgeon General Notes Significant Disparities in Oral Health
The Surgeon General's Report on Oral Health highlights numerous
disparities in oral health relative to age, race, gender, insurance
status, and income level. Some of the significant disparities noted
include:
Children from families without dental insurance are three
times more likely to have dental needs than children with either public
or private insurance.
Poor children suffer twice as much dental caries as their
more affluent peers.
34% of black older Americans have lost all of their teeth
compared to 23% of whites.
A national survey found that employed Hispanic adults
were twice as likely to have untreated dental caries as non-Hispanic
whites
In general, the American Indian and Alaska Native
populations have much greater rates of dental caries and periodontal
disease in all age groups than the general U.S. population.
Adult females are less likely than males at each age
group to have severe periodontal disease as measured by periodontal
loss of attachment of 6 mm or more for any tooth.
As follow-up to Oral Health in America, the Surgeon General issued
A Nation Call to Action to Promote Oral Health in 2003 which called on
stakeholders in oral health to change perceptions of oral health,
overcome barriers to care, and increase collaborations. The report also
called on stakeholders to make strides to ``increase oral health
workforce diversity, capacity, and flexibility''--moving towards
optimal use of healthcare professionals.
The Oral Healthcare Delivery System Must be Reformed Along with the
Medical Care Delivery System
As prevention specialists in one of the fastest growing
professions, dental hygienists are well positioned to work as part of
the overarching effort to increase access to oral healthcare,
particularly for those in underserved populations. Workforce experts
have recognized that dental hygienists can and must play an increasing
role if the nation's oral health needs are to be met. An article in
Health Affairs explored the oral health workforce and found:
``abundant evidence that a sizable segment of the population
does not have access to private [dental] care, while the dental
safety net is ``poorly defined and underdeveloped.'' Dentists'
participation in Medicaid is not robust; community health
centers and public health facilities have scant dental
capabilities; and Medicare offers no dental coverage. ``Radical
steps'' will be needed to correct ``a growing disconnect
between the dominant pattern of practice . . . and the oral
health needs of the nation,'' . . . including new practice
settings for dental care, integration of oral and primary
healthcare, and expanded scope of practice for hygienists and
other allied professions.''
Increasingly, states are recognizing the benefits associated with
policy changes that make it easier for dental hygienists to work with
less supervision in settings outside of the private dental office.
Currently, 26 states have policies in place that enable patients to
access preventive services offered by dental hygienists via direct
access, meaning a patient can be treated without the presence or prior
authorization of a dentist. In the past ten years, 23 states have
enacted policies that facilitate care via direct access, making it
easier for dental hygienists to treat patients in schools, community
clinics, long term care facilities, mobile health units, and other
public health settings.
Similarly, the last decade has brought about an insurgence of
policies at the state level to allow dental hygienists to be directly
reimbursed by Medicaid for dental services included in their scope of
practice. Currently, 12 states allow for direct Medicaid reimbursement,
making it easier for dental hygienists to work within the Medicaid
system to provide care.
These types of policy changes better leverage the existing dental
hygiene workforce and make care more accessible for those who currently
have difficulty securing services in the private dental office.
Bringing patients into the oral healthcare system for preventive and
other oral healthcare services through additional access points such as
schools, community health centers, and nursing homes can avert more
costly restorative care, allow appropriate referral to dentists, and
help save valuable healthcare dollars in the long-run.
A New Oral Healthcare Provider to Improve Access to Care: The Advanced
Dental Hygiene Practitioner
In response to the Surgeon General's identified need to enhance the
oral health workforce capacity, ADHA has supported efforts to improve
the delivery of care by dental hygienists, but has also striven to come
up with new ideas to improve the system. ADHA has defined a new oral
healthcare provider, the Advanced Dental Hygiene Practitioner (ADHP).
This new provider would provide preventive, therapeutic, diagnostic,
prescriptive, and minimally invasive restorative services directly to
underserved Americans. The ADHP would be a member of a comprehensive
healthcare team, and would refer patients in need of more advanced oral
healthcare services to dentists. This new provider would be state-
licensed and be a graduate of a Master's degree ADHP program.
ADHA has been working in a transparent and inclusive fashion to
shape this advanced practitioner concept. An ADHP Advisory Committee
that included representatives of major oral healthcare organizations,
the Federal Government, health advocacy groups and others interested in
oral health access issues was convened by ADHA in 2005 to solicit
feedback on the new provider. ADHP competencies have been developed by
the ADHP Task Force which worked for two years to systematically define
the educational domains and competencies that will serve as the
framework for ADHP educational programs. ADHP competencies were
finalized by ADHA's Board of Trustees in 2008 and are available at
www.adha.org.
The ADHP will function as a mid-level oral healthcare provider akin
to the nurse practitioner in medicine. The medical fields have long
accepted mid-level providers as integral components of the healthcare
team able to reach out to patients currently unable to access care.
Similarly, the ADHP is being developed to provide a new point of entry
into the oral healthcare system for those currently disenfranchised,
offering a wider range of services in public health settings. A key
component to making care accessible is offering the services patients
need most in settings they are able to reach, such as schools, public
health clinics, and nursing homes.
In the National Governors Association Center for Best Practices
issue brief entitled, ``State Efforts to Improve Children's Oral
Health,'' the authors noted that ``Maximizing auxiliary personnel can
increase access to preventive services. . . . In most states, the scope
of practice for auxiliary personnel is quite restricted, even when the
services necessary don't require a dentist. Some states are
restructuring their Dental Practice Acts to maximize the use of dental
hygienists.'' Two illustrative examples highlighted by the NGA are set
forth below.
Maine changed the rules governing the practice of
hygienists to allow them to practice in public health settings such as
school health centers, hospitals, and public clinics without a dentist
on site--provided that the hygienists have an established relationship
with a dentist. The state believes this strategy offers great promise
for addressing dentist shortages. In 2008, the state passed legislation
to allow dental hygienists to own and operate dental hygiene practices.
Minnesota passed legislation in 2001 to allow dental
hygienists to perform certain primary care functions without dentist
supervision, provided they are employed by one of the following
entities: hospitals, nursing homes, group homes, home health agencies,
state-operated facilities, federal, state or local public health
facilities, or community or tribal clinics. In order to qualify, the
hygienist must meet prescribed practice experience requirements and
must engage in a collaborative agreement with a dentist who authorizes
and accepts responsibility for these hygienist services.
Minnesota is slated to become the first state to house an ADHP
education program. In late 2007, Metropolitan State University in St.
Paul approved a Master's degree ADHP program that is anticipated to
accept its first class in mid-2009. Additionally, Minnesota is the
first state to consider legislation to facilitate the expanded scope of
practice for the Advanced Dental Hygiene Practitioner. Legislation was
introduced in both the Minnesota state House and Senate in mid-February
2008 and is supported not only by the dental hygiene community, but
also by a number of state healthcare stakeholders and dentists. A
legislative compromise, supported by the Minnesota Dental Association,
was reached in May 2008 which established the need for a mid-level
provider in state statute and established a baseline scope of practice
that nearly mirrors the clinical services outlined in the ADHP
competencies. As a result of the compromise, a workgroup will convene
in mid-2008 to further define the educational and licensure
requirements for the new provider, known as the Oral Health
Practitioner.
As the April 2004 ``Report to the Secretary: Rural Health and Human
Services Issues'' found, ``oral health has been described as one of the
single greatest unmet healthcare needs in the United States. The Report
also finds that ``in rural areas that face acute and growing dentist
shortages, some form of alternative provider model may be particularly
useful as a means to extend basic dental demonstrations to evaluate the
viability and efficacy of models.''
ADHA urges this Subcommittee and all Members of Congress to shape a
future in which oral health services will be readily available to
children and other vulnerable Americans who need them. Facilitating
better utilization of dental hygienists through the establishment of
the Advanced Dental Hygiene Practitioner is a vital part of this
future.
Additional Support for Improving Access to Dental Care through
Exploration of the ADHP
The National Dental Association included support to ``expand the
role of the dental hygienist as the Advanced Dental Hygiene
Practitioner in underserved areas'' in its Access to Care statement.
The American Public Health Association Oral Health Section also
supports the Advanced Dental Hygiene Practitioner concept, calling it
``a role comparable to the Medical Nurse Practitioner,'' which
``presents a timely and appropriate way to explore new approaches to
delivery of oral healthcare to those populations in rural and
underserved areas, i.e. the 25percent in whom 80percent of oral disease
is found.''
The National Rural Health Association determined that ``It is time
for exploration of a new way to deliver oral health services--it is
time to test the feasibility of an advanced dental hygiene
practitioner--similar to the nurse practitioner but in the dental
arena. NRHA sees great potential for the advanced dental hygiene
practitioner to improve access to oral healthcare in rural areas.''
The National Rural Education Association writes that ``For a child
to be ready to learn in school, a child must be healthy and free from
pain. One proven strategy for reaching children at high-risk for dental
disease is providing oral health services in school-based health
centers; another strategy is to support linkages between schools and
dental providers in the community. Presently there is a shortage of
dentists. We must better utilize the dental hygienist. NREA is excited
about the prospect of an advanced dental hygiene practitioner.''
Major media outlets are also recognizing the access to oral
healthcare crisis Americans face and the ways in which the current
delivery system is failing millions of Americans. In the wake of the
tragic death of Deamonte Driver in February 2007, national attention
has become more focused on the dangers associated with not obtaining
oral healthcare services.
An article from the October 11, 2007 edition of the New York Times
stated, ``American children are dying because of a lack of access to
healthcare. . . . There are nine million children who lack healthcare
in the U.S. and millions more who are eligible for coverage but fall
through the cracks for one reason or another.''
Similar sentiments were echoed by The Washington Post in a July 13,
2007 article, ``At the heart of this issue is a lack of understanding
of the importance and implications of good oral healthcare--every day
there are children who can't pay attention in school and who can't fall
asleep at night because they have problems with their teeth.''
On April 22, 2008 The Washington Post featured an article,
``Brushed off no Longer: citing Gaps in Care, Hygienists are Beginning
to Treat Patients Without Direct Supervision by Dentists,'', which
stated that allowing dental hygienists to have a wider role in public
health settings without direct supervision by dentists allows dentists
to take care of more acute issues and which could in turn prevent
``many difficult and expensive problems from developing in the first
place.''
Medicaid and the State Children's Health Insurance Program
Medicaid dental coverage for children is an essential benefit;
regrettably, too few Medicaid-eligible children access dental care.
More must be done to ensure that Medicaid-eligible children are able to
access this essential benefit. Today, twelve states recognize dental
hygienists as Medicaid providers of oral health services and provide
direct reimbursement for their services. These states are: California,
Colorado, Connecticut, Maine, Minnesota, Missouri, Montana, Nevada, New
Mexico, Oregon, Washington, and Wisconsin. Other states should adopt
this approach, which appropriately recognizes the experience, education
and expertise of dental hygienists and fosters increased access to much
needed Medicaid oral health services.
While the profession of dental hygiene was founded in 1913 as a
school-based profession, today the provision of dental hygiene services
is significantly tied to the private dental office, which many patients
are unable to access. With over 90 percent of all practicing dentists
in the private sector, it is time to promote the provision of oral
health services directly to Medicaid and SCHIP-eligible children at
schools, community health centers and other public health settings by
better utilizing the education, experience, and expertise of dental
hygienists, who could be linked through referrals and/or teledentistry
to dentists.
SCHIP has extended dental coverage to millions of additional
children who would otherwise be without dental insurance. ADHA and
others in the dental community strongly support reauthorization of and
adequate funding for SCHIP. As this Subcommittee well knows, although
all states presently include dental benefits in their SCHIP program,
dental benefits are not required to be included in the SCHIP program.
