Policy Responses to Healthcare &
Health Status Disparities
Carmen R. Green, M.D.
Associate Professor, Anesthesiology, Health Management and Policy
Faculty Associate, Program for Research on Black Americans
Director, Health Disparities Research Program Michigan Institute for
Clinical and Health Research
Disclosures
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Speakers bureau - none
Stocks - none
Grant Support
-
Aetna Quality Care Fund
Blue Cross Blue Shield Foundation of Michigan
Hartford Foundation
Lance Armstrong Foundation
NIH
Clinical and Translational Science Awards
Michigan Center for Urban African American Aging Research
- Robert Wood Johnson Foundation
Morbidity and mortality
5
Mortality Rate
African American
American Indian
Latino
Asian
White
0
0-14
15-24
25-44
Ages
45-64
“Of all the injustices, injustice in health
is the most shocking and most
inhumane.”
Martin Luther King, Jr.
“Racial and ethnic
disparities in health care are
unacceptable in a country
that values equality and
equal opportunity for all.
And that is why we must act
now with a comprehensive
initiative that focuses on
health care and prevention
for racial and ethnic
minorities.”
“These gaps are simply
unacceptable in America.
Turning our back on these
health disparity problems
would be a national failure.”
Projected Population Growth, by
Race
Source: U.S. Census Bureau, 2004, “U.S. Interim Projections by Age, Sex, Race and Hispanic Origin,”
<http://wwww.census.gov/ipc/www/usinterimproj/> Released March 18, 2004
1999 U.S. Census Projections
(millions)
Projected Pop. (in thousands)
Gender and Aging
Source: U.S. Census Bureau, 2004, “U.S. Interim Projections by Age, Sex, Race and Hispanic Origin,”
<http://wwww.census.gov/ipc/www/usinterimproj/> Released March 18, 2004
Coverage, Access and Quality
Legislative Process
House
Senate
Conference
Senate
House
President
Health reform legislation
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
Three authorizing committees
Bicameral
- Coburn/Burr & Ryan/Nunes
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House
- Conyers
- Dingell
- Stark
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Senate
- Sanders
- Wyden/Bennett
General legislation
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Coverage
Chronic Disease
Environmental Public Health
Prevention
Quality
Senate Finance Committee:
Expanding Health Care Coverage

Approach
- Creates a Health Insurance Exchange

Individual mandate
- Requires all to meet minimum coverage standards

Expansion of public programs
- Expand Medicaid to individuals with incomes up to 115% FPL
- Expand CHIP eligibility
- A temporary Medicare buy-in for the pre-Medicare population, aged
55-64, at full-cost.
- Reduces two-year waiting period for Medicare eligibility for people
with disabilities

Cost containment
- Promotes health information technology adoption
- Restructure Medicare Advantage plan payments
Senate Finance Committee


Improving quality and health system performance
- Payments for primary and chronic care management
- Establish a comparative effectiveness research framework
- Creates a Chronic Care Management Innovation Center
within CMS for high-cost, chronically ill beneficiaries
- Develop, select, implement, and report quality and
performance information
- Requires race, ethnicity, language and disability status data
and federally funded surveys must collect sufficient data to
compare
Other investments
- Extends the 75% matching rate for translation services
- Increase Maternal and Child Health Services Block Grant
program funding
- Changes Medicaid FMAP formula to include state poverty
- Promotes training of primary care providers in outpatient
settings and in rural and underserved areas
Senate HELP Committee:
Affordable Health Choices Act


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Approach
- Create state-based American Health Benefit
Gateways
Individual mandate
- Require all individuals to have qualifying health
coverage
Expansion of public programs
- Expand Medicaid to all with incomes up to 150% FPL
- Create a public plan offered through state Gateways
Cost containment
- Develop a national prevention and health promotion
strategy
- Provide grants for improving health system
efficiency (e.g. community health teams to support a
medical home model and medication management)
Senate HELP Committee


Improving quality and health system performance
- A national strategy to improve health care delivery and
outcomes
- An annual national health care quality report card to assess
outcomes, continuity and care coordination, and disparities
- Develop and adopt interoperable standards for health
information technology
Other investments
- Establish a national, voluntary insurance program for
community living assistance services and supports.
- Establish a National Health Care Workforce Commission
- Increase supply, education, and training of healthcare
professionals, especially in pediatrics, geriatrics, and primary
care
- Additional funding to increase the number of community
health centers and school-based health centers.
- Grants to establish community health teams to support a
medical home model and medication management
House Tri-Committee (Ways and Means, Energy
and Commerce, and Education and Labor):
Health Reform Proposal

Approach
- Creates a National Health Insurance Exchange



Individual mandate
- Requires acceptable health coverage for all
Expansion of public programs
- Expand Medicaid to all individuals with incomes up
to 133% FPL - non-traditional (childless adults)
- Optional Medicaid coverage to low-income HIV+
individuals
- Optional Medicaid coverage for family planning
services to low-income women
Cost containment
- Increases Medicaid payments for primary care
- Reduce payments for excess readmissions
House Tri-Committee
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Improving quality and health system performance
- Creates an office within the CMS for dual eligibles
- Develop national priorities for performance improvement
and quality measures
- A feasibility study on developing Medicare payment
systems for language services
- Develop standards for collecting race, ethnicity, and
language data
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Other investments
- Require a report on the role for Medicare and Medicaid
Disproportionate Share Hospital payments
- Redistributes health professional training to outpatient
and underserved areas (includes public health, diversity,
and cultural competence)
- Provide full federal funding for Medicaid expansions
- Enhanced federal funding for Medicaid improvements.
What is missing from
the debate?
“In this instance we must disagree with the AMA as we did at
Medicare’s inception in 1965. The public option, properly
designed, will better serve the needs of our people.”
Mohammad N. Akhter, MD, MPH
“Knowing is not enough; we must apply. Willing is
not enough; we must do.”
-Goethe
U.S. Health Professions Workforce
Physician
U.S.
RN
Population MD/DO Nurses Dentists Pharmacists Assistants
(2000 est) (1998 est) (1996 est) (1996 est) (1995 est) (1998 est)
Hispanic 12%
5%
2%
3%
**
3%
White
71%
78%
90%
90%
83%
91%
Black
Native
American
Asian/Pacif
ic
Islander
12%
3%
4%
2%
5%
3%
1%
**
1%
**
**
1%
4%
11%
3%
55
**
2%
**
**
**
**
12%
**
Other
Gaps and implications
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Broadening and clarifying the definition of populations
at risk for disparities across the lifespan (e.g. race,
ethnicity, gender, language, and disability status)
Collecting data and monitoring process and outcomes
by geography
Health care systems/providers have to step up
- Lack of financial and practical resources, and poor
collaboration between disciplines
Investment in research: Advances in knowledge that
translates to better patient care and policy
Local, state, and federal policy to support efforts to
reduce disparities: Integrating health and social policy
Healthcare provider pipeline and organizations
engagement