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Setting the Foundation for Health Reform

January 24, 2017 Written By: Margie Schaps

Last week in honor of Martin Luther King, Jr. Day, Health & Medicine’s Executive Director Margie Schaps was invited to present on the future of healthcare at Northwestern University. Presenting to students from the Priztker School of Law and the Feinberg School of Medicine, Schaps offered an overview of historic roots of health inequities as well as the impact of the Affordable Care Act and directions for future work. We are pleased to share her presentation here.

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. So said Martin Luther King in 1966.

What King also taught us is that we must confront structural racism and the values of our institutions: that we must be “creative dissenters” and hold the country to a higher destiny—he was a wise man.

So today I hope to leave you understanding some of the underlying reasons for health inequities, why it is that people of color are disproportionately unhealthy, what laws and systems have been changed to address these inequities, what was in place before the Affordable Care Act, and what we need to continue to address if we want to eliminate health inequities.

To go back in history a bit, there have been some significant civil rights efforts that have addressed health equity, directly or indirectly. I am not claiming that we have fully realized the intent of these laws, nonetheless some of the most significant among them were:

  • 1954 Brown vs. the Board of Education assuring equal access to education—we know that poverty and education have the most significant relationship to health outcomes and life expectancy
  • 1966 Medicare and Medicaid assuring health care insurance for older adults regardless of income under Medicare, and certain groups of low income people, people with disabilities, and older adults under Medicaid
  • Ending the Jim Crow practice of segregating patients by race, allowing for all patients to have access to better hospitals and care
  • Ending practices of not allowing Black physicians to practice at most hospitals—a charge led by my mentor and a graduate of this medical school, and lifelong social and health justice advocate, Quentin Young

What we know about health inequities is that they arise out of structures we have set up as a society which then have an impact on the social determinants of health which then result in health inequities. So addressing all of the levels of policy to practice, not simply access to medical care, is the only way to fully address health equity for racial and ethnic minorities. The World Health Organization acknowledges that roughly 10-20% of health is a result of medical care; much of the other 70-90% is related to structural/institutional practices, social determinants, genetics, and individual behavior.

So what are structural factors?

These include things like education financing policies that benefit wealthier geographic districts, fair wage policies impacting personal income and income inequality, fair housing policies, and policing practices that disproportionately affect communities of color.

Social determinants are intermediate factors that impact health and include things like access to healthy food, green space, and social cohesion as well as environmental factors such as air quality and exposure to lead. When we put these together and lay them on top of each other on maps, the negative structural factors and social determinants pile on to racial and ethnic minority communities. The communities with the most poverty are the ones with the least investment in schools, the highest drop-out rates, poorest housing, the greatest interaction with police and resulting incarceration…..and the greatest health inequities and disparities, the worst health outcomes, lowest life expectancy, and least access to affordable health care.

From a health care perspective, race remains a significant factor in determining whether an individual receives health care, whether he or she receives high quality health care, and in determining health outcomes. In the 80s and 90s reports emerged describing poor health status and outcomes of African Americans and other people of color in the US. Congress requested that the IOM study the differences in kind and quality of health care received by racial and ethnic minorities in the US. The IOM study culminated in the 2003 report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care in the US” and I recommend this report to all of you. The report made recommendations in the areas of policy, regulation, health systems reform, programs to enhance individual education and empowerment, research on racial and ethnic disparities and development of intervention strategies, and integrating cross-cultural training into training of all health professionals.

So how does this play out in real life?

Here in Cook County, data we have from before the ACA showed us that life expectancy in our highest Socio-economic (SES) status communities (nearly all white) is about 87 years, and in our lowest SES communities (nearly all communities of color) was 73.2 years—a difference of 13.8 years.

Life expectancy is directly correlated with level of education, and African Americans and ethnic minorities have generally lower educational attainment. Furthermore, educational attainment is associated with health behaviors and outcomes including smoking rates, drug use, and obesity. Poorer educational systems in poorer communities result in higher dropout rates, more criminal justice involvement, more poverty, and poorer health.

There is increasing evidence that discrimination itself has a negative impact on health outcomes—youth trauma and discrimination results in poorer health later in life and earlier death. Nancy Kreiger, the Harvard epidemiologist, has shown a direct link between racial discrimination and elevated blood pressure and increased risk of cardiovascular events.

So where were we with regard to health inequities by race and ethnicity before the Affordable Care Act?

  • We know that about 46 million Americans had no health insurance and that the risk of being uninsured for Latinos was 36%, for African Americans it was 22%, and for whites it was 13%. We know that people of color without health insurance use the emergency room more frequently for less urgent issues than do whites, but we also know that they live in communities where their local hospitals are more likely to be closed.
  • Uninsured adults are at least twice as likely to go without a physician visit as whites and are more likely to be hospitalized for preventable conditions.
  • African American children had hospitalization rates for asthma four¬ times higher than white children.
  • We know that infant mortality rates for Black college educated women was three times higher than for white women.
  • Breast cancer incidence rates in 2008 were 1.4 times higher for white women than Black women, yet Black women had a 41% greater risk of dying from breast cancer.
  • Quality measures for care for non-white populations were not getting better—at least half of core quality measures in this country were worse or the same.

Finally, I’d like to talk for a moment about the health care workforce, quality, and public health before the ACA. There were major efforts in the 70s, notably the federally qualified health centers and the National Health Service Corps that made significant contributions toward increasing the numbers of health professionals and facilities in medically underserved areas, but:

  • Racial and ethnic minority groups were woefully under-represented in the workforce
  • Racial and ethnic minority health workers are more likely to live in neighborhoods lacking health resources
  • Very little data was being collected on patterns of use of health systems/quality/outcomes/and disparities
  • Investments in population health and public health were extremely low—investments we knew were key to uncovering and addressing health equity

The ACA addressed some of the issues I’ve laid out, but what I hope you leave here understanding is that to address health inequity, addressing health insurance access is just a beginning—an important one—but just a beginning.

We must develop a workforce that reflects the population they are serving, invest in population health not just individual health, invest in addressing the structural policies and practices that underpin inequities, gain the trust and collaboration of communities most affected by disproportionate and unequal practices, collect data that shows progress and gaps, and develop programs and service in response to what the data tells us. We must disproportionately invest in our most under-resourced communities, break out of our siloes, and figure out how to create new solutions to persistent problems.

The challenges ahead are great, but as King himself said, the arc of the moral universe is long, but it bends toward justice. We can only bend this arc if we commit to doing it together.