Easing the Burden: Using Health Care Reform to Address Racial and Ethnic Disparities in Health Care...

8/8/2019 Easing the Burden: Using Health Care Reform to Address Racial and Ethnic Disparities in Health Care for the Chroni

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Easing the BurdenUsing Health Care Reform to Address Racial andEthnic Disparities in Health Care for the Chronically Ill

Lesley Russell December 2010


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Easing the BurdenUsing Health Care Reform to Address Racial andEthnic Disparities in Health Care for the Chronically Ill

Lesley Russell December 2010

The subjects in the cover photo are models and the image is being used or illustrative purposes only.


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1 Introduction and summary

3 The current situation

7 Easing the burden7 Tackling chronic illness among American racial and ethnic minorities

8 Improved access to health insurance coverage

11 Improved access to primary care

14 Addressing disparities in treatment and quality of care

17 Provision of culturally competent care

20 Improved patient literacy

23 Conclusion

25 Endnotes

27 About the author

Contents


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1 cen er r Amer an pr gre | Ea ng e Burden

Introduction and summary

Chronically ill Americans rom racial and e hnic minori ies have much o gainrom he implemen a ion o he A ordable Care Ac . Tese Americans are more

likely o be wi hou heal h insurance coverage hey make up more han hal o Americas uninsuredand hey su er higher ra es o chronic illness han he gen-eral popula ion. Tey are more likely o have he risk ac ors such as obesi y hapredispose hem o chronic illnesses, and are less likely o receive he preven ivescreenings, regular care, and necessary medica ions ha could preven or amelio-

ra e heir chronic condi ions.

Being uninsured o en means pos poning needed heal h care services. Ta s why people o color in our na ion are diagnosed a more advanced disease s ages, andonce diagnosed, hey receive poorer care. Nearly hal (46 percen ) o nonelderly black adul s and more han a hird (35 percen ) o nonelderly Hispanic adul s who do no have insurance repor having one or more chronic heal h condi ions.Many more o hese Americans do no have a usual source or heal h care, havesubs an ially higher unme heal h needs han heir insured coun erpar s, and havehigh ou -o -pocke cos s.1

Inevi ably, hey are sicker and die sooner.2

Tis paper will ocus primarily on how implemen a ion o provisions in he new heal h care re orm law can help hose who bene he leas rom our currenheal h sys em by addressing dispari ies in preven ion, diagnosis, and rea men o chronic illnesses, hus easing he addi ional heal h care burdens borne by racialand e hnic minori ies wi h chronic condi ions.

A key ene o heal h care re orm and making he heal h care sys em sus ainable in ohe u ure is he recogni ion ha mos chronic diseases can be preven ed. Improving

access o preven ion services, in combina ion wi h beter managemen and coordi-na ion o he care delivered o he chronically ill, is an inves men ha pays o in hemedium erm wi h reduced ra es o heal h care services u iliza ion, and in he long

erm wi h beter heal h ou comes and more produc ive lives a lower cos .


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Tis paper addresses ve key issues in addressing curren racial and e hnic dispari-ies in he preven ion, diagnosis, and rea men o chronic illnesses:

Improving access o heal h insurance coverage Improving access o primary care

Addressing dispari ies in rea men and quali y o care Providing cul urally compe en care Improving pa ien li eracy

Each o hese issues is discussed in he pages ha ollow, looking rs a he cur-ren si ua ion, hen a how his can be addressed hrough he implemen a ion o selec provisions o he A ordable Care Ac , and nally a he di erence hesere orms can po en ially make in he lives o minori y Americans wi h chronic ill-nesses or a risk o chronic illness.

Te ul ima e goal mus be ha all Americans, regardless o race or e hnici y, gehe quali y heal h care services hey need when hey need hem. We can ill a ordo ignore he high cos in dollars and human li e ha he na ion pays each yearha is atribu ed o heal h care dispari ies, especially when much o he burdenrom chronic illnesses is preven able. Te o al annual cos o racial and e hnic

heal h dispari ies, including direc medical cos s and indirec cos s such as losproduc ivi y, los wages, absen eeism, amily leave, and prema ure dea h, is o heorder o $415 billion.

Te causes o heal h dispari ies are complex, bu we know ha he ime o akeac ion is now.


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The current situation

The factors that give rise to increased rates of chronic illness inracial and ethnic minorities

Racial and e hnic minori ies in our na ion experience dispari ies across a sig-ni can number o heal h s a us measures and heal h ou comes. Issues such asincome, educa ion, and work s a us as well as poor housing, neighborhood seg-rega ion, and o her environmen al ac ors wi hin communi ies drive hese racial

and e hnic di erences. Bu dispari ies in heal h s a us and ou comes may alsoresul rom ailures wi hin he heal h care sys em. Problems accessing services anda lower quali y o care or racial and e hnic minori ies clearly impac he heal h o

hese popula ions.

Minori ies generally ra e heir heal h as poorer han whi es. Almos hal o black adul s repor having a chronic illness or disabili y. Te dispari ies in chronic ill-ness be ween blacks and whi es persis s across income levels and a er adjus ing

or age. Dispari ies are also widespread across a number o risk ac ors or diseaseand disabili y, including obesi y and smoking.3

Adul obesi y ra es or A rican Americans and Hispanics are higher han hoseor whi es in nearly every s a e o he na ion. Adul obesi y ra es or A rican

Americans are grea er han or equal o 30 percen in 43 s a es and he Dis rico Columbia. In nine s a es, he ra es exceed 40 percen . Adul obesi y ra es orHispanics are grea er han or equal o 30 percen in 19 s a es.4 Higher ra es o obe-si y ransla e in o higher ra es o obesi y-rela ed diseases, such as ype 2 diabe esand hear disease, so i is no surprise ha A rican Americans and Hispanics havehigher ra es o diabe es, hyper ension, and hear disease han o her groups.5

