Health Disparities Policy

Neighborhood Health Networks

2011-08-02T17:51:00.012-04:00

Many of you may know my friend and colleague Sheila Ryan, Ph.D., R.N., F.A.A.N. Sheila is a Professor, Charlotte Peck Leinemann and Distinguished Alumni Endowed Chair, and Director of International Programs at the University of Nebraska Medical Center College of Nursing. Sheila has served as President of NLN and as an executive officer for AACN. Sheila is a member of the Institute of Medicine and a fellow in the American Academy of Nursing and has served on many programs and committees for the past two decades. Sheila has been a nursing dean for 22 years at two universities and has board service with IHI, IBHI and RJW/IOM committees. Sheila is presently Chair of the Board of AIHA, American International Healthcare Alliance.

Sheila has been working on the idea of neighborhood health networks as a potentially powerful tool to serve disadvantaged populations right where they live. Here is an outline of the neighborhood health networks concept, by Jo Ellen Kerner and Sheila Ryan.

Barbara Ross Lee D.O.

books from people we know or will hear from at our summit...

2011-06-22T11:22:00.003-04:00

6 books all recently published have come to our attention, as follows....be sure and add to this list: 1. r.williams, "Eliminating Healthcare Disparities in America", Humana Press (2007)
2. D Satcher and R Pamies, "Multicultural Medicine and Health Disparities", McGraw Hill, (2006)
3. B Smedley, A Stith, and A Nelson, (Editors), Unequal Treatment, "Confronting Social and Ethnic Disparities in Health Care", National Academies Press (2003)
4. Norma and Wm. Anderson,"Autobiographies of a Black Couple of the Greatest Generation", (2004).
5. D Wilson with C. Spitzer, "Wilson's Way - Win Don't Whine" (2009) Go to www.booksurge.com>
6. L Grouse, "Cable Hell - The Birth and Death of Medical Television" (2011), Barrenger Publishing.

The first three on the list are the go to texts for excellent overview of health disparities.....the latter three are the personal stories of people involved at the core of the struggle for justice and equality (#4 and #5), and in #6, how an amazingly promising educational innovation/intervention can be effectively destroyed by excessive commercialism.

a simple way to read all the material on the blog...

2011-06-02T09:24:00.003-04:00

The Index published yesterday is aimed at helping readers get to specific essays/comments on the blog thus far. However, if one wishes to approach it another way, the following may help some readers: scroll down from the front page to the bottom of the page, where you will see in the lower right hand corner the words "Older Posts"; click on "Older Posts", and scroll down that page until you get to the bottom and you see "Older Posts"; again, click on "Older Posts" and scroll down till you pass the first post dated 4/27/10 and under which you will see "Newer Posts" and "Home". From there, by reversing the process and scrolling back up, one can review the posts in the order in which they were posted.

Index to existing major contributions to the Blog (June,2010-June 1, 2011)

2011-06-01T15:15:00.002-04:00

INDEX CONTINUED.....FROM "ARCHIVES"
3. Entry from 7/14/10 by Dr. William Straub - describes a new proposed model to develop a Senior physician corps made up of retired physicians willing to work to fill the anticipated primary care workforce gap in community health clinics and elsewhere.
4. Entries posted on 8/24/10, from Dr. John Geyman, a former Chair of Family Medicine at the University of Washington School of Medicine, who is a prolific and persistent author on health care reform and on disparities; he describes first the disparities currently extant in cancer in the USA and secondly his belief that the health reform act is doomed to failure and the reasons why.
5. Entries of 8/27/10 and 8/31/10 describing the careful analyses of Dennis Andrulis, Brian Smedley and others of the Affordable Care Act (the health reform law) passed a year ago. The reader will find the link to the website of the Joint Policy Center where the report is available in full. An update report is planned for the MLKjr Health Equity Summit this August.

Index to existing major contributions to the Blog (June,2010-June 1, 2011)

2011-06-01T13:05:00.005-04:00

INDEX to materials on the blog, its Archives Section (to be found by clicking on "Archives" on the Right side of the Home Page),and The Planned Segments section (to be found by clicking on "Planned Segments" under "Home" listed in the upper right hand corner of the home page).
TO BE FOUND UNDER "PLANNED SEGMENTS:
1. introductory comments to each of the ten separate planned seminars or segments;
2. included in "first seminar" is a commentary on Dr. Howard Koh's NEJM (September 2010)article on Healthy People 2010 and his foreshadowing of Health People 2020;
3. included in the "second seminar" entitled "Health Care in the American Grain" is a discussion of the need to identify a set of Foundational American Values against which to measure our health care system/systems and a trial balloon of four such basic american values, along with some relevant references.
4. the "third" through the "tenth seminars" cover the following - disease-specific disparities, diversity and socio-economic factors in disparities, challenges to health workforce development, health information technology, new and anticipated technological breakthroughs, multicultural-integrative-complementary care, health as a team game/new models, America and its interactions with the world.
TO BE FOUND UNDER "ARCHIVES"
1. Entry of 6/14/10 by Mary Woolley, "Health Equity - Getting Beyond Hope". The CEO of Reseaqrch!America speaks out about the relationship of Hope to our fundamental values and our unique american capacity to deliver innovations that work.
2. Entry of 6/16/10 by University of Michigan scholars, Carmen Green and Gilbert Omenn; an essy "Unequal Burdens and Unheard Voices: Minority Aging"
TO BE CONTINUED ON NEXT BLOG POST...

Further Preparatory Stuff

2011-06-01T11:35:00.004-04:00

As we approach the Ides of June, when Co-Editor Barbara Ross-Lee will take over the direction of this blog in her role as the Co-Leader for Program Development for the Augus 22-23, 2011 Summit, there are a few more introductory and preparatory observations/comments to be made for the potential reader. First, I should point out that by scrolling down continuously through this and the several blogs that follow, you will find included in those few blogs from August, 2010, material that is relevant to a section of the program that Dr. Ross-Lee will want to be discussing in more detail, because it is a part of the planned agenda for the Summit. I will, in a separate blog, identify the subjects of what can be found on the blog either in the archives or in the items listed under Home to the right of the top of the blog; in this way, one can find particular items of interest from the first blog May through August of 2010.

Expanding the range of expertise!!!......

2011-05-31T09:55:00.003-04:00

For reasons that have only been dimly perceived by me, I have felt the need to subscribe for more than twenty years to two major policy journals. The first subscription is natural for me....HEALTH AFFAIRS.....and we discussed yesterday that journal's decision to expand it's range of interest to include environmental challenges, which are clearly meant to include socio-economic and cultural matters. We discussed yesterday some of the health disparities-relevant articles to be found in the most recent issue of HEALTH AFFAIRS, the theme for which is "Environmental Challenges for Health". Perhaps as a commentary on how boring is my life, last night I happened upon a recent issue of that other major policy to which I have longn subscribed, but have rarely read, FOREIGN AFFAIRS. The november/December 2010 issue blares out it's theme on the cover......"THE WORLD AHEAD". Fresh from the stimulation of reading HEALTH AFFAIRS' maiden environmental challenges issue, I was emboldened to look in detail at this special issue, which is clearly aimed at examining the future of our world through a dozen articles, and a closing special list of "must-read books".
The twelve articles' titles as listed on the front cover are instructive by the absence of any significant interface with the contents of the HEALTH AFFAIRS' special them issue on environmental challenges for health. On closer inspection, however, four of the articles offered some potential overlap with health matters: "Clean Energy's Future"; "The Education Gap"; "Feeding the World"; and "The Demographic Implosion". Of the many books recommended by a collection of experts, only one seemed to be directly relevant to health and health care in general and health disparities in particular, and that cam from Judith Rodin, the President of the Rockefeller Foundation, who discussed "Thinking in Systems" by Donella H. Meadows, published by Chelsea Green (2008). Dr Rodin concludes her review as follows, "Presented in a clear and concise manner, the book makes evident that in order to succeed in the world ahead,prediction, control, andsiloed analysis must be transformed into a framework in which complexities are embraced,silos broken,and partnerships welcomed. Doing so will not be easy, but as Meadows notes,only then can we 'use our insights to make a difference in ourselves and in our world'." I could not help but guess that this last words might be a useful closing commentary for our upcoming Summit on Health Equity.

