Bridging the Gap; Eliminating Racial
and Ethnic Health Disparities
Annual Meeting, Chicago 2000
Welcome to our forum on dealing with health disparities and racial and ethnic minorities. Despite what's been described as unprecedented national economic growth, two of the biggest issues in this on-going presidential campaign are a) a prescription drug benefit for Medicare recipients and b) a Patient Bill of Rights. This reminds us again that questions about American health care, specifically who gets what kind of care and who doesn't, remain unresolved. What we do know is that how healthy you are and what kind of care you get when that health fails depends a great deal on who and where you are. For example, while heart disease is still the No. 1 killer in all ethnic groups, HIV and AIDS are in the top 5 for Black Americans and Latino's, but not for Whites for Asians.
Issues of income do matter, to be sure but some of our panelists here will tell you, quite frankly that when it comes to good health care, money isn't everything. It's a lot more complicated than just who has the money or the insurance to see a doctor. That's why we have assembled this distinguished panel this morning that's going to take on what it will take to bridge the gap and eliminate the racial and ethnic health disparities.
Now, the way we're going to run this this morning, we're going to first hear from all our panelists and then we'll begin sort of a dialogue with me as moderator; my name is Derek McGinty by the way, and after that at some point we will take questions from the audience and hopefully if you have some questions and I'll bring it up as our conversation goes along, hopefully there will be a microphone by that time.
We're first going to hear from Dr. Marcia Brand. She is Deputy Directory of the Federal Office of Rural Health Policy. It's located within the Health Resources and Services Administration and promotes better health care service in rural America to a variety of health policy research and grant activities.
We'll then hear from State Rep. Ray Miller of Ohio. He was elected in 1998 and during his time in the General Assembly he has been the chief sponsor of some of the most significant health care, human services and education legislation ever enacted in the State of Ohio.
Later on we'll hear from Toni Plummer, the Executive Director of Cherish our Indian Children, Inc. She's a native of Families Empowerment in Whitefish, Montana. These organizations are a collaborative initiative of tribal governments and urban Indian organizations across the state committed to improving the health and well being of Montana's Native American populations.
Also here with us is Mr. Adolph Falcon. He is Vice President for Policy and Research at the National Alliance for Hispanic Health. Now the NAHH is the oldest and largest network of health and human service providers serving more than 5 million Hispanic consumers throughout the U.S.
DR. MARCIA BRAND: Thank you for inviting me to be here with you today. It's my pleasure and it's always my pleasure to come to Chicago. This is one of my favorite cities. The last time I was in Chicago I was here with my sister; we ran the Chicago Marathon. It's a great race; I highly recommend it if you're interested in that kind of thing and if you stop at Nike Town over on Michigan Avenue this afternoon and buy your shoes I think by the end of October you'd be about ready, so I would encourage you to consider that.
It's also very nice to get out of Washington at this time of the year. It's hot as Derek and others can tell you and it's also, as you may have noticed, it's an election year and that sort of makes things a bit different. I know that the general population experiences that election year in a different way than perhaps those of us who work in the Administration do. We begin to look around and we begin to get kind of anxious because we know that things are going to change regardless of the outcome of the election and so we start thinking about what those changes might be. For example, right now we have Secretary Shalala who is the longest serving secretary in the history of the Department of HHS. We no longer brief Donna; she briefs us. If you had any idea how difficult it is to get a surgeon general confirmed, you would understand why we are not looking forward to some of these changes. So it's nice to be in Chicago and to be away and to be thinking about a different set of problems.
I bring you greetings from Dr. Claude Earl Fox. He is the Administrator of the Health Resources and Services Administration. He regrets that he had a prior commitment and can't join us here today.
The topic of this session, eliminating racial and ethnic disparities, is so important that the federal government recently made it one of two principle health goals for the nation. In January the Department of HHS released Healthy People, 2010; a document containing health goals the nation will work towards over the next decade. It follows two previous Healthy People documents for the years 1990 and 2000. Healthy People 2010 is a large a very complex document. It has 28 focus areas; it has 467 objectives and this is the unfortunate outcome of a concerted attempt to simplify the previous documents, so it is certainly a pretty daunting document. But it does have two clear overarching goals. One of those goals is to eliminate racial and ethic disparities in health, and a second is to increase the number of years Americans live and the quality of their life.
What do we mean when we discuss health disparities along racial and ethnic groups. It means that African Americans, Hispanics, American Indians and Alaska Natives and Pacific Islanders have higher rates of illness and death than the U.S. population as a whole. Because these groups are expected to grow as a proportion of the total U.S. population during the 21st century, America's collective well being will reflect our ability to improve their health.
Let me give you some statistics that I think will help to frame our discussion this morning. The infant mortality rate among African American, American Indians and Alaska Natives is more than double the rate for Whites. Death rates, as Derek said, due to heart disease are more than 40% higher for African Americans than for Whites. The cancer death rate is 30% higher for African Americans than for Whites. The AIDS death rate among African Americans is more than 7 times that of Whites. Hispanic Americans, American Indians and Alaska Natives are almost twice as likely to die from diabetes as non-Hispanic Whites. In fact The Pima Tribe in Arizona has one of the highest rates from diabetes in the world. Hispanics account for twice as many new cases of tuberculosis than their percentage in the national population and have higher rates of high blood pressure and obesity than non-Hispanic Whites.
