Subjects: Health policy
Twelve years after our nation began a serious effort to reduce racial disparities in health care, minorities in our country are still less likely to get the preventive care they need and more likely to suffer from serious illnesses. And when they get sick, racial minorities are still less likely to have access to quality health care.
To progress matters, the Department of Health and Human Services (HHS) has recently released an action plan. The plan calls for development of new care models and more service delivery sites. It bolsters the nation’s health and human services workforce through a pipeline program that channels people from underserved communities into public health and biomedical sciences careers. There are targeted efforts to reduce cardiovascular disease, childhood obesity, tobacco-related diseases, flu and asthma. And there are plans to improve health data collection and increase outcomes research.
Strengths of the Plan
As we described last week, the problem of racial disparities in health care is exceedingly complex. Efforts to address it must feature a broad, multifaceted approach if they are to have any chance for success. The strength of the HHS plan is that it contemplates just such an approach. The plan should trigger useful activity at National Institutes of Health, the Centers for Disease Control, the Health Research and Services Administration, the Agency for Healthcare Research and Quality, the Indian Health Service and other agencies as well. Cross-agency collaboration of the sort envisioned by HHS is likely to generate effective outreach and preventive programs and more capable oversight of such programs.
A narrower plan—for example, one that focused solely on providing insurance to those who don’t have it—would have a surprisingly small impact on racial disparities.
Take Canada for example, a country that has universal, free access to health services. If poor access was primarily responsible for disparities in health care, then disparities shouldn’t exist in Canada.
However a recent study by David Alter and colleagues shows unequivocally that disparities do exist there. In their prospective study of 15,000 Canadian adults, Alter’s team showed that participants in the lowest income group were nearly 3 times more likely to die of any cause than those in the highest income group. They were also more likely to have diabetes, high blood pressure, cancer, cataracts and many other conditions.
The disparities occurred despite higher utilization rates among participants in the lowest income group. These people averaged 62 visits to primary and specialty care physicians during the study period, whereas those in the highest income group averaged 47 such visits. Alter’s group found similar results when participants were stratified by educational level.
Weaknesses of the Plan
At least for now, the HHS plan has no actual funding attached to it. The purpose of the plan is to drive an internal review. All agencies within HHS are supposed to use the plan to assess their current policies and programs, assure that racial disparities become part of their decision-making, and to guide them in developing cross-agency programs directed at racial disparities.
So everybody can sit down, I guess. Why even bother announcing an internal review like this?
In all likelihood, this is a political move by the Obama administration. In its heart, the administration would like to pull the trigger on funding something like this, but it doesn’t think that funding such plan will fly politically right now, given the urgent need to focus on the budget deficit.
The way I see this playing out is that Democrats will make the HHS plan, or something like it, a lynchpin social issue for the 2012 presidential campaign, right there along with the preservation of Medicare. It’s an issue the Democrats can win and a way to reposition the Affordable Care Act—on whose back much of the HHS plan would be carried—as part of a larger economic strategy to assure the nation’s long term prosperity.
In the likely event that the Dems clean-up in 2012, some version of the HHS plan will then be funded, and the Affordable Care Act will be implemented with less resistance.
That’s a lot to ask for, but it’s the best chance this plan will ever have to make a serious impact.
The Really Big Problem
Of perhaps greater significance, the plan has a fatal flaw even if it does get funded. The flaw is that it assumes a “medical model” can solve racial disparities in health care. While great progress can be made implementing such a plan, racial disparities in health care aren’t fundamentally about health, at all. They are about socioeconomic status, and HHS can’t fix that by itself.
Alter’s study (mentioned above) proves the point. Participants in the lowest income and education strata were more likely to be distressed and to have fewer social supports than other participants, they found. They also smoked cigarettes more often, were more likely to be obese and had a more sedentary lifestyle.
Inequalities in wealth, income and education are the root causes of “racial” disparities. If you look at a racially-mixed, but socioeconomically homogeneous community, say, you’ll find the rates of mortality, diabetes and most everything else to be similar across the races.
If racial disparities in health care are actually a socioeconomic problem, then solving them requires input from government agencies involved with education, urban planning, transportation and more, in addition to HHS. Issues like the availability of healthy food options, making it safe to play outside, and better health educational outreach need to be addressed.
That war was declared 56 years ago, by the way, and no one thinks we won. It was started when the nation, however briefly, thought that a Great Society could work. Even if Democrats take it to the house in 2012 it’s unlikely that they would try something like that again.
The political challenges facing those who want to eliminate racial disparities are gargantuan. This is another reason why, in my last post, I called the fight against Racial Disparities a 100 Years’ War.