Diabe es is a major risk ac or or hear and kidney diseases and o her condi ionscausing severe disabili y. American Indians/Alaska Na ives are a he grea es risk

or diabe es; nearly 18 percen o his popula ion su ers rom diabe es. Nearly 15


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percen o A rican Americans and 14 percen o Hispanics have been diagnosed wi h diabe es compared wi h 8 percen o whi es.6 Many people wi h diabe esremain undiagnosed, and hose who have reduced access o heal h care are morelikely o have heir diabe es unrecognized and un rea ed.7 I curren rends con-

inue, one in every wo minori y children born oday will develop ype 2 diabe es

a some poin in heir lives.8

Black women have a higher prevalence han whi e women or our rela ed condi-ionshear ailure, coronary hear disease, hyper ension, and s roke. Black men

have a higher prevalence han whi e men or hree o he our condi ionshearailure, hyper ension, and s roke.9

A rican Americans experience higher incidence and mor ali y ra es rom many cancers ha are amenable o early diagnosis and rea men . For ins ance, hey aremore likely han whi es o su er rom colorec al, pros a e, and cervical cancers,

and hey are also more likely o die rom hese cancers. Hispanics have a higherincidence ra e o in ec ion-rela ed cancers, including s omach, liver, and cervicalcancers. Hispanic women are less likely o be screened or cervical cancer han bo h whi e and black women.10

Al hough whi e women have he highes incidence o breas cancer, black women have he highes mor ali y ra e rom his cancer among all races and e h-nici ies. While black women are jus as likely as whi e women o ge a mammo-gram, hey are less likely o ge imely access o quali y care i hey hen receivean abnormal diagnosis.11

As hma is ano her heal h condi ion ha dispropor iona ely impac s minori-ies. As hma prevalence is highes among blacks, ollowed closely by American

Indians/Alaska Na ives. More han 9 percen o hese minori y groups su er romas hma, compared o 7.6 percen o whi e Americans. Dea hs rom as hma, anou come ha should be wholly preven able hrough e ec ive managemen o hedisease, are also higher among his group.12

Dispari ies exis in bo h access o and quali y o men al heal h care or racial and

e hnic minori y groups.

Examples o hese dispari ies include he underu iliza iono psychia ric services by persons rom e hnic minori y groups, problems in getingpeople rom hese groups o seek rea men , and he inappropria e prescribing o an ipsycho ic medica ions or A rican Americans and Hispanics. American Indians/


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Alaska Na ives have he highes ra es o requen men al dis ress, wi h nearly 18 per-cen o he popula ion repor ing 14 or more men ally unheal hy days, and his groupalso has high ra es o subs ance use disorders and comple ed suicide.13

The costs of racial and ethnic disparities in health care for thechronically ill

Te reduc ion or elimina ion o racial and e hnic dispari ies in heal h care can be viewed as a moral impera ive or a goal or a heal h care sys em ha is based onquali y, bu i is also an economic issue. Minori y Americans bear excess ra es o chronic disease ha impose cos burdens on public programs as well as individu-als and o her purchasers o priva e heal h insurance.

A recen paper rom he Urban Ins i u e es ima ed ha in 2009, dispari ies among

A rican Americans, Hispanics, and non-Hispanic whi es as a consequence o eleva ed ra es o selec ed chronic illnesses (diabe es, hyper ension, s roke, andrenal disease) and general poor heal h cos he heal h care sys em $23.9 billion.14 Mos o his expendi ure ($15.6 billion) was or Medicare, al hough priva einsurers spen $5.1 billion. Ou -o -pocke cos s were more han $2 billion. Even wi hou aking in o accoun projec ed grow h in per capi a heal h care spending,

hese annual cos s will more han double o $50 billion by 2050 as he number o elderly Hispanics and A rican Americans increases.

Te es ima ed o al cos o hese dispari ies is approxima ely $337 billion, includ-ing $220 billion or Medicare over he 10-year period rom 2009 hrough 2018.In reali y hese cos s are much larger, as his analysis considered only selec edchronic diseases among wo minori y groups, and hey did no include nursinghome cos s.

Te Join Cen er or Poli ical and Economic S udies commissioned a s udy haprovides some insigh in o he ull ex en o he nancial burden ha racial ande hnic dispari ies are puting on he heal h care sys em and socie y a large.15 Tes udy ound ha be ween 2003 and 2006, 30.6 percen o direc medical care

expendi ures or A rican Americans, Asians, and Hispanics were excess cos sdue o heal h dispari ies. When he indirec cos s o hese dispari ies such as losproduc ivi y, los wages, absen eeism, amily leave, and prema ure dea h wereincluded, he o al cos was $1.24 rillion. Elimina ing heal h dispari ies or minor-i ies would have reduced direc medical care expendi ures by $229.4 billion over

he hree years s udied.


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O se agains hese cos s o he heal h care sys em are he cos s o he in erven-ions o address heal h care dispari ies, so i is essen ial o consider he business

case or hese.16

Tese new cos s may come rom adding heal h care personnel, beter educa ing

pa ien s or providers, and providing addi ional services. Any new cos can pose asubs an ial barrier o a heal h care providers willingness o in roduce and sus ainnew in erven ions. Tis prac ical reali y holds rue even hough he in erven ionmay be expec ed o add value by reducing dispari ies in he care provided, by rais-ing he quali y o services or minori y pa ien s, by reducing he downs ream need

or services, or by improving he u ure heal h o disadvan aged pa ien s.


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Easing the burden

Tackling chronic illness among American racial and ethnic minorities

Many ac ors give rise o increased ra es o chronic illness in racial and e hnicminori ies, and no all o hem have heir origins in he heal h care sys em.Pronounced dispari ies in heal h s a us mirror inequi ies in a range o social andeconomic ac ors (such as income, educa ion, employmen s a us and workingcondi ions, social ne works and communi y cohesion) and environmen al ac ors

(such as clean air and wa er, he buil environmen , and he availabili y o sa e anda ordable housing, ranspor a ion, and nu ri ious oods).

Te cri ical role o hese ac ors in de ermining heal h s a us, however, does nodiminish he impor ance o an equi able approach o delivering quali y, a ord-able, and imely heal h care services and addressing behavioral risks such as smok-ing and physical inac ivi y.