American Indians and Alaska Natives have disproportionately high death rates from unintentional injuries and suicide, and minority children, ages 2 to 4, have twice as much dental decay as White children and American Indian children have 5 times more decay than White children. I see some of you going my gosh; that's to me a particularly alarming statistic. How many of you have ever had a toothache. About half of the audience and this why this is particularly interesting to me. One of my original disciplines was dental hygiene which was why when Derek was going to eat a blueberry muffin I was willing to tell him if he had blueberries stuck in his teeth. But my concern is a large co-hort of the population has not experienced any kind of dental pain so they had no idea how debilitating it is and those children with untreated dental disease are certainly not able to learn and are not able to flourish. So that's a particularly alarming statistic.
This past February, soon after the release of the Healthy People 2010, President Clinton announced an initiative to combat six of the most significant racial disparities, most of which I just mentioned. The disparities cover infant mortality; cancer; cardiovascular disease; diabetes; HIV/AIDS and immunizations and they were picked for two very important reasons. First, because these disparities together represent a major portion of the health problems in minority communities. Substantial improvement in these area will significantly improve the groups overall health. Secondly, we already have good base line data in these six areas and that can help us to monitor our progress in reducing the disparities.
I want to take a minute to consider some of the federal perspectives; some of the federal activities that are taking place and I know that the other panelists will talk about what's happening in their states and through their organizations. First of all will reducing these disparities be an easy task and the answer is of course, no. We have no illusions as we begin our work toward the President's goals. We know that these health disparities often mirror inequities in income and education among groups, so much so that income and education can serve as proxy measures for health status.
In general, groups with higher rates of illness and death have higher poverty rates and less education, because higher incomes allow access to medical care, better housing; and safer neighborhoods. Better education gives individuals more access to information and that promotes good health habits and behaviors. But doing this is the right thing and there are many things we can and will do to meet the President's goals.
In helping introduce Healthy People 2010, Surgeon General David Satcher called on the nation to move forward toward a balanced community health system; one that makes access to quality care available to all; that balances early detection of disease with health promotion and disease prevention and that draws on the assets of the entire community including homes, schools, churches and other faith based organizations and civic and local groups. Reducing disparities is more a matter of human cooperation than scientific inspiration.
Those of us who help set this national health policy must reach out and create what we think are real and meaningful partnerships with state and community health officials and professionals. Federal government officials must listen to and learn from you. In turn what we will try to do is provide the resources, the information and the technical assistance that state and local leaders need to make a difference in their communities. And we must help them successfully find their way through the increasingly complex health care system. That's sort of the overall policy at large.
Now I want to tell you a little bit about the agency that I work for and what HRSA is trying to do to reduce these health disparities and the activities that I'm going to talk about principally take place in your state and in your community already. These aren't things that happen in Washington. First, we fund about 700 community health centers around the country and these centers in turn support more than 3,000 clinic sites that provide free or reduced cost, basic health services, such as pre-natal care, immunization, physical exams and chronic disease and management. These centers are the provider of choice for about 10 million people and they serve a large number of minorities. About 30% of the total folks that see are minorities; 34% of the health center clients are Hispanics; and 26% are African Americans.
There is some good news. Funding for the community health centers was just over a billion dollars in FY 2000 and in the markups that congress and there back have begun over the past several weeks, the FY 2001 appropriations bills, it looks like congress will add about 100 million dollars more to the community health center budget. That's particularly important because a number of these health centers are involved in special initiatives that help to monitor and control clients diabetes; boost in for immunization; keep patient's blood pressure under control and reduce the number of low birth weight babies and these are some of the same disparities that the President's initiative has targeted.
We also administer the programs funded under the Ryan White Care Act, which provides health and social services to low income people with HIV and AIDS. In FY 2000 funds for Ryan White were about $1.6 billion. We think that in the year coming that figure could be increased by 50 million to 100 million dollars. So it's good news for HIV/AIDS funding too; not enough, but going in the right direction. Most of the Ryan White funds are spent under Title II of the Act which provides grants to states for comprehensive and life saving drug treatments. About 64% of the Title II clients are minorities. Combating HIV and AIDS disparities among racial and ethnic groups is probably going to be our greatest challenge over the next couple of years.
Another thing that HRSA does, to try to reduce the disparities, is the loan or scholarship programs that promote minority participation and in health professions. Minorities are about 30% of the total U.S. population but only 15% of med school graduates are minorities; 13% of dental school graduates and just 5% of the medical school faculty. The reason this is a problem is because the studies tell us that African American and Hispanic physicians are far more likely than other physicians to treat patients from their own racial and ethnic groups. Additionally, they are more likely than White physicians to treat Medicaid and uninsured patients. That's why HRSA is dedicated to building a health professions work force that looks more like America, because a work force that looks like America will serve America better by increasing minority access to health care. Greater access to health care will help reduce racial disparities we believe and health outcomes. We have put about $300 million annually in these programs and we're trying to encourage the right folks to go into health care and to go into health care in the right places.
That's sort of a brief overview of what the department and the agency are doing to reduce racial and ethnic disparities. I would encourage you to get more information and for those who have a pen handy; there's always some speaker who begins with I'm so glad to be here today and ends with a couple of Web Sites, so I guess I'm traditional in that regard. There are two that you might want to go to. HRSA's Web Site is www.HRSA.gov and another one that I would encourage you to check out is www.raceandhealth.hhs.gov. I think my career as a primary school teacher is probably limited. This is sort of the context within which we'll be having our discussion today and I look forward to hearing what our other panelists have to say.
