Unhealthy Differences: September 2012 | STATE LEGISLATURES MAGAZINE

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The health care system needs to work smarter, not harder, to eliminate health disparities.

By Megan Foreman  

Most Americans contribute to the $2.6 trillion spent on health care every year. Yet the health they enjoy often varies by their population group or ZIP code, not by what they spend. An uncomfortable reality exists: Racial minorities die sooner and live with diseases more than whites, even when research controls for income and health insurance coverage.

Since health disparities became part of the national dialogue in the 1980s, policymakers and public health professionals have tried to address them piecemeal, one disease and one population group at a time. But few of these activities got to the root of the problem:  an inefficient health care machine.

Disparities highlight systemwide deficiencies, such as a lack of understanding about cultural differences and an uneven distribution of doctors and nurses. These issues are exacerbated in minority populations that tend to have not only fewer available health services, but also a lack of knowledge about how best to use the system.

“Our goal is to make sure people are getting preventive care—blood tests for diabetes, colonoscopies and mammograms for early cancer detection—because many in minority communities are undiagnosed,” says Delaware Representative Joseph Miro (R). “The disparities in the rates of conditions like obesity, diabetes and health disease are great among minorities.”

Creating a Smarter System

Working to make the system smarter has promise, but Miro warns, “it’s a struggle to find the money for research to develop programs that can help eliminate disparities.”

Yet states, which spend up to a quarter or more of their yearly budgets on health care, have a stake in creating a more efficient, less costly, system.

Massachusetts Representative Jeffrey Sanchez (D) believes the health care system must work smarter, and can only do so when all of its components work together and its payment model changes.

Health Disparities By the Numbers

How much more prevalent asthma is among black children than white children.
How much more likely American Indians and Alaska Natives are to be diagnosed with diabetes.
The percentage of people newly diagnosed with HIV in 2010 who were African American.
The percentage of people newly diagnosed with HIV in 2010 who were Latino.
The rate at which African American babies die compared with white babies.

Source: The U.S. Department of Health and   Human Services’ Office of Minority Health, June 2012.

“Health system integration and payment reform—which are in the pipeline now—must be based on data-driven measures that account for race, ethnicity, language and income,” he says.

The importance of adequate data cannot be overstated. “We don’t understand all the aspects of health disparities—what drives them and how to eliminate them—so we need the data to build a system where prevention and health promotion are at the crux,” Sanchez says.

Sanchez believes the nation is generally moving in the right direction.“The Medicaid expansion in health reform will get more people into primary care and go a long way toward eliminating health disparities.”

Making the health care machine more efficient can go only so far. The vast majority of money and problem-solving energy in the national debate centers on clinical care, but the University of Wisconsin Population Health Institute estimates the health care services a patient receives in a doctor’s office or hospital determine only about 20 percent of the patient’s overall health. The other 80 percent is based on socioeconomic status, physical environment, health behaviors, biology and genetics.

Past efforts to eliminate disparities among racial and ethnic groups have focused on the individual, rather than on the entire context of where and how they live. Experts are now considering “big picture” questions—called social determinants of health—into their efforts to make the health care system work smarter, not harder, for all people.

The continual challenge for lawmakers in discussing these social determinants of health is which, if any, policies can make a difference. For instance, educational practices that improve reading comprehension and high school completion rates can give people the skills to take charge of their health for a lifetime. Policies that encourage more healthy food options in areas that lack them and development that promotes safe walking and biking, also may have long-term effects on residents’ health.

Individual behavior regarding tobacco, alcohol, diet, exercise and sexual activity factor in as well, accounting for 30 percent of a person’s health, according to the University of Wisconsin Population Health Institute.

“It is a constant fight,” says Miro, “to maintain a level of awareness around healthy behavior and prevention within communities and with parents.”

Megan Foreman is a former NCSL staffer who tracked health issues.


Federal Efforts

The U.S. Department of Health and Human Services released two plans to reduce health disparities in 2011. The first, the National Stakeholder Strategy for Achieving Health Equity, incorporated ideas and suggestions from thousands of people and organizations across the country to create a common set of goals to guide the many regional efforts that affect health but often work in isolation from each other. The second plan, the Action Plan to Reduce Racial and Ethnic Health Disparities, complements the first and outlines federal priorities to address the social determinants of health and reduce the disparities.