Tis paper addresses he ollowing as he key issues in addressing currenracial and e hnic dispari ies in he preven ion, diagnosis, and rea men o chronic illnesses:

Improved access o heal h insurance coverage Improved access o primary care Addressing dispari ies in rea men and quali y o care Provision o cul urally compe en care Improved pa ien li eracy

Le s examine each o hese i ems in urn.


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Improved access to health insurance coverage


Te Ins i u e o Medicine ound ha insurance s a us, more han any o her demo-

graphic or economic ac or, de ermines he imeliness and quali y o heal h care, i i is received a all.17 Among he nonelderly, 36 percen o Hispanics, 33 percen o American Indians/Alaska Na ives, 22 percen o A rican Americans, 17 percen o Asian and Paci c Islanders, and 13 percen o whi es are uninsured.18

Te ex en o medical care and he loca ion where ha care is delivered varies wi hinsurance s a us. Lack o insurance is associa ed wi h less care in all setings excep

he emergency depar men .19 Compared o people who have heal h insurance, heuninsured receive less preven ive care, are less likely o have an early diagnosis o

heir disease, and once diagnosed, receive less care and have higher mor ali y ra es.

Regardless o income, people wi h a chronic illness have o en ound i di cul , i no impossible, o ge a ordable heal h insurance coverage. (see able 1)

Table 1

Chronically ill and uninsured

Percentage of nonelderly adults with chronic conditions who lack healthinsurance coverage

Adults with Percentage uninsured

Any chronic condition 17%

White 13%

African American 19%

Hispanic 35%

Hypertension 14%

Heart disease 13%

Asthma 18%

Diabetes 15%

Arthritis 12%

Source: Amy J. Davidof and Genevieve M. Kelley, Uninsured Americans with Chronic Health Conditions: Key Findings rom the NationalHealth Interview Survey (Princeton, NJ: Rober t Wood Johnson Foundation, 2005).


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How this will change under health care reform

When he provisions o ACA are ully implemen ed by 2014, some 32 million Americans who curren ly do no have heal h insurance coverage will be covered,and coverage will be more a ordable or many millions more.

People wi h an income below 133 percen o he pover y level (curren ly $14,404or a single person and $19,378 or a couple), including hose wi hou dependen

children, will be eligible or Medicaid.

People making up o our imes he pover y hreshold will ge subsidies on asliding scale o help hem purchase insurance coverage hrough he new heal hinsurance exchanges.

Te heal h insurance exchanges ha will enable he uninsured o access a ord-

able, quali y heal h care will provide a new ransparen and compe i ive insur-ance marke place where individuals and small businesses can buy heal h beneplans. Exchanges will o er a choice o heal h plans ha mee required bene sand cos s andards.

Eligible small businesses will receive subsidies o help hem purchase heal hinsurance coverage or heir employees.

Large businesses ha ail o help employees ge heal h insurance coverage will be nancially penalized.

A number o measures o re orm heal h insurance will par icularly bene people wi h chronic illnesses or a risk or developing a chronic illness.

A Pre-Exis ing Condi ion Insurance Plan will provide new coverage op ions oindividuals who have been uninsured or a leas six mon hs because o a pre-exis ing condi ion. Tese plans are curren ly being es ablished in each s a e and will opera e un il 2014, when all discrimina ion agains pre-exis ing condi ions will be prohibi ed.

Annual ou -o -pocke medical cos s will be capped a $5,950 or individuals and$11,900 or amilies (indexed).

Insurers canno deny coverage or charge higher premiums because o a personssex or heal h s a us.


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All new plans mus o er a minimum package o bene s de ned by he ederalgovernmen , including cer ain preven ive services wi hou any cos s.

Why this is important for racial and ethnic minorities with chronic illnesses

Many s udies demons ra e ha uninsured American adul s receive less appropri-a e care and ewer needed heal h services han heir insured peers.20

A 2001 s udy looked a he e ec s o being uninsured on e hnic minori ies man-agemen o chronic illness and ound ha , compared wi h insured responden s,uninsured responden s were much less e ec ive a managing heir illnesses.21 Teuninsured had poorly con rolled illnesses, requen heal h crises, di cul y procur-ing medica ion, used medica ion incorrec ly, demons ra ed poor unders anding o

heir illness, and displayed litle knowledge o sel -care measures or risk awareness.

Tey rarely had a regular physician or atended a speci c heal h clinic. Lack o money was he primary reason given or no seeking heal h care and responden so en repor ed eeling ex remely ill be ore hey sough care. Tose who had iden i-

ed and used a ree clinic were much less likely o delay seeking care.

Uninsured near-elderly people ( hose aged 5564) represen a par icularly vulner-able popula ion. Te risks o experiencing major heal h problems and incurringsubs an ial medical expenses increase drama ically or his age group, so he conse-quences o lacking insurance are more severe.22

Expanding coverage o he near-elderly uninsured may grea ly improve heal hou comes or hese groups and may also lead o reduced Medicare spending or

hose previously uninsured.23 For example, a comparison o heal h care use andspending a er age 65 or a group o Americans who did no have heal h insurance be ore quali ying or Medicare wi h ha o a group o Americans who were con-

inually insured ound ha he previously uninsured spen a mean o $1,023 morein heir rs year in Medicare. Te spending di erence was larger or people wi hdiabe es, hear disease, and ar hri is.24

Insurance coverage

alone, however, may no reduce mor ali y or near-elderly A rican Americans. One s udy sugges s ha insurance may be insu cien o over-come li elong risk ac ors or ill heal h and mor ali y, including income inequali y

and broader discrimina ion and biases.25


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Improved access to primary care


Primary care is he underpinning o he heal h care sys em and research s udies

have shown ha having a usual source o care raises he chance ha people receiveadequa e preven ive care, early diagnosis, and o her impor an heal h services.Da a show ha :

Abou 30 percen o Hispanic and 20 percen o A rican Americans lack a usualsource o heal h care compared wi h less han 16 percen o whi es.