REP. RAY MILLER: The presentation of the data was powerful to me and hopefully significant for all of us. I'm not moderating the panel but I think she deserves a round of applause for the fine presentation. She said something and I wish I had a note pad I would have written it down exactly about the human factor essential here, not just the scientific approach to health care but the human factor and as Marcia was talking I was thinking about the words of Dr. Martin Luther King when he said "...we are inextricably linked, tied in a single garment of destiny; I can never be all that I ought to be until you are all that you ought to be and you can never be all that you ought to be until I am all that I ought to be". He talked about an interdependence of man. And often times we separate out. The poet John Dunne talked about that same kind of interdependence, the reliance that we have upon one another.
The Bible teaches us that we have a responsibility one to another, to feed the hungry, clothe the naked and so forth but we separate out too much. We really do separate out that that's their problem over there in the urban communities. That's a shame how bad things are for African Americans and Latino's and Native Americans; that's a shame how bad things are for them. So there's no real internalization of the data. There is an approach that we use to fashion programs at the local level, utilizing the data but we don't really internalize it. We don't really feel that pain. Our tolerance of suffering is simply too great; our tolerance of suffering is simply too great. So we've got to learn to work together. There's too much division; there's a lack of cooperation. We've got to form real partnerships and I'm going to talk about a declaration that I think is needed a little bit later on.
Let me have just a couple of points and then I'll sit down because I had 22 points that I wanted to make; 22 very specific recommendations and one should always have just 10. It always sounds good; it's your 10 point plan, so I was able to whittle these down to 10 and I'm not even going to talk about them right now. When we look at why these disparities continue to persist; why do these disparities continue to persist; there are a number of factors; socio-economic factors. I was thinking about a presentation I heard from Uwe Rhinehart more than a decade ago, probably 12, 15 years ago, and he talked about all of those in America who are uninsured. I looked at the data once again; now we have 44 million people in America who are uninsured. 44 million people; 10 million more than we had, actually 11 million more than we had 10 years ago. So the number of people who are uninsured are growing in America as opposed to us having put in place policies at the highest level to reduce the number of those who are uninsured. So the socio-economic factors are obvious. Poverty certainly contributes to poor health. Education or the lack thereof contributes to poor health. Lifestyle choices; smoking and drinking and certainly illegal drug usage. Cultural differences are significant in the area of the reduction of disparities in the area of health care. Diet, nutrition and exercise, obviously; these are things that we know so well. Good preventive health.
Distrust of the medical establishment is an important factor and the lack of diversity, overall. The lack of diversity whether we're talking about physicians or nurses, other health care professionals; even those who engage the health care industry or complex it some way if you will many of you who are seated here in the audience today. But it goes a lot deeper than that and this is what we don't normally talk about. We don't normally talk about the real underlying causes; the real underlying causes. We don't go back to 1619 for African Americans and the African slave trade. These are things that often times make people feel a little bit uncomfortable. But these are the real causes. So when you go back to the African slave trade and African's being brought to this country spoon fashion in the bellies of slave ships and all of the denials that occurred as a result of that; all of the denials that occurred as a result of the African slave trade. The denials after African's were brought to this country. Denials in the area of employment and education and housing and health care, obviously; and voter participation. Make sure that a community of people, that a race of people, isn't disenfranchised politically where you are not powerful politically, then you cannot advocate for the things that you really need. So the Tuskegee syphilis experiment is real with regard to health care for African Americans and other minorities. And there are major policy issues. The 1954 Brown v Board of Education; are you with me, I'm not sure you're with me on these things, but 1954 Brown v Board of Education and the 1964 Civil Rights Act and the 1965 Voting Rights Act and the 1968 Fair Housing Act amendments; all of these things are the real underlying causes and those are the policies that had to come forth to address to disparities and inequities that are so pervasive in America. So Indian reservations and internment camps and the RDP factor; the RDP factor; racism, discrimination and prejudice. That factor is so real when we talk about disparities in the area of health care so all of these factors have contributed greatly to the health disparities that we're talking about today and I'm looking forward to bring forth some recommendations and solution. Thank you much.
TONI PLUMMER: Good morning. My name is Toni Plummer and I'm from Montana. I work in a community called Whitefish, Montana. I work for a state-wide non-profit that is responsible for supporting tribal policies and working with the tribes. We work with 8 tribes in Montana; 2 tribes in Wyoming and our job is to enhance and give information and build policy with these tribes as they come forward on a federal level, on a national level and on a local level. We do also some direct service support through infant mortality and morbidity, MCH, on the tribal level and we have programs on each of the reservations in the state and in both in Wyoming.
So, in that; I'm a little nervous, so if start turning blue, you've got to tell me to breathe, and this is an amazing place to be. I've never been at a conference so huge before and it's an incredible opportunity to come and to see all these different people and just experience Chicago in this way, so I'm grateful to be here in that way.
What I would like to say is a couple of things. No. 1, we are the only minority group in the United States of America that has to go to Washington, D.C. to lobby for our health care. That's an incredible thing in the year 2000. It's an incredible thing in the year 2000 that American Indian people still carry the highest death rate for children in the United States of America. That's an incredible thing. When you look at tribes in Montana and I can only speak to Montana, when you have the highest rates of diabetes in several communities and they have no access to health care. They have no dialysis unit and you have, and I'm going to give you an example and I always give this example because it's an amazing thing. My aunt is 58 years old; she's on dialysis. Her dialysis, she goes 3 days a week; she lives on the reservation and she gets up at 6:00 am and then she goes and she travels 2 1/2 hours; she goes to dialysis all day; she can't afford to stay in that community and so she has to turn around after dialysis and she's home at 8:00 that night. She does that 3 days a week and that is not uncommon and she's just one. That's a disparity; that's a problem.
