Affordable Care Act May Help Close Gap on Health Disparities

About half of those expected to gain access to health care are minorities.

J. Nadine Gracia serves as the deputy assistant secretary for minority health and director of the Office of Minority Health at the Department of Health and Human Services.
National Journal
Janell Ross
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Janell Ross
April 9, 2014, 11:42 a.m.

On April 8, 2011, the Health and Hu­man Ser­vices De­part­ment un­veiled a doc­u­ment called “The Health and Hu­man Ser­vices Ac­tion Plan to Re­duce Ra­cial and Eth­nic Health Dis­par­it­ies.” The HHS Ac­tion Plan iden­ti­fied strategies, policies, and pro­grams that the de­part­ment be­lieves will nar­row and even­tu­ally elim­in­ate per­sist­ent gaps between the health of ra­cial and eth­nic minor­ity pop­u­la­tions and oth­ers. Now, pro­vi­sions of the Af­ford­able Care Act are ex­pec­ted to provide as many as 41 mil­lion un­in­sured in­di­vidu­als with bet­ter ac­cess to care. Al­most half of these are mem­bers of eth­nic and ra­cial minor­ity groups.

J. Nad­ine Gra­cia, deputy as­sist­ant sec­ret­ary for minor­ity health and dir­ect­or of the Of­fice of Minor­ity Health at HHS, re­cently spoke with Na­tion­al Journ­al about what all of this really means for minor­ity health. Ed­ited ex­cerpts fol­low.

What are the ma­jor causes of health dis­par­it­ies? 

Health dis­par­it­ies are dif­fer­ences that we see in the health status of dif­fer­ent pop­u­la­tions that are tied to so­cial, eco­nom­ic, and en­vir­on­ment­al dis­ad­vant­ages. Health dis­par­it­ies are com­plex. They are mul­ti­factori­al. But the lack of ac­cess to health in­sur­ance, to health care, and to health care pro­viders [can con­trib­ute to these gaps]. Also the qual­ity of care that one re­ceives when he or she ac­cesses care, es­pe­cially if that care is not cul­tur­ally and lin­guist­ic­ally ap­pro­pri­ate [ad­versely im­pacts health]. We also know our health is in­flu­enced by more than what hap­pens in a health care set­ting. Our health is in­flu­enced by the con­di­tions in which we live, where we work, where our chil­dren play. Those so­cial de­term­in­ants of health play a sig­ni­fic­ant role in con­trib­ut­ing to health dis­par­it­ies.

What are some of the largest or per­haps most troub­ling health dis­par­it­ies that ex­ist in the United States?

We see health dis­par­it­ies across a range of con­di­tions. For ex­ample, Afric­an-Amer­ic­an wo­men are 10 per­cent less likely to be dia­gnosed with breast can­cer but 40 per­cent more likely to die of breast can­cer. We also see, for ex­ample, that Lat­i­nas are twice as likely to have cer­vical can­cer and are 1.4 times as likely to die of cer­vical can­cer. Asi­an-Amer­ic­ans rep­res­ent just about 5 per­cent of the Amer­ic­an pop­u­la­tion but they rep­res­ent more than 50 per­cent of Amer­ic­ans who live with chron­ic hep­at­it­is B. We also see dis­par­it­ies in dia­betes with the Hawaii­an Pa­cific Is­lander pop­u­la­tion, as well as in the Amer­ic­an In­di­an and Alaska Nat­ive pop­u­la­tions — Amer­ic­an In­di­ans and Alaska Nat­ives are twice as likely to have dia­betes as the gen­er­al pop­u­la­tion.

For a lot of people, health dis­par­it­ies fall in the cat­egory of po­ten­tially in­tract­able prob­lems. Why should elim­in­at­ing them be a na­tion­al pri­or­ity?

