an alternate route to posting

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

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

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

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

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

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

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

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.

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...

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.

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

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

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

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.