When we look at health disparity; when I look at health disparity I don't look at it from they aren't giving us enough, whoever they are because that's not the answer for me anymore; that's part of it. Policy speaks to that and that's our responsibility to really enhance policy on a federal level at the highest level, but the other piece is we really need to believe that communities can heal themselves and it's our responsibility to give them the ability to do that. They know their health care needs. They know their history of poverty. I can't speak to that but I know that if I can go to that community and I can find one person, they will give me four generations of history of how long welfare has been there; how long they've been going without dental care; what they see as a solution to that and what they see as their responsibility in that community. We have forgotten and I speak in generalities because we talk about this a lot at our office, we have forgotten the power of poverty, not so much in a negative way but that poverty keeps us together and it keeps us strong. But we have to give that back to that community and we need to help them in that way.
When we talk about bridging the gap, one of the issues that I do on a community level is when I go to the state of Montana I know that I'm going to prepare for war. I know when I go there it's like okay, here we go and we go through the whole 101 stuff about American Indian people and then we go through the whole piece around it's your responsibility and you have to help us and then we get down to the real stuff and the real stuff is is that these are people's lives. These are children and they need care. Let's figure out how we're going to do it and I really agree with the whole piece around partnership. Partnerships need to go farther. The last 5 or 10 years in the Administration we've talked a lot about collaboration. Everybody who writes a grant and you have to throw the word collaboration in there. You do and it's like you've got to figure out who is going to sign the support letter. But I'm saying let's be responsible and take it another step farther and let's feel it and let's work together and let's see what we can do to change our communities in a good way so that we can really enhance the health care of our children. So that's all I was going to open with and thank you for letting me be here.
ADOLPH FALCON: First a commercial. I'm from the National Alliance for Hispanic Health; we're the nation's oldest and largest network of Hispanic health care providers. Right now our community members serve out 1 in 3 Hispanics with health care services in the United States.
There's about 4 things about us that I would like you to know. One, is that we believe in community based solutions; our work is all around community based solutions and we believe that's where the answer is going to be. Secondly, we're founded on the idea that all Hispanic groups really had to work together in order to promote a common health care agenda and that's our approach to work. Third, is that we believe very much that health is holistic; experience, it needs to be done in a holistic environment, so we talk very much about mind, body and spirit and we talk about health care from that approach. The fourth thing is that we're the only national Hispanic organization not to accept funds from alcohol and tobacco companies and we think that gives us a validity in how we deliver health care services.
We've heard a few things about health disparities and about health risk for Hispanic communities. I believe we heard about tuberculosis; there's issues of asthma; there's issues of diabetes; there's a whole range of client illnesses and diseases where Hispanics have much higher rates. Hispanics are also a poor population; have some of the highest high school dropout rates and we have the lowest rates of insurance; 40% of Hispanics are uninsured in the U.S.
Given that entire history, here's the other piece of news. Hispanics have a life expectancy that is higher than non-Hispanic Whites; we live longer. Something is going on "right" in our communities. We think it has a lot about what's going on right in all racial and ethnic minority communities that has to do around family; has to do around the role of culture; has to do around the role of faith and the medical system has never done a really good job of integrating those kind of factors into our health care. We've never done a real good job of looking at family, faith, community, culture and the role that that plays in health care. Given the fact that with all of our risks we live longer than non-Hispanic Whites. I think everybody would be wanting to research us; find out what's going on right. Less than 1% of NIH grants right now go to Hispanic researchers that don't have anything to do around Hispanic health care. We've just accepted this model of problems for health care for minority communities. I think my message is and we have to look at also what's going right in minority communities and what that can bring to the health care debate. Thanks.
DEREK: Thanks to all our panelists and let's get our conversation started here. I think that some of this conventional wisdom has been we've spent so much time in government and politics working on the idea of getting insurance for everyone and just about all of you has said that there's something wrong with that picture and I wonder if you could elaborate a little bit on why it's not just cash that makes people not as healthy as other folks.
MARCIA: I don't know that we have gotten insurance to enough folks for it to make a difference and I think there have been a number of efforts over the past several years to at least begin to segment out the population and begin to provide health insurance coverage to some groups. I think the group in particular that I would refer to is children, with SCHIP, which we put into place in 1997. The states in a remarkable way have taken up the charge and tried to expand coverage to kids and we don't know yet the impact on the outcomes of health of those children. So it may be that increasing health insurance coverage does indeed improve health outcomes.
DEREK: Well I didn't say it didn't help at all, but I think the point was that that's not the complete answer and I wanted to hear you talk about why it's not and what are the real answers.
MARCIA: I think one of the reasons that just having health insurance coverage doesn't necessarily work is you may have a card, but if you don't have access to the appropriate provider you may not get the necessary services that you need.