Keeping up with the literature and the experts

2011-05-30T12:14:00.002-04:00

One of the reasons that IAMMM plans to continue this blog and other educational venues throughout the year between our first and second annual MLKjr Health Equity Summits, is that no single meeting can cover every relevant subject and issue. The May 2011 issue of the journal Health Affairs, which is totally dedicated to environmental challenges for health, is a case in point. In her introductory comment, entitled "Embarking on a New Course: Environmental Health Coverage", editor Susan Dentzer, recognizing the stimulus provided by a supportive Kresge Foundation grant, introduces this major commitment to the most wide-ranging, complex and challenging of all the various threats to our population's health. She begins by saying, "Our nation's approach to health and health care is so famously siloed that we've long neglected the obvious: The environment plays a role in nearly 85 percent of all disease."
She concludes as follows, "Authors in this issue propose major policy changes, including updating the Toxic Substances Control Act and removing incentives for producing unhealthy food. Requiring state and federal 'health impact assessments' in a 'health in all policies' approach would seem a reasonable starting point." Several of the published articles touch upon the health disparities dimensions of the envirnmental health problems, particularly that authored by Rachel Morello-Frosch et al, "Cumulative Effects on Racial and Ethnic Minorities" and another on "Unique Vulnerabilities of Children" byP. Landgren and L. Goldman.
It is clear that much of the health disparities problem resides in the area covered within this ground-breaking issue and those of us committed to analyzing health policies as they relate to disparities must take note of and follow carefully what this impoprtant health policy journal has put on its major "To-Do List". This is yet another reason why we are fortunate in having Susan Dentzer pllaying such a prominent role in our Summit and its outcomes.

Innovative Examples...an initial listing...

2011-05-26T10:33:00.002-04:00

The following are some examples that have come to our attention over the past year or so, placed here to stimulate readers to add other promising activities and to alert them to these efforts such that you can pursue any that interest you in further detail. Here are some which could be of use in our program evolution for the August 22/23, 2011 Summit: State universal coverage programs...Hawaii, Vermont, Michigan; state based programs that are having an impact...South Carolina..(ray greenberg/ med. Univ. Of S.C.), MD/Univ. MD (Claudia Bacquet); programs with a regional reach - WAMI, univ of wash educational collaboration; univ. Of Colorado Native American Center Telecommunications-based public health (Spero Manson, Director); public health educational organizational innovations - Texas A & M School of Rural Public Health, Ciro Sumaya (Founding Dean Emeritus), NEOCOM community based medic an and public health school (Jay Gershen, President.......), striking example of new health education community model involving nurse educative training Native American community leaders in public health...a new model that seems to work...Sheila Ryan and JoAnn Koerner).

A pre-season (ie pre-re-awakening of HDP Blog) example!

2011-05-24T09:53:00.003-04:00

Each day, between now and "opening day" for this health disparities blog, I hope to provide examples of why our organization decided there was a pressing need for it's August 22/23 MLKjr Health Equity Summit and a continuing educational effort through each year between subsequent Summits. The health policy blog is envisioned as a potentially useful venue to keep abreast of this complex and ever-changing societal effort to reduce health disparities. Illustrative examples are a good tool to appreciate why we think this is true.
Today's example has to do with the pressing need to address the issue of growing and perhaps reshaping the health care workforce over the coming decade if we are to have any reasonable chance of delivering excellent and cost effective health care to over 32 million currently unisured citizens. In the Jan. 20, 2011 issue of the New England Journal of Medicine, the editors published a cluster of short reports dealing with nursing education and practice. The first article, entitled "broadening the Scope of NursinG Practice"' by J A Fairman and others, summarizes the evidence that Advanced Practice Nurses, working indepently or in teams with physicians and other health professionals, can provide excellent primary care in a significantly cost-effective manner. After describing the traditional obstacles to such an expansion of nurse practice and pointing out that already 17 states allow such independent practice by qualified nurses, they conclude as follows, "Fighting the expansion of nurse practitioners' scope of practice is no longer a defensible strategy. The challenge will be for all health care professionals to embrace these changes and come together to improve US health care."
A major new Institute of Medicicine report provides a major foundation for the evidence and opinions above. One policy implication here is that the 33 remaing states which do not allow independent practice for nurses, should address that issue. But, there remains the question that there remains a dramatic nursing shortage in the USA.
A second relevant article in the same issue of the NEJM, "Nurses for the Future" by Linda Aiken, addresses that complex problem of an insufficienr supply cominG from the nursing educational pipeline. Dr.Aiken cites the impressive expansion in recent year of so-called retail clinics, staffed primarily by APRNs and that the supply os newly- minted APRNs is insufficienr to meet the anticipated demands. AIken argues that by shifting all nurse preparation program to the baccalaureate level via collaborative efforts involving community colleges and baccalaureate level institutions, tahr problems of nurse shortfal can be met. She argues that " public funding for nursing education must be used to steer the change in basic nursing education, just as public funding for patient care steers change in health care delivery." she goes on to identify existing educational public funding that can be used to address these changes. Aiken's ideas open up an area of innovative thinking about one of the most important issues (ie how to expand the health workforce) facing us right now and suggests to that there are certain workforce data that should be added to our growing list of evaluative benchmarks to check on as we follow progress in reducing health disparities over the coming decade.

Introducing samples of health disparities policy issues.

2011-05-22T10:01:00.003-04:00

The goal of this blog is to highlight relevant disparities issues, progress in the reduction (or lack thereof) of health disparities in America and globally, and to identify innovative approaches to addressing those disparities associated with unnecessary societal burden of disease. IAMMM expects to focus on the issues surrounding the existence of health disparities through the lenses of those suffering from them, until health disparities are no longer a major societal challenge. To prepare the new reader of our blog for the upcoming commentaries from some of the major contributors to the august 22/23 Summit on Health Equity, let me enumerate here some of the major themes the will be covered. Our program will give attention to the following issues: a review of the past decade and more of the nature and dimensions of health disparities; an examination of the health disparities' reduction goals of Healthy People - 2020; a review of plans for adjustment to the health clinical care workforce to accomodate coverage of an expanded population; a review of progress and plans for meeting existing and projected research needs in health disparities; innovations and initiatives in public health, prevention and health promotion; innovations and trends in meeting the complex needs of acute and chronic clinical care and the changing demography of an aging population; the cost-effectiveness of integrative (complementary) medicine and health care with relation to health disparities reduction; the impact of social/economic status on health status and disparities; analysis of the Health Reform Act and it's potential impact and relevance to the reduction of our national disease burden through health disparities reduction; health information technology and it's potential impact on improving quality and efficiency in the health care delivery systems; and finally, some models of innovative approaches in the US and globally tha deserve our attention as we look to future strategies for improvement. More to come from those hard at work on the development of the August Summit!

Announcing the re-emergence of the health disparities policy blog

2011-05-20T15:33:00.002-04:00

The parent organization of this blog has now announced the First Annual Martin Luther King jr Center for Health Equity Summit, scheduled for august 22/23, 2011 in Washington DC at the Willard Hotel. Program details and registration information will be posted shortly on this blog and on the IAMMM website shortly. The program is being planned by experts in the various areas relevant to health disparities policy, and we shall be publishing notes from these individuals, beginning in the first week of June, concerning the the issues and questions they expect to address at the August meeting. We hope that readers will chip in with their own relevant insights and opinions and questions, such that presenters will be able to include your ideas and concerns in their remarks. The edited blog archives will include the give and take as well as the major points ultimately presented at the summit itself.
Each day until these contributions by our program leaders start appearing, we will be adding policy relevant information that we think will illustrate the kinds of issues that we think will come forth through the blog venue and we look forward to the commentary of our readers.