In order to stabilize and buttress the dental component of SCHIP,
the dental community urges (1) a federal guarantee for dental coverage
in SCHIP; (2) development of a dental wrap-around benefit in SCHIP; (3)
support for outreach and enrollment of all SCHIP-eligible children; and
(4) support for a national performance measure that would provide data
necessary to evaluate SCHIP dental benefits. Strengthening SCHIP,
however, should not come at the expense of Medicaid. SCHIP stands on
the shoulders of Medicaid, and any effort to erode Medicaid will
adversely affect SCHIP.
ADHA strongly supported the State Children's Health Insurance
Program Reauthorization Act (CHIPRA), which included significant dental
provisions, including a guaranteed dental benefit and a study on dental
access and workforce that would examine the ``feasibility and
appropriateness'' of dental mid-levels such as the ADHP. The
association will look forward to the opportunity to work collectively
with others in oral healthcare on future efforts to reauthorize SCHIP.
Improving the Nation's ``Oral Health IQ''
Changing perceptions of oral health and oral disease is a
critically important step in the movement to have the general public
recognize oral health as an accepted component of general health.
Indeed, the perceptions of the public, policymakers and health
providers must be changed in order to ensure acceptance of oral health
as an integral component of general health.
The national oral health consciousness will not change overnight,
but working together we can heighten the nation's ``oral health IQ.''
ADHA is already working to change public perceptions so that oral
health is rightly recognized as a vital component of overall health and
general well being. For example, ADHA has launched a public relations
campaign to highlight the link between oral health and overall health;
our slogan is ``Want Some Lifesaving Advice? Ask Your Dental
Hygienist.''
This ADHA campaign builds on the Surgeon General's report, which
notes that signs and symptoms of many potentially life-threatening
diseases may appear first in the head, neck and oral cavity precisely
at a time when the conditions are most treatable. For example, dental
hygienists are educated to conduct a head and neck examination and a
screening for oral cancer at every visit and can advise patients of
suspicious conditions.
Conclusion
The American Dental Hygienists' Association appreciates this
Subcommittee's interest in addressing healthcare disparities. The oral
healthcare delivery system needs radical restructuring as evidenced by
the untimely death of Deamonte Driver and national statistics that
bring to light the systemic realities that serve as barriers to care
for the underserved. ADHA wants to be part of a collaborative solution
to the current problems of oral health disparities and inadequate
access to oral health services for many Americans. ADHA firmly believes
that exploration of the Advanced Dental Hygiene Practitioner model will
better utilize the existing oral healthcare workforce and improve
access to care for vulnerable populations, which in turn will work to
ameliorate the nation's persistent oral health disparities. ADHA is
committed to working with this Subcommittee--and all Members of
Congress--to improve the nation's oral health, a fundamental part of
overall health and general well-being. As lawmakers work to reform our
nation's healthcare delivery system, please remember that the oral
healthcare delivery system also requires reform and oral healthcare
must be a part of the overall healthcare reform effort. Thank you for
the opportunity to share the views of the American Dental Hygienists'
Association.
WDC99 1577269-1.014468.0010
Statement of American Hospital Association
``Addressing Disparities in Health and Healthcare: Issues for Reform''
On behalf of our nearly 5,000 member hospitals, health systems and
other healthcare organizations, and our 37,000 individual members, the
American Hospital Association (AHA) appreciates the opportunity to
submit this statement for the record addressing the issue of
disparities in health and healthcare. America's hospitals take very
seriously their charge to provide healthcare to everyone in their
communities, regardless of race, color or creed. But there are
challenges to meeting that mission.
BACKGROUND
Research confirms that healthcare delivery can differ for different
patient populations; that significant variations exist by ethnicity and
gender; and that care provided to Black and Latino patients can differ
from care otherwise provided and lead to poorer health outcomes.
Healthcare providers realize that multiple factors contribute to these
disparities, including whether a patient has health coverage and access
to preventive medical care, different cultural norms, and whether the
patient has a limited understanding of English.
In fact, the Institute of Medicine's 2002 landmark report, Unequal
Treatment: Confronting Racial and Ethnic Disparities in Care, suggests
that disparities in care can result from both patient-related and
provider-related factors.
WHAT THE AHA IS DOING
Racial and ethnic disparities in health outcomes are systemic. As
the above chart notes, they are caused not by a single factor but by a
host of factors. Because hospitals provide care 24 hours a day, seven
days a week to many diverse patients, hospitals must develop policies
and systems to address all of these factors.
To address this issue, the AHA convened in December 2007 the
Special Advisory Group on Improving Hospital Care for Minorities. The
group has met several times to address its charge of examining and
providing guidance on how hospitals can help eliminate disparities in
care. This diverse group includes national leaders representing civil
rights organizations, hospitals, public health agencies, state and
Federal Government, academic medicine, healthcare researchers and
others. Their specific priority is to answer the question: How can the
hospital field improve the care we provide to minorities and eliminate
disparities in care?
The group developed a consensus on specific activities that
hospitals can undertake and identified areas where hospital executives
should focus time, attention and resources, which would address the
urgent need to reduce or eliminate disparities in healthcare outcomes
while also strengthening overall operations. These are the group's
recommendations:
Further investment in quality improvement. A commitment
to quality improvement by hospitals improves healthcare for all, not
just minorities. Pay-for-performance efforts should focus on reducing
disparities among conditions that disproportionately affect minority
populations, such as infant mortality, diabetes, asthma, HIV, heart
disease and cancer.
Enhanced transparency and data collection measures.
Gathering meaningful data in a systematic and uniform way can pinpoint
whether and what type of disparities exist within a hospital's service
areas. Linking these data to medical records and other patient
information can provide hospital leaders with a compelling landscape of
their communities--the demographics of their patients, what their
healthcare needs are, the health outcomes that are attained, and where
there might be gaps or disparities in health outcomes that need to be
addressed. The Health Research and Educational Trust (HRET), an AHA
affiliate, has developed a useful tool kit to guide hospitals through
the process of collecting data on patients' race, ethnicity and primary
language.
Enhance governance. Through its Center for Healthcare
Governance and Institute for Diversity in Health Management, the AHA is
developing an ongoing training and board development program to expand
the diversity of governing boards. By identifying and training
potential minority trustees, hospitals and health systems will have a
larger pool of qualified governance candidates. The goal is to make the
governing body a better mirror of the community it serves.
Greater focus on public health issues. The public health
sector has identified several priority health issues as leading causes
of poor health among minority groups--smoking, alcohol and drug abuse,
obesity and poor nutrition and lack of exercise among them. For many
people in lower socio-economic areas, these lifestyle management issues
pose just as much a risk as a genetic predisposition to heart disease,
diabetes or other chronic conditions. Hospitals can work with groups
that focus on mitigating these risk factors.
Improve connections with communities and populations
within service areas. Use established organizations such as community-
based ethnic organizations, the YMCA, churches, colleges and others as
partners in promoting health. Hospitals and healthcare systems should
develop and sustain relationships with civil rights organizations,
local outreach groups, networks and others, to determine specifically
how the healthcare provider and community organizations can work
together for the benefit of the community.
Enhance wellness and prevention outreach efforts among
uninsured patients. Reducing the number of acute healthcare episodes
among uninsured patients, thereby improving their overall health, is
essential. Helping connect uninsured patients with coverage and care
options can ensure that they have continued access to healthcare
services.
Enhance healthcare workforce opportunities. Creating
recruitment opportunities for minority populations not only can offer
healthcare-related training, it also can generate a clinically and
culturally proficient workforce that mirrors the community it serves.
By focusing on these factors, hospital leaders can help improve
outcomes not just for minority patients, but for all patients.
WHAT HOSPITALS ARE DOING
Addressing disparities in care is not new to America's hospitals.
Hospitals around the country have identified healthcare needs within
their communities, determined how to address them, and dramatically
improved the health of their minority patient populations. For example:
The Cambridge Health Alliance in Boston, Massachusetts,
created the Volunteer Health Advisor Program (VHA) in 2001. This is a
volunteer-driven program that provides multicultural and multilingual
health education and outreach to the communities in the Boston area,
all in an effort to improve community health status. In 2007, the VHA
staff and more than 200 volunteers offered health and wellness services
to more than 5,500 people through 93 community events in 16 languages.
Their outreach efforts resulted in 1,500 screenings for blood pressure,
glucose and cholesterol levels in traditionally medically underserved
and hard to reach minority populations.
Adventist HealthCare System in Rockville, Maryland,
recognized that 25 percent of the people in their service area speak a
language other than English--part of an increasingly diverse community.
In September 2005, the Adventist Board of Trustees appointed a blue
ribbon panel of community leaders to develop a locally driven approach
that addresses and eliminates healthcare disparities in all of the
communities served by Adventist HealthCare. The panel recommended and
the health system implemented the Adventist HealthCare Center on Health
Disparities.
The Center's three areas of focus are increased services for
underserved populations; a research program to identify and promote
best practices; and an education initiative to improve the ability of
caregivers to provide quality care to those populations. Their efforts
include three education modules that will foster culturally competent
care: Health Disparities: Understanding Our Population is a discussion
of local demographics, the definition of culturally competent care and
a diversity training program; Stereotypes, Biases and Assumptions
focuses on characteristics that can have an impact on patient care and
adherence to treatments, and includes cross-cultural communication
tools; and Health Beliefs and Practices of Different Populations helps
caregivers incorporate differing beliefs into care and treatment plans.
The Center also instituted patient advocacy and linguistic access
programs, and incorporated an infrastructure for research into
healthcare disparities that exist in their region of the Metropolitan
Washington, D.C. area.
Expecting Success, a national program sponsored by the
Robert Wood Johnson Foundation, is a multi-hospital collaborative
focused on reducing disparities in cardiovascular care. The program is
helping 10 general acute care hospitals measure the quality of cardiac
treatment they provide to patients based on race, ethnicity and primary
language. For the first time, these hospitals, using the HRET data
collection tool mentioned above, are tracking data to identify racial
and ethnic disparities in the care they provide by focusing on the
continuum of cardiovascular care delivered in inpatient and outpatient
settings, and specifically care delivered to African American and
Latino patients.
These are just a few examples of what hospitals around the country
are doing to eliminate healthcare disparities in their communities.
There is a growing body of research around disparities--where it
exists, why it exists, etc.--and the AHA is working to compile the case
studies and best practices of these programs.
CONCLUSION
There are several immediate steps that Congress can take to address
disparities in care. First, safety net providers must be protected.
These hospitals play an important role in caring for all populations,
including minority populations in inner cities, patients in rural
areas, and the uninsured and underinsured.
Congress should ensure that the moratorium on proposed Medicaid
regulations is approved, thus providing safety net hospitals with the
resources to treat those most affected by disparities in care. If these
regulations are implemented, it will affect coverage of rehab services
for people with disabilities; certified public expenditures and
intergovernmental transfers; graduate medical education; outpatient
services; provider tax arrangements and outreach and enrollment in
schools and specialized medical transportation to school for children
covered by Medicaid. These budget-cutting policies proposed by the
Centers for Medicare & Medicaid Services would have a devastating
effect on state Medicaid programs, along with the hospitals and
physicians that serve our nation's most vulnerable populations. Much of
Congress has expressed opposition to these rules with bipartisan
support.
Congress also should support the permanent ban on self-referral to
new physician-owned facilities, with appropriate grandfathering of
existing facilities. The rapid proliferation of physician ownership
must be slowed to ensure that safety-net services and the continued
viability of full-service hospitals in communities are maintained.
