[House Hearing, 107 Congress]
[From the U.S. Government Printing Office]




    RACIAL DISPARITIES IN HEALTH CARE: CONFRONTING UNEQUAL TREATMENT

=======================================================================

                                HEARING

                               before the

                   SUBCOMMITTEE ON CRIMINAL JUSTICE,
                    DRUG POLICY AND HUMAN RESOURCES

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                               __________

                              MAY 21, 2002

                               __________

                           Serial No. 107-196

                               __________

       Printed for the use of the Committee on Government Reform


  Available via the World Wide Web: http://www.gpo.gov/congress/house
                      http://www.house.gov/reform


                                 ______

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                            WASHINGTON : 2003
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                     COMMITTEE ON GOVERNMENT REFORM

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       MAJOR R. OWENS, New York
ILEANA ROS-LEHTINEN, Florida         EDOLPHUS TOWNS, New York
JOHN M. McHUGH, New York             PAUL E. KANJORSKI, Pennsylvania
STEPHEN HORN, California             PATSY T. MINK, Hawaii
JOHN L. MICA, Florida                CAROLYN B. MALONEY, New York
THOMAS M. DAVIS, Virginia            ELEANOR HOLMES NORTON, Washington, 
MARK E. SOUDER, Indiana                  DC
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
BOB BARR, Georgia                    DENNIS J. KUCINICH, Ohio
DAN MILLER, Florida                  ROD R. BLAGOJEVICH, Illinois
DOUG OSE, California                 DANNY K. DAVIS, Illinois
RON LEWIS, Kentucky                  JOHN F. TIERNEY, Massachusetts
JO ANN DAVIS, Virginia               JIM TURNER, Texas
TODD RUSSELL PLATTS, Pennsylvania    THOMAS H. ALLEN, Maine
DAVE WELDON, Florida                 JANICE D. SCHAKOWSKY, Illinois
CHRIS CANNON, Utah                   WM. LACY CLAY, Missouri
ADAM H. PUTNAM, Florida              DIANE E. WATSON, California
C.L. ``BUTCH'' OTTER, Idaho          STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia                      ------
JOHN J. DUNCAN, Jr., Tennessee       BERNARD SANDERS, Vermont 
JOHN SULLIVAN, Oklahoma                  (Independent)


                      Kevin Binger, Staff Director
                 Daniel R. Moll, Deputy Staff Director
                     James C. Wilson, Chief Counsel
                     Robert A. Briggs, Chief Clerk
                 Phil Schiliro, Minority Staff Director

   Subcommittee on Criminal Justice, Drug Policy and Human Resources

                   MARK E. SOUDER, Indiana, Chairman
BENJAMIN A. GILMAN, New York         ELIJAH E. CUMMINGS, Maryland
ILEANA ROS-LEHTINEN, Florida         ROD R. BLAGOJEVICH, Illinois
JOHN L. MICA, Florida,               BERNARD SANDERS, Vermont
BOB BARR, Georgia                    DANNY K. DAVIS, Illinois
DAN MILLER, Florida                  JIM TURNER, Texas
DOUG OSE, California                 THOMAS H. ALLEN, Maine
JO ANN DAVIS, Virginia               JANICE D. SCHAKOWKY, Illinois
DAVE WELDON, Florida