Link to Joint Center for Political and Economic Studies

2010-08-31T09:25:00.003-04:00

I am sorry to say that I am having difficulty posting either or both of two items, which however are available on the Website of the Joint Center. The two items are the press release describing the new report from the Center, entitled "PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010: ADVANCING HEALTH EQUITY FOR RACIALLY AND ETHNICALLY DIVERSE POPULATIONS". I shall keep trying to get the report from my computer onto our Health Disparities Blog. However, both are available on the Joint Center's website at www.jointcenter.org/hpi
The team of analysts who wrote this very important report include Dr. Dennis Andrulis, Nadia Siddiqui, Jonathon Purtle,and Dr. Lisa Duchon describe the new law as having "the potential to seed, promote and guide diversity initiatives in this country for decades to come". Dr. Andrulis notes the enormous potential for ultimately creating the necessary environment for our multi-cultural society to on an equal basis have access to necessary and basic health care. Getting thgere will require a series of steps, some budgetary in the future, some from the legislative branch of our government and others via Executive branch actions. Thus it is a wonderful report to have as the closing offering of this survey course on health disparities policy. The over-riding recommendation that stikes me regarding the question we posed at the beginning about whether or not we should not strongly recommend that the MLKjr Center for Health Equity continue with its plans for development of the first annual Health Equity Conference to be held in 2011. This report lays out many of the reasons and the parameters we shall use in following progress or regression in our national drive for the elimination of health disparities. So thank you to Ralph B. Everett (President and Ceo of the Joint Center) and Dr. Brian Smedley (Vice-President and Director of the Joint Center Health Policy Institute) for developing this important report. As Dr. Smedley said, "Going forward, policy-makers will have to make the reduction of health inequities a top priority in the implementation and administration of the new law, because doing so is essential to achieving its stated goals of expanding health insurance, improving the quality of health care, and reducing the costs of care."

Fw: Fwd: request from Roger Bulger

2010-08-31T08:52:00.000-04:00

----- Forwarded Message ----
From: dennis andrulis <dpandrulis@gmail.com>
To: Roger Bulger <roger.bulger@yahoo.com>
Sent: Mon, August 30, 2010 10:39:12 AM
Subject: Fwd: request from Roger Bulger

Roger:

Attached are the formal, final documents straight from the Joint Center should you wish to post part or all of the press release and the report. 

Dennis

---------- Forwarded message ----------
From: Kendall Alexander<kalexander@jointcenter.org>
Date: Mon, Aug 30, 2010 at 9:34 AM
Subject: Re: request from Roger Bulger
To: dennis andrulis <dpandrulis@gmail.com>, Brian Smedley <bsmedley@jointcenter.org>

Hi Dennis,
I have attached PDFs of both the report and press release.  Let me know if you need anything else.

Best,
Kendall

Kendall Alexander
Joint Center for Political and Economic Studies
Health Policy Institute
(202) 789 6374
kalexander@jointcenter.org

>>> Brian Smedley 8/30/2010 10:00:26 AM >>>
Hi Dennis, this is great - eager to see our friends help with dissemination.  Either option is fine with us.  I will ask Kendall Alexander (copied here) to send the pdf to you in case you don't have it.
Brian

>>> dennis andrulis <dpandrulis@gmail.com> 8/30/2010 9:52 AM >>>
Brian:

Roger Bulger wrote me about our report and is requesting either posting the entire report on the IAMMM blog or linking it to the Joint Center website. See his note below. He has also asked us to write or have him summarize the report. Do you have a preference re posting v. linking to your website? or other comments?

Dennis

---------- Forwarded message ----------
From: Roger Bulger<roger.bulger@yahoo.com>
Date: Mon, Aug 30, 2010 at 6:17 AM
Subject: Re: new mailing address for you...even temporary
To: dennis andrulis <dpandrulis@gmail.com>

Dennis....I have read your report. It is wonderful and extremely valuable and sholuld be spread as far and wide as possible. I am delighted at your apparent association with my old school, the University of Texas School of Public Health (at Houston I presume). It was my personal #1 project when I was President of that Health Science Center from 1978-1988. 
     We have two options re the blog. One is that I can insert from your email both the press release and the whole report. I have just learned, to my utter astonishment, by myself hoiw to do that from an email and have used that to add just last week two long pieces from John Geyman.
     Since you have already a gmail address, you can sign into the blog directly yourself and if you were willing, you could say two things: introduce both the press release and the entire report in your own words; and secondly, (making your work entirely relevant to being inserted in the tenth and final seminar),you could comment that the largest implication and action agenda of yout report is the need for continuing follow-up on progress or the opposite on all the points your report has identified for the reduction of health disparities and that you personally would welcome the opportunity to participate in such a review as IAMMM is proposing and planning on an annual basis to begin in 2011 around the time of the MLKjr Memorial Dedication one year hence. Follow-up would  involve using your report as one of the center pieces of such a conference, perhaps an entire half day or even perhaps a whole  day. 
    I suggest you look at the blog and decide which path you prefer. If your prefer to have me do it, I can say the piece about the MLK conference. Either way is fine with me, but even if you don't want us to publish your report on the blog at all, I can insert a blog of my own about it and in any case, the future efforts are what I for sure want to be able to discuss with you particularly in the light of your new position.   
    The blog address is http://healthdp.blogspot.com/ Let me know your preferences...finishing this this week is first on my agenda, so make it easiest on yourself. But I don't want to add the report verbatim without your permission...if you don't want that, perhaps you could give me a link through which an interested reader can access the entire report.   Thanks again for doing this work....roger 
  From: dennis andrulis <dpandrulis@gmail.com>
To: Roger Bulger <roger.bulger@yahoo.com>
Sent: Fri, August 27, 2010 9:35:41 AM
Subject: Re: new mailing address for you...even temporary

Nice to hear from you Roger. We have just published our health care reform and disparities report which i have attached along with the Joint Center press release.i haven't posted something on your blog since it hadn't been completed but if you think the blog or some other vehicle might be worth a paragraph or two please let me know.

Hope you are well.

address is: 4602 avenue G
austin, TX 78751

On Fri, Aug 27, 2010 at 5:45 AM, Roger Bulger <roger.bulger@yahoo.com> wrote:
 hi....hope all is well....have a book to send you...roger

Fw: new mailing address for you...even temporary

2010-08-31T08:39:00.001-04:00

----- Forwarded Message ----
From: dennis andrulis <dpandrulis@gmail.com>
To: Roger Bulger <roger.bulger@yahoo.com>
Sent: Fri, August 27, 2010 9:35:41 AM
Subject: Re: new mailing address for you...even temporary

Nice to hear from you Roger. We have just published our health care reform and disparities report which i have attached along with the Joint Center press release.i haven't posted something on your blog since it hadn't been completed but if you think the blog or some other vehicle might be worth a paragraph or two please let me know.

Hope you are well.

address is: 4602 avenue G
austin, TX 78751

On Fri, Aug 27, 2010 at 5:45 AM, Roger Bulger <roger.bulger@yahoo.com> wrote:
 hi....hope all is well....have a book to send you...roger

Fw: [Health Disparities Policy] New comment on Fw: John Geyman's submission for Health Disparitie....

2010-08-24T19:56:00.001-04:00

----- Forwarded Message ----
From: Kimmy kard <noreply-comment@blogger.com>
To: rogerjbulger@gmail.com
Sent: Tue, August 24, 2010 5:30:37 PM
Subject: [Health Disparities Policy] New comment on Fw: John Geyman's submission for Health Disparitie....

Kimmy kard has left a new comment on your post "Fw: John Geyman's submission for Health Disparitie...": 

Good thing this is so, hopefully provide fast and effective solutions since many people will be grateful ... in findrxonline indicate that we must all fight against cancer .... 