Studies have found that physician-owned limited-service hospitals have
a devastating impact on communities by, among other effects, reducing
patient access to specialty and trauma care at community hospitals;
damaging the financial health of full-service hospitals that must
maintain stand-by capacity for emergencies, even if they lose elective
services; and ``cherry-picking'' the most profitable patients by
avoiding low-income populations, both uninsured and Medicaid.
In addition, as Congress considers legislation to implement value-
based purchasing, legislators should be mindful that minority
populations often have unique and vastly different cultural and health
needs. Standardizing delivery of care in order to measure and reward
improvement is a laudable goal, but we must ensure that members of
minority populations do not slip through the safety net.
In the long term, Congress should include elimination of
disparities in care--fair and equitable care for all--in its
deliberations as the country seems poised to debate the future of our
healthcare system.
The price of poor health is high, but ensuring that disparities in
care are eliminated, that wellness and prevention measures are
implemented in a community-partnership mode and that America's
hospitals continue to improve care for all can dramatically enhance our
efforts to close the gap and eliminate disparities. Providing quality
care to every patient is at the heart of a hospital's mission.
Continually striving to eliminate disparities in care is a major
priority for America's hospitals, but can only be achieved if all
stakeholders work together for the good of patients.
Statement of Glenn Flores, M.D., Director of the Division of
General Pediatrics, Professor of Pediatrics and Public Health, and the
Judith and Charles Ginsburg Chair in Pediatrics, UT Southwestern
Medical Center and Children's Medical Center, Dallas, Texas.
Thank you, Chairman Stark and the Ranking Member Camp, for inviting
me to provide this written testimony on cultural and linguistic issues
in healthcare and their importance in addressing disparities in health
and healthcare in the United States.
My name is Glenn Flores, M.D., and I am Director of the Division of
General Pediatrics, Professor of Pediatrics and Public Health, and the
Judith and Charles Ginsburg Chair in Pediatrics at the University of
Texas Southwestern Medical Center and Children's Medical Center Dallas.
I am a pediatrician who has cared for under-served children for 16
years, as well as a researcher who has conducted many studies on
racial/ethnic disparities, cultural competency, and language issues in
health and healthcare.
My testimony will address cultural and linguistic issues in
healthcare, and how culturally competent healthcare is crucial in the
reduction and elimination of disparities in health and healthcare.
Why Is Culture So Important in Healthcare?
The world's population of 6.7 billion people inhabits 191 countries
and speaks over 6,000 languages. In the U.S., approximately 103 million
people (34% of the nation's population) are of non-white race/
ethnicity. By 2050, racial/ethnic minorities will comprise half of the
U.S. population. Since 2000, minorities have comprised more than half
of the population of the nation's 100 largest cities, and 42 of the 100
largest U.S. cities are ``minority majority'' (defined as populations
in which racial/ethnic minorities outnumber whites).\1\ Rapid growth in
diversity makes it increasingly likely that healthcare providers will
care for patients from different cultures.
---------------------------------------------------------------------------
\1\ The Brookings Institution Center on Urban and Metropolitan
Policy. Census 2000 Matters. Racial Change in the Nation's Largest
Cities: Evidence from the 2000 Census. Available at: http://
www.brookings.edu/es/urban/census/citygrowth.htm.
---------------------------------------------------------------------------
Mounting evidence demonstrates the profound impact culture can have
on healthcare. Failure to consider a patient's culture can have serious
clinical consequences, including inaccurate histories,
miscommunication, and difficulties with informed consent; decreased
access to care and lower likelihood of having primary care provider;
non-adherence and decreased satisfaction with care; and less preventive
screening, inadequate analgesia, delayed immunizations, and receipt of
fewer prescriptions.\2\
---------------------------------------------------------------------------
\2\ Flores G. Culture and the patient-physician relationship:
achieving cultural competency in healthcare. Journal of Pediatrics
2000;136:14-23.
---------------------------------------------------------------------------
Normative Cultural Values
Normative cultural values are defined as beliefs, ideas, and
behaviors that a particular cultural group values and expects in
interpersonal interactions. Lack of awareness of normative cultural
values can have a profound impact on healthcare. For example, central
to the Navajo concept of Hozhooji is the importance of thinking and
speaking in a positive way, and the belief that thought and language
have the power to shape reality and control events. The expectation is
that communication between healers and patients will embody the concept
of positive thoughts and words, and that negative thoughts and words
can actually cause harm. A lack of awareness of hozhooji can therefore
cause an inadequate discussion of medical risks, miscommunication about
advanced directives, and failure to obtain informed consent. For
example, a Navajo patient was told by a surgeon that in all operations
there is a risk of not waking up; the patient viewed this to be a death
sentence, so he refused to consent to having surgery. One study
documented that 86% of Navajo patients said that advance care planning
(establishing a living will or durable power of attorney) was a
dangerous violation of the traditional Navajo values and thinking, and
many would not discuss this issue because they felt it to be too
dangerous.\3\
---------------------------------------------------------------------------
\3\ Carrese JA, Rhodes LA. Western bioethics on the Navajo
reservation. Benefit or harm? JAMA 1995;274:826-9.
---------------------------------------------------------------------------
Fatalismo (fatalism) is the belief that individual can do little to
alter fate. It has been noted as a normative cultural value among
Latinos, African-Americans, and other ethnicities and cultures.
Fatalismo can lead to avoiding effective therapy for cancer and chronic
diseases and less preventive screening. For example, a study of cancer
beliefs revealed that Latinos were significantly more likely than
whites to prefer not to know if they had incurable cancer, and to
believe that there is little one can do to prevent getting cancer,
having cancer is like a death sentence, and cancer is God's
punishment.\4\
---------------------------------------------------------------------------
\4\ Perez- Stable EJ, Sabogal F, Otero-Sabogal R, Hiatt RA, McPhee
SJ. Misconceptions about cancer among Latinos and Anglos. JAMA
1992;268:3219-23.
---------------------------------------------------------------------------
Protective Effects of Traditional Culture and Improving the Health of
All Americans
Multiple studies document that for a variety of health issues, less
acculturation (e.g., less ``Americanization'') is associated with
better health indicators. For example, less acculturation is associated
with lower low birth weight rates, higher immunization rates, less teen
depression and suicide, less cigarette smoking, less illicit drug use,
and a significantly older age at first sexual intercourse for Latino
girls. The reasons for this ``healthy immigrant effect'' are not yet
completely understood, but further studies of this phenomenon hold
potential for improving the health of all Americans.\5\
---------------------------------------------------------------------------
\5\ Flores G, Brotanek J. The healthy immigrant effect: A greater
understanding might help us improve the health of all children.
Archives of Pediatrics and Adolescent Medicine 2005;159:295-297.
---------------------------------------------------------------------------
The Critical Impact of Language on Healthcare
English Proficiency in the U.S.
Fifty-five million Americans (20%) speak a language other than
English at home, and 24 million (9%) have limited English proficiency
(or LEP, defined as self-rating one's English-speaking ability as less
than ``very well''). Eleven million school-age children (19%) speak a
language other than English at home.
Adverse Consequences of Language Barriers in Healthcare
Studies demonstrate a wide range of adverse effects that LEP can
have on health and healthcare, including impaired health status, a
lower likelihood of having a regular physician, lower rates of
mammograms, pap smears, and other preventive services, non-adherence
with medications, a greater likelihood of a diagnosis of more severe
psychopathology and leaving the hospital against medical advice among
psychiatric patients, a lower likelihood of being given a follow-up
appointment after an emergency department visit, an increased risk of
intubation among children with asthma, a greater risk of hospital
admissions among adults, an increased risk of drug complications,
longer medical visits, higher resource utilization for diagnostic
testing, lower patient satisfaction, impaired patient understanding of
diagnoses, medications, and follow-up, and medical errors and
injuries.6,7 For example, one study found that 26% of
mothers of Latino children cited language problems as single greatest
barrier to healthcare, and 6% reported not bringing their child in for
needed medical care because of language problems. LEP patients in
psychiatric settings experience a greater likelihood of diagnosis of
more severe psychopathology, are more likely to leave hospital against
medical advice, are less likely to establish a good rapport with
physician, are less likely to receive adequate explanation of
therapeutic regimen, and are less likely to give feedback to physician.
---------------------------------------------------------------------------
\6\ Flores G. The impact of medical interpreter services on the
quality of healthcare: A systematic review. Medical Care Research and
Review. 2005;62:255-299.
\7\ Flores G, Laws MB, Mayo SJ, et al. Errors in medical
interpretation and their potential clinical consequences in pediatric
encounters. Pediatrics 2003;111:6-14.
---------------------------------------------------------------------------
LEP patients have a higher risk of experiencing adverse healthcare
outcomes. For example, Mexican-American children whose parents speak
English were found to be 12 times more likely to have a regular
healthcare provider vs. those with LEP parents (regardless of
insurance).\7\ Another study revealed that LEP women receive fewer
mammograms and pap smears.\7\ Asthmatic children with LEP parents are
three times more likely to be intubated for their asthma than those
with English proficient parents, and monolingual Spanish-speaking
adults with asthma whose physicians speak English are three times more
likely to miss one or more follow-up appointments.\7\ A recent
nationally representative survey of over 102,000 U.S. households
revealed that children in households speaking a non-English primary
language experience numerous disparities in medical and oral health,
access to care, and use of services, even after adjustment for health
and dental insurance and family income.\8\
---------------------------------------------------------------------------
\8\ Flores G, Tomany-Korman S. The language spoken at home and
disparities in medical and dental health, access to care, and use of
services in U.S. children. Pediatrics 2008;121;e1703-e1714.
---------------------------------------------------------------------------
Patient Safety: Language Barriers, Medical Errors, and Injuries
Research documents that language barriers can result in preventable
medical errors and injuries. Dramatic examples in the medical
literature include:
A 2-year-old fractured her clavicle after falling off her
tricycle. A resident physician misinterpreted two Spanish words,
diagnosed child abuse, and contacted the Department of Social Services,
who, without an interpreter, had the mother sign over custody of her
two children. The mother did not regain custody of her children until
48 hours later, when a medical interpreter finally was obtained.\9\
---------------------------------------------------------------------------
\9\ Flores G, Abreu M, Schwartz I, Hill M. The importance of
language and culture in pediatric care: case studies from the Latino
community. Journal of Pediatrics 2000;137:842-848.
---------------------------------------------------------------------------
A 10-month-old girl with iron-deficiency anemia was given
a 13-fold overdose of iron and hospitalized for iron intoxication after
her LEP parents were given medication instructions and a prescription
only in English by their healthcare provider. The parents gave 15 ml of
iron elixir (one tablespoon instead of a dropperful) based on a
prescription label that read: ``15 mg per 0.6 ml, 1.2 ml daily.'' \10\
---------------------------------------------------------------------------
\10\ Flores G. Language barrier. AHRQ WebM&M Morbidity and
Mortality Rounds on the Web 2006;April. Available at: http://
www.webmm.ahrq.gov/case.aspx?caseID=123.
---------------------------------------------------------------------------
Misinterpretation of single Spanish word (``intoxicado'')
resulted in an 18-year-old's quadriplegia after being misdiagnosed with
a drug overdose. The patient's hematomas, brain-stem compression, and
paralysis were actually due to a ruptured aneurysm, and the hospital
paid $71 million in a malpractice settlement.\11\
---------------------------------------------------------------------------
\11\ Harsham P. A misinterpreted word worth $71 million. Medical
Economics 1984;June:289-292.