A rican Americans and Hispanics are ar more likely o rely on hospi als orclinics or heir usual source o care han are whi e Americans.26

Chronically ill, uninsured pa ien s are our o six imes more likely han sick pa ien s wi h insurance o have problems accessing care.27 (see able 2) A 2008survey by he Commonweal h Fund ound ha compared o pa ien s in seveno her coun ries, chronically ill adul s in he Uni ed S a es are ar more likely o

Table 2

Chronically ill and lacking care

Percent of adults with chronic illness who lack a usual source of health care, byinsurance status

Adults withPercent without a usual source of care

All adults Uninsured Insured

Any chronic condition 11% 38% 5%

White 9% 36% 5%

African American 11% 33% 5%

Hispanic 20% 46% 6%

Hypertension 7% 30% 3%

Heart disease 8% 37% 4%

Asthma 10% 36% 5%Diabetes 5% 25% 2%

Arthritis-related conditions 7% 30% 4%

Source: Amy J. Davidof and Genevieve M. Kelley, Uninsured Americans with Chronic Health Conditions: Key Findings rom the NationalHealth Interview Survey (Princeton, NJ: Rober t Wood Johnson Foundation, 2005).


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skip care because o cos s.28 More han hal (54 percen ) o American chronically ill pa ien s did no ge recommended care, ll prescrip ions, or see a doc or whensick because o cos s, compared o 7 percen o 36 percen in o her coun ries.

People wi h chronic illnesses who don receive regular medical care run he risk

o disabling and expensive consequences. For ins ance, individuals whose diabe-es is no properly con rolled are more suscep ible o blindness, nerve damage,limb ampu a ion, or dialysis or he res o heir lives.


Te emphasis in ACA on improving primary care will par icularly bene peoplerom racial and e hnic minori ies wi h chronic illnesses.

Primary care capaci y will be boos ed hrough a range o inves men s and pay-men incen ives, including a 10 percen Medicare bonus paymen or primary careand general surgeons; an addi ional 10 percen Medicare bonus or primary carephysicians prac icing in heal h pro essional shor age areas; and gradua e medicaleduca ion re orms ha redis ribu e residency posi ions, promo e raining in ou -pa ien setings, and suppor he developmen o primary care raining programs.

Te new Cen er or Medicare and Medicaid Innova ion will develop and expandhe medical home model or Medicare and Medicaid pa ien s. Medical homes

heal h care setings ha provide pa ien s wi h imely, well-organized care andenhanced access o providersare associa ed wi h a reduc ion in heal h caredispari ies or adul s and beter access o preven ive services.

Te s a es are provided wi h an op ion o enrolling Medicaid bene ciaries wi hchronic condi ions in o a heal h home. Heal h homes would be composed o a

eam o heal h pro essionals and would provide a comprehensive se o medicalservices, including care coordina ion.

A program is crea ed o es ablish and und communi y heal h eams o suppor

medical homes by providing increased access o comprehensive, communi y- based, coordina ed care. Communi y heal h eams usually include care coordi-na ors, nu ri ionis s, behavioral and men al heal h specialis s, nurses and nurseprac i ioners, and social, public heal h, and communi y heal h workers. eammembers work oge her wi h providers, pa ien s, and heir amilies o preven


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chronic illnesses such as diabe es, hyper ension, and hear disease and coordi-na e and manage pa ien care.

New unding will es ablish more communi y heal h cen ers o provide compre-hensive, a ordable care ha is responsive and cus omized o he low-income,

racial, and e hnic minori y communi ies hey serve.


Recen research indica es ha access o a medical home is a s rong indica or o quali y o care. When adul s have a medical home ha provides imely, well-orga-nized care and enhanced access o he needed range o heal h providers, racialand e hnic dispari ies in access and quali y are reduced or elimina ed. Wi h amedical home, minori y pa ien s are jus as likely as nonminori y pa ien s o have

care when needed, receive preven ive screening, and have chronic condi ionsmanaged appropria ely.29

Indeed, da a show ha when pa ien s wi h diabe es rom low-income minori y groups are provided wi h a ordable access o primary care and pharmacy services,hospi aliza ion ra es are reduced.30

Te expansion o communi y heal h cen ers is also an e ec ive way o deliver care,especially o communi ies ha are o herwise medically underserved. Tey deliverimproved heal h ou comes or heir pa ien s, diminish heal h gaps or racial ande hnic minori ies, and lower he cos o rea ing chronically ill pa ien s.31

Communi y heal h cen ers are required o provide comprehensive heal h andenabling services, o ailor hese o he special needs and priori ies o heir com-muni ies, and o provide linguis ically and cul urally appropria e services. Tey are open o all residen s, regardless o income, wi h sliding scale ee charges orou -o -pocke paymen s based on income and abili y o pay.32

Heal h cen ers improve access o imely screening and preven ive services or

minori y pa ien s who would no o herwise have access o cer ain services andelimina e dispari ies by race/e hnici y or insurance s a us in receiving preven iveservices. Hispanic and A rican-American women who atend communi y heal hcen ers are more likely o receive mammograms and pap smears compared o heircoun erpar s na ionally.33


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Heal h cen ers mee or exceed na ionally accep ed prac ice s andards or hemanagemen and rea men o chronic condi ions. Te Ins i u e o Medicine and

he Governmen Accoun abili y O ce bo h recognize heal h cen ers as modelsor screening, diagnosing, and managing chronic condi ions such as diabe es,

cardiovascular disease, as hma, depression, cancer, and HIV.34 Nine y percen

o Hispanic and A rican-American heal h cen er pa ien s wi h hyper ension, orexample, repor ha heir blood pressure is under con rol. Tis is more han ripleha o comparable na ional groups.35

Communi y heal h eams can help wi h arge ing he righ pa ien s, medica ion,es ing adherence, ransi ional care programs a er pa ien s are discharged romhe hospi al, and he coordina ion o care across a range o providers.