Posted by Kimmy kard to Health Disparities Policy at 8/24/2010 

Fw: John Geyman's submission for Health Disparities Policy Blog / with hotlinks

2010-08-24T16:20:00.001-04:00

----- Forwarded Message ----
From: Macman <macman@rockisland.com>
To: roger.bulger@yahoo.com
Cc: John Geyman <jgeyman@u.washington.edu>
Sent: Wed, August 4, 2010 8:12:29 PM
Subject: John Geyman's submission for Health Disparities Policy Blog / with hotlinks

Disparities within the U. S. health care system result in serious impacts on access to care for patients with cancer at all stages from screening and prevention to treatment and survival. Access barriers further lead to disparities in the quality of care received. These concerns led the American Cancer Society to launch a national effort in 2007 calling for system reform that will provide "4 As coverage":
•  Adequate—timely access to the full range of evidence-based health care including prevention and early detection.
•  Affordable—costs are based on the person's ability to pay.
•  Available—coverage available regardless of health status or prior claims.
•  Administratively simple—processes are easy to understand and navigate. (1) (Sack, K. Cancer society focuses its ads on the uninsured. New York Times, August 31, 2007)
Access barriers take a wide variety of forms and affect many disadvantaged groups within the U. S. population. The single most important aspect of access is the status of the patient's health insurance coverage. (2) (Siminoff, LA, Ross, L. Access and equity to cancer care in the USA: a review and assessment. Postgrad Med J 81: 674, 2005) For all types of cancer, the uninsured are 1.6 times more likely to die within five years compared to cancer patients with insurance. (3) (Ward, E, Halpern, M Schrag, N et al. Association of insurance with cancer care utilization and outcomes. CA Cancer J Clin 58: 19-20, 2008) 8/1/9
The lack of health insurance is much more common among racial and ethnic minorities than among whites. According to the U. S. Census Bureau, when 15.9 percent of the population was uninsured in 2005, the uninsurance rate for whites was 11.3 percent compared to 19.6 percent for non-Hispanic blacks and 32.7 percent for Hispanics. (4) (Income, poverty, and health insurance coverage in the United States: 2005, update.)
These examples illustrate how the lack of insurance adversely impacts patients with cancer across the entire spectrum of care:
•  Women aged 40 to 64 without insurance are only half as likely to have had a mammogram within the last two years as those with insurance. (5) (Ibid #3)
•  One in four uninsured cancer patients delay or forego care because of cost. (6) (Ibid #3)
•  Uninsured African-American women with breast cancer have a five-year survival rate of only 63 percent compared to 89 percent for insured Caucasian women. (7) (Ibid # 3)
•  Cancer has become a chronic disease for the estimated 12 million cancer survivors in this  country, many of whom have co-morbidities such as heart disease, diabetes and arthritis as well as under-recognized and under-treated anxiety and depression. A 2008 national study found that uninsured cancer patients were three times more likely than their insured counterparts to have not seen health professional in the last year, twice as likely to have no regular source of care, and five times more likely to use the emergency room for care. (8) (Wilper, AP, Woolhandler, S, Lasser, KE et al. A national study of chronic disease prevalence and access to care in uninsured U. S. adults. Ann Intern Med 149: 170-76, 2008)
Under-insurance is another big problem for many patients with cancer, since many insurance policies provide little protection against the rapidly rising costs of cancer care. Two examples illustrate the financial burdens placed on cancer patients and their families even when insured:
•  Despite being consistently insured, a 2006 study by the Kaiser Family Foundation and the Harvard School of Public Health found that almost one-half of cancer patients used up most or all of their life savings, while 8 percent were turned away or unable to get a specific treatment because of insurance issues and 3 percent ended up declaring bankruptcy. (9) (Kaiser Family Foundation. Survey of families affected by cancer shows people with and without health insurance suffer serious financial hardships. USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer, November 20, 2006)
•  Some "insurance" policies are ludicrous in the extent of their undercoverage—one example is the limited-benefit basic cancer policy marketed by AllState, starting  at $420 a year for family "coverage", which pays a one-time benefit of $2,000 if diagnosed for the first time with cancer (other than skin cancer). (10) (McQueen, MP. The shifting calculus of workplace benefits. Wall Street Journal, January 16, 2007: D1)
Do patients with cancer covered by Medicare and Medicaid fare any better than their counterparts with or without private insurance? Here again, their access to care falls far short of their needs. An increasing number of physicians will not accept new patients on Medicare or Medicaid because of low reimbursement. Medicare Advantage plans may impose high cost burdens on patients who are referred to out-of-network physicians and facilities for cancer care, sometimes leading to disenrollment. (11) (Medicare Rights Center. Why consumers disenroll from Medicare private health plans. Summer 2010) Medicaid remains an underfunded porous safety net with many restrictions on coverage varying from state to state. (12) (Ramirez de Arrelano, AB, Wolfe, SM. Unsettling Scores: A Ranking of State Medicaid Programs. Washington, D.C. Public Citizen Health Research Group, April 2007)   Medicaid enrollees are more likely to have late-stage cancers when diagnosed, resulting in worse outcomes. (13) (Halpern, MT, Ward, EM, Pavluck, AL et al. Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: A retrospective analysis. Lancet Oncol 9 (3): 222-31, 2008) Many oncologists refuse to provide chemotherapy for Medicaid patients in their offices due to low reimbursement, sending them on to hospitals. (14) (Lung Cancer Connections. Caring 4Cancer. An introduction to Medicaid. Web site accessed October 31, 2008)
Because of access barriers to care and other factors in our market-based system of care (based as it is on ability to pay, not medical need), the quality of care for cancer patients in our present system leaves much to be desired for these kinds of reasons:
•  Perverse financial incentives pervade our business-oriented health care system. Hospitals and physicians make higher revenues by providing services that are often unnecessary, inappropriate or even harmful. When Medicare reduced reimbursement rates for outpatient chemotherapy drugs in 2005, oncologists switched from drugs that were most reduced in profitability to other high-margin drugs at increased cost but without good evidence of improved outcomes. (15) (Jacobson, M, Earle, CC, Price, M, Newhouse, JP. How Medicare's payment cuts for cancer chemotherapy drugs changed patterns of treatment. Health Affairs 29 (7): 1391-99, 2010)  A 2008 study by United Health found that Procrit, a very expensive anti-anemia drug also highly remunerative to prescribing oncologists, was being prescribed  for about one-third of patients who were not anemic at all. (16) (Culliton, BJ. Interview: Insurers and 'targeted biologics' for cancer: A conversation with Lee N Newcomer. Health Affairs Web Exclusive 27 (1): W 41-W51, 2008)  More than 30 million full-body CT scans are performed each year for screening purposes despite the lack of evidence of benefit or the approval by the FDA or the American College of Radiology. (17) (Brenner, DJ, Hall, EJ. Computed tomography—An increasing source of radiation exposure. N Engl J Med 357: 2277-84, 2007)  Over-screening, over-diagnosis and over-treatment of prostate cancer are endemic in this country, without evidence of improved outcomes. A 2009 report of a randomized ten-year  trial of 76,000 American men found that widespread screening does not lower the death rate from the disease. (18)  (Andriole, GL, Grubb, RL, Buys, SS et al. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med online. March 18, 2009).  Dr. Peter Bach, oncologist at Sloan-Kettering Cancer Center and former senior advisor on health care quality at the Centers for Medicare and Medicaid Services (CMS), estimates that 30 to 40 percent of spending on cancer care is of marginal value. (19) (Bach, P, as quoted in McNeil, C. Sticker shock sharpens focus on biologics. News. J Natl. Cancer Inst 99 (12): 911, 2007)
•  We have an industry-friendly system of deciding what services  and treatments will be covered. Coverage policies are not rigorously evidence-based, and the use of cost-effectiveness as a criterion for coverage decisions is vigorously opposed by industry. Many expensive and toxic drugs are used for indications beyond FDA approval—so-called "off label" use. In 2009, Medicare coverage of off-label cancer drugs was expanded despite the lack of clinical evidence for effectiveness. (20) (Abelson, R, Pollack, A. Medicare widens drugs it accepts for cancer care: More off-label uses. New York Times, January 27, 2009)
•  Quality of care breaks down at the interface between primary care and oncology-related subspecialty care. A just-published monograph by the National Cancer Institute documents the scope and magnitude of this serious problem, ranging from lack  of communication and collaboration to overlapping and ambiguous roles. (National Cancer Institute. Division of Cancer Control and Population Sciences. Toward Improving the Quality of Cancer Care: Addressing the Interfaces of Primary and Oncology-Related Subspecialty Care. Number 40, 2010)  For the best quality of care, cancer patients need to be followed by both groups of physicians working together in their areas of expertise. One study of almost 15,000 survivors of colorectal cancer, for example, found that patients followed by oncologists were less likely to receive influenza vaccination, cervical screening and bone densitrometry, while those followed by primary care physicians reported less screening by colonoscopy and mammography. (21) (Earle, CC, Neville, BA. Under-use of necessary care among cancer  survivors. Cancer 101 (8): 1712-19, 2004) Continuity of primary care throughout the care of cancer from screening to survivorship is essential to the best outcomes. We cannot expect subspecialists to care for co-morbidities so common among cancer patients, and treatment decisions often require consideration of co-morbidities, personal and family considerations.
As is clear from the above, access and quality of care are closely entwined and multi-dimensional. Addressing these problems is a complex challenge since they are embedded in a dysfunctional health care system. But that is the subject of our next post, which will consider to what extent the new health care reform law, the Patient Protection and Affordable Care Act of 2010, can remedy these problems.
Adapted in part from The Cancer Generation: Baby Boomers Facing a Perfect Storm, 2009, with permission of the publisher, Common Courage Press.
TAGS: cancer,cancer care, Access and Quality of Cancer Care, Under-use of necessary care, The Cancer Generation: Baby Boomers Facing a Perfect Storm, John P. Geyman M.D., patient's health insurance coverage,  lack of health insurance, cancer chemotherapy drugs, Patient Protection and Affordable Care Act of 2010, PPACA, wellness plans, AHA, American Hospital Association, America's Affordable Health Choices Act, America's Health Care Plans