---------------------------------------------------------------------------
The Importance of Medical Interpreters in Healthcare
Data indicate that medical interpreter services are often
inadequate for millions of LEP patients in America. One study of an
urban emergency department revealed that no interpreter was used for
46% of LEP patients for whom an interpreter was needed, interpreters
were not called in 1/3 of cases when both the clinician's Spanish and
patient's English were poor, and 39% of interpreters used had no
training. LEP patients who need but don't get interpreters are more
likely than LEP patients who use interpreters and English proficient
patients to have a poor or fair self-reported understanding of their
diagnosis and treatment plan, and to wish their healthcare provider
explained things better.
The Dangers of Medical Interpretation by Family Members, Friends, and
Untrained Staff
All too often, ad hoc interpreters (including family members,
friends, untrained medical staff, strangers pulled from the waiting
room and the streets, and custodians) are used when language barriers
are encountered in healthcare. The hazards of using these ad hoc
interpreters are well documented, and include the patient being less
likely to be told about medication side effects, and more frequent
interpretation errors that are more likely to have actual or potential
clinical consequences. In addition, studies show that family members
misinterpret 23-52% of questions asked by physicians; children who
interpret are embarrassed by and tend to ignore questions about
menstruation, bowel movements, and other bodily functions; non-medical
staff who interpret can exclude or distort key clinical information;
and patient satisfaction with ad hoc interpreters is significantly
lower than with other interpreter types.\6\
---------------------------------------------------------------------------
\6\ Flores G. The impact of medical interpreter services on the
quality of healthcare: A systematic review. Medical Care Research and
Review. 2005;62:255-299.
---------------------------------------------------------------------------
The dangers of ad hoc interpreters are dramatically illustrated in
the following actual patient encounter that occurred in an emergency
room and was published in the New England Journal of Medicine.\12\ A
12-year-old boy presented to the physician with dizziness, and attempts
to interpreter for himself and his mother:
---------------------------------------------------------------------------
\12\ Flores G. Language barriers to healthcare in the United
States. New England Journal of Medicine 2006;355:229-231.
Mother: La semana pasada a el le Last week he had a lot of dizziness
dio mucho mareo y no tenia fiebre and he did not have fever or
ni nada, y la familia por parte de anything, and his dad's family all
papa todos padecen de diabetes. suffer from diabetes.Doctor: Uh-humMother: A mi me da miedo porque el I'm scared because he's dizzy,
lo que estaba mareado, mareado, dizzy, dizzy and he didn't have
mareado y no tenia fiebre ni nada. fever or anything.Doctor: Ok. So she's saying you look kind of yellow, is that what she's
saying?Patient: Es que si me vi amarillo? Is it that I looked yellow?
Mother: Estaba como mareado, como You were like dizzy, like pale.
palido.
Patient: Like I was like paralyzed, something like that.
The Many Benefits of Providing Adequate Language Services to LEP
Patients
Multiple studies document the many benefits of providing trained,
professional medical interpreter services to LEP patients.\6\
Interpreter services have a positive impact on preventive screening,
including increased breast cancer screening after implementation of
language services in clinics, and elimination of disparities between
LEP and English-proficient patients in flu vaccinations and fecal
occult blood testing. Interpreter services positively impact health
outcomes. In children presenting to the emergency department, LEP
patients with professional interpreters did not differ from English-
proficient patients in test costs or use of IV hydration, and had a
lower likelihood of testing. LEP patients with Type 2 diabetes mellitus
who have trained professional interpreters are two times more likely
than English-proficient patients to receive care meeting American
Diabetes Association guidelines, three times more likely than English-
proficient patients to have dietary consults, and did not differ from
English-proficient patients in 18 other processes and outcomes. In
patients with hypertension and diabetes, health status, physical
functioning, psychological well-being, health perceptions, and pain
scores are higher in those with language concordant vs. discordant
physicians.
Providing Language Services to All Americans Who Need Them Would Not be
Costly
In a 2002 report to Congress, the Office of Management and
Budget\13\ estimated it would cost only a $4.04 premium per patient to
provide interpreter services to all LEP patients needing these
services, which is equivalent to a 0.5% increase in overall U.S.
healthcare expenditures. This cost estimate includes coverage for LEP
patients of interpreter services for inpatient hospitalizations, as
well as outpatient, emergency room, and dental visits.
---------------------------------------------------------------------------
\13\ Office of Management and Budget. Report to Congress.
Assessment of the Total Benefits and Costs of Implementing Executive
Order No. 13166: Improving Access to Services for Persons with Limited
English Proficiency. Washington, D.C.: 2002.
---------------------------------------------------------------------------
Ethnomedical Conditions or Folk Illnesses and Their Impact on Medical
Care
Folk Illnesses and Their Impact on Healthcare
Ethnomedical conditions, or folk illnesses, are culturally
constructed diagnostic categories commonly recognized by an ethnic
group. The prevalence of beliefs varies tremendously, depending on
subpopulation, region, levels of acculturation. The prevalence of
certain folk illness beliefs, however, can be as high as 96% in certain
Mexican-American communities. Folk illness beliefs and practices can
affect clinical care because the symptoms often overlap with important
biomedical conditions, the first healthcare provider contact may not be
a physician, some folk remedies can be harmful or even fatal, and
satisfaction with care and adherence can depend on the accepting
response of healthcare provider
Example: How Folk Illnesses Can Affect Healthcare
Empacho is a Latino folk illness in which food or saliva is
believed to get ``stuck'' in the stomach because of dietary
indiscretions such as eating the wrong foods or eating at the wrong
time. One study\14\ found that 90% of Latino parents knew of empacho,
and 64% said that a child in the household had suffered from it in
past. Symptoms of empacho include vomiting, diarrhea, anorexia,
bloating, and fever. These symptoms overlap with such biomedical
conditions as gastroenteritis, milk allergy, formula intolerance,
gastrointestinal obstruction, intussusception, and appendicitis. But
the treatment of choice for empacho is not usually a physician visit.
The most common treatments of choice among parents whose child has
empacho include a santiguadora (a traditional healer) in 77%, home
remedies for 58%, and doctor visits for only 37%. Only 9% of parents
reported physicians as the initial choice for treatment, and 85% of
those visiting physicians for empacho sought another form of therapy
afterwards.
---------------------------------------------------------------------------
\14\ Pachter LM, Bernstein B, Osorio A. Clinical implications of a
folk illness: Empacho in mainland Puerto Ricans. Medical Anthropology
1992;13:285-299.
---------------------------------------------------------------------------
Most traditional empacho treatments are harmless, and include
dietary restriction, teas, abdominal massage with warm oil, and
treatment by folk healers or parents. But some empacho treatments are
harmful or even fatal. For example, Mexican-American families may treat
empacho with powders containing high concentrations of lead (greta,
azarcon, albayalde) whose lead content varies from 70% to 97%. Multiple
cases of severe lead toxicity have been reported in the medical
literature, with outcomes that include lead levels as high as 124 g/dl
(normal is considered <10), severe lead encephalopathy, and death. The
use of lead-based empacho remedies in certain communities can be as
high as 35% in Mexico and 11% in U.S. Cultural competency training of
healthcare providers that includes education about common folk
illnesses and their treatment thus has the potential to save lives.
There are dozens of other ethnomedical conditions that have similar
important clinical ramifications.
Patient and Parent Beliefs and Their Impact on Healthcare
Patient and parent beliefs are defined as a cultural group's
beliefs about disease causality (excluding specific folk illnesses).
Treatments associated with these beliefs include home remedies, folk
remedies (except those used for specific folk illnesses), and over-the-
counter medications. Patient/parent beliefs can profoundly affect
different aspects of clinical care, including prevention, therapy, and
seeking medical care. Several home treatments for common childhood
symptoms can result in clinical findings that can be confused with
child abuse, and misunderstandings can lead to costly and unnecessary
medical evaluations. In addition, certain harmful parent/patient
beliefs and practices can cause serious morbidity and fatalities.
Lack of Awareness of Patient Beliefs Can Lead to Costly, Unnecessary
Medical Evaluations
Infant head molding (the application of pressure or bindings to
cranial bones to alter their shapes) is practiced by various Caribbean,
Latino, European, African-American, Asian, and Native American groups,
with the intent of promoting infants' beauty, health, or intelligence.
The failure of healthcare providers to inquire about infant head
molding could lead to unnecessary, expensive evaluations for such
medical conditions as dysmorphism or craniosynostosis. Indeed, one
study documented that none of the 30 parents interviewed told their
child's physician that they were molding their infant's head.
Serious Morbidity and Fatalities Resulting from Harmful Cultural
Beliefs/Practices
An outbreak of Gonococcal conjunctivitis occurred in Florida due to
the use of adult urine to treat conjunctivitis in children. Serious
Salmonella infections have been caused by use of rattlesnake meat
capsules, powder, or jerky by Mexican-Americans to treat various
ailments (including diarrhea, infections, AIDS, diabetes, heart
disease, cancer). Liver injury and death from liver failure have been
caused by a cough treatment using a tea made from the herb Senecio
longilobus, which contains potent toxins.
Culturally Biased Attitudes and Practices and How They Can Affect
Healthcare
Cultural bias in the attitudes and practices of some healthcare
providers can have a profound impact on clinical care, including access
to care, impaired diagnostic evaluations, lower quality of care, and
causing and perpetuating racial/ethnic disparities in healthcare.
Provider Practices That Impair Diagnosis
Among adolescent girls presenting to the emergency department with
abdominal pain, race/ethnicity was found to be a significant
determinant of whether physicians obtain sexual histories.\15\
Physicians significantly more often obtained sexual histories on Latino
and African-American girls (88%) compared with whites (50%), and for
girls <15 years old, 100% of minority girls but only 44% of white girls
were asked about sexual activity. In a study of a white
psychotherapists in which two case histories presented were identical
except for race of adolescent boy (white vs. African-American),
therapists gave significantly lower ratings of the clinical
significance of eight of 21 pathological behaviors in the African-
American adolescent. White therapists were less concerned about the
African-American adolescent beating his girlfriend, stealing cars,
mistrusting the interviewer, and hating his mother. The findings
supported the hypothesis that mental disorders in African-American
adolescents are under-diagnosed because pathological behaviors are
rated less severely.
---------------------------------------------------------------------------
\15\ Hunt AD, Litt IF, Loebner M. Obtaining a sexual history from
adolescent girls. A preliminary report of the influence of age and
ethnicity. Journal of Adolescent Healthcare 1988 9:52-4.
---------------------------------------------------------------------------
Provider Practices and Quality of Care
Studies show providers give less pain medication to Latinos. For
example, Latino adults presenting to an emergency room with long-bone
fractures were found to be seven times more likely than Whites to
receive no pain medication (after adjustment). Multiple studies also
document that minority children are significantly less likely to
receive known effective asthma therapies, even after adjusting for
insurance coverage and family income.
Are These Healthcare Provider Practices Due to Inadequate Cultural
Competency Training?
A study of the teaching cultural issues in U.S. and Canadian
medical schools revealed that very few schools (8% in the U.S. and 0%
in Canada) have separate courses on cultural issues.\16\ Eight percent
of U.S. medical schools were found to offer no courses on cultural
issues. In addition, few schools teach about the specific cultural
issues of the largest minority groups in their geographic area. For
example, only 35% of U.S. schools address the cultural issues of the
largest minority groups in their state.
---------------------------------------------------------------------------
\16\ Flores G, Gee D, Kastner B. The teaching of cultural issues in
U.S. and Canadian medical schools. Academic Medicine 2000;75:451-455.
