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Health Equity Lessons from…the United States? Really?

Matt Kanter

December 16, 2009

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Outline of Presentation

• Health Equity Statistics in the U.S.

• Discuss Current U.S. Health Care Reform

• State and Local Equity Initiatives• Massachusetts

– The City of Boston

• California

• New Jersey

• Possible Lessons for Canada

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Health Equity in the U.S.

• Canadians’ perceptions of the American health care system

• Medical expenditures are the leading cause of personal bankruptcies in the U.S.

• What could the U.S. possibly teach Canadians about Health Equity?

• First, the statistics…

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Health Equity in the U.S.: The Uninsured

• 17.4% of non-elderly Americans are uninsured (45.7 million people)

• 32% of those considered “low-income” lack health insurance

• 10.3% of children are uninsured

• 20.6% of African-Americans and 32.2% of Hispanic Americans do not have insurance

• 18.8% of non-elderly workers are uninsured

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Health Equity in the U.S.: Health Spending

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Health Equity in the U.S.: Health Spending

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Health Equity in the U.S.: Health Outcomes

• Life Expectancy:• U.S.: 78.1 years

• Canada: 80.7 years

• OECD Average: 79.0 years

• The U.S. also has vast disparities in health care quality and outcomes across race, ethnicity, SES, gender, place of residence (urban vs. rural) and language (Institute of Medicine)

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Current U.S. Health Care Reform Explained

• (1) The Political Process: Where are We?

• (2) The Basics of Reform (H.R. 3962)

• (3) Forgotten (Ignored?) Health Equity Elements of the Proposed Legislation

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Health Care Reform: The Process

• House: Blended Bill passed November 7, 2009 (220 – 215)

• Senate: Blended bill introduced on November 18, 2009; No vote yet

• What’s Next? If it passes the senate, a joint House/Senate Committee will re-write the bill which must pass both houses and be signed by the President

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Health Care Reform: The Basics

• Individual Mandate – With Subsidies

• Employer Mandate

• National Health Insurance Exchange– With a Public Option?

• Key Changes to Private Insurance

• Paying for the Legislation/Cost Containment

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Health Care Reform: Forgotten (Ignored?) Health Equity Initiatives

Health Disparities Definition (in H.R. 3962):

“‘Health Disparities’ includes health and health care disparities and means population specific differences in the presence of disease, health outcomes or access to care”

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Health Care Reform: Forgotten (Ignored?) Health Equity Initiatives

• ss. 1221 – 1223: Concerned with reducing language barriers for limited-English-proficiency populations

• Sec 1442: The Secretary shall ensure that reducing health disparities is an explicit goal in her national priorities for quality improvement in health care

• Sec 2251: The Secretary shall establish a cultural and linguistic competency training program for health professionals

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Health Care Reform: Forgotten (Ignored?) Health Equity Initiatives

• Sec 2301: The CDC shall establish a program for the delivery of community based-preventive/wellness services

– At least 50% of the funds must be spent on planning/implementing wellness services whose primary purpose is to achieve a measurable reduction in one or more health disparities

• Sec 2402: The Department of HHS shall establish the position of Assistant Secretary for Health Information

– The Assistant Secretary shall “facilitate and coordinate identification and monitoring of health disparities…to inform program and policy efforts to reduce health disparities”

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State and Local Equity Initiatives: Massachusetts

Chapter 58 of the Acts of 2006

• Based on the premise of shared responsibility– Included an individual mandate with subsidies for low-income

individuals, an employer mandate and a state-wide insurance exchange (called “The Connector”)

• 2 years after implementation, 439,000 people had signed up for health insurance

– The uninsurance rate dropped from 11% in 2005 to 2.6%

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Massachusetts Continued

• The MA legislation also contains several provisions which deal explicitly with reducing health disparities

• Legislation creates a Health Disparities Council

• It also requires a study on the possibility/cost-effectiveness of using CHWs to reduce racial/ethnic health disparities

• Subsequently, MA developed an Office of Health Equity within the State Department of Health and Human Services

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State and Local Equity Initiatives: The City of Boston

• First U.S. city to establish a comprehensive plan to eliminate racial and ethnic health disparities (2005)

• Disparities Project made 12 recommendations, including:– (1) Requiring health care organizations to gather uniform patient data on race,

ethnicity, language and SES

– (2) Developing skills to enable community members to become better informed and equipped patients

– (3) Providing cultural competence education and training to health care professionals

– (4) Increasing resources to improve workforce diversity

– (5) Increasing public awareness about health disparities

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Boston Continued

• One year into the Project, significant results, including:

– Significant progress toward building a uniform data collection system

– More than 460 health care professionals completed cultural competency training

– Approximately 3,000 people were directly involved in targeted community-wide education, training and advocacy;

– 3,000 more received direct patient education and support

– The Boston Neighborhood Network (BNN) created an 8-segment TV series about the Disparities Project

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State and Local Equity Initiatives: California

Health Care Language Assistance Act (SB 853) – Key Elements

• Health plans must conduct a needs assessment to calculate threshold languages and collect race, ethnicity and language data

• Health plans must provide quality, accessible and timely access to interpreters at all points of contact in the health care system and at no cost to the enrollee

• Health plans must translate vital documents into threshold languages

• Health plans must ensure that interpreters are trained, competent and that translated materials are of high quality

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State and Local Equity Initiatives: New Jersey

• In 2005, NJ became the first state to develop mandatorycultural competency training for physicians

• SB 144 requires medical professionals to receive cultural competency training to graduate from a NJ med school or to get (or renew) a license to practice medicine

• Improving cultural competence is widely recognized as integral to the reduction of health disparities

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Potential Lessons for Canada

• (1) Create an Office of Health Equity

• (2) Need Uniform Data Collection and Analysis

• (3) Recruit a Diverse Workforce

• (4) Need Collaboration Among Stakeholders

• (5) The Importance of Quality, Trained Health Care Interpretation

• (6) Increased Cultural Competency Training

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Questions and Discussion

Any questions/comments?

Paper available here: http://www.wellesleyinstitute.com/files/Health%20Equity%20Lessons%20from%20the%20US%20-%20Formatted%20v.3_1.pdf