Fw: John Geyman's blog 45: Lessons From the Inevitable Failure of Health Care Reform 2010

2010-08-24T16:18:00.000-04:00

----- Forwarded Message ----
From: Macman <macman@rockisland.com>
To: roger.bulger@yahoo.com
Cc: John Geyman <jgeyman@u.washington.edu>
Sent: Tue, August 10, 2010 4:29:22 PM
Subject: John Geyman's blog 45: Lessons From the Inevitable Failure of Health Care Reform 2010

Lessons From the Inevitable Failure of Health Care Reform 2010

In a recent post, we brought together an overall assessment of the Patient Protection and Affordable Care Act of 2010 (PPACA), showing how it cannot be expected to remedy our health care system's four major problems—lack of universal access, unrelenting surge in costs, decreasing affordability for much of the population, and variable, often mediocre quality of care. That was followed by other posts that took cancer as a bellwether for how patients with serious illness are likely to fare under the new law, again with disappointing results.
Even though the new law is just entering its implementation phase, we already know how and why it will fail to meet urgent needs for reform. More fundamental reform that more directly attacks the forces responsible for system problems will be required, sooner rather than later. But to be more successful the next time around, we need to learn the lessons as to how and why this last reform effort went off the tracks if we are to avoid making the same mistakes once again. That is the subject of this post.
Here are some of more important ways in which the politics of reform diverted the process from the real goals of reform, ending up instead with a nearly $1 trillion bill that serves corporate interests in the medical-industrial complex and Wall Street much better than Main Street and ordinary Americans.
1. Framing of the issues and the entire political process were hijacked by the very interests that are largely responsible for the system's problems of access, cost and
quality. The opening assumption was that we had to build on the existing system, thereby serving the interests of insurers, drug and medical device makers, hospitals, organized medicine and other parts of the system that would resist structural change. Missing from the subsequent health debate were more basic issues, such as whether health care is a right or a privilege based on ability to pay for just another commodity on the open market, and whether the business model underlying our system is consistent with the long-term public interest. Instead, the language of the debate was dominated on the right by defense of markets as the solution and that government is the enemy, and on the left by such meaningless slogans as "competition" and "guaranteed affordable choice". The  debate then devolved to such arcane details as public options, exchanges and triggers, which much of the public found difficult to track and understand.
2. The democratic process was commandeered by corporate money. Corporate interests, intent on expanding their markets through the "reform" bill, pushed their agenda through lobbying, campaign contributions to key legislators, advertising campaigns through disease advocacy groups and Astroturf organizations, and feeding talking points the media (which thrived on the 24-7 coverage of the battle over a year and a half). These examples illustrate this coordinated effort by industry: Industry representatives were often in critical places as illustrated by these examples: (1) (MSNBC. Obama health czar directed firms in trouble) (2) (Center for Public Integrity, as cited in Moyers, B, Winship, M. The unbearable lightness of reform. Truthout, March 27,  2010)
• Elizabeth Fowler, insurance industry representative turned staffer of the Senate Finance Committee, largely wrote that bill.
• Nancy-Ann DeParle, White House Director of the Office of Health Reform, had received $6 million previously while serving on boards of directors of at least half a dozen companies that were targets of federal investigations, whistleblower lawsuits and other regulatory actions.
• By the time the reform law was finally passed, about 1,750 businesses and organizations had hired some 4,525 lobbyists, eight for every member of Congress, at a cost of $1.2 billion.
3. Market failure was not recognized as the wellspring of our system problems. Market advocates were successful in perpetuating the myth that competition in health care markets can rein in uncontrolled costs, even when experience and many studies confirm the opposite. These examples make the point:
• Continuous escalation of prices and costs by drug and medical device manufacturers, hospitals, physicians and other members of the medical-industrial complex.
• A nine-year study by the Community Tracking Study of 12 major U. S. health care markets found these four barriers to efficiency and quality of care: (1) providers' market power; (2) absence of efficient provider systems; (3) employers' inability to push the system toward efficiency and quality; and (4) insufficient health care competition, (3) (Nichols, L et al. Are market forces strong enough to  deliver efficient health care systems? Confidence is waning. Health Aff (Millwood) 23 (2): 8-21, 2004))
• Consolidation among providers limits choice and competition in many markets. (4) (Kronick, R, Goodman, DC, Weinberg, J, Wagner, E. The marketplace in health care reform. The demographic limitations of managed competition. N Engl J Med 328: 148, 1993)
• A 2006 AMA study found near-monopolies by private insurers in 95 percent of HMO/PPO metropolitan markets. (5) (Associated Press. Study: Health insurers are near monopolies. April 18, 2006)
4. The private insurance industry, already dependent on various kinds of government subsidies, does not offer enough value to retain its 1,300 insurers.
These are the main reasons that the present multi-payer system should be replaced by a not-for-profit single-payer financing system: (6) (Geyman, JP. Do Not Resuscitate: Why the Health Insurance Industry is Dying, and How We Must Replace It. Common Courage Press, 2009)
• continued inflation of health care costs, which insurers cannot control.
• growing unaffordability of premiums and health care.
• decreasing coverage of policies with often unaffordable out-of-pocket costs.
• growing economic insecurity and hardship, even for the insured.
• shrinking private insurance markets and cutbacks in public markets.
• adverse selection in shrinking risk pools.
•  increasing profits despite declining enrollments (e.g. Aetna profits up by 42 percent in second-quarter 2010). (7) (Veiga, A. Aetna posts higher 2Q profit up 42 percent. Associated Press, July 28, 2010)
• Stockpiling large surpluses even while hiking premiums. (8) (Young, A. Consumer group: Insurers kept surplus while hiking premiums USA Today, July 22, 2010)
5. The Obama Administration has so far been unwilling to confront the special interests and address the real problems. After winning the 2008 election, with the Democrats taking both the House and Senate as well as the White House, the pragmatic and overly cautious incoming president did a 180-degree turn from this statement made five years previously to the Illinois AFL-CIO:
I happen to be a proponent of a single payer universal health care program… (applause)…I see no reason why the United States of America, the wealthiest country in the history of the world, spending 14 percent of its Gross National Product on health care, cannot provide basic health insurance to everybody….But as all of you know, we may not get there immediately. Because first we have to take back the White House, we have to take back the Senate, and we have to take back the House. (9) (Obama. Speech to the Illinois AFL-CIO, June 30, 2003)
As a result of the deals the  president made with corporate interests through their voluntary, unenforceable pledges, he joined forces with them in gaining political support for "reform". But this "alliance" with corporate interests assured that the legislative outcome would meet corporate interests more than those of ordinary Americans. And it leaves the president with little clout to rein in these interests, since he now depends on the PPACA to work. It would be a PR and political disaster if more insurers leave the market, more physicians refuse to see newly "insured" patients, and growing numbers of patients and families see affordable care and choice as disappearing. The state of Maine has already asked the federal government to waive its medical loss ratio (MLR) requirement, fearing disruption of the individual and small business market. (10) (Pear, R. Covering new  ground in health system shift. New York Times, August 3, 2010: A13)
6. Policy makers and politicians ignored the lessons of history in attempting incremental "reforms" that had already failed over the last 30 years. Improved access and containment of health care costs have been addressed by many initiatives over the last 30 years, including managed care, employer and individual mandates, tax credits, association health plans, chronic disease management, pay for performance, and expansion of health information technology. Although all have failed to redress these two system problems, they were included in one way or another in the PPACA as more fundamental financing reform, such as shifting to a not-for-profit financing system, was intentionally kept off the table for political reasons. 
In sum, the medical-industrial complex won this last battle over health care reform. Robert Kuttner, co-founder of The American Prospect 20 years ago, reminds us of the political challenge ahead: President Obama took office at a moment when free-market ideology, Wall Street hegemony, and conservative incumbency were thoroughly disgraced by recent events. But Obama has not yet been able to translate that failure into a durable progressive counterrevolution. (11) (Kuttner, R. A 20-year odyssey. The American Prospect 21 (7): 3, 2010)
Adapted in part from Hijacked! The Road to Single Payer in the Aftermath of Stolen Health Care Reform, 2010, with permission of the publisher Common Courage Press. 