Addressing disparities in treatment and quality of care


Tere are signi can dispari ies in he quan i y and quali y o care delivered oracial and e hnic minori ies across all areas. A number o s udies have ound haeven a er con rolling or pa ien age, severi y o illness, heal h insurance, andhospi al ype, A rican Americans and Hispanics are signi can ly less likely han whi es o receive needed herapeu ic procedures.36 Racial and e hnic minori iesreceive a lower quali y and in ensi y o care han o her Americans who preseniden ical heal h problems.37

Abou 84,000 dea hs occur in he Uni ed S a es each year due o he heal h caregap ha separa es minori ies rom nonminori ies.38 Tis is unaccep able e hically and genera es huge social and economic cos s on he individuals and communi-

ies involved and on he public a large.

Receiving medical rea men in a imely ashion is impor an or reducing mor al-i y and long- erm disabili y rom many condi ions, including s roke, hear atack,and bac erial in ec ions. Minori y pa ien s o en experience longer wai imes or

heal h care, bo h in he ou pa ien and acu e care setings.39

Racial and e hnic minori ies are also a risk or problema ic access o pain care andpoor pain assessmen . Tey o en receive in erior rea men or heir pain com-plain s or all ypes o pain and across all kinds o rea men setings.40


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Minori y groups are grossly underrepresen ed in clinical rials. According os a is ics compiled by he In ercul ural Cancer Council, 88.8 percen o hoseenrolled in clinical rials be ween January 2003 and June 2005 were whi es, com-pared o 8 percen who were A rican Americans, 2.8 percen who were Asians/Paci c Islanders, 0.5 percen who were Na ive Americans/Alaska Na ives, and 0.1

percen who were o her races.41

Only 5.6 percen o all pa ien s were Hispanicscompared o 94.4 percen who were non-Hispanics.

Te consequence o his underrepresen a ion is wo old. Pa ien s wi h seri-ous illnesses are denied access o po en ially li e-saving rea men s. And many

rea men s ha are es ed have insu cien da a abou heir sa e y and e cacy inminori y groups. Tis later poin can be crucial when gene ic dispari ies a ec hee cacy o a new medicine.

Each year in he Uni ed S a es medical errors cause an es ima ed 44,000 o 98,000

dea hs and cos an es ima ed $29 billion in los income, disabili y, and increasedheal h care cos s.42 Errors and avoidable complica ions rom surgery a ec peopleo color more han whi es. Asians and Hispanics, or example, are more likely odie rom complica ions during hospi aliza ion han whi es, and A rican Americansare much more likely o su er pos opera ive pulmonary embolism or deep vein

hrombosis han whi es.43

Te sources o hese dispari ies are he subjec o considerable deba e. Emergingevidence poin s o varia ion in quali y among providers depending on he race ore hnici y o heir pa ien s. Tis may be due o he inabili y o primary care doc-

ors, especially hose who care or racial and e hnic minori ies, o provide imely and a ordable access o high-quali y subspecialis s, diagnos ic imaging, ancillary services, and nonemergency hospi al admissions.44


Tere are a number o provisions in ACA ha will address dispari ies in rea men ,heal h care quali y, and sa e y. Iden i ying priori ies in heal h care quali y and he

developing quali y measures and per ormance indica ors will help improve heal hcare services and pa ien ou comes or all Americans, bu improvemen s willdispropor iona ely bene hose segmen s o he popula ion which are leas likely

o ge quali y care. Ini ia ives include:


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Te es ablishmen o a Na ional S ra egy o Improve Heal h Care Quali y oimprove he delivery o heal h care services, pa ien heal h ou comes, and popu-la ion heal h. Funding is provided or he developmen o quali y measures a

he Agency or Heal hcare Research and Quali y and he Cen ers or Medicareand Medicaid Services, or he collec ion o per ormance in orma ion, and

or public repor ing on his. An In eragency Working Group on Heal h CareQuali y comprised o ederal agencies will collabora e on he developmen anddissemina ion o quali y ini ia ives consis en wi h he na ional s ra egy.

A requiremen or he secre ary o heal h and human services o develop guide-lines or use by heal h insurers o repor in orma ion on ini ia ives and programs

ha improve heal h ou comes hrough he use o care coordina ion and chronicdisease managemen , preven hospi al readmissions and improve pa ien sa e y,and promo e wellness and heal h.

A requiremen or he secre ary o HHS o iden i y and publish a core se o quali y measures or Medicaid-eligible adul s (as or Medicaid-eligible children),and or he secre ary and he s a es o repor agains hese measures will benemany people o color.

Linking paymen o quali y ou comes under he Medicare program. Tis includes:1. A value-based purchasing program or hospi als, under which a percen age

o hospi al paymen will be ied o per ormance on quali y measuresrela ed o common and high-cos condi ions, such as cardiac, surgical, andpneumonia care .

2. Improvemen s o he physician quali y repor ing ini ia ive program, whichprovides incen ives o doc ors who repor quali y da a o Medicare .

3. Paymen adjus men s or heal h care-acquired condi ions such as in ec ions.

In addi ion, he abili y o drive e or s o address dispari ies will be boos ed by requiremen s or more da a and by raising he pro le o minori y heal h andresearch in o unders anding and addressing heal h care dispari ies. wo speci cini ia ives which will do his are:

Codi ying he O ce o Minori y Heal h a he Depar men o Heal h andHuman Services and a ne work o minori y heal h o ces loca ed wi hin HHS.Te O ces o Minori y Heal h will moni or heal h, heal h care rends, and qual-i y o care among minori y pa ien s and evalua e he success o minori y heal hprograms and ini ia ives.


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Eleva ion o he Na ional Cen er on Minori y Heal h and Heal h Dispari ies ahe Na ional Ins i u es o Heal h rom a cen er o an ins i u e.


While he causes o dispari ies in rea men and quali y o care are many, a consis-en ocus on quali y is one very e ec ive way o help render he heal h care sys-em blind o he race and e hnici y o he pa ien and ensure ha every pa ien

ge s he bes , mos appropria e rea men and care in a imely ashion.