RAY: If I could, Derek, just say one thing before I respond to the question. I'm also going to give a little commercial too. There's a newsletter that's been passed around from our commission on minority health, the Ohio Commission on Minority Health which was the first commission on minority health in America which I sponsored. Derek said that I had done all these great things as a legislator and I came in in 1998, I had to smile. I actually was elected first in 1981 and served until 1993 and I left for 6 years or so and then I came back into the legislature, so I wasn't able to do all those things in 2 years. I think money does matter, always. Whenever people kind of put down, you know, money doesn't matter; I think money matters in just about everything and often times I hear people talk about education in the same way, that it's not so important to have the college degree or it's not so important to have advanced degrees and I simply don't subscribe to that. There are some individuals who don't have to go to college and maybe it's not the best thing for them but I think generally we ought to be encouraging our young people to go off to college and we ought to encourage people to earn decent incomes and to be able to care for themselves and their families. So money matters a lot in terms of being able to have good health care and purchase insurance and so forth.
The whole issue of health promotion disease prevention is so important it doesn't make any difference how much money you have. We live such a sedentary lifestyle; I was listening to a lady out in front of the building the other day, she was really upset that that bus wasn't there on time and she was going to go from here to the Sheraton. She could have walked around the corner to the Sheraton but our sedentary lifestyle is such that we're going to ride everywhere; we're going to sit back, diet, nutrition, exercise, all of those things are so important and so we can have the health insurance card in our pocket but there's a lot that we have to do and it has to be more than just a personal level or a programmatic level as well and I do want to speak to a broader issue.
TONI: I think that for American Indian populations and again, I don't speak for any tribal government and I don't speak for any tribally elected official; I can just speak from our experience from our program level in working with the state. When we looked at children's health insurance; when we looked at the hard cash dollar of access to health care for American Indian people, it was very clear to us that there was an attitude about Indian health service that all Indians were taken care of because we have an entitlement program. The reality is is that that's not true and it's not true because there are limited access to those health care facilities; the care is limited at best. There is no dialysis sites on every reservation in which there should be, given our diabetes rate and children's health insurance. When you look at Indian populations across the board and on a national level, not all children are based on a reservation and if they're in a urban setting that doesn't mean that they're on CHIP. What we're finding in Montana and it's very clear is that there's a huge gap of children who are urban Indians who cannot go back to the reservation because if you're gone after 6 months, you're not eligible for care. You're not eligible for contract care. So if I get sick in Chicago and I go to the hospital, I can't bill that back to my Indian health service facility; they won't pay for it, because I've been gone. So I'm without health care and that's for every child. They have to live within the reservation boundary for 6 months. If they don't do that, they do not get care. So if they're living in an urban setting and they're not eligible for CHIP or they're not enrolled in CHIP and they're bridging the gap with Medicaid, then they're stuck and we're only allotted I think like 5,000 slots or 4,000 slots in the Medicaid enrollment.
DEREK: But you bring up a really important point about where you live being critical in terms of how much health care you get because we talked about this a little bit before, Dr. Brand and I, about so many rural communities of all complexions struggle with health care because they don't have the solution. I wonder if we could address a little bit about the way you live factor; the location, location, location, as it were.
ADOLPH: I just wanted to say one point on that. About 15 years back we used to tell folks, if you're going to move some place, move to California for the health care. We're not telling folks that anymore. Across the nation there's been a real problem with access to health care and unfortunately instead of going to the best level, it seems like we've all kind of brought down the level of access, even though we have CHIP and we have Medicaid programs; we've had expansions of Medicaid, we still really haven't dealt with the problem of the uninsured. So you just cross the populations and wherever you live, we still have real problems with levels of access.
MARCIA: I'd like to respond to your question about some urban, rural differences. One of the problems regarding racial disparities in rural communities is we just don't have good information about; when we look at differences between urban and rural settings we often don't cross-cut by race and ethnic background. This is a urban situation; this is a rural situation, so I think we need to do as a department better research so we have a better understanding of what those disparities are. But once got response has to be that the transportation is poor there; that poverty is greater there and access to health care is more limited in a number of those rural communities and so probably those same problems that we are talking about and we have statistics for are exacerbated in those communities. But I also want to say that some of the most elegant solutions to health care problems come from rural communities because they're not necessarily sitting there waiting for someone to provide them a solution and so they begin to integrate their system; they begin to think of what providers they have available and they think about how they can maximize what existed in the rural communities. Sometimes it seems to me that we ought to look to rural communities for strategies to increase access because in the most difficult situations they seem to be able to come up with some pretty interesting solutions.
DEREK: I like what you were saying about the Latino community and working with community based organizations to find those kind of solutions.
ADOLPH: Well I think there's a lot of options that have just never been explored and it's the problem when you work with one model. Unfortunately sometimes you develop a real affinity for that model and you stick with that model even if the data that's beginning to come out doesn't really quite fit that model and I think the whole idea about minority health being a term of only negative is doing a real disservice to a lot of the energy of community based organizations and to a lot of the really wonderful solutions that were found in our communities where they really integrate more than just physical health.
DEREK: But on the other hand and you brought this up in your opening statement about how the Latino community has a longer life span, but according to another survey, they report being sicker. That they may be living longer but they're not feeling too good while they're doing it and I wanted if you could talk a little bit about that as well.