                               Ex Officio

DAN BURTON, Indiana                  HENRY A. WAXMAN, California
                   Christopher Donesa, Staff Director
                Roland Foster, Professional Staff Member
                          Conn Carroll, Clerk
                  Julian A. Haywood, Minority Counsel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on May 21, 2002.....................................     1
Statement of:
    Christensen, Hon. Donna M., a Delegate in Congress from the 
      territory of the Virgin Islands; Dr. Thomas LaVeist, 
      associate professor, Johns Hopkins School of Public Health; 
      Dr. Lisa Cooper, associate professor, Johns Hopkins 
      University School of Medicine; and Dr. Elena Rios, 
      president, National Hispanic Medical Association...........   112
    Ruffin, John, Ph.D., Director, National Center on Minority 
      Health Disparities, National Institutes of Health; Nathan 
      Stinson, Jr., Ph,D., M.D., M.P.H., Deputy Assistant 
      Secretary for Minority Health, Office of Public Health and 
      Science; Ruben King-Shaw, Jr., Deputy Administrator and 
      Chief Operating Officer, Centers for Medicare and Medicaid 
      Services; Carolyn Clancy, M.D., Acting Director, Agency for 
      Healthcare Research and Quality, U.S. Department of Health 
      and Human Services.........................................    28
Letters, statements, etc., submitted for the record by:
    Christensen, Hon. Donna M., a Delegate in Congress from the 
      territory of the Virgin Islands, prepared statement of.....   115
    Clancy, Carolyn, M.D., Acting Director, Agency for Healthcare 
      Research and Quality, U.S. Department of Health and Human 
      Services, prepared statement of............................    95
    Cooper, Dr. Lisa, associate professor, Johns Hopkins 
      University School of Medicine, prepared statement of.......   126
    Davis, Hon. Danny K., a Representative in Congress from the 
      State of Illinois, prepared statement of...................    10
    King-Shaw, Ruben, Jr., Deputy Administrator and Chief 
      Operating Officer, Centers for Medicare and Medicaid 
      Services, prepared statement of............................    80
    LaVeist, Dr. Thomas, associate professor, Johns Hopkins 
      School of Public Health, prepared statement of.............   146
    Rios, Dr. Elena, president, National Hispanic Medical 
      Association, prepared statement of.........................   136
    Ruffin, John, Ph.D., Director, National Center on Minority 
      Health Disparities, National Institutes of Health, prepared 
      statement of...............................................    32
    Souder, Hon. Mark E., a Representative in Congress from the 
      State of Indiana, prepared statement of....................     3
    Stinson, Nathan, Jr., Ph,D., M.D., M.P.H., Deputy Assistant 
      Secretary for Minority Health, Office of Public Health and 
      Science, prepared statement of.............................    55
    Waxman, Hon. Henry A., a Representative in Congress from the 
      State of California, prepared statement of.................    26