Tis is par icularly rue or hose pa ien s wi h chronic illnesses. O en hese pa ien shave mul iple illnesses and he secondary e ec s o disease processes such as s rokeand kidney ailure, which may limi mobili y. Teir abili y o coordina e heir careacross a range o providers and manage heir medica ion regimes may be limi ed.

Ta s why new ways o unding and delivering coordina ed care services, hroughini ia ives such as he es ablishmen o medical homes and accoun able care orga-niza ionswhich are also required o ocus on quali y and pa ien ou comes will be impor an or his popula ion group.

O her ini ia ives in heal h care re orm ha will make a di erence here are heprovisions ha will help ensure cul urally compe en care, and he mul i ude o requiremen s or he collec ion and analysis o da a around racial and e hnic dis-pari ies in par icular and he quali y o care and heal h ou comes in par icular. I will be cri ical ha he da a collec ed and he research conduc ed by he Ins i u eon Minori y Heal h and Heal h Dispari ies is direc ed a beter unders anding andaddressing he signi can dispari ies in he quan i y and quali y o care delivered

o racial and e hnic minori ies.

Provision of culturally competent care


Clear communica ion is essen ial o heal hy pa ien ou comes even when here isno language barrier. A leas 66 million pa ien -provider encoun ers occur acrosslanguage barriers each year.45 Wi hou in erpre er services, hese pa ien s have amore di cul ime ob aining medical services, receive lower-quali y heal h care,


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and have a grea er chance o experiencing nega ive heal h ou comes. As many asone in ve Spanish-speaking Americans repor no seeking medical care becauseo language barriers.46

Research sugges s ha heal h care providers diagnos ic and rea men decisions,

as well as heir eelings abou pa ien s, are infuenced by pa ien s race or e hnic-i y.47 Addi ionally, pa ien -provider communica ion has been linked o heal hou comes and pa ien sa is ac ion.48

Several s udies show ha racial and e hnic concordance be ween heal h care pro-essional and pa ien is subs an ially and posi ively rela ed o pa ien sa is ac ion,

al hough i is no essen ial or pa ien sa is ac ion.49 Qui e simply, pa ien s eelmos com or able wi h doc ors similar o hemselves. Because blacks, Hispanics,and American Indians/Alaska Na ives in par icular are very underrepresen edin he heal h care pro essions, his means ha i is signi can ly more di cul or

mos racial and e hnic minori ies o nd a heal h care provider ha hey rus oprovide regular care.

In 2004, he Sullivan Commission on Diversi y in he Heal hcare Work orceexamined dispari ies and diversi y in he heal h care sys em and no ed ha helack o minori y heal h pro essionals is compounding he na ions persis en racialand e hnic heal h dispari ies.50 Indeed, minori y represen a ion in he heal h pro-

essions grew a a snails pace over he pas several decades. Te propor ion o U.S.physicians who are minori ies is jus 6 percen , he same propor ion as a cen ury ago.51 A rican Americans represen 5 percen o regis ered nurses and 12 perceno he popula ion. Hispanics represen abou 4 percen o regis ered nurses and15 percen o he popula ion. Asian Americans all shor , oo, wi h 3 percen o regis ered nurses and nearly 6 percen o he popula ion.52

A 2007 repor ha looked a cul ural and linguis ic services in hospi als oundha much needs o be done o address cul ural and linguis ic barriers, par icularly

in he areas o language access services, in ormed consen and rela ed pa ieneduca ion processes, and he collec ion and use o pa ien demographic da a.53

Al hough many di eren ypes o raining courses have been developed o help

heal h care pro essionals provide services in a cul urally compe en manner, hesee or s have no been s andardized or incorpora ed in o raining or heal h pro es-sionals in any consis en way.


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ACA has provisions o ensure an increase in he cul ural diversi y o he heal hcare work orce. Tese include:

Ini ia ives o increase he diversi y o he work orce by he provision o scholar-ships and nancial assis ance o disadvan aged s uden s who commi o work inmedically underserved areas and serve as acul y in eligible ins i u ions.

Gran s o s a es, public heal h depar men s, clinics, and hospi als o promo ehe use o communi y heal h workers in medically underserved areas. Tis ype

o peer ou reach and educa ion model has been shown o be e ec ive in crea -ing a bridge be ween providers o heal h, social, and communi y services and

he underserved and hard- o-reach popula ions hey serve. Communi y heal h workers o er in erpre a ion and ransla ion services, provide cul urally appro-

pria e heal h educa ion and in orma ion, o er in ormal counseling and guidanceon heal h behaviors, advoca e or individual and communi y heal h needs, andcan provide some direc primary care services and screenings.

Programs o suppor he developmen , evalua ion, and dissemina ion o modelcurricula or cul ural compe ency or use in heal h pro essions schools andcon inuing educa ion programs are reau horized and expanded.


Increasing he number o underrepresen ed groups in he heal h pro essions canhelp address heal h care dispari ies by bo h improving access and respondingmore e ec ively o he needs o minori y popula ions. S udies show ha minori y heal h care pro essionals are more likely o work in underserved areas.54

Grea er heal h pro essions diversi y will also provide increased oppor uni iesor minori y pa ien s o see prac i ioners wi h whom hey share a common race,

e hnici y, or language. Race, e hnici y, and language concordance is associa ed

wi h beter pa ien -prac i ioner rela ionships and communica ion, and increasespa ien s likelihood o receiving and accep ing appropria e medical care.55


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Cul urally sensi ive care can help providers unders and wha complemen ary andal erna ive rea men s pa ien s migh be using, o recognize men al heal h prob-lems ha migh o herwise be hidden, and o address concerns abou sensi iveissues such as sexuali y and end-o -li e care ha are no easily discussed.

Te provision o cul urally and linguis ically appropria e in orma ional ma eri-als and ransla ional services are also essen ial o ensuring ha racial and e hnicminori ies can naviga e he heal h care sys em e ec ively and access all he ben-e s o which hey are en i led.