When we look at our coun­try and how it is be­com­ing in­creas­ingly di­verse, the fu­ture health of our na­tion will really be de­term­ined by how we work at the fed­er­al, state, and loc­al levels — and in the private sec­tor — to ad­dress health dis­par­it­ies. When you see minor­ity chil­dren who have, for ex­ample, high­er rates of asthma, that can im­pact the fu­ture of our na­tion in the sense that they may miss more days of school. An un­healthy child can­not do as well in school. A par­ent then may have to stay home from work in or­der to take care of that child, and that im­pacts our work­force and work­er pro­ductiv­ity. There is still a lot of aware­ness-rais­ing that must be done. We con­duc­ted a study a few years ago in which we learned that only 60 per­cent of adults ac­tu­ally knew that there are health dis­par­it­ies that im­pact the na­tion. Yet, between 2003 and 2006, the com­bined cost of health in­equit­ies and pre­ma­ture deaths ex­ceeded a tril­lion dol­lars. It was $1.24 tril­lion dol­lars. These kinds of costs are really un­sus­tain­able.

What is the Health and Hu­man Ser­vices Ac­tion Plan to Re­duce Ra­cial and Eth­nic Health Dis­par­it­ies?

The HHS Ac­tion Plan to Re­duce Ra­cial and Eth­nic Health Dis­par­it­ies … launched in April of 2011 dur­ing Na­tion­al Minor­ity Health Month. It truly is the most com­pre­hens­ive fed­er­al com­mit­ment to­ward re­du­cing health dis­par­it­ies among ra­cial and eth­nic minor­it­ies. It builds on the strong found­a­tion of the Af­ford­able Care Act.

Are there any spe­cif­ic changes or im­prove­ments in health dis­par­it­ies that you can point to in the three years since the HHS Ac­tion Plan has been put in place?

Achiev­ing re­duc­tions in health dis­par­it­ies takes time, as well as sus­tained ef­fort and en­gage­ment. You may see changes at the loc­al level be­fore you see those changes at the na­tion­al level. To give you an ex­ample, pro­grams like the Vac­cines for Chil­dren Pro­gram, as well as good policies re­gard­ing re­quire­ments for im­mun­iz­a­tion and tar­geted ef­forts to reach com­munit­ies that are un­der­served, have over the past two dec­ades closed the gap in child­hood im­mun­iz­a­tions between white chil­dren and minor­ity chil­dren. This is im­port­ant and it is really a mile­stone in pub­lic health. Im­mun­iz­a­tions pre­vent ill­ness and the sub­sequent health dis­par­it­ies that may res­ult. 

Also, we are now at the nar­row­est gap in life ex­pect­ancy between Afric­an-Amer­ic­ans and whites that we have seen since life ex­pect­ancy was meas­ured. That is why the Af­ford­able Care Act, the Dis­par­it­ies Ac­tion Plan, the Na­tion­al Part­ner­ship for Ac­tion are so crit­ic­al. They ad­dress some of the sys­tem­ic factors that have con­trib­uted to health dis­par­it­ies for so long.

In tan­gible terms, what will the Af­ford­able Care Act likely do to the land­scape of health dis­par­it­ies and the coun­try’s abil­ity to com­bat them?

Ra­cial and eth­nic minor­it­ies have high­er rates of be­ing un­in­sured, one of the sig­ni­fic­ant factors that con­trib­utes to health dis­par­it­ies. Due to the Af­ford­able Care Act, mil­lions of Amer­ic­ans, es­pe­cially people of col­or, now have ac­cess to af­ford­able health cov­er­age. The law is also in­creas­ing ac­cess to care. For ex­ample, there are in­vest­ments in com­munity health cen­ters that provide care in many un­der­served com­munit­ies. We know that nearly two out of three pa­tients seen at com­munity health cen­ters are ra­cial and eth­nic minor­it­ies. The Af­ford­able Care Act not only in­creased the num­ber of com­munity health cen­ters that ex­ist across the coun­try, but also ex­pan­ded the ser­vices those com­munity health cen­ters provide.