ADOLPH: Yeah, that's exactly right. If you put it in we live long lives but they're pretty unhealthy lives and that's why access is so important for us. One of the figures where we do have a high death rate is in the area of diabetes and when you think about that it's because that's one of those chronic illnesses that requires good on-going access to health care services. We don't have that, so why we're more likely to die or have complications are very preventable things. The rates of lower leg amputations for people with diabetes; it's extraordinarily high and it's just a real offense because it is not necessary. It's such simple preventative issue and that's where access becomes clearly an important issue. On the other hand we've also got to do better about access to what. We've really got to improve the health care system so that the health care system is something we want to go to as community, so there are providers that we trust; so there are resources available in the community that look like the community and are committed to that community.
DEREK: I wanted to ask you; you bring up diabetes which is a big problem in a lot of minority communities, but a significant part of that problem is issues of obesity, diet and weight control, exercise. In your look at the new examination of that problem how much have you found that has been to deal with that part of the issue.
RAY: I think you're exactly right about the causes. One of the things that I want to do and I'll come back specifically to that. We need to elevate this whole issue to the presidential level and we need a president of the United States who declares that very clearly and strongly, declares that the disparities will not continue to exist. That the access will be at zero level as the DHHS has said.
DEREK: I think the current guide did say something about this a few years back that like the Year 2010 it was all going to be cleared up. I don't know what went wrong.
RAY: That's why I put that adjective in there. That it's so important to see it clearly and strongly and then to drive it as opposed to say it and then have to deal with all of the attacks from the various interest groups that basically say this cannot be done and you're insane, etc. and then your wife has to retreat and all of those kinds of things and then you no longer put forth the initiative and now the Secretary of DHHS and the bureau within the DHHS that now has this total access kind of initiative, now we're down within the bowels of the administration and that's important but what I'm saying is that we have to have the pronouncement and the drive at the highest possible level, at the national level. Then we have to do the same thing in our states amongst our governors and our state legislatures.
Again, I didn't just start with rhetoric but people have to understand that we're all tied together on this and if the help of the Latino community is poor or the African American community is poor, we all suffer from that; we all pay for that and I think right now it's an attitude of it's not my problem; it's yours. On the issue of diabetes; whether we're talking or diabetes or cancer cirrhosis or whatever, we've got to do an awful lot more in terms of public education which made me think about our local health departments, both at the state and the local level. There's so much more that they should be doing in the area of public health and education but those are education wishes.
DEREK: I want to get a little more basic because one of my own experiences is I used to run at a track in Washington, D.C. and I would get there and I would run around and one day the high school, it's a high school, so the kids came out from the high school to work out in a gym class and the lack of conditioning was just unbelievable. I mean I was 25 years older than all of those kids and I could probably outrun them all, just because most of them look like they've never seen the track before and that to me is such a base level of education and habits that are going to stay with those kids for the rest of their lives.
RAY: I don't have the data, someone else could probably give the exact data but I know we're becoming more obese and less healthy overall. I'm old enough to remember when President Kennedy made the pronouncement about our physical health and he was driving that from the highest level and that's something that's not occurring today.
DEREK: So what are some solutions. What can we do.
RAY: There needs to be an increased attention; the kind of commission that I formed in the state of Ohio is so important for every state in America to have established. I think it's best to do it as a separate agency as opposed to having a commission within a state health department, but what we're able to do with our minority health commissions is to focus attention and dollars to those local organizations throughout our entire state that knows the culture; that knows the communities; has the relationships with the base community, etc., to fund those programs at the local level for improved health promotion disease prevention.
DEREK Let's talk some more about some solutions; some ideas that the four of you might have that we can throw out that might deal with some of the issues we've been talking about.
MARCIA: I think we all share the concern that our children don't have good health habits and in particularly they're inactive. But I also think that community based programs are important and I also think that parents have a critical responsibility for sharing and modeling the behavior they want their children to have and as parents, if we're sitting there watching the tube or spending the evening in front of a computer and then we tell our children to go out and play and they say no, I'm waiting for you to get off the Web so I can get on, we shouldn't be surprised. We have some responsibility I think for modeling that behavior.
TONI: I wanted to continue to follow this up because you have said things that we need providers that are sensitive to the cultures; all of you have said that. But in Washington State we're in an era of if we develop anything like a commission on minority affairs we are considered racist. If we wanted more Hispanic Americans or African Americans to become doctors and to become dental assistants, the dental pacts are going to say, wait a minute, isn't that discrimination. So I want to know from the President up what are you going to do about this whole issue of affirmative action. It's rampant. A color blind society is not going to work.
RAY: I think it's a matter of leadership that's a predictable kind of a response but somebody has to be committed enough and in my opinion angry enough to push the initiatives forward. I think there could be a commission on minority health in the state of Washington. You live there; I don't but I know some legislators who are pretty strong there.
TONI: (could not hear). I do too. _____________________.
RAY: Oh, you're talking about just straight politics of being able to simply get it enacted.
TONI: It's true. That's the problem. We've got the leadership. The issue is how do you get it through.
RAY: I don't want to take up all the time but I'd love to talk with you about the mechanics of how you get it through. That will take a little bit more time.
SEN. DAVID JORDAN (Mississippi) (cannot hear)
DEREK: So it sounds like you're talking about the issue of education. I don't mean to cut you off there.
SEN. DAVID JORDAN: It's education and it is programs; we need the programs from the top down, as the representative indicated, with congress approval, in place and yet prevention needs to be taught simultaneously along with it.