Improved patient literacy


Heal h li eracy he abili y o read and comprehend basic heal h in orma ionis an impor an barrier o he e ec ive managemen o chronic illness. I is associ-a ed wi h a higher use o heal h services and may well direc ly con ribu e opoorer pa ien ou comes.56 Pa ien s who have marginal or inadequa e unc ionalheal h li eracy will have di cul y reading, unders anding, and in erpre ing mos writen heal h ex s and ins ruc ions and hey are more likely o misunders anddirec ions or heal h care.

Consequen ly, hese pa ien s are also more likely o ake medica ions incorrec ly and more likely o ail o ollow a prescribed die or rea men regimen. Heal hcare exper s pos ula e ha he higher ra es o poor heal h li eracy in racial ande hnic minori ies may represen an impor an variable con ribu ing o higher ra eso diabe es complica ions in minori y groups.57

O her ac ors apar rom reading and comprehension may also come in o play.Case in poin : A research s udy on knowledge and care o chronic illness in e hnicminori y groups ound ha Hispanics did no hold mains ream cul ural views o heal h and he managemen o illness. Teir knowledge abou illnesses was qui e variable, and al hough hey described symp oms clearly, hey were, almos wi h-

ou excep ion, vague abou he de ails o illness managemen . Tis mean ha hegroup s udied did no unders and ha hey had a role in managing heir illness beyond aking medica ion.58


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Te use o al erna ive herapies ins ead o or alongside mains ream herapies iscommon among Hispanics, and many use herapies ha may be un amiliar oheal h care prac i ioners.59


Te major e or s o address heal h li eracy across he board or provid-ers, pa ien s, he media, and governmen agencieswill come as a resul o

he Na ional Ac ion Plan o Improve Heal h Li eracy ha was released by heDepar men o Heal h and Human Services in May 2010. Te plan calls orimproving he jargon- lled language, dense wri ing, and complex explana ions

ha o en ll pa ien handou s, medical orms, heal h websi es, and recommen-da ions o he public, and making consumer and pa ien in orma ion easier ounders and and cul urally and linguis ically appropria e.

Tere are several provisions in ACA ha will help address heal h li eracy:

A number o requiremen s o ensure ha in orma ion abou heal h insuranceplans and heal h insurance exchanges is provided in a way ha is linguis ically and cul urally appropria e. In addi ion ou reach e or s are also required oensure ha all Americans are aware o he bene s o which hey are en i led.

A program ha will develop, es , and dissemina e educa ional ools o acili a eshared decision-making and help pa ien s, caregivers, and au horized represen-

a ives unders and heir rea men op ions.

A requiremen ha he Food and Drug Adminis ra ion evalua e and de erminei he use o drug ac boxes which would clearly communica e drug risks and bene s and suppor clinician and pa ien decision-making in adver ising ando her orms o communica ion or prescrip ion medica ions is warran ed.

Gran s o implemen medica ion managemen services in rea men o chronicdisease. Medica ion managemen services will help manage chronic disease,

reduce medical errors, and improve pa ien adherence o herapies while reduc-ing acu e care cos s and reducing hospi al readmissions.


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Low li eracy is associa ed wi h several adverse heal h ou comes, including low heal h knowledge, increased incidence o chronic illness, and less han op imaluse o preven ive heal h services. I can compromise heal h care by hindering

he pa ien -clinician communica ions, leading o unnecessary, repea or invasive,cos ly procedures on he one hand; or missed oppor uni y o preven , de ec , orrea heal h problems. E or s o make pa ien s cen ral o e or s o improve heal h

care and o involve hem in sel -managemen o heir illness ou side o he clinicalseting also rely on heal h li eracy.

I is par icularly impor an o address he higher prevalence o heal h li eracy problems in he elderly because hey are also mos likely o have chronic heal hcondi ions. Approxima ely 80 percen o all seniors have a leas one chroniccondi ion and 50 percen have a leas wo. On average, Medicare bene ciaries use

18.5 prescrip ions annually and hose wi h a chronic condi ion see eigh di erenphysicians yearly.60

Te cos s o care or persons wi h low heal h li eracy are believed o be our imesha o he general popula ion.61 One es ima e places cos o low heal h li eracy ohe U.S. economy in he range o $106 billion o $238 billion annually. Tis repre-

sen s be ween 7 percen and 17 percen o all personal heal h care expendi ures.62

Given he higher ra es o poor li eracy in racial and e hnic minori ies, and hepar icular language barriers aced by hose whose rs language is no English,

hese popula ion groups will bene dispropor iona ely rom e or s o improveheal h li eracy.


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Lack o physical ac ivi y Poor nu ri ion obacco use Excessive alcohol consump ion

Tese risk ac ors are common across all popula ion groups, al hough he preva-lence may vary. Ra es o obesi y, or example, are higher in A rican Americans andHispanics han in he general popula ion.

Tere are many provisions in ACA ha bo h ackle he preven ion o chronicdisease and encourage he beter managemen o care o he chronically ill, ande ec ive implemen a ion o hese will bene all Americans, regardless o race ande hnici y. Racial and e hnic minori ies will only derive maximum bene rom

hese provisions, however, i in orma ion and services are provided in ways hamee he cul ural and linguis ic needs o he pa ien s. Mee ing hese needs is no

jus abou improving heal h care services, i s also abou respec ing he digni y o minori y pa ien s.

Finally, i is impera ive ha progress owards closing he gap on heal h caredispari ies is moni ored and measured, ha da a are collec ed and evalua ed andused o in orm ur her decision making and unding. Te ul ima e goal is ha all

Americans, regardless o race or e hnici y, ge he heal h care services hey need when hey need hem, in a manner ha ensures quali y and equali y.


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Endnotes

1 Amy J. Dav d and Genev eve M. kelley, Un n ured Amer anw c r n heal c nd n : key F nd ng r m e Na nalheal in erv ew survey (pr n e n, NJ: R ber W d J n nF unda n, 2005), ava lable a ://www.urban. rg/u l aded-

d /411161_un n ured_amer an . d .

2 Ga l c. c r er, t e c n equen e Be ng Un n ured rA r an Amer an (Wa ng n: J n cen er r p l al andE n m s ud e , 2005), ava lable a ://www.j n en er. rg/

/ e /all/ le /Un n ured%20A r an%20Amer an . d .