Fw: Disparities blog on cancer

2010-08-24T16:10:00.001-04:00

----- Forwarded Message ----
From: John Geyman <jgeyman@u.washington.edu>
To: Roger Bulger <roger.bulger@yahoo.com>
Sent: Wed, August 11, 2010 11:25:47 PM
Subject: Re: Disparities blog on cancer

Roger.  This is the second one on cancer.  John

the tenth Seminar began yesterday and ends next saturday, August 14

2010-08-09T15:10:00.002-04:00

We welcome your input to this tenth seminar, the stage set for which can be found by clicking onto the Planning Segments item under the Background for this Blog section on the home page, and then scrolling down to the tenth seminar to read the brief "stage set" for this seminar. We shall keep the blog open for the last two weeks of August during which time the editors will be adding material, as they judge useful, and will be linking the individual stage sets for each seminar to the various postings that seem to fit most appropriately with individual seminars. Anyone wishing to post items before the 28th of August can be sure that their comments will be included in the archives for an indefinite period of time and should be accessible as long as the blog is in existence. We anticipate that the blog will remain viable even if the format will be less formal and style-ized.

the Eighth Seminar has begun and the Ninth will begin on August first

2010-07-26T18:48:00.002-04:00

As a reminder to all interested, the stage sets for each of these seminars can be accessed by clicking on the Planned Segments to the right on the home page under Background for the Blog, and by scrolling down to the selected Stage Set. However, PARTICIPANTS CAN COMMENT FOR ANY OF THE SEGMENTS BY SIMPLY IDENTIFYING THE SEMINAR TO WHICH THEY WOULD LIKE THEIR POSTING TO ULTIMATELY GO WHEN THE TEN WEEKS ARE OVER.

an alternate route to posting

2010-07-20T12:37:00.002-04:00

Because I sense that some people are having trouble posting, please e-mail your comment to me and I shall make every effort to get it posted. roger.bulger@yahoo.com

Seventh Seminar Open for comments and posts

2010-07-18T10:50:00.003-04:00

This seventh seminar: "Health Care Reform-new diagnostic and therapeutic agents" has a stage set, which may be found by clicking on "Planned Segments" to the right on the home page, and then scrolling down to the Seventh Seminar. As usual comments from any of our readers are welcome now or, if you are on vacation at any time within the next month.

Bill Straub has a new post for the fifth seminar

2010-07-14T14:52:00.003-04:00

Bill Straub's post for the fifth seminar follows.
"Somewhat belatedly in this segment, I would like to introduce the notion of bringing retired physicians and nurses back into the workforce as a partial solution to the staffing crisis facing community health centers (CHCs)as they brace to provide access for upwards of fifteen million of the thirty-two million Americans to be covered by ACA by 2014. For the current 8000 CHC sites to meet this challenge will require doubling their capacity and staff, amounting to an additional 15,000 physicians and 11,000 nurses.
Increasing the supply from the educational pipeline; further increasing the use of nurse practitioners and physician assistants; and doubling the contribution from the National Health Service Corps are all necessary, but likely insuffeicient to meet the 2014 need.Tapping into the approximately 200,000 retired physicians (40% with primary care backgrounds)and 800,000 retired nurses offers one partial and temporary solution, until an adequate workforce can be stabilized.
Our (American Health Initiative) experience over the past five years, recruiting retired health professionals for volunteer service in Free Clinics, suggests that this valuable resource could be tapped to help ameliorate the coming CHC workforce crisis. Recently retired clinicians have much to offer and many are seeking opportunities to stay professionally and mentally active in such constructive and collegial efforts."

The Sixth Seminar begins tomorrow, July 11, 2010

2010-07-10T22:37:00.002-04:00

Entitled "Health Care Reform - IT, digitalization, and advanced technologies", we welcome especially commentaries upon promising advances as well as concerns about our national tendency to perhaps put technologies into widespread practice too soon. The stage set for the sixth seminar may be found by clicking onto the "Planned Segments" to the right on the front page of the blog.

the Fifth Seminar begins tomorrow

2010-07-03T12:17:00.003-04:00

The fifth Seminar begins tomorrow, the fourth of July and deals with the impacts now and in the future of the the recently passed health care reform act. The stage set with some recent references may be found by clicking on "Planned Segments" to be found on the right on the front page of the blog and then scrolling down to the fifthe Seminar. As usual, posts are welcome from all quarters. Names of those contributing and recommended references are especially valuable.

The fourth Seminar begins today 27 June

2010-06-27T08:04:00.004-04:00

New posts may be added this week for any of the first four blogs; but if you post something intended for one of the earlier blogs, please identify which one. Please remember to click on "planned segments" to scroll down to "fourth seminar stage set" to read the goals for this week.

Third Seminar-Specific Health Care Disparities

2010-06-20T08:41:00.004-04:00

Beginning today through next saturday, June 26, we are open to commentaries and observations on any specific health care disparities. I know already that some of the listed invited commentators may not be able to comment this week and as noted last week, we welcome comments whenever the time to make yours presents itself. If it does not fit perfectly in this week's subject, simply suggest the particular seminar you wish to attach it and we'll take care of placing comments appropriately at the end of the ten weeks. PLEASE GO TO SEMINAR THREE FOUND UNDER PLANNED SEGEMENTS FOR THE BRIEF STAGE SET FOR THIS WEEK.
I am aware that policy thinking and assessment tools make it possible to look at data from urban vs rural polulations, but since we have access to the District of Columbia and LA data, whether city to city variation has been noted and re rural regions whether region to region variation is sufficient to advocate more strongly than we have heretofore, the importance of reinforcing local initiatives to target the most important disparities.

Unequal Burdens and Unheard Voices: The Need for Minority Aging Research and Policy

2010-06-16T14:32:00.004-04:00

Unequal Burdens and Unheard Voices:
The Need for Minority Aging Research and Policy

Carmen R. Green, MD, and Gilbert S. Omenn, MD, PhD
University of Michigan

"The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life, the sick, the needy and the handicapped."
Hubert H. Humphrey

Health disparities policymaking and health disparities research need a special focus on the elderly. The Annual Older Americans’ Month was celebrated for the first time in May 1963. At that time 17 million Americans had reached their 65th birthday; today, nearly 40 million Americans have reached their 65th birthday.(1) Despite numerous references to an aging America, there is less attention directed at who are aging. Currently, 16.1% of all Americans 65 years or older are minority elders, with the majority being African-American. Looking into the crystal ball to the year 2050 reveals a darker and older America with an 81% increase of white elders and a 217% increase in minority elders.(2) Estimates project increases of 128%, 301%, 322%, and 193% for African Americans, Asian Americans, Hispanic Americans, and American Indian and Alaska Native elders respectively.(2) Among the old-old, 85 years of age and older, the relative growth will be less due to lower survival.(3) Elderly women will continue to significantly outnumber elderly men, making aging a particularly important women's health issue.

