Memorandum
Date: 11/24/2008
To: Hillary Clinton, President Elect
From: Policy Analyst, Health Care Transition Team
RE: Multilevel Approach to Eliminating Racial and Ethnic Health Disparities
Background
Differential health outcomes in racial and ethnic minorities include: obesity in African Americans [1], liver cancer in Asian Americans [2], infectious diseases in Latinos [3], and diabetes in Native Americans. [4]
Access and quality factors are additional markers of disparities. According to the 2006 National Healthcare Disparities Report, differentials exist in quality measures, access to care, different level and type of care, many care settings, and in subpopulations. Attempts to address these factors to eliminate health disparities have not been sufficient. Of the measures documented in the 2006 report, a quarter has shown improvement, while a third has worsened. [5] There is a need to both reconceptualize existing frameworks as well as develop strategies that are more effective.
The Institute of Medicine in its notable 2002 report, Unequal Treatment, declared that health disparities for racial and ethnic minorities persist despite controlling for access-related factors. Furthermore, “the sources of these disparities are complex, are rooted in historic and contemporary inequities, and involve many participants at several levels…” [6] Residential segregation and its ability to shape socioeconomic status at individual, neighborhood, and community levels have been cited as a major cause of differential health outcomes. [7]
These structural considerations offer a new perspective for understanding health disparities. Current frameworks attempt to eliminate disparities without addressing the structural barriers that institutionally reinforce differential outcomes. As the Institute of Medicine suggests: “a comprehensive, multi-level strategy is needed to eliminate these disparities.” [6]
Priorities
All priorities attempt to address any combination of access, quality, and/or societal structures as part of a multi-level effort to eliminate racial and ethnic health disparities.
Priority 1: Universal coverage should also include immigrants, many of whom are currently restricted from accessing Medicaid and SCHIP. [8]
PRO: Ensuring access to all people despite immigration status would diminish the utilization of safety net resources. [8,9] Prevention could diminish the incidence of many communicable diseases. [9,10]
CON: Funds are required in order to expand coverage. Furthermore, anti-immigrant sentiment may lead to opposition. The issue should be promoted as a public health issue.
Priority 2: Incorporate equity goals into existing policy for related fields such as education, schools, and housing.
PRO: By focusing upon socioeconomically related areas, improving societal structures will indirectly help eliminate health disparities where access and quality strategies have made insufficient progress [5,6,11] Development of entirely new strategies is unnecessary due to reliance upon existing goals. Low-income racial and ethnic communities would support.
CON: Improvements in health status are not directly obvious. Those opposed are likely to disfavor integrationist policies.
Priority 3: Direct the Department of Health and Human Services (HHS) to improve standardized collection of disaggregated data that includes both socioeconomic factors and ethnic specific information.
PRO: Insufficient data collected for ethnic subgroups have reinforced the lack of attention to disparities. In particular, Latino and Asian American data are inadequate as reflected in few Healthy People objectives. [12-14] Systematic data collection could monitor the impact of health policy changes on racial and ethnic groups. [11]
CON: Investment of resources is required to develop a coordinated and comprehensive system that could collect information nationally.
Priority 4: Expand HHS efforts to develop, disseminate, and enforce quality standards.
PRO: Translating research into practice and policy would apply evidence-based methods to improve tested standards of quality. [15]
CON: The coordination of systematic literature reviews, large-scale dissemination of guidelines, and enforcement of standards require an investment of resources.
Priority 5: Structurally improve provision of culturally appropriate services in medical institutions through language assistance, culturally sensitive practices, and provider education curricula.
PRO: Title VI (Civil Rights Act) prohibiting discrimination by institutions receiving federal funding is already in place to legally enforce measures such as language assistance. [9,11] Racial/ethnic concordance of providers and language assistance only are insufficient to ensure high quality. [9,16]
CON: Healthcare institutions and schools may object to interference by legal standards. Administrators of institutions should be carefully approached to garner support. Additional Policy Considerations
Specific policy issues including some of those noted above should be given special consideration.
Funding, Time, and Labor Constraints: Priorities 1, 3, and 4 require direct allocation of funding. Priorities 2 and 5 shift some responsibility to other institutions but may require funding indirectly. Priority 1 may ultimately be profitable as strains on safety net and public health disaster response systems are reduced. All priorities require time, labor constraints, and commitment to implement systems and structures.
Evaluation of Effectiveness:
All strategies, especially priority 2, will require a span of many years before the effects can be conclusively positive. The collection of standardized data will help facilitate measurements of improvement.
Eliminating racial and ethnic disparities is as complex as the causes. This multifaceted strategy should help make great improvements. These proposed priorities allow a variety of options that the new presidential administration may focus on under your leadership. _____________________________________
[1] Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. JAMA. 2006;295:1549-1555.
[2] Rosenblatt KA, Weiss NS, Schwartz SM. Liver cancer in Asian migrants to the United States and their descendants. Cancer Causes Control. 1996;7:345-350.
[3] Sumaya CV. Major infectious diseases causing excess morbidity in the Hispanic population. Arch Intern Med. 1991;151:1513-1520.
[4] Yeates K, Tonelli M. Indigenous health: update on the impact of diabetes and chronic kidney disease. Curr Opin Nephrol Hypertens. 2006;15:588-592.
[5] 2006 National Healthcare Disparities Report. Rockville: Agency for Healthcare Research and Quality; 2006.
[6] Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press; 2003.
[7] Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116:404-416.
[8] Thamer M, Rinehart C. Public and private health insurance of US foreign-born residents: implications of the 1996 welfare reform law. Ethn Health. 1998;3:19-29.
[9] Derose KP, Escarce JJ, Lurie N. Immigrants and health care: sources of vulnerability. Health Aff (Millwood). 2007;26:1258-1268.
[10] Adekoya N. Infectious diseases treated in emergency departments: United States, 2001. J Health Care Poor Underserved. 2005;16:487-496.
[11] Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev. 2000;21:75-90.
[12] Vega WA, Amaro H. Latino outlook: good health, uncertain prognosis. Annu Rev Public Health. 1994;15:39-67.
[13] Williams DR, Collins C. U.S. Socioeconomic and Racial Differences in Health: Patterns and Explanations. Annual Review of Sociology. 1995;21:349-286.
[14] Chen MS, Jr., Hawks BL. A debunking of the myth of healthy Asian Americans and Pacific Islanders. Am J Health Promot. 1995;9:261-268.
[15] Kerner JF. Integrating research, practice, and policy: what we see depends on where we stand. J Public Health Manag Pract. 2008;14:193-198.
[16] LaVeist TA, Nuru-Jeter A, Jones KE. The association of doctor-patient race concordance with health services utilization. J Public Health Policy. 2003;24:312-323. |