3 h lly Mead and er , Ra al and E n D ar e n U.s. healcare: A c ar b (New Y r : t e c mm nweal Fund, 2008),ava lable a ://www. mm nweal und. rg/u r_d /Mead_ra-

ale n d ar e _ ar b _1111. d .

4 tru r Amer a heal , F a n Fa : h w obe y t rea enAmer a Fu ure (2010), ava lable a ://www.rwj . rg/ le /re ear /20100629 a n a ma nre r . d .

5 ib d.

6 Mead and er , Ra al and E n D ar e n U.s. heal care.

7 c eryl D. Fryar and er , hy er en n, h g serum t al c le -er l, and D abe e : Ra al and E n prevalen e D eren e n U.s.

Adul , 1999-2006, Nchs Da a Br e , Number 36, A r l 2010, cen err D ea e c n r l and preven n, ava lable a ://www. d .

g v/n /da a/da abr e /db36. m.

8 Amer an D abe e A a n, Fa s ee r Amer an D abe eM n (2010),.ava lable a ://www.d abe e . rg/a e /amer -

an-d abe e -m n -2010/Amer an-D abe e -M n -2010. d .


10 M n r y heal --heal care Qu Fa , ava lable a://www.am l e u a. rg/ ue /m n r y- eal / a /m n r y- eal -eal - are-qu - a . ml


12 ib d.

13 sylv a A dj an and W ll am A. Vega, D ar e n Men al heal trea men n U.s. Ra al and E n M n r y Gr u : im l a n

r p y a r ,Psychiatric Services 56 (12) (2004): 16001602, ava lable a :// y erv e . y a ry nl ne. rg/ g / n en /

ull/56/12/1600.

14 t m y Wa dmann, E ma ng e c Ra al and E n healD ar e (Wa ng n: Urban in u e, 2009), ava lable a://www.urban. rg/u l aded d /411962_ eal _d ar e . d .

15 t ma A. LaVe , Darrell J. Ga n, and pa r R ard, t eE n m Burden heal inequal e n e Un ed s a e (Wa ng n: J n cen er r p l al and E n m s ud e , 2009) ,ava lable a ://www.j n en er. rg/ / e /all/ le /Burden_o _heal _FiNAL_0. d .

16 Randall R. B vbjerg, harry p. ha ry, and Ela ne M rley, Ma ng a Bu -ne ca e r Redu ng Ra al and E n D ar e n heal care:

key i ue and ob erva n (Wa ng n: Urban in u e, 2009),ava lable a ://www.urban. rg/u l aded d /411951_Bu ne -

are nal. d .

17 in u e Med ne, c verage Ma er : in uran e and healcare (2001), ava lable a ://www.na .edu/ a al g. ?re rd_

d=10188# .

18 ka er Fam ly F unda n, t e Un n ured: A pr mer (2009), ava lablea ://www. . rg/un n ured/7451. m.

19 Ge rge E. Fryer Jr. and er , Var a n n e E l gy Med alcare, Annals o Family Medicine 1 (2) ( 2003): 8189, ava lable a

://www.ann ammed. rg/ g / n en /ab ra /1/2/81? j ey=2932 34 627 b8454ade826174004edaaa65038& ey y e2= _ -

e a.

20 in u e Med ne, c verage Ma er .

21 Gay Be er, E e be ng un n ured n e n m n r e managemen r n llne ,Western Journal o Medicine 175(1) (2001): 1923, ava lable a ://www.n b .nlm.n .g v/ m /ar le /pMc1071457/.

22 R ard W. J n n and s e en cry al, heal n uran e veragea m dl e: c ara er , , and dynam ,Health Care Financ-ing Review 18 (3) (1997): 123148, ava lable a ://www.n b .nlm.n .g v/ m /ar le /pMc1089176/; N all J. Brennan, heal in ur-an e c verage e Near Elderly (Wa ng n: Urban in u e,2000), ava lable a ://www.urban. rg/ ubl a n /309612. ml.

23 J. M ael M W ll am and er , heal in uran e c verage andM r al y Am ng e Near-Elderly,Health A airs 23 (4) (2004):223233, ava lable a :// n en . eal a a r . rg/ g / n en /

ab ra /23/4/223;J. M ael M W ll am and er , Med ares end ng r prev u ly Un n ured Adul , Annals o Internal Medi-cine 151 (11) (2009): 757766.

24 M W ll am and er , Med are s end ng r prev u ly Un n uredAdul .

25 M W ll am and er , heal in uran e c verage and M r al yAm ng e Near-Elderly.

26 Addre ng Ra al and E n D ar e n heal care: Fa s ee ,ava lable a ://www.a rq.g v/re ear /d ar . m.

27 Anne hard ng, Many U.s. adul w r n llne are un n ured,Reuters, Augu 4, 2008, ava lable a ://www.reu er . m/ar le/

dUskRA47698620080804.

28 t e c mm nweal Fund 2006 heal care Qual y survey, ava l-able a ://www. mm nweal und. rg/c n en /survey /2006/

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About the author

Lesley Russell, B.Sc. (Hons.), B.A., Ph.D., is a Visi ing Fellow a he Cen er or American Progress and a visi ing pro essor in he depar men o heal h policy aGeorge Washing on Universi y. She is a research associa e a bo h he Menzies

Cen re or Heal h Policy and he U.S. S udies Cen re a he Universi y o Sydney.


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The Center for American Progress is a nonpartisan research and educational institute

dedicated to promoting a strong, just and free America that ensures opportunity

for all. We believe that Americans are bound together by a common commitment to

these values and we aspire to ensure that our national policies reflect these values.

We work to find progressive and pragmatic solutions to significant domestic and

international problems and develop policy proposals that foster a government that

is of the people, by the people, and for the people.

Easing the Burden: Using Health Care Reform to Address Racial and Ethnic Disparities in Health Care...

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Transcript of Easing the Burden: Using Health Care Reform to Address Racial and Ethnic Disparities in Health Care...