---------------------------------------------------------------------------
Cultural Competency is Associated with High-Quality Patient Care
A recent study of asthmatic children in five health plans in three
states found that practice sites with the highest cultural competency
scores have significantly lower patient under-use of preventive asthma
medications and significantly better parent ratings of the quality of
asthma care.\17\
---------------------------------------------------------------------------
\17\ Lieu TA, Finkelstein JA, Lozano P, et al. Cultural competence
policies and other predictors of asthma care quality for Medicaid-
insured children. Pediatrics 2004;114:e102-10.
---------------------------------------------------------------------------
Summary
Failure to consider a patients' culture can have serious clinical
consequences. Dissatisfaction with care, miscommunication, less
preventive screening, and failure to obtain informed consent and
advance directives can occur when normative cultural values not
considered. Decreased access to care, impaired health status, lower use
of services, adverse outcomes, and medical errors and injuries are
documented among those facing language barriers. Serious morbidity and
fatalities have been associated with harmful folk remedies and parent
beliefs and practices. Delayed medical care, confusion with child
abuse, and unnecessary and costly medical evaluations are associated
with certain parent cultural beliefs and practices. Decreased access to
care, impaired diagnostic evaluations, lower quality of care, and
racial/ethnic disparities are associated with biased provider
practices. Multiple studies in the medical literature document that the
highest quality of care is delivered when healthcare providers are able
to effectively overcome language problems and are culturally competent.
Action Steps: Enhancing Culturally Appropriate Care and Eliminating
Disparities
Action steps in five areas would substantially enhance culturally
and linguistically care and have the potential to eliminate disparities
in healthcare. They are as follows:
Routine Collection of Data on Race/Ethnicity, Primary Language, and
English Proficiency
Healthcare institutions and health plans should routinely
collect data on patients' self-reported race/ethnicity. Racial/ethnic
disparities in health and healthcare cannot be monitored and eliminated
without this essential measure.
Healthcare institutions and health plans should routinely
collect data for all patients on the primary language spoken at home
and English proficiency. Such data are essential not only to monitor
and eliminate linguistic barriers to healthcare, but also to anticipate
the future language service needs of patients who regular access
healthcare services and systems.
Strategies to Eliminate Language Barriers
Provide nationwide third-party reimbursement for medical
interpreters and other language services. Only 13 states and the
District of Columbia currently provide third-party reimbursement for
interpreter services, and only through Medicaid and SCHIP--not through
Medicare or other health insurance plans. It is time for our nation to
provide third-party reimbursement for interpreter services for all LEP
patients.
Increase the number of trained medical interpreters and
their pay. Training programs and recruitment strategies need to be
developed to take advantage of the 55 million Americans who are
bilingual or multilingual.
Increase the number of bilingual healthcare providers.
This can be achieved by having medical and other health professions
schools offer or require population-relevant foreign language
instruction.
Do better at teaching our children foreign languages.
Only 44% of U.S. high-school students are currently enrolled in foreign
language courses.
Implement and fund more free or low-cost English classes
to help LEP patients and families learn English. In my 16 years caring
for underserved children and their families, I have never met a parent
that did not want to learn English. The biggest barrier to English
proficiency for the families that I provide care to is the lack of
availability of free or low-cost English classes.
Ensure comprehensive, ``door-to-door'' language access
and services for LEP patients. Key services that often are overlooked
include multilingual phone operators and phone trees for making
appointments, and multilingual signage, consent forms, patient
information materials, and prescriptions. Trained interpreters also
need to be present throughout the medical visit (especially when
scheduling follow-up appointments and during radiological and
laboratory procedures).
Enforce compliance with Title VI requirements. The Office
of Civil Rights issued a 1998 guidance memorandum regarding the Title
VI prohibition against national origin discrimination affecting LEP
persons which states that denial or delay of medical care for LEP
patients because of language barriers constitutes a form of
discrimination, and requires recipients of Medicaid or Medicare funds
to provide adequate language assistance to LEP patients. When all other
options fail, legal action has been successful in enforcing compliance
with Title VI requirements, as occurred in recent settlements with four
New York state hospitals.\18\
---------------------------------------------------------------------------
\18\ Office of New York State Attorney General Eliot Spitzer.
Spitzer reaches agreement with two Brooklyn hospitals to provide
language assistance for patients with limited English proficiency. URL:
http://www.oag.state.ny.us/press/2003/mar/mar03a--03.html.
---------------------------------------------------------------------------
Funds and more research should be devoted to evaluating
telemedicine options for enhancing access to language services.
Telemedicine may prove to be highly cost-effective means for states and
health plans to provide language access, allowing hospitals and clinics
to quickly link to centralized bank of trained interpreters.
Strategies to Enhance Cultural Competency in Healthcare
Cultural competency should be a standard component of
curricula in health professions schools. Cultural competency knowledge
and skills should be an essential part of the education of healthcare
providers, given the substantial medical literature documenting that
the highest quality of care and optimal patient outcomes occur when
providers are culturally competent and are able to effectively overcome
language problems.
Cultural competency may need to be a requirement for
certification of healthcare professionals and licensing of healthcare
facilities. In 2004, the state of New Jersey enacted a law requiring
that medical professionals be trained in the provision of culturally
competent healthcare as a condition of licensure to practice medicine
in NJ.\19\ As part of its state-required hospital licensure renewal
process, Rhode Island mandates that hospitals demonstrate evidence that
they are providing meaningful access to language services for their LEP
patients.\20\
---------------------------------------------------------------------------
\19\ Senate Substitute for Assembly, No. 492. State of New Jersey
211th Legislature. Adopted March 22, 2004.
\20\ Rhode Island General Laws Section 23-17-54; 14 090 CRIR 007
Section 20.3. Available at: http://www.rilin.state.ri.us/statutes/
title23/23%2D17/23-17-54.HTM.
---------------------------------------------------------------------------
Strategies to Reduce Healthcare Disparities through Community-Based
Interventions
More federal funding should be devoted to innovative,
community-based, culturally appropriate interventions targeting
elimination of healthcare disparities. For example, a recent
randomized, controlled trial was performed that resulted in the
elimination of a healthcare disparity. This study demonstrated that,
compared with traditional Medicaid/SCHIP outreach and enrollment,
community-based health workers are substantially more effective in
obtaining health insurance for Latino children, obtaining insurance
quicker, continuously insuring children, and achieving high parental
satisfaction with the process of obtaining insurance.\21\ To ensure
that healthcare disparities are eliminated for all Americans, more such
studies and programs are needed.
---------------------------------------------------------------------------
\21\ Flores G, Abreu M, Chaisson CE, et al. A randomized trial of
the effectiveness of community-based case management in insuring
uninsured Latino children. Pediatrics 2005;116:1433-1441.
Statement of the National Black Nurses Association
Mr. Chairman, I am providing a written statement for consideration
by the Committee and for inclusion in the printed official record of
the hearing regarding an important issue the elimination of health
disparities. I applaud your efforts for addressing this critical matter
facing millions of Americans.
The National Black Nurses Association's mission is to provide a
forum for collective action by African American nurses to
``investigate, define and determine what the healthcare needs of
African Americans are and to implement change to make available to
African Americans and other minorities healthcare commensurate with
that of the larger society''.
Eliminating health disparities is one of the most pressing
challenges facing the Nation on all fronts. Report upon report outline
racial and ethnic disparities in health and healthcare. At issue are
access, quality and accountability to culturally competent healthcare
services. The IOM study entitled, Unequal Treatment: Confronting Racial
and Ethnic Disparities in Healthcare, documented disparities in quality
of healthcare that are NOT due to access-related or solely economic
factors. It focused on disparities related to how healthcare systems
operate, including their regulatory and legal context, and to
discrimination. The IOM report confirmed that ``cultural and linguistic
competence'' is essential to helping close the gaps in mortality and
morbidity.
Ethnic and racial disparities in healthcare have been well
documented in recent decades across a broad range of medical
conditions. Differences have been noted in health outcomes, which
include quality of life, mortality, and appropriateness of care.
Despite all that is known regarding health disparities, little
improvement has been made, and racial and ethnic minorities continue to
be disproportionately affected by illness and disease due in part to an
inadequate understanding of cultural differences.
It is our belief that we have collected enough data and that action
should be taken now to move toward an agenda that will eliminate
disparities. The following should be taken into consideration as
strategies are developed.
The 2003 ``National Healthcare Disparities Report'' developed by
the Agency for Healthcare Research and Quality (AHRQ) offered a
comprehensive tool to measure access and use of healthcare services by
various populations. The NHDR provides seven key findings to
policymakers, clinicians, health system administrators, and community
leaders who seek to use this information to improve healthcare services
for all populations:
1. Inequality in quality persists
2. Disparities come at a personal and societal price
3. Differential access may lead to disparities in quality
4. Opportunities to provide preventive care are frequently missed
5. Knowledge of why disparities exist is limited
6. Improvement is possible
7. Data limitations hinder targeted improvement efforts
Findings in this report can help target efforts more effectively to
improve quality and reduce disparities. In its 2005 National Healthcare
Quality and Disparities report released on January 9, 2006, AHRQ
reported that access to care for African Americans was narrowing.
Improvements were observed among non-Hispanic Whites and Non-Hispanic
Blacks relative to blood pressure control. Yet, cardiovascular disease
is the number one killer of African Americans. Only 40 percent of those
diagnosed with diabetes have their HbA1c under optimal control (<7
percent). Blacks with diabetes are more likely than Whites to have
their total cholesterol under control. Only 70 percent of those
diagnosed with diabetes had their blood pressure under control. Rates
of late-stage breast cancer decreased more rapidly from 1992 to 2002
among black women (169 to 161 per 100,000 women) than among white women
(152 to 151 per 100,000), resulting in a narrowing disparity. Yet,
Black women had higher rates of advanced stage breast cancer than White
women in 1992, 1993, 2002. Over 12 million children ages 2-19 years old
are overweight, 20% are African American.
The Behavioral Risk Factor Surveillance System (BRFSS), a random
telephone survey conducted by state health department and the CDC; and
the National Health and Nutrition Examination Survey (NHANES) 1999-2002
found that Blacks had the highest prevalence of hypertension, the
highest self-report prevalence of diagnosed diabetes and the highest
rate of hospitalizations for stroke. The basic philosophy of this
program was to collect data on actual behaviors, rather than on
attitudes or knowledge, that would be especially useful for planning,
initiating, supporting, and evaluating health promotion and disease
prevention programs.
The Uninsured
Over 47 million Americans are uninsured and millions lack adequate
care. Communities of color have a higher incidence of chronic diseases,
cardiovascular disease, diabetes, cancer, violence and HIV/AIDS,
leading to high rates of morbidity and mortality. African Americans
accounted for 47 percent of AIDS cases in 2005. 20 million Americans
have diabetes; it is estimated that 20 million Americans have
undiagnosed diabetes. 2.7 million African Americans aged 20 and older
have diabetes. African Americans develop diabetes at 1.6 times the rate
of whites. Diabetes is the leading cause of kidney failure and African
Americans are more likely to suffer from kidney disease. According to
the Centers for Disease Control and Prevention, the incidence of
diabetes is expected to double by the year 2050 and healthcare costs
associated with diabetes exceeded $132 billion in 2002.
Insurance Coverage
Even more distressing are those individuals who have insurance
coverage and continue to experience healthcare disparities. In a recent
report from the Families USA Foundation it was revealed that insurance
companies in most states are not required to provide health coverage to
individuals with pre-existing conditions. This results in insurance
companies refusing to pay for needed services that treat common
conditions. Individuals are denied coverage and are left with large
medical bills they can not pay many ending up in bankruptcy. Employer
sponsored health coverage is the major vehicle for the purchase of
health insurance for most people. This employee benefit is on the
decline and coverage is out of reach for many Americans due to cost.