An­oth­er chal­lenge is that minor­it­ies have high­er rates of many chron­ic con­di­tions such as dia­betes or high blood pres­sure or cer­tain types of can­cer. Yet, many of the factors that con­trib­ute to those con­di­tions are pre­vent­able. Be­cause of the health care law, re­com­men­ded pre­vent­at­ive ser­vices such as colon-can­cer screen­ing, mam­mo­grams, vac­cin­a­tions, dia­betes screen­ing, and blood-pres­sure screen­ing are now provided at no cost. Cost could of­ten be a bar­ri­er for those who have to make the de­cision between pay­ing for bills or their gro­cer­ies versus get­ting that pre­vent­ive health screen­ing. And pri­or to the health care law, people who had preex­ist­ing con­di­tions such as can­cer, or dia­betes, asthma could be locked out of the health in­sur­ance mar­ket­place. Now in­sur­ance com­pan­ies can no longer dis­crim­in­ate against people who have preex­ist­ing con­di­tions and young adults can stay on their par­ents’ in­sur­ance un­til the age of 26.

The Ac­tion Plan men­tions the need to di­ver­si­fy the group of people work­ing in health care and the role this can play in im­prov­ing the qual­ity of care all pa­tients re­ceive. What is the fed­er­al gov­ern­ment do­ing on this front?

[The health law] is help­ing to di­ver­si­fy the work­force through in­vest­ments in the Na­tion­al Health Ser­vice Corps, a corps of health care pro­viders that, in ex­change for re­pay­ment of their edu­ca­tion­al loans, prac­tice in un­der­served and vul­ner­able com­munit­ies. Since 2008, we have seen that the num­ber of clini­cians in the Na­tion­al Health Ser­vice Corps has doubled. The per­cent­age of Afric­an-Amer­ic­an phys­i­cians in the na­tion­al work­force is about 6 per­cent; if you look at the per­cent­age of Afric­an-Amer­ic­an phys­i­cians in the Na­tion­al Health Ser­vice Corps, it is 17 per­cent.

Giv­en that states have the op­tion to ex­pand Medi­caid un­der the Af­ford­able Care Act, there are health care or­gan­iz­a­tions and ob­serv­ers of health trends who tell me they are ex­pect­ing to see real health dif­fer­ences to emerge across states. Will HHS be watch­ing for these trends?

States have the op­tion to ex­tend Medi­caid at any time. We con­tin­ue to work with states edu­cat­ing them about the be­ne­fits and im­port­ance of ex­pand­ing Medi­caid and un­der­stand­ing that the ex­pan­sion of Medi­caid is paid for at the 100 per­cent level by the fed­er­al gov­ern­ment for the first three years and then doesn’t go be­low 90 per­cent. So really these states are leav­ing money on the table when we are talk­ing about im­prov­ing the health of their res­id­ents. We re­main open to work­ing with those states.

I will say that an im­port­ant part of our out­reach ef­fort is to in­form people about the in­vest­ments in their loc­al com­munit­ies, such as fed­er­ally qual­i­fied com­munity health cen­ters — an in­vest­ment of $11 bil­lion over five years. It ex­pands the num­ber of com­munity health cen­ters that ex­ist around the coun­try as well as the stand­ard ser­vices that they provide — not only primary care, but ser­vices such as or­al health care and phar­macy ser­vices. They are an im­port­ant part of the safety net.

You men­tioned the found­a­tion­al prin­cipals of the coun­try and our of­ten-stated com­mit­ment to equal­ity. Do you have the sense that three years in­to this Ac­tion Plan and 50 years after the Civil Rights Act passed, that health care has joined the panoply of rights that Amer­ic­ans ex­pect?

Dr. King said it very well when he said that of all the forms of in­equal­ity, in­justice in health care is the most shock­ing and in­hu­mane. We are in the midst of a trans­form­a­tion and a re­mark­able op­por­tun­ity to ad­dress health dis­par­it­ies and fur­ther ad­dress pro­gress to­ward health equal­ity.

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HAVE AN OPIN­ION ON POLICY AND CHAN­GING DEMO­GRAPH­ICS? The Next Amer­ica wel­comes op-ed pieces that ex­plore the polit­ic­al, eco­nom­ic and so­cial im­pacts of the pro­found ra­cial and cul­tur­al changes fa­cing our na­tion, par­tic­u­larly rel­ev­ant to edu­ca­tion, eco­nomy, the work­force and health. Email Jan­ell Ross at jross@na­tion­al­journ­ Please fol­low us on Twit­terand Face­book.

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