Racial and ethnic minorities are disadvantaged when compared to whites on most major health indices.(4, 5) Increasing survival after cancers, strokes, and other catastrophic illnesses and injuries has been less among minority elders. The medical and technological advances that have yielded healthier aging for whites have not been applied as successfully for other populations, thus contributing to health and health care disparities. Overall, minorities have increased morbidity, shortened lives, and lower self-reported health even when their health insurance status is similar to whites.(4, 6) Furthermore, minority elders face significant barriers to quality health care because of more limited financial resources and diminished health care access and follow up.(7)

The National Institute on Aging has funded six National Resource Centers for Minority Aging Research.(8) These flagship programs have served an important mission through their commitment to 1) including minority elders in aging research designed to reduce and eliminate disparities, 2) developing the methodology and measures to accurately assess health and predict important outcomes in minority elders, and 3) developing investigators committed to careers in minority aging research. The literature suggests minority elders struggle with greater physical disability and functional limitations.(9) Interdisciplinary scholarship and social research focusing on subpopulations of the aging minority (e.g., in rural and inner city areas) and addressing economic, housing, and urban planning issues is critically important.(10) Local, state, and federal funding for minority aging research, including facilitation of public/private partnerships, is needed. Substantial, sustained efforts to improve the health and well-being of these understudied and vulnerable populations can help the nation’s health status and hopefully 3
our international standing. Both translation of what is known and research on open issues to gain useful new knowledge are needed for more effective policy initiatives in an age- and culturally-sensitive context.

Of course, the determinants of health in the elderly do not begin to act only after reaching age 65. Nevertheless, it is never too late to practice healthier behaviors, promote better health, and prevent chronic and acute diseases. Thirty years ago we showed that the reduction in relative risk from stopping smoking was just as great in people 65 and older participating in the Coronary Artery Surgery Study population (CASS) as among 55-64 and 35-54 year-olds. Moreover, due to the much higher rates of heart attacks and deaths, the absolute benefit in lives saved was far greater per 1000 persons among the elderly.(11) This result was so striking that it was highlighted in the President’s Budget presented to Congress for FY91.

A robust, innovative research agenda to promote successful aging for all should utilize a representative and diverse population across the life span with translational research from bench to bedside and clinic to community to policy--engaging laypersons, clinicians, researchers, and policymakers.(12, 13) Emerging issues that threaten quality of life and public health for millions of Americans such as pain and Alzheimer’s Disease, have received increased awareness and new legislation designed to address knowledge deficits and research funding (e.g., National Pain Care Policy Act of 2009 and the Comprehensive Alzheimer’s Breakthrough Act of 2009), but translation to broader communities is lacking.(13-15) Effective and highly respected participants from the community under study is also critical.(16) In addition, health policy research should work in concert with bench, bedside, and community researchers using4
community-based participatory research principles to address the most perplexing issues (e.g., aging in place, end of life and palliative care) in an interdisciplinary fashion.

Policy initiatives focusing on minority aging are sorely lacking. Often the special implications for minority elders are not even considered. The impact on and discussions including minority elders have attracted minimal attention, for example, during the recent economic meltdown, health care reform debates, and rhetoric about death panels. All in all, there seems to be a continuing failure to recognize that the overall well-being of America is intimately intertwined with the health status of those who are vulnerable, carry an unequal burden, and tend to be unseen and unheard. This situation continues despite increased awareness about increasing social and economic inequalities, clinician variability in decision-making based upon age, race, gender, and class, and many health professionals’ reports of feeling poorly equipped to address the needs of a diverse society in a culturally competent manner.(17, 18) These last points emphasize the importance of workforce preparation, on-the-job training, and diversity issues. For an aging and diverse society, there is a disconnect between such policy goals as the Healthy People 2010 metrics and the fragile academic pipeline, research funding, and service programs to help our country achieve Healthy People 2020 objectives, especially for older adults in reducing functional limitations.(19, 20)

As we turn our attention to implementing the 2010 healthcare reform legislation, we must commit to address health disparities at all ages from children to the elderly. Health promotion, disease prevention, improvements in the health care delivery system, and fundamental enhancements of the social and economic determinants of health all require a health disparities
lens. Nowhere is that lens needed more than in research, policy, and community engagement for minority elders.

REFERENCES
1. Projections of the Population by Age and Sex for the United States: 2010 to 2050 (NP2008-T12) [database on the Internet]2008. Available from: http://www.aoa.gov/AoARoot/Aging_Statistics/index.aspx
2. Projected Population by Single Year of Age, Sex, Race, and Hispanic Origin for the United States: July 1, 2000 to July 1, 2050 (NP2008_D1) [database on the Internet]2008 [cited June 10, 2010]. Available from: http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth/future_growth.aspx#hispanic.
3. Interim State Projections of Population for Five-Year Age Groups and Selected Age Groups by Sex: July 1, 2004 to 2030 [database on the Internet]2005 [cited June 10, 2010]. Available from: http://www.aoa.gov/AoARoot/Aging_Statistics/future_growth/future_growth.aspx.
4. Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Washington, DC: The National Academies Press; 2002.
5. Green CR, Anderson KO, Baker TA, Campbell LC, Decker S, Fillingim RB, et al. The Unequal Burden of Pain: Confronting Racial and Ethnic Disparities in Pain. Pain Medicine. 2003;4(3):277-94.
6. Satcher D. The Unequal Burden of Cancer. Cancer. 2001;91(S1):205-7.
7. Green CR, Ndao-Brumblay SK, West B, Washington T. Differences in Prescription Opioid Analgesic Availability: Comparing Minority and White Pharmacies across Michigan. The Journal of Pain. 2005;6(10):689-99.
8. Resource Centers for Minority Aging Research. [cited 2010 June 10, 2010]; Available from: http://www.rcmar.ucla.edu/centers.php.
9. Whitfield KE. Closing the gap: Improving the health of minority elders in the new millennium (p. ix). Washington D.C.: The Gerontological Society of America; 2004.
10. Committee on Facilitating Interdisciplinary Research, National Academy of Sciences, National Academy of Engineering, Institute of Medicine. Facilitating Interdisciplinary Research. Washington, D.C.: The National Academies Press; 2004.
11. Hermanson B, Omenn GS, Kronmal RA, Gersh BJ. Beneficial six-year outcome of smoking cessation in older men and women with coronary artery disease. Results from the CASS registry. New England Journal of Medicine. 1988;319(21):1365-9.
12. Curry L, Jackson J. The science of including older ethnic and racial group participants in health-related research. Gerontologist. 2003 Feb;43(1):15-7.
13. Green CR. The Healthcare Bubble through the Lens of Pain Research, Practice, and Policy: Advice to the New President and Congress. Editorial. The Journal of Pain 2008;9(12):1071-3.
14. Capps L. H.R. 756: National Pain Care Policy Act of 2009. 2009.6
15. Mikulski B. S. 1492: Alzheimer's Breakthrough Act of 2009 2009.
16. Omenn GS. Caring for the community: The role of partnerships. Academic Medicine: Journal of the Association of American Medical Colleges. 1999;74(7):782-9.
17. Weissman JS, Betancourt J, Campbell EG, Park ER, Kim M, Clarridge B, et al. Resident physicians' preparedness to provide cross-cultural care. Jama. 2005 Sep 7;294(9):1058-67.
18. Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The Effect of Race and Sex on Physicians' Recommendations for Cardiac Catheterization. The New England Journal of Medicine. 1999;340(8):618-26.
19. U.S. Department of Health and Human Services. Healthy People 2020, Objectives New to Healthy People 2020, OA HP2020–1: Reduce the proportion of older adults who have moderate to severe functional limitations Washington, D.C.2009.
20. U.S. Department of Health and Human Services. Healthy People 2020, Objectives New to Healthy People 2020, OA HP2020–8: Increase the proportion of older adults with reduced physical or cognitive function who engage in light, moderate, or vigorous leisure-time physical activities. Washington, D.C.2009.

2010-06-14T19:28:00.002-04:00

Health Equity–Getting beyond Hope

Health is a top priority for Americans, as is often shown in polls commissioned by Research!America and others. In the latter 20th century the Congress invested in that priority, and that investment paid off. Stunning advances made a reality of many Americans’ hopes for longer, better life and a more productive life for ourselves and future generations. From 1950 to 2000, nearly one million early deaths related to coronary disease have been averted, bringing an economic return of $3.6 trillion. To achieve that, the investment in NIH by each American taxpayer has been around $3.70 per year for 30 years. Seat belt laws and public education campaigns about putting babies to sleep on their backs have saved hundreds of thousands of American lives from car accidents and SIDS.