According to Families USA upon completion of their 50 state surveys it
is time for the Federal Government to step in and curb the harmful
abuse by insurance companies. Citizens of this country are devastated
by debilitating illness and disease they should not have to tolerate
abuse by the insurance industry.
Study after study provides evidence of the devastating effects on
the quality of life of people of color due to healthcare disparities.
The staggering statistics related to these disease states are only a
snapshot of the continuing pain and suffering, let alone the economic
impact that continues to plague our communities. While advances in
prevention, diagnosis and treatment, particularly through biomedical
research and technology, offer incredible promise for improved health
and delivery of care, for a good number of this Nation's citizens, this
dire state of health continues.
Demographics
According to a recent IOM report the U.S. healthcare system is not
prepared for the influx of baby boomers that will be entering the
healthcare system. The current system is difficult to navigate there
are issues with staffing ratios, mandatory overtime, bed closures and
patient safety issues. The U.S. is experiencing a shortage of nurses,
which are more severe in certain areas than others. The Department of
Labor estimates that the number of vacancies for RNs will be 800,000 in
2020.
Nursing Shortage
The National Black Nurses Association was founded because of
inequities in healthcare that existed. Healthcare disparities are not
new to us. Black nurses are the pulse of the community and are
confronted with the devastation of disparities in our communities on a
daily basis. Out of 2.7 million nurses in the U.S., Black nurses
represents 4.9%.
We are faced with barriers preventing minority students from being
admitted to and completing nursing school. We must increase the
pipeline of minority students. We cannot close the healthcare
disparities gap without nurses. More efforts must be focused on
workforce diversity and ensure that all areas of the healthcare
delivery system are reflective of the populations served. This can be
accomplished by ensuring that cultural competence is an integral
component of curriculums. The lack of ethnic minority representation in
the healthcare system limits a healthcare professional's access to
those who may be able to provide information about the cultural groups
they represent.
There are fundamental questions that remain unanswered that need to
be addressed to reform the healthcare system if our Nation is to
eliminate healthcare disparities:
What is being done to expand health insurance coverage
for the uninsured?
How is the latest biomedical research and technology
being used to help close the disparities gap?
Why are African Americans less likely to get the
expensive, newer treatments?
How can more vigorous intervention research, occurring in
clinical and community based settings, be funded to produce critical
findings that underpin evidenced based practice?
How will the education and training at health professions
institutions help to improve the access, and quality of healthcare
services to communities of color?
What are the strategies to recruit and retain nurses and
other health professionals to help reduce and eliminate healthcare
disparities?
Can a comprehensive health disparities bill like that
introduced by Representative Elijah Cummings (D-MD) and other Members
of Congress change our Nation's healthcare infrastructure to eliminate
racial and ethnic healthcare disparities? Elements of such legislation
seek to ensure quality healthcare; expand access; strengthen
accountability; implement the IOM study recommendations; enhance the
Office of Minority Health, Office for Civil Rights and the National
Center on Minority Health and Health Disparities; support and empower
communities in their efforts to eliminate health disparities; improves
workforce diversity; reduce diseases and related complications from
HIV/AIDS to asthma; and improve racial, ethnic and primary language
data collection, use and monitoring.
Thank you, Mr. Chairman, for the opportunity to present written
testimony. The National Black Nurses Association and the 150,000 Black
nurses we represent look forward to working with you on this issue in
the future.
Statement of National Business Group on Health
The National Business Group on Health (The Business Group) commends
the Congress for including a hearing on disparities in health and
access to care as part of its ongoing health reform hearing series and
thanks the Committee for the opportunity to submit this statement for
the record.
Background:
The Business Group, representing over 300 large employers that
provide health coverage to more than 55 million U.S. employees,
retirees and their families, is the nation's only non-profit,
membership organization devoted exclusively to finding innovative and
forward-thinking solutions to large employers' most important
healthcare and related benefits issues. Business Group members are
primarily Fortune 500 and large public sector employers, with 63
members in the Fortune 100.
Starting in 2007, the Office of Minority Health (OMH) at the U.S.
Department of Health and Human Services and the Business Group have
agreed to co-sponsor the National Partnership for Action for
Eliminating Racial and Ethnic Disparities in Health (NPA); a multi-
faceted, national effort led by the OMH at the community, business,
state, regional, and national levels.
The goal of the partnership is to reduce racial and ethnic
disparities in healthcare by 1) improving employers' awareness of the
causes and consequences of disparities, and 2) changing employers'
healthcare purchasing strategies in health insurance, wellness
programs, etc. to reduce the impact that racial and ethnic disparities
have on employees' and employers' health and healthcare costs.
Overall Goal:
The National Business Group on Health supports the reduction and
ultimate elimination of healthcare disparities among covered employees.
Problem:
Research has shown that disparities occur regardless of insurance
status. A difference in the quality of healthcare resulting from
disparities received by insured populations is a problem. Simply
providing insurance for employees does not guarantee equitable
healthcare will be provided.
Effect on Employers:
Aside from addressing healthcare disparities among employees
because it is the right thing to do, employers recognize that healthy
employees are the foundation for successful business. Improving and
maintaining the health status of employees is essential to producing
high-quality, goods and services, which, in turn increases shareholder
value.
Solutions:
The National Business Group on Health/OMH partnership has created
the Racial/Ethnic Health Disparities Advisory Board, whose
subcommittees consisting of members from academia, business leaders,
and experts in the field of healthcare disparities are responsible for
defining elements of data collection, communication and the business
case for addressing healthcare disparities.
Appropriate collection and utilization of racial and ethnic data to
close the gaps in healthcare disparities is essential. Additionally,
communicating data findings and health messages are key factors to
reduce disparities. The Racial/Ethnic Health Disparities Advisory Board
will be presenting strategies for addressing both of these factors to
employers with an updated Analysis Paper of the business case for why
employers should address healthcare disparities among their employees.
We also support the current efforts of Congress to improve the ongoing
data collection, measurement, and evaluation of healthcare disparities
by the Federal Government.
A current survey by a Business Group member company found that
employers are collecting race and ethnicity data as required under law
and using this data to actively measure quality. Another Business Group
member is using race and ethnicity data as evidence of corporate
responsibility to its investors,\1\ while others are using this data to
highlight, and promote the diversity of their
workforces.\2,3\
---------------------------------------------------------------------------
\1\ General Motors. 2005/06 Corporate Responsibility Report. 2006.
Available at http://www.gm.com/corporate/responsibility/reports/06/
700--social/700--na.html#minhourly; Verizon. Press Kits: Work Force
Development. 2007. Available at http://newscenter.verizon.com/kit/
diversity/workforce.html
\2\ Wal-Mart. Employment and Diversity Fact Sheets. 2008. Available
at http://www.walmartfacts.com/FactSheets/
\3\ IBM. Workforce Diversity. Government Requirements. 2004.
Available at http://www.ibm.com/ibm/responsibility/people/diversity/
government-requirements.shtml.
---------------------------------------------------------------------------
The National Committee for Quality Assurance (NCQA) is also leading
efforts to reduce healthcare disparities through the Recognizing
Innovation in Multicultural Healthcare award program to publicly
recognize health plans that have implemented initiatives to ensure
culturally and linguistically appropriate services and reduce
healthcare disparities. In addition, the Health Research & Educational
Trust has created a healthcare disparities toolkit with information on
how to collect racial/ethnic data and how to use this data.
Again, the Business Group appreciates the opportunity to submit
this statement for the record. As one of the largest purchasers of
healthcare, large employers are often the driving force to change and
improve our nation's healthcare system and can play a key role in the
elimination of healthcare disparities. The National Business Group on
Health looks forward to working with Members of the committee, the
Congress and to continuing our existing partnership and collaboration
with OMH to address the role of large employers in eliminating
healthcare disparities and their repercussions on the health and well
being of the American workforce.
Statement of National Council of Urban Indian Health
Introduction: On behalf of the National Council of Urban Indian
Health (NCUIH), our 36 member clinics, and the 150,000 American Indian/
Alaska Native patients that we serve annually, I would like to thank
the Health Subcommittee for this opportunity to submit testimony on
``Addressing Disparities in Health and Healthcare: Issues for Reform.''
The Native American community suffers the highest rates of health
disparities of any minority group. Moreover, Congress has repeatedly
recognized over the decades the staggering health disparities suffered
by the First Americans. Congress was first horrified into action by
these health disparities in 1927 when Congress passed the Snyder Act.
In 1976 Congress renewed their dedication to end these disparities with
the Indian Healthcare Improvement Act, and again in 1986 and in 1992.
Now the Native American community waits for the House of
Representatives to again renew their pledge to eradicate the alarming
health disparities suffered by the Native American Community by passing
H.R. 1328, the reauthorization of the Indian Healthcare Improvement
Act. With all the legislation passed one would think that the health
disparities and barriers to access suffered by American Indians and
Alaska Natives would have been ended or at least ameliorated and yet
these disparities persist.
Current Health Disparities Levels: Native Americans continue to
face the highest levels of health disparities for all races combined.
The infant mortality rate is 150% greater for Native Americans than
that of Caucasian infants.\1\ For a quick comparison, the rate of
Sudden Infant Death Syndrome for Native American infants is the same as
for infants in Haiti. American Indians and Alaska Natives are 2.6 times
more likely to be diagnosed with diabetes than the general
population.\2\ Native Americans suffer higher mortality rates due to
``accidents (38% higher than the general population rate), chronic
liver disease and cirrhosis (126% higher), and diabetes (54% higher).''
\3\ Native peoples ages 15 to 34 constitute 64% of all suicides
nationwide. American Indians and Alaska Natives are only 1% of the
general population.\4\ As a recent example, in the past 12 months there
have been 213 suicide attempts on the Rosebud Sioux reservation. That
is at least one suicide attempt a day. Alcohol-related deaths in
general were 178% higher than the rate for all races combined.\5\
Native Americans also have the fastest transition between diagnosis and
death for HIV/AIDs and most forms of cancer.\6\ Urban Indians share
fully these health disparities as the 2000 U.S. Census found that over
60% of self-identified Native Americans live in urban areas.
---------------------------------------------------------------------------
\1\ Trends in Indian Health 2000-2001, Indian Health Service, 2002.
\2\ Indian Healthcare Improvement Act Fact Sheet, National Indian
Health Board, 2008. See also, Unnatural Causes: Is Inequality Making Us
Sick? PBS Documentary, 2008.
\3\ The Health Status of Urban American Indians and Alaska Natives,
Urban Indian Health Institute, 2004.
\4\ 2006 National Survey on Drug Use and Health: National Findings
\5\ ibid
\6\ fn 1.
---------------------------------------------------------------------------
These health disparities are the direct result of continuing social
and economic inequality that lead to disparities in healthcare
accessibility. The idea that health disparities are the direct result
of health inequality is not a new idea\7\ and in the Native American
community its existence is well documented.\8\ Lifting the Native
American community out of the abyss of inequalities that impact their
health and dramatically shorten their life requires Congress to stand
by the treaty promises and the passed legislation. It requires
addressing the chronic underfunding of IHS programs, the lack of
culturally competent providers, and the poor social determinants of
health. The following testimony will address each of these problems
from the urban Indian provider prospective.
---------------------------------------------------------------------------
\7\ See Reducing Health Disparities, presentation by Dennis
Raphael, PhD Dec 14th, 2006 http://video.google.com/videoplay?docid=-
4129139685624192201&hl=en last accessed 6/23/2008.
\8\ fn 2.