 
    RACIAL DISPARITIES IN HEALTH CARE: CONFRONTING UNEQUAL TREATMENT

                              ----------                              


                         TUESDAY, MAY 21, 2002

                  House of Representatives,
 Subcommittee on Criminal Justice, Drug Policy and 
                                   Human Resources,
                            Committee on Government Reform,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 12:09 p.m., in 
room 2154, Rayburn House Office Building, Hon. Mark E. Souder 
(chairman of the subcommittee) presiding.
    Present: Representatives Souder, Cummings, and Davis of 
Illinois.
    Also present: Representative Waxman.
    Staff present: Christopher Donesa, staff director and chief 
counsel; Roland Foster, professional staff member; Conn 
Carroll, clerk; Julian A. Haywood, minority counsel; Karen 
Lightfoot, minority senior policy advisor; Josh Sharfstein, 
minority professional staff member; and Jean Gosa, minority 
assistant clerk.
    Mr. Souder. The subcommittee will now come to order.
    Good afternoon. I'd like to thank all of you for being here 
today. I want to start by recognizing and thanking Ranking 
Member Cummings for raising the issue of racial disparities in 
health care. We have scheduled today's hearing at his request.
    I would like to express my own serious concerns at the 
findings which we will be reviewing today. They ought to be of 
concern to all Americans because the Institute of Medicine has 
raised fundamental questions that could continue to weaken 
public perception of the health care system, threaten to 
perpetuate a health gap between minorities and nonminorities if 
not addressed, and further challenge already beleaguered health 
care providers.
    A comprehensive report by the Institute of Medicine 
released in March of this year found that minorities in America 
generally receive poorer health care than whites even when 
income, insurance and medical conditions are similar. The IOM 
found that this inequality has contributed to higher minority 
death rates from a host of chronic conditions.
    For example, relative to Caucasians, African Americans and 
Hispanics are less likely to receive appropriate cardiac 
medication or to undergo coronary artery bypass surgery even 
when factors such as insurance and income are taken into 
account. African Americans with end-stage renal disease are 
less likely to receive hemodialysis and kidney transplantation, 
and African American and Hispanic patients with bone fractures 
seen in hospital emergency departments are less likely than 
whites to receive pain medication.
    The report identified a number of causes for racial health 
disparities including language barriers, inadequate coverage, 
provider bias and lack of minority doctors.
    In addition to other recommendations for remedying these 
disparities which we will discuss more in depth, the IOM 
suggested that public awareness should be raised of this issue. 
We hope to further that goal today and discuss with 
representatives from the administration and other witnesses how 
best to close the gap.
    The IOM report is at least the fourth study released this 
year indicating racial disparities in the health care system. A 
January Centers for Disease Control and Prevention [CDC], 
report found that although the health gap between whites and 
minorities narrowed in the 1990's, substantial disparities 
remain. A Commonwealth Fund survey released earlier this month 
found that minorities do not fare as well as whites on almost 
every measure of health care quality. And a Harvard study 
released earlier this month found that African American 
patients enrolled in Medicare/Choice plans receive poorer 
quality of care than Caucasian patients across several 
measures.
    In November 2000, Congress passed the Minority Health and 
Health Disparities Research and Education Act of 2000, which is 
now Public Law 106-525, to confront many of the shortcomings 
noted in these reports. This law established the National 
Center on Minority Health and Health Disparities at the 
National Institutes of Health, provided increased fundings and 
incentives for minority health and health disparities research 
and new support for education for both health professionals and 
patients to increase positive health outcomes for minorities. 
It also provided funding for schools that are researching 
health disparities.
    While it is too soon to determine what effects this law has 
made, it is clear that more must be done to improve patient 
care for minorities. Particularly patients must have the 
ability to take control of their own health care 
decisionmaking. To do so will require improved patient 
education access to affordable care and more choice in making 
health care decisions.
    I look forward to today's testimony from the administration 
and health care leaders on how best to move toward meaningful 
progress, and I want to encourage the Department of Health and 
Human Services to move promptly toward tangible steps to help 
level the quality of care.
    Again, I thank Congressman Cummings for his leadership in 
bringing this important issue before us today, and I look 
forward to continuing to work in the subcommittee toward an 
equality of health care opportunities and care for all 
Americans.
    [The prepared statement of Hon. Mark E. Souder follows:]