COMMENT: For me, one of the issues is, personally I pay every week for a nutrition management program and I have a great health insurance plan but it won't pay that and that's my health problem. I have a friend whose trying to quit smoking; can't afford the patch system, healthy otherwise but that's his health problem and that's going to kill him. Weight is going to kill me; those are health issues but we do not fund in our health insurance system any kind of preventive measures, the same is true at the community base level. If they try to launch community prevention programs, that funding is not going to really come from any type of reimbursement system. That funding has to come from special programs; special initiatives. There should be nothing special about prevention. Prevention should be the first item funded.
COMMENT: One of the things that I wanted to respond to real quickly from the lady from Washington State and then over here to the senator was and this is just from an Indian perspective is No. 1, I understand your plight. Washington State; we're getting wiped out there. The GOP passed a resolution to abolish tribal governments there and that was passed by a 100% vote or I think there were 2 negatives but other than that it passed to abolish all tribal governments within the state of Washington and then moved that forward on a national level. Our response to that is they need to go back and read treaties and we'll just continue to go on but it's sort of like that's a real issue and it's a very heartfelt issue because there are several tribes that are doing great work out there that are now going to have to move their work into the political realm to fight that issue rather than do the work that we need to be doing. The second thing is is that in the Indian Health Service Budget on a national level, on a presidential level and then on a local level, we are not allowed to place in our budget a line item for prevention. So we have no prevention line item in any Indian health service facility in the United States.
COMMENT: My question is about to what extent is it that these issues are ethnic or gender based or based on minorities and it's not just a poverty issue because from what I understand about health issues and uninsured and poor health instances is that it's about economics and education and how much more, what's the benefit of looking at it from a cultural issue as opposed to just an economy kind of issue.
DEREK: That question goes back to the first question I asked as a matter of fact about why it's not just money.
RAY: One thing is clear is that it's multifaceted and so economics are critically important and poverty is a major cause but so is racism and discrimination and prejudice and for example in the shortage of African American physicians or practitioners of color. I mean it has nothing to do with the economics per se', it has to do with the discrimination that occurs in the system historically. So if you look at education overall historically, and the denial of opportunity; if you look at the kind of policies that we had in place not too long ago where only a few African Americans would be admitted to the medical schools. So one says well, why don't we have more African American physicians or Latino or Native American or Asian physicians, it's because of the kind of discrimination and prejudice that's occurred and that has nothing to do with poverty; that has to do with that RDP factor that I talked about and those are the kinds of things that have to be addressed by us all.
DEREK: I seem to recall reading at some point, even when you control for income, minority health is still not quite as good, so it's not just money.
RAY: That's correct, yes.
ADOLPH: One of the other growing affluence can buy you health insurance. It also buys you greater access to the Cheesecake Factory and McDonald's. When you look at Hispanic health by generation, actually the folks who are doing the best are immigrants; first generation immigrant do the best, we get all kinds of health educators. This isn't just our bias research; this is true to medicine; government's data and where health starts declining as you get into second generation and higher. So clearly there's something going on there and here I come back to it again, that has to do with culture and family and community and what that has to do with health.
REP. BILL CRAWFORD (Indiana): I want to first commend Ohio for taking the lead in establishing the commissions. Indiana has followed suit; we enacted legislation in 1993. We have an umbrella group, the Indiana Minority Health Coalition. It's funded through the state budget each year. We have 16 local coalitions geographically disbursed throughout the state of Indiana; the last one operational was a Native American coalition which was formed in 1999. Each of those coalitions have the objective of reducing the disparities; they go through training; they're given the equipment. I agree with Ray. The issue is how we organize and mobilize in our state. In Indiana, African Americans are about 7.9% of the total population. If you add in Hispanics and Native Americans, we would be around 10% to 11% of the total population, yet we're able to fund these kind of programs. So I agree if we organize and mobilize, nothing should stand in our way. There are only 13 members of the Indiana General Assembly that are of African ancestry; no Latino; yet we're able to get legislation passed if you organize and mobile.
The attorney general recently gave our tobacco settlement dollars, $500,000 for the Indiana Minority Health Coalition; $300,000 of which we'll start a minority epidemiology center so that we can have the appropriate research base to move forward. The tobacco legislation chaired by our public health chair, Rep. Charlie Brown, requires the state to look at using tobacco funds for further evolving the epidemiology center and there are other ways that we can get dollars out there but it all comes down to organizing and mobilizing and having a "can do" attitude that no matter whether it's democrat or republican, we all happen to be democrats. Whether it's democrats or republicans, that we have the same objective. The final thing that I will say is that I have arguably the most urban district in the state of Indiana; I have so suburbs, I have all inner-city. The district that I live in is medically underserved and a health professional shortage area. I live in the shadow of a great teaching university, the best hospitals in the state. I have no differences and we form coalitions with rural health centers and we use tobacco dollars to fund both rural and our community health centers because we recognize we all have the same problem. So we don't look at rural as different. We come together; we coordinate. Our surgeon general came out, met with us for a full day to develop a plan of implementation.
RAY: It seems like we started in it Ohio and you're pretty much finishing it very well in Indiana. You're doing some things that we're not doing. But we have within the National Black Caucus of State Legislatures a very strong health committee that's chaired by Sen. Roscoe Dixon from Tennessee and again, to the woman right here in the front, we would love to talk with you about the steps that are necessary to do the kind of things in your state. We know the demographics are totally different; the politics are totally different but there are some things that we can do to strengthen minority health programs, etc. in all of the states in the country with people like Bill and Charlie Brown, etc. and others here. I see our executive director, one of assistance from the Black Caucus in the room as well. So we've got assistance for all of the states to help you with developing these kinds of initiatives.