---------------------------------------------------------------------------
Lack of Funding: As this Subcommittee knows the Urban Indian Health
Program has been under sustained attack from the Administration. The
UIHP has been zeroed out of the President's proposed budget for FY
2009. This is the third attempt by the Bush Administration to eradicate
the Urban Indian Health Program under the false assumption that the
UIHP provides duplicitous services. This assumption not only ignores
the trust responsibility of the Federal Government to provide
healthcare to Native Americans regardless of where they reside\9\, it
also ignores the health inequalities suffered by AI/AN. Zeroing out the
UIHP program would have a devastating impact not only on the 36 urban
Indian clinics dedicated to serving urban Indians, it would also be
extremely damaging to the Tribes as they would be the ones absorbing
the nearly 200,000 patients served annually.
---------------------------------------------------------------------------
\9\ Senate Report 100-508, Indian Healthcare Amendments of 1987,
Sept. 14, 1988, p. 25.
---------------------------------------------------------------------------
Fortuitously for the UIHP, Congress vehemently disagrees with the
Administration's views and has rejected each and every attempt by the
Administration to kill the program.\10\ However, constantly fighting
for even baseline funding necessary to maintain the clinics limits the
UIHPs ability to expand services to meet the growing needs of the
patient population--a population that is itself rapidly growing.
Although urban Indian health clinics are able to leverage two non-IHS
dollars for every IHS dollar received--making a program a very sound
investment--the constant threat of elimination from the Bush
Administration places the 36 clinics in a difficult situation. Clinics
report that it is difficult to obtain necessary loans for facilities
repair and expansion, that they have problems recruiting and retaining
necessary personal, and that they are unable to expand programs needed
by their patient population. Urban Indian health clinics have done
impressive things with limited resources from significantly reducing
the rates of diabetes in their patient populations to decreasing
suicide attempts and relapse of addictive behaviors. However, these
services are only the bare minimum of what the patient population needs
and what the Urban Indian Health Program could provide if time, energy,
and resources were not constantly drained by the need to fight the
Administration's attack on the program's very existence.
---------------------------------------------------------------------------
\10\ See House Report 109-46, House Report 110-187, and Senate
Report 109-275.
---------------------------------------------------------------------------
It is difficult to determine whether or not the urban Indian
health clinics reside in areas that follow the so-called 80-20 rule,
which says that 80% of the medical costs for an area are driven by 20%
of the population because the urban Indian population tends to be
highly fluid, transitioning between reservation and urban centers with
increasing frequency.\11\ The UIHP does not have the funds to do an
appropriate needs assessment study of this shifting population to even
determine what needs are driving the costs. There hasn't been a needs
assessment done for the urban Indian population since the early 1980s.
The most recent estimates done by the Indian Health Service suggests
that the urban Indian clinics are currently funded at 22% of the need,
and that was the need rates calculated in 1981.
---------------------------------------------------------------------------
\11\ ``[The] patterns of cross or circular migration on and off the
reservations make it misleading to suggest that reservations and urban
Indians are two well-defined groups,'' United States v. Raszkiewicz,
169 F.3w 459, 465--7th Cir. 1999.
---------------------------------------------------------------------------
The most recent regulations promulgated by the Centers for
Medicaid and Medicare services are also badly damaging to the financial
security of the Urban Indian Health Program. As will be discussed in a
later section, nearly one in four Indians living in urban centers live
in poverty and nearly half live below the 200% of the Federal poverty
level.\12\ This means that the UIHP sees a high number of Medicaid
patients. The patients are often what are classified as `complex
patients' meaning they suffer from chronic disease, and often multiple,
co-morbid, chronic diseases.\13\ The regulations on case-management and
outpatient hospital services significantly undercut the financial
stability of many urban Indian health clinics as States' limit services
available in their State Medicaid plans.\14\ Urban Indian health
clinics are better able to weather the damage of these regulations than
many other clinics, assuming that their base funding through IHS
continues and is no longer under attack. However, the combined impact
of these regulations and the attack on the UIHP funding by the
Administration, if both are successful, would mean the complete
shutdown of nearly all 36 clinics across the country, leaving the UIPH
potential patient population of 939,588 Native Americans without
primary care.
---------------------------------------------------------------------------
\12\ fn 3.
\13\ The general trifecta of chronic disease suffered by urban
Indians is diabetes, heart disease, and hypertension. These three
disease reinforce the symptoms and debilitating impact of the others.
Fn 3.
\14\ See generally The Administration's Medicaid Regulations:
State-by-State Impacts. Committee on Oversight and Reform, March 2008.
---------------------------------------------------------------------------
Recommendations:
Restoration of the Urban Indian Health Program in the FY
2009 Budget, and continued funding of the program.\15\
---------------------------------------------------------------------------
\15\ The suggested restoration level for UIHP in the FY 2009 budget
is 40 million. Views and Estimates. Senate Committee on Indian Affairs.
Febuary 2008.
---------------------------------------------------------------------------
Repeal of the CMS regulations related to case management
services\16\ and redefinition of Medicaid outpatient hospital
services.\17\
---------------------------------------------------------------------------
\16\ The case management regulation was published December 4, 2007
at 72 Federal Register 68007.
\17\ The redefinition of outpatient hospital services was published
September 22, 2008 at 73 Federal Register 9685.
---------------------------------------------------------------------------
Appropriate funds to conduct a full needs assessment for
the urban Indian community.
Culturally Competent Care: One of the single largest barriers to
care, and largest reasons for continuing health inequality, is the lack
of culturally competent care available to not just Native Americans,
but all minorities. Patients treated without necessary cultural
sensitivity and understanding suffer worse health outcomes, are more
likely to have a relapse, and more likely to have a serious medical
crisis.\18\ Culturally competent care is not a luxury, but a necessity
if we are going to be serious about reducing the health disparities and
health inequality faced by all minorities.
---------------------------------------------------------------------------
\18\ See fn 1.
---------------------------------------------------------------------------
Cultural competency for Native Americans means the provider must
not only be aware of the larger historical and cultural context of the
patient, but also be aware of the specific culture of that patient's
tribe. Each tribe has its own language and belief systems, which forms
the structure of values within which the provider must be able to speak
in order to achieve good health outcomes. Native American patients have
a greater tendency to distrust non-Native providers as their history is
replete with instances where the health provider has actually been the
deliverer of illness and ultimately death.\19\ Providers, when dealing
with Native American patients, have consistently found that placing the
needs of the patient in the framework of family needs and
responsibilities, as opposed to individual needs, leads to greater
compliance health and medicine regimens.\20\
---------------------------------------------------------------------------
\19\ Broken Promises: Evaluating the Native American Healthcare
System. Civil Rights Commission. 2004
\20\ Invisible Tribes: Urban Indians and Their Health in a Changing
Worlds. Urban Indian Health Commission. 2007
---------------------------------------------------------------------------
Culturally competent care is one of the major reasons that the
Urban Indian Health Program can not seriously be considered duplicitous
with other Federal programs such as the Community Health Centers.\21\
The Urban Indian Health Program is currently the only source of
culturally sensitive care for Native Americans living in urban centers.
However, the UIHP, like IHS as a whole, has difficulty finding
healthcare providers with the appropriate cultural knowledge. The
growing lack of primary care providers from obstetricians to RNs is
well documented. What has not been well documented, or even
significantly explored, is the lack of culturally competent health
providers. Only recently have there been serious discussion regarding
paying for on-the-job training in cultural competency within CMS.\22\
More important, from the perspective of NCUIH, are programs that
encourage Native Americans and minorities to enter into the health
professions. Not only enter into the health professions, but return to
their communities to provider care.
---------------------------------------------------------------------------
\21\ The National Association of Community Health Clinics has
consistently supported the Urban Indian Health Program, and have
declared in Congressional testimony and letters of support.
\22\ There was very limited discussion regarding a potential
payment code regarding culturally competent care.
---------------------------------------------------------------------------
Current proposed changes by the Health Resources and Services
Administration (HRSA) to the classification and methodology of the
health professional shortage areas (HPSA) and medically underserved
areas/populations (MUA/P) are concerning as it could have an damaging
impact on rural health providers and the providers with a largely
minority patient populations. The proposed change to the classification
and methodology does not include a calculation for determining the
cultural competency of the providers available. Any potential change to
the HPSA and MUA/P classifications must also include an analysis of the
cultural competency of the health providers of that area for the
patient population that they serve.
Recommendations:
Increase the number of scholarships available to minority
students that not only encourage them to enter into the health
profession, but to return to their communities. Programs such as the
Indian Health Professions Scholarships (P.L. 94-437, section 104),
Indian health Service Loan Repayment Program (P.L. 94-437, section
108), and the Health Professions Recruitment Program for Indians (P.L.
94-437, section 102). It is not enough to simply encourage minority
students to enter into the health professions; there must also be a
financially viable way for them to return to their communities.
Include cultural competency of health providers as a
metric for determining classifications such as HPSA and MUA/P.
Include cultural competency as a requirement for
government health programs and grants, such as 330 CHC grants, SAMHSA
provider grants, and similar programs.
Social Determinates of Health: As the health professionals become
more alarmed at the growing and irrefutable health disparities between
the general population and minorities, rich and poor, urban and rural,
greater amounts of research have been dedicated to determining the
social determinants of health. The results of this research are not
surprising. Poverty, homelessness, social and physical isolation are
all key indicators of health inequality. The differences between the
general population and minorities, particularly Native Americans, in
living conditions are directly linked in the extreme differences in
health status. It is an enormous social injustice that those with the
greatest living disparity also suffer the greatest health disparity. It
is an even greater injustice when one realizes that the group living
with the greatest disparities across the board from education,
purchasing power parity, and health are the Native Americans.
Urban Indians suffer greater rates of poverty, homelessness,
unemployment, and social isolation than the general population.\23\
These disparities translate into health disparities that are difficult
for any one provider, or set of providers, to seriously address.\24\
Rather, in order for the underlying causes of the health disparities to
be seriously addressed there must be a comprehensive rethinking of
Federal health and social policy towards Native Americans. The
clustering of disadvantage--meaning Native Americans suffer
unemployment, poverty, poor housing, and poor health outcomes all at
once--means that there must be a coherent attempt to address those
problems as part of the continuum of inequality as opposed to
approaching each problem individually.
---------------------------------------------------------------------------
\23\ See fn 3, fn 20.
\24\ See generally fn 7.
---------------------------------------------------------------------------
From the health provider perspective this means transitioning from
a medical crisis model of care to a wellness model of care that
involving dealing not only with the immediate illness but also the
underlying social causes. This would require a shift in Federal payment
policy for programs such as Medicare and Medicaid from incremental
payment scale to an episodic payment plan. It would also mean a focus
on developing a medical home for the patients rather than the current
split between primary care, specialty care, mental health, and social
services. Developing a medical home means employing the `medical pod'
method organizing health professionals. These proposed changes are
discussed below.
The current payment method under Medicaid and Medicare, unless the
patient is considered a `complex patient,' pays providers in 15 minute
increments. Generally speaking those 15 minutes are `sticky,' meaning
that Medicaid and Medicare pay an increasingly smaller percentage of
the cost the longer the appointment takes. If a patient has been
classified as a `complex patient,' meaning that the patient has
multiple conditions, or a complex chronic disease, then the entire
episode of treatment is paid for. It is a good thing that CMS has moved
towards a complex patient code, but if we are to be serious about
reducing health disparities we want to address chronic disease and
illness before the patient becomes diabetic, develops heart disease or
hypertension. The National Council of Urban Indian Health would
encourage broadening the complex patient code to include those who are
in the preconditions for chronic disease. It is difficult, if not
impossible, to explain the significant life style changes that must
happen when someone is diagnosed as pre-diabetic in order to prevent
the onset of diabetes in a single 15 minute appointment. Changing the
patient codes to expand the definition of complex patient would give
providers the necessary time with their at-risk patients before they
become patients with chronic illness.