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    Mr. Souder. I'd now like to yield to Mr. Cummings for an 
opening statement.
    Mr. Cummings. Thank you, Mr. Chairman, and I thank you for 
agreeing to my request to holding this important hearing today. 
Today we will examine the progress that this Nation is making 
toward creating a health care system in which being a minority 
is not a mortality factor. As a Member of Congress and as an 
American of color, I deeply appreciate your willingness to 
examine the unequal treatment that minority Americans continue 
to receive within America's health care system, especially the 
compelling and disturbing evidence analyzed by a blue ribbon 
panel of scientists under the auspices of the Institute of 
Medicine.
    I join with you, Mr. Chairman, in welcoming all of our 
witnesses from the Department of Health and Human Services 
today, and particularly I want to thank Dr. Ruffin for being 
here under very difficult circumstances. Your presence here 
today speaks volumes about your commitment to fighting the 
persistent disparities we find in our Nation's health care 
system, and I thank you.
    And our second panel, we'll hear from our colleague 
Congressman Donna M. Christensen from the Virgin Islands, a 
physician who has a long-standing interest in issues 
surrounding minority health disparities; as well as Dr. Elena 
Rios, president of the National Hispanic Medical Association.
    Finally, let me also express a special welcome to the 
important witnesses who are joining us here today from Johns 
Hopkins University in Maryland's 7th Congressional District, 
which is, of course, the district I represent. Dr. Thomas 
LaVeist, the associate professor in the Bloomberg School of 
Public Health, and Dr. Lisa A. Cooper, who serves as associate 
professor on the faculties of both the Bloomberg School of 
Public Health and the School of Medicine.
    Mr. Chairman, in 1998, with strong encouragement from the 
Congressional Black Caucus, President Clinton committed this 
Nation to eliminating racially based health disparities in six 
specific areas by the year 2010. Those areas were infant 
mortality, cancer, cardiovascular diseases, diabetes, HIV 
infection, AIDS and immunizations. To their credit HHS 
Secretary Thompson and the Bush administration have reaffirmed 
this important national objective.
    Naturally, in order to cure and eliminate minority health 
disparities, we must first arrive at the understanding of their 
nature and causes. That is why I was proud to join with 
Congressman Bennie Thompson of Mississippi and other colleagues 
who care deeply about this issue in sponsoring legislation to 
create the National Center on Minority Health and Health 
Disparities at the National Institutes of Health. The Center's 
support for the IOM disparity studies was critical, and I want 
to recognize the efforts of my good friend and colleague 
Congressman Jesse Jackson, Jr., and the other Members of 
Congress who worked diligently to secure funding for the Center 
and for the study in the appropriations process.
    Today we will discuss the implications of that study 
entitled Unequal Treatment: Confronting Racial and Ethnic 
Disparities in Health Care. The IOM's central conclusion is 
that Americans of color tend to receive lower quality health 
care even when the patient's income and insurance plans are the 
same, and that these disparities contribute to our higher death 
rates and poorer health outcomes from heart disease, cancer, 
diabetes, HIV/AIDS and other life-endangering conditions.
    This unfortunate indictment of our health care system by 
America's health care establishment is a monumental moral 
challenge to the policymakers of this great country. We have 
known for years that Americans of color die before our time 
from a wide range of illnesses, and that black mortality rates 
are higher than those of Caucasians. While lack of health care 
access has played an obvious role, the impact of racial biases 
and stereotypes on the quality of medical care received has 
been more difficult to assess. The IOM report demonstrates that 
these phenomena do exist, and we must now ensure that America's 
medical establishment comes to terms with the impact of race as 
an independent factor.
    When we know that the quality of care one receives in a 
doctor's office or in an emergency room may depend upon the 
color of one's skin, it is clear that we are dealing with a 
national civil rights issue of the highest order, and we must 
address it in those terms. Unless we dramatically expand the 
civil rights remedies available to people of color, the 
national 2010 initiative to eliminate racial and ethnic health 
disparities will simply fail. Title 6 enforcement is critical, 
and we must provide resources to the Office of Civil Rights so 
that it can aggressively enforce the civil rights laws and 
regulations that exist to protect Americans from discrimination 
in the health care system. Discriminatory effects of policies 
that limit minority access to medical care continue to be 
deadly, and without effective remedies, we will not see them go 
away.
    Our witnesses will address a range of other initiatives 
that must be undertaken if we were to achieve the 
administration's goal, the Nation's goal, of ending racial 
disparities in health care. As the IOM report tells us, 
education of both patients and providers improved data 
collection and monitoring, and increasing the proportion of 
minority health professionals are promiment among them.
    Mr. Chairman, I hope we can develop some consensus around 
implementing these initiatives so that the race will no longer 
be a predictor of negative health care outcomes, and I again 
thank you for holding this hearing. Thank you as well to all of 
our witnesses for being with us today. I look forward to 
hearing your testimony.
    Mr. Souder. Thank you.
    I now yield to Mr. Davis.
    Mr. Davis of Illinois. Thank you, Mr. Chairman, and let me 
first of all thank you for holding this hearing. I also want to 
commend the ranking member, Representative Cummings, for 
bringing this subject matter to this venue.
    I would like to ask for permission to submit my statement 
for the record, to revise and extend it, and also thank my 
young colleague who's graduating from medical school next 
month, Scott, for preparing it. And I look forward to attending 
his graduation, where I am scheduled to be the commencement 
speaker.
    I've been around this issue now for close to 40 years, and 
we've been talking about disparities. When it comes to 
minorities, there are disparities in everything that deal with 
quality of life in these United States of America. And I guess 
if there's anything that I've learned, one of the things that 
I've learned and discovered is that change is oftentimes a 
rather slow and subtle process. Matter of fact, people have 
been talking about problems of health care in a documented way 
in this country ever since the 1800's, when I guess one of the 
first real studies were put together in Massachusetts, 
something called the Shattuck report. And I find that the same 
problems that were being talked about then are being talked 
about now relative to what the issues are when it comes to 
health care.
    Obviously one of the real factors contributing to 
disparities facing African Americans and other minority groups 
is the disparity of income, is the issue of poverty, the issue 
of people being poor and not having resources.
    I always suggest that my mother died prematurely because 
she had to travel from the small town where she lived in 
Arkansas to the University Medical Center in Little Rock in 
order to get treatment for the dialysis problem, the kidney 
problems that she was having.
    I've known other individuals who could not get treatment 
because there was not the availability of resources where they 
were. And then, of course, you look in other places and there 
is an overabundance of resources.
    I represent a congressional district that has 23 hospitals 
in it, four medical schools, 25 community health centers, three 
or four large research institutes. And so the problem there is 
not necessarily the unavailability of care. But you can go 2 
miles from the largest medical center complex in the country, 
which is in my congressional district, and find some of the 
most dire health needs and health statistics that exist.
    And so it seems to me that in many ways we have a certain 
amount of skill; we probably do some of the best medical 
education in the world. Something called the Flexner Report was 
put out, but--not only did it improve medical education, but it 
also put most of the black medical schools out of business, and 
they have not come back yet. I think it left only two, Howard 
and Meharry.
    So it seems to me that when we talk about disparities, 
we're really talking about how willing are we, as a Nation, to 
live up to the notion that we can move toward equal justice, 
equal opportunity. There is still a paucity of African 
Americans who are trained medical personnel. You look at the 
disparities in terms of the numbers of physicians and other 
professionals who are African Americans, and we still have the 
same problem. And so there needs to be a revamping, I think, of 
the system, more emphasis placed upon education, more emphasis 
placed upon life-style, more emphasis placed upon the desire 
and the need to be healthy.
    Of course, when it comes to racism and race orientation and 
all of those factors, we know that's not so much a factor of 
skill, but it's a factor of will.
    And so the struggle must continue. One of the things that 
Frederick Douglass taught that I try and subscribe to is that 
if there is no struggle, there is no progress. And so when you, 
Mr. Chairman, will hold a hearing on this subject in this 
committee, that is a part of the continuing and ongoing 
struggle.
    And you, Mr. Cummings, when you will raise the issue in 
this committee so that we can have the kind of discussion with 
the experts who have come to testify--and I want to thank all 
of them for coming and bringing their expertise. But what we 
really need to do is move toward a national health system, a 
national health plan, everybody in, nobody out, a system that 
takes the idea that health care is indeed a right and not a 
privilege. And a country with as much technology, with as much 
proficiency, as much resource and as much understanding as we 
have can, in fact, do that.
    So I thank you and look forward to the information that 
will be shared by our expert panelists. And I yield back the 
balance of my time.
    [The prepared statement of Hon. Danny K. Davis follows:]