DEREK: I've got bring up something close to my heart; dental work. I've had so much done I told my dentist he ought to nickname me "summer home". You brought that up earlier Marcia and we don't hear anything about it and if you talk to people in the dental business they'll tell you it's actually getting worse; insurance coverage less; people are less likely to have dental insurance. I got to think that there needs to be some real work done here.
MARCIA: I wish I were getting ready to offer up a solution. I'm really worried about this. It's something that doesn't get discussed as often as it should. The department has just started an oral health initiative but there are some problems that seem to be intractable; access to dental health insurance is one. Only 15% of folks over the age of 65 have dental health insurance and Medicaid covers very little. So very few seniors are getting dental services and the other thing that's a problem too I think is that there are very low numbers of dental providers who take Medicaid and CHIP.
DEREK: We don't pay them enough.
MARCIA: But the problem I think is and others can certainly correct me if their experience in their state has been different, but even when you significantly increase the reimbursement rates those folks don't sort of quickly move into the plan because they're busy enough and why should they clutter up their waiting room. I mean that's sort of the attitude that you hear and I am concerned about what are we going to do to improve access to dental care.
DEREK: Have you looked at that in your Latino community at all in your studies.
ADOLPH: Yes, it mirrors the same issue of uninsurance and lower access and there's a higher level of untreated dental care among Hispanic kids.
RAY: One of the major issues in Ohio as well. I've not even had a chance to meet him well but in the state of Ohio, the new public health director, Nick Baird, and so we've just done a major study around oral health and particularly focused on children and the shortage of providers, etc. So it's a major issue in our state as well.
MARCIA: I think the solutions particularly around children are public health kinds of solutions with sealants and fluoride and behavior education and that's not the situation we're going to improve by increasing the number of dentists and so I think where states can, look at their state practice acts and expand the number of providers who can provide oral health services. You may be able to increase access to them for a lower cost.
REP. PULLIAM (Maryland). Although in the state of Maryland we have had some excellent firsts in health care issues. I just want to tell you quickly since I'm standing here, you're talking about dental health, that we've just passed an Oral Cancer Initiative, this past legislative session that we're going to effect because we realize that African American males has one of the highest death rates in oral cancer.
On the other issue to say African Americans overall, in all of the diseases, have the highest mortality and morbidity rate and Malone and Heckler's findings back in the '60's, many of you may know about said at that time that there over 60,000 excess deaths, meaning deaths that needlessly have occurred. Now we're up to over 120,000, even with the different programs that we've put in place. Again, because even with the CHIP program, it speaks to a certain level of federal poverty but those who fall in the gray area, they still do not get the kind of care. One of the solutions is that we still fail to look at culturally, competent health care and taking some of the issues that you were speaking about and as you talk about the obesity and the other thing; obesity goes to hypertension and diabetes. And in the legislature, because I'm a registered nurse, I get really frustrated when I have to fight for these issues. But clearly we continue to spend our money at the cost of bad results. We don't spend it up front as my colleague over here said, in terms of prevention and until we begin to do that we're never going to see or get where we need to go. We will continue to see these high numbers in all of these different areas. We did a whole task force on minority health in Maryland. Didn't get it passed in terms of a commission to the level where you are and I'm very appreciative of that. I know having worked for over 20 years with Lou Stokes and the Congressional Black Caucus Health _____ Trust, I know it is even more frustrating to sit here in the year 2000 and find that we haven't gotten that far.
DEREK: Any responses? I'm curious about something we haven't gotten to at all which is genetic predisposition. How much does that play into these disparities we've spent the morning talking about.
RAY: It's an evolving area right now. The human gnome project I'm watching very closely. There's just some things that as African Americans we have some concerns about. I referenced the Tuskegee experiment and that kind of thing so when you start talking about genetic engineering, etc. and the human gnome project there's some ethical issues that we're going to have to sort of be ready for and some race related issues that we have to be ready for but I think there's much promise in the area of genetic research in this human gnome project. It's evolving right now and that's about all I can say about it.
TONI: One of the issues in our alcoholism rate is people are always saying that Indians are predisposed to being alcoholics and that it's in our genes; it's in our blood and everything we know from a cultural and spiritual basis tells us different. Whether we are raised in a cultural and traditional and spiritual basis in our homes or whether we're not, that influence is still carried over in our families for generations and so it's real hard to talk about that and acknowledge that as an issue because we don't see that as something that could really happen, from a cultural perspective or a traditional perspective. I think it's sort of like the Bering Strait theory I guess and I'm getting way off; I don't think we came across the Bering Strait. I think we were like here in regards to the first Americans and that's just the way it is.
SEN. HARPER (Connecticut): I just wanted to speak a little bit to the whole dental issue. We had Medicaid managed care in our state and the dentists basically refused to join our networks and it was a very difficult thing. They cited some of the things that you talked about which is they don't want those people waiting in their waiting rooms; that those people don't come to appointments on time and those kinds of issues and so one of the things that we're going to have to do is to carve that out and to look at building the safety net services. I guess what I would ask and want you to talk a little bit about is we've gone into across the country this whole idea of Medicaid managed care and in some states it's actually eroded the public health and safety net infrastructure. Are there any ideas that you're thinking of how we can reinvest in the safety net and how we can begin to make sure that at that level, services are available to folks.
(end)
|