There has been a great deal of discussion regarding the development
the medical home model of care within the United States. A medical home
means that the patient receives all of their care except complex
specialty care for advanced illness through a single provider. This
model increases communication between the healthcare professionals
involved in the patient's care, increases patient involvement, and
increases compliance with the health regimen developed by the health
professionals. When the medical pod method is employed in conjunction
with medical home model social workers and similar professionals become
involved in the care of patients, increasing their health outcomes.
These professionals close the loop in patient care to ensure that the
patient continues implementation of the health regimen outside the
healthcare delivery setting. Social workers also bringing in the social
aspects of health: unemployment, poverty, poor housing. Addressing
these issues through the healthcare lens increases the likelihood the
patient will have a good health outcome.
Recommendations:
Broaden the definition of `complex patient' for Medicaid
and Medicare payment codes.
Encourage the transition to a medical home by allowing
billing of social services and case management to Medicaid and
Medicare.
Encourage the use of the `medical pod' method of care.
Statement of Papa Ola Lokahi
Aloha Chairman Stark and Members of the Subcommittee on Health.
Thank you for the opportunity to provide a statement on addressing the
on-going and increasing health disparities which our nation's
population is experiencing. My name is Hardy Spoehr, Executive Director
of Papa Ola Lokahi (POL), the Native Hawaiian Health Board. My comments
will be primarily focused on health disparities in the Native Hawaiian
population.
Native Hawaiians, like American Indians and Alaska Natives, are
Indigenous Peoples of the United States. The Native Hawaiian population
comprises a little over 400,000 people with the majority still being
resident in the State of Hawai`i. It is important to note, however,
that today Native Hawaiians live in every state of the nation. The 2000
Census identified:
Where Native Hawaiians Live State of Hawai`i Number PercentCounty of Kaua`i 13,511 ................
City and County of Honolulu 153,117 ................
County of Hawai`i 43,010 ................
County of Kaua`i 30,017 ................
Total, State of Hawai`i 239,655 61%Continental United States ............... ................(by HRSA Region) ............... ................
Southwest Region (excluding Hawai`i) 85,754 ................
Northwest Region 42,247 ................
Southeast Region 18,258 ................
Northeast Region 15,248 ................
Total, Continental U.S. 161,507 39% Total, Native Hawaiians 401,162 100%Source: 2000 U.S. Census
The top ten Congressional Districts with Native Hawaiian residents
are:
Hawai`i--2nd District........ 162,128 Washington--9th 2,521
District.
Hawai`i--1st District........ 77,527 Washington--6th 2,237
District.
Nevada--1st District......... 3,464 California--7th 2,045
District.
Nevada--3rd District......... 3,451 California--10t 1,957
h District.
California--13th District.... 2,972 Alaska--0 1,878
District.Source: 2000 U.S. Census
Health Disparities and Native Hawaiians
Native Hawaiians along with other Pacific Islanders are identified
by the U.S. Census Bureau as one of six racial and/or ethnic
populations within the United States. These designations are in federal
statutes and Executive Branch policy directives and serve as a basis
for relative socio-economic comparisons in the United States. These
comparisons also influence funding levels for various federal programs
targeting socio-economic disparities in and among the various
populations. As a specific population, Native Hawaiians have serious
health disparities which trace their root causes back to times of
contact with foreigners during the 18th and 19th centuries. The
severity of these disparities continues and have been enumerated in
proposed reauthorization legislation for the Native Hawaiian Healthcare
Improvement Act.
In a study by Johnson, Oyama, and Le Marchand entitled ``Hawaiian
Health Update'' (1998) and funded by POL, five major findings were
identified which remain valid today:
1. That when reviewing the mortality trends since 1910, Native
Hawaiians have experienced the highest mortality rates of any ethnic
group in Hawai`i and have had among the lowest life expectancy of all
groups in the population.
2. That Native Hawaiian life expectancy at birth has ranged from
five to ten years less than the overall population average.
3. That Native Hawaiians have higher age-adjusted morbidity rates
for hypertension, asthma, diabetes and heart conditions than the total
population.
4. That the ``years of productive life lost'' by Native Hawaiians
is the highest of any ethnic group in Hawai`i.
5. That cancer mortality rates for Native Hawaiians, particularly
females, are among the highest in the United States. Death rates for
Native Hawaiian women are 70% higher than for all women in Hawaii.
The extent of health disparities is clearly evident in Hawai`i
State health data which, it is assumed, is similar for Native Hawaiians
living on the Continental United states.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In general, the current status of Native Hawaiian health can be
summarized in five major points:
1. There is a general lack of awareness nationally about Native
Hawaiians and Native Hawaiian health status and related issues.
2. There is indifference by the general Hawai`i population to
Native Hawaiian health.
3. There is a general lack of acceptance of Native Hawaiian-
specific data among federal agencies in the national arena where
resources are allocated.
4. There is a general lack of cultural competency and
understanding of Native Hawaiians in the providing of healthcare
services, teaching and education, and in conducting research.
5. There is under representation of Native Hawaiians in health,
allied-health, and research professions.
Data is critical to determining how best to move in the future. A
number of federal agencies have not fully implemented the reporting
requirements mandated by Office of management and Budget in 1998 and
continue to use an antiquated `Asian Pacific Islander' (API) or `Asian
American Pacific Islander' (AAPI) identifier instead of the required
disaggregated `A' (Asian), `AA' (Asian American) and `NHOPI' (Native
Hawaiian and Other Pacific Islander) or ``NHPI'' identifiers. The
result is that often in national health studies and reports, the
national health status trends, or health profiles, for Native Hawaiians
and other Pacific Islanders is not apparent because it is masked by the
larger Asian component.
Papa Ola Lokahi strongly recommends that the Congress reviews the
untimely implementation of Office of Management and Budget (OMB) policy
and clearly states that health and related data needs to be collected,
analyzed, and reported in accordance with OMB Circulars and Directives
including its ``revisions to the standards for classification for
Federal data on race and ethnicity,'' dated October 30, 1997, and
codified as 62 FR 58782-58790; its Bulletin No. 00-02 dated March 9,
2000; its Working Group Report dated December 15, 2000; and its
memorandum for the President's Management Council dated January 20,
2006, entitled ``Guidance on Agency Survey and Standardized Information
Collections.'' All of these have to do with collecting and reporting
data specifically for Native Hawaiians and other Pacific Islanders.
Additionally, Papa Ola Lokahi through its years of operations in
Hawai`i and across the nation commends to the Congress its findings:
1. There is no ``one-size-fits-all'' model for healthcare
delivery--each community has its own priorities and ways of doing
things. This is applicable to Native Hawaiians living in Hawai`i and to
Native Hawaiian and Pacific Islander communities spread across the
Continental United States.
2. The health programs that are working in Native Hawaiian
communities need to be highlighted, replicated and built upon for
continued success.
3. Traditional Native Hawaiian healing and spirituality must be
integral components of any major effort to address Native Hawaiian
health.
4. Research must be respectful of Native Hawaiian ways and
customs.
5. Disease prevention focused on individual responsibility needs
to be emphasized in any health program.
6. Physicians, more specifically Native Hawaiian physicians, need
to be involved in program development and community interventions.
7. Native Hawaiians who participate in data collection and
analysis feel they are part of making the Native Hawaiian community as
a whole healthier.
8. When working with Native Hawaiian individuals, health
providers need to utilize the strengths of the family--a multi-
generational approach.
9. Service providers working in Native Hawaiian communities need
to utilize mentors and role models to educate communities and
professionals alike.
10. The academic approach to research is often incompatible with
Native Hawaiian community approaches and desires.
11. A major effort needs to continue to increase the number of
Native Hawaiian health researchers and health and allied-health
professionals.
12. An Institutional Review Board (IRB) model controlled by the
community in which research is being conducted is an excellent model
and tool for monitoring research and ensuring that there is a definable
community benefit.
Mahalo for the opportunity to provide these thoughts for
consideration.
Statement of Special Olympics International
Testimony on Behalf of Special Olympics
As Senior Vice President of Special Olympics International, I,
Stephen B. Corbin, submit this written testimony on behalf of Special
Olympics International, to the record of the U.S. House of
Representatives, Committee on Ways and Means, Subcommittee on Health's
hearing of June 10, 2008, ``Addressing Disparities in Health and
Healthcare: Issues for Reform.'' Special Olympics provides year-round
sports training and athletic competition in a variety of Olympic-type
sports for children and adults with intellectual disabilities, giving
them continuing opportunities to develop physical fitness, demonstrate
courage, experience joy and participate in a sharing of gifts, skills
and friendship with their families, other Special Olympics' athletes
and the community. Last year, almost 550,000 athletes with intellectual
disabilities participated in 20,000 sports competitions across the
United States--an average of almost 28 events per day. What began as a
sports movement for individuals with intellectual disabilities has
evolved into a worldwide movement to improve the health and quality of
life of individuals with intellectual disabilities through sports
competition and related programs such as our Healthy Athletes Program.
Health issues are of particular concern for those we serve. Like
race, ethnic origin, and gender, intellectual disabilities are a life-
long phenomenon accompanied by significant health disparities across
the lifespan. Similarly, like other members of groups who face health
inequity and health disparities, both access to healthcare and quality
healthcare are significant issues for individuals with intellectual
disabilities. For example, only 1 in 50 primary care physicians has
received clinical training to qualify to properly treat the more than 6
million individuals with intellectual disabilities in the United
States. Complicating the matter further, there is no reliable source
for people with intellectual disabilities and their families to find
qualified healthcare providers who are willing to treat their special
needs. Few health practitioners want to ``deal'' with individuals with
intellectual disabilities. As a result, when they are able to find
healthcare providers willing to see them, the quality of care provided
to people with intellectual disabilities is often inferior and
inconsistent.
Our research shows that individuals with intellectual disabilities
in the United States have poorer health, more specialized healthcare
needs, and greater difficulty accessing healthcare services and
doctors. For example, in 2006, at the U.S. National Games in Iowa, 1337
Special Olympic Athletes were screened through our Healthy Athletes
program. More than 53% of our athletes failed hearing tests. Almost 50%
failed vision screenings and were given prescription glasses onsite.
Twenty-three percent (23%) were overweight in addition to the 36% who
were obese. More than 20% had untreated tooth decay and 38% had
diseases of the gums. Some 34% had osteoporosis screenings that
indicated a need for further examination.
Though routinely denied access to healthcare, the population of
individuals with intellectual disabilities is excluded from current
policies that cover the ``medically underserved'' in the Health
Resources and Services Administration (HRSA), the National Institutes
of Health (NIH), and other United States Government programs.
Individuals with disabilities are not only underserved, they are ill-
served. They do not even receive the same benefits, research dollars,
and government attention as other individuals who face disparate
treatment based on race, gender, and ethnic origin.
Special Olympics has documented that health equity and health
status disparities are significant issues for individuals with
intellectual disabilities. This Committee can have a dramatic impact as
it seeks ways to address disparities in health and healthcare and looks
at health disparities as an issue for future healthcare reform. We urge
the Committee to: include individuals with intellectual disabilities
amongst those with documented disparities in health and access to
healthcare; include them amongst the ``medically underserved;'' and
include the health and healthcare needs of individuals with
intellectual disabilities in discussions of all aspects of health
disparities.