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    Mr. Souder. I'd like to yield to the distinguished 
gentleman from California, the ranking member of the full 
committee and member of the subcommittee, Mr. Waxman.
    Mr. Waxman. Thank you, Mr. Chairman.
    Democrat or Republican, conservative or liberal, I do not 
believe there is any Member of Congress who can ignore the 
findings of the March 2002 report from the Institute of 
Medicine called ``Unequal Treatment.'' This landmark report 
surveyed hundreds of scientific studies and found significant 
disparities in medical treatment and life-or-death outcomes by 
race and ethnicity.
    What the report found was tragic. Minorities are less 
likely to receive needed cardiac medication and cardiac surgery 
and are less likely to receive kidney dialysis or transplants. 
Minorities are also less likely to receive the most effective 
treatments for HIV. Minorities are also less likely to have 
their pain adequately treated. The list goes on and on.
    Here in Congress we are proud of our record of expanding 
NIH funding to develop new breakthrough treatments for diseases 
that cause immense human suffering, but these efforts are 
tarnished if we cannot make the treatments available. We have 
accomplished little if we permit the fruits of research to 
remain out of the reach of so many thousands of American 
citizens.
    It is a testament to the importance of this issue that the 
Subcommittee on Criminal Justice has called this hearing in 
bipartisan fashion, and I commend the Chair, Representative 
Souder, and the ranking member, Representative Cummings, for 
their leadership.
    Today, we will hear about the findings of the Institute of 
Medicine panel. We will also discuss solutions. It is not 
enough just to denounce health disparities. We must also take 
action to reduce them. The Institute of Medicine report 
includes a set of recommendations that I hope we will explore 
today.
    For example, one recommendation is that patients with 
public insurance receive the same managed care protections as 
those in private insurance. Because patients on Medicaid and 
other public insurance programs are disporportionately 
minorities, inadequate patient protections can increase health 
disparities. We need to ask whether the current administration 
is committed to following this recommendation.
    The Institute of Medicine panel also supports funding for 
innovative efforts to deliver medical care so that all 
patients, regardless of ethnicity or race, receive necessary 
treatments. We need to ask whether the current administration 
has supported full funding for such initiatives.
    The Agency for Healthcare Research and Quality has 
developed a program to accomplish some of these ideas. We need 
to ask whether the current administration is supporting full 
funding for these initiatives.
    The report calls for efforts to fight discrimination 
against racial and ethnic minorities in the health care system. 
We need to ask whether the current administration has backed 
away from a rule to prevent discrimination against Medicaid 
patients, many of whom are minorities.
    I am pleased that the administration has sent several 
witnesses from the Department of Health and Human Services here 
today. I am also pleased that several experts from medical 
professional associations and the Institute of Medicine have 
come for today's second panel. And I hope that today's hearing 
is not an end, but a beginning. By discussing the policies that 
are necessary to address health disparities, this hearing can 
be an important step toward a greater understanding of the 
commitment that Congress, as well as the medical profession, 
must make to provide equal treatment in the United States.
    Thank you very much, Mr. Chairman.
    Mr. Souder. Thank you.
    [The prepared statement of Hon. Henry A. Waxman follows:]

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    Mr. Souder. Before proceeding, I'd like to take care of a 
couple of procedural matters.
    First, I ask unanimous consent that all Members have 5 
legislative days to submit written statements and questions for 
the hearing record, that any answers to written questions 
provided by the witnesses also be included in the record.
    Without objection, it is so ordered.
    Second, I ask unanimous consent that all exhibits, 
documents and other materials referred to by Members and the 
witnesses may be included in the hearing record and that all 
Members be permitted to revise and extend their remarks.
    Without objection, it is so ordered.
    We begin with our panel of administration witnesses. We 
have excellent representation from the department today, for 
which I'd like to thank each of you and the department. As I'm 
sure most of you know, we also ask you to summarize your 
testimony in 5 minutes, and we will include your complete 
statement in the record. As an oversight committee, it's our 
standard practice to ask all of our witnesses to testify under 
oath, so if each of you could rise, I'll administer the oath.
    [Witnesses sworn.]
    Mr. Souder. Let the record show that each witness responded 
in the affirmative.
    As you have heard, Dr. John Ruffin, Director of the 
National Center on Minority Health and Health Disparities, has 
had some family matters that he has to attend to. And we want 
to express our sympathy to you and your family for your 
struggles. And because of that, we're going to have you give 
your testimony and then take some questions; and then you can 
be excused because we know you need to get on to that.
    But we thank you for taking the time to come to us today 
for this hearing.

STATEMENTS OF JOHN RUFFIN, Ph.D., DIRECTOR, NATIONAL CENTER ON 
  MINORITY HEALTH DISPARITIES, NATIONAL INSTITUTES OF HEALTH; 
  NATHAN STINSON, JR., Ph,D., M.D., M.P.H., DEPUTY ASSISTANT 
  SECRETARY FOR MINORITY HEALTH, OFFICE OF PUBLIC HEALTH AND 
 SCIENCE; RUBEN KING-SHAW, JR., DEPUTY ADMINISTRATOR AND CHIEF 
OPERATING OFFICER, CENTERS FOR MEDICARE AND MEDICAID SERVICES; 
 CAROLYN CLANCY, M.D., ACTING DIRECTOR, AGENCY FOR HEALTHCARE 
   RESEARCH AND QUALITY, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Mr. Ruffin. Thank you, Mr. Chairman.
    Good afternoon, Mr. Chairman and Mr. Cummings and other 
members of the subcommittee. I'm honored to join you today as 
the first Director of the National Center on Minority Health 
and Health Disparities for this special hearing on racial 
disparities in health.
    It is quite timely for me to update you on work of the new 
center to eliminate health disparities in light of the recent 
findings in the IOM report.
    To echo the words of the Deputy Secretary of Health and 
Human Services Claude Allen, these are issues that we in the 
Department have been confronting and working to resolve for 
many years. We are always alarmed, however, by the extent and 
impact of health disparities across our Nation.
    One of the great challenges we have faced over the past 
decade is the need to convince people that these problems are 
real and that they can be addressed through science. The IOM 
report helped greatly in this regard by serving to further 
document this crisis.
    As you know, the new center at the NIH was created by 
Public Law 106-525, the Minority Health and Health Disparities 
Research and Education Act of 2000. The timing could not have 
been better. The law has help us transition from the NIH Office 
of Research on Minority Health to a new center designated to 
address health disparity issues from a research perspective. 
The Center cannot do this alone, however. In fact, no single 
agency can do this alone. The health disparity crisis is 
multifaceted and will require a multidisciplinary approach from 
institutions across the country.
    Ours is an NIH-wide effort with the Center at the focal 
point. To reduce and eliminate health disparities, we will work 
with our other partners at NIH, but we will also work with 
other agencies and outside organizations and institutions 
involved in health disparities.
    We at the table this morning are networking among ourselves 
and with our constituencies. Only in this way will we be able 
to produce the results that will address the IOM 
recommendations. We have asked our stakeholders across the 
country what should we be doing that we're not doing. We have 
taken their advice and are now developing the NIH strategic 
plan and budget to reduce and, ultimately, eliminate health 
disparities.
    We also have three core programs provided in law that 
established our center. Our loan repayment program will give us 
an opportunity to produce a core of individuals who are 
culturally sensitive to health disparities. This type of 
program has worked well in other areas, such as HIV/AIDS. This 
work force--doctors, researchers, nurses, health care 
professionals--will sensitize even more individuals to the 
health disparities and help us combat the crisis.
    In fiscal year 2001, as a result of the creation of the 
Center and the creation of the loan repayment program, 8 months 
after the creation of the Center, 45 health professionals 
received loan repayment programs or loan repayment awards. We 
will set up a new round of competition for additional awards to 
be made this year.
    We must sensitize not only individuals, but also 
institutions to the health disparity crisis. Our endowment 
program, also provided by law, is available to section 736 
institutions under the Public Service Act. This program will 
provide assistance for training and research and will bring 
more individuals into the health disparity research arena. 
Seven institutions were approved for awards in fiscal year 
2001. Payments already have been made to five of these 
institutions, and payments are on the way for the other two 
institutions.
    We also are now accepting applications for the next round 
of competition and plan to make more awards this year. This is 
a collaborative effort between the National Institutes of 
Health and HRSA.
    The crown jewel of all of our efforts will be the creation 
of our Health Disparity Centers of Excellence around the 
country. We will establish these centers across the country to 
level the playing field supporting a wide array of institutions 
to engage in research, research training and health 
disparities.
    We have developed three mechanisms, Mr. Chairman, of 
support for this program in order to involve institutions at 
all levels of capability. We are currently accepting 
applications and plan to make awards this year.
    We also continue to buildupon our collaborative 
relationships with our HHS partners, many of whom are sitting 
at the table. Last year, we participated in 214 collaborative 
projects. This year we have received over 250 requests to 
cofund new initiatives from other NIH institutes and centers. 
This is a testament--it is an indication of the seriousness of 
the health disparity issues.
    While we would like to fund them all, there are 
congressional mandates within the new center that we're also 
committed to. However, we will maintain our obligation to 
several other NIH institutes and centers projects as well as 
our support to various OMH, AHRQ and CDC projects.
    With the Centers for Disease Control, we continue to 
support the Reach 2010 program of Racial and Ethnic Approaches 
to Community Health, which is entering its second phase. This 
program is a cornerstone initiative aimed at eliminating 
disparities in health status experienced by ethnic minority 
populations, and I'm sure those at CDC will talk more about 
their collaboration with the National Institutes of Health and 
our support for that program.
    The collaboration of the National Center on Minority Health 
and Health Disparities collaborated