But while this is cause for celebration, we cannot take this pace of progress for granted, and we have much to do to achieve the hope of better health for all Americans.

In Advocacy in Health Care, former Congressman Paul G. Rogers (1921-2008), Research!America’s former chair emeritus, wrote, “We do not hear much in Washington these days about protecting the vulnerable.” It is a sad commentary that his statement is as true today as when he wrote it in 1986.

According to United Health Foundation’s 2009 America’s Health Rankings™ report, the average mortality rate for African-Americans far exceeds that for Caucasians or Hispanics. The CDC found similar disparities in cancer rates. Americans see this as unacceptable: In a 2010 poll commissioned by Research!America, 83% said it is important to conduct research to understand and eliminate these differences and achieve health equity.

Paul Rogers was renowned for saying, “Without research, there is no hope.” Research brings hope for solutions to diseases that currently have none. It tells us which treatments work for which patients. Yet for hope to make an impact, it must inspire action and commitment to a purpose. Health disparities cannot be eliminated without a sustained, significant investment in research.

The hope for health equity is consistent with Americans’ fundamental view that all are created equal. It is long overdue that we make that hope a reality, but without research, there is no hope. We must fund our health research agencies—NIH, CDC, AHRQ, NSF and FDA—at a strong sustained level, to better understand disparities and find new solutions through personalized medicine and prevention. We must fully engage the public as partners in their own health and agenda-setting for research; all health is local, and the public has an invaluable role to play in identifying factors in their communities that contribute to disparities. Lastly, if you are reading this, you likely already have an interest in and knowledge of health disparities. Seek out like-minded organizations or individuals as partners in the fight to end disparities. You may find partners in unexpected places. Educate yourself about ways to tell your elected officials that health equity is important to you and to most Americans. Visit www.researchamerica.org/speaking_out for resources to help.

Seminar 2 begins now...

2010-06-13T10:12:00.002-04:00

Readers and cinbtributors are directed to The Planned Segments item beneath the BACKGROUND ON THE BLOG SECTION of our front page. Then scroll down to "The Second Seminar: Health Care in the American Grain which provides the stage set for our blog for the next week thru the 20th of June.

2010-06-12T13:53:00.002-04:00

As this first week draws to a close, it is important to note that for those who sign on later as participants or wish belatedly to contribute to an earlier seminar, they may add comments for this first seminar at any time in the next nine weeks but should identify at the opening of their post which seminar they intend for their comments to be connected. We shall see to getting such posts in the right positions in the archives at the end of the tenth seminar.

Third Seminar: Stage Set

2010-05-07T11:43:00.003-04:00

Third Seminar: Specific Health Care Disparities- Stage Set

To go from the sublime and philosophical to some significant specifics, we now ask our experts to speak to some tangible big ticket items, both in terms of successes and regressions in Cancer, Maternal and Infant Care, Diabetes and Nutrition, and Hypertension and Heart Disease, and mental health/substance abuse. We hope our expert posts will provide pertinent references as well as examples of successes and failures over the past decade that point to relevant policy interventions for the next decade.

Commentators (invited) are Dr. John Geyman (author of “The Cancer Generation”, Common Courage Press, 2009), Dr. Henry Foster, Dr. Rodgers NIDDK, Dr Richard Williams.

First Seminar: Stage Set

2010-05-07T11:38:00.004-04:00

First Seminar: Background session on health disparities - First Seminar - Stage Set (posted on 6 June, 2010(R J Bulger)

As a prelude to this first seminar on health disparities policy, I hope all participants and readers will envision our primary audience as those people who are already working in the field of disparities reduction, either through research or clinical work or community public health efforts. These are people who are not primarily policy wonks but rather find it important for them to gain some degree of policy sophistication so that they have a more realistic platform for appraisal of our situation and for advocacy for important changes or improvements. This our goal is to enlighten those who are listening or reading our posts either through our insights or the questions we have raised. Participants can also be helpful if we can pass along through our posts, the best references or sources we have found most useful.

As an example at the outset here, I would offer my own impression that the journal Health Affairs is the monthly journal I would recommend to persons interested in following developments at the interface of health/health disparities policy, and health care. In the April 2010 issue, the focus was on Health IT, while the May 2010 issue concentrates on the reinvention of primary care with work force manipulations and innovative new team models for providing care for the expected expanding patient base. At the same time, professional medical and nursing journals (especially those with wide public exposure like the New England Journal of Medicine and the Journal of the American Medical Association) are providing fewer, but nonetheless excellent health policy articles which sometimes shape or reflect important movement.

I am old enough to remember quietly celebrating when Dr. Julius Richmond, President Carter’s choice for US Surgeon General, initiated the Healthy People Program, through which specific goals for improvement of our population’s health status were established and data was collected and made available for all to see concerning our progress toward our national health goals Through the years, this data-driven instrument has become more and more useful, refined and precise. We, in 2010 are able to look back at the third decade of these public records and will have a fresh look at our nation’s progress towards the elimination of health disparities.

In the May 6, 2010 issue of the NEJM, the lead article is by MH Koh, Assistant Secretary for Health, US Department of Health and Human Services. Dr. Koh concisely presents the history of the Healthy People Program, summarizes the results of the last decade and prefigures the official plan or vision for the year 2020. Dr. Koh says, As part of Healthy People 2010, ten leading health indicators were selected with input from the Institute of Medicine as high-priority areas for motivating societal action. These indicators provide both a concise summary of major, preventable health threats and a gateway into the broader framework; preliminary data show progress for about half of the indicator objectives.”

Dr. Koh gives as an example of a significant gain in the fight against health disparities is the progress in immunization rates for infants 19 to 35 months of age, up from 72.8% in 1998 to 80.6% in 2006, with great progress in shrinking racial and ethnic differences. On the down-side, we have lost ground in weight control and diabetes both in the population as a whole and within virtually all racial groups.

The ten leading health indicators Healthy People 2010, are: Physical activity; Tobacco use; Responsible sexual behavior; Injury and Violence; Immunization; Overweight and obesity; Substance abuse; Mental health; Environmental quality; Access to health care. (As an aside, it gave me great pleasure, having served as the chair of that IOM committee which recommended the list of Leading Indicators, to realize that the effort did not go in vain and that it is possible for people to come together to produce work that in turn influences public policy and seems to still be of some continuing value.)

The two overarching goals of the 2010 program were to increase the quality and years of life and to reduce disparities: the first was achieved; the second wasn’t. Of interest in Dr. Koh’s paper was his presenting some hints about the 2020 plan which will be presented in six months or so. Dr. Koh says, “It reaffirms the two overarching goals from the past decade but adds two more: promoting quality of life, healthy development, and healthy behaviors across life stages; and creating social and physical environments that promote good health.” This means that there will need to be a stretch beyond traditional health sectors to achieve these broader social goals for health, issues sure to spark important debate.

At this initial seminar, I am pleased to identify three very important books exploring the breadth and depth of health disparities, whose authors have been invited to comment early if they would in this seminar and of course as they are moved to in subsequent seminars. They are as follows: David Satcher MD, PhD and Rubens Pamies MD, Multicultural Medicine and Health Disparities, McGraw Hill, 2006; Brian Smedley, Adreinne Stith and Alan R. Nelson, Unequal Treatment – Confronting racial and ethnic disparities in healthcare, Institute of Medicine national Academies Press, 2003; Richard Allen Williams, MD, Eliminating Healthcare Disparities –beyond the IOM Report, Humana Press, 2007.

For the next seven days, the seminar is open for anyone who has registered to add their comments, references and insights, all of which will be archived (saved) at the end of the week.

Check back soon for information the first seminar

2010-04-27T11:40:00.007-04:00

The first seminar will be a background session on health disparities and will begin on June 7th. The stage set for that first seminar is seen below and comments may be made by anyone who has signed in as a participant. If others have comments they would like to make, please contact the administrator at mlawson@iammm.org or rbulger@comcast.net. On June 13, the stage-set piece for the second seminar will be posted and similarly, comments by others will be posted by them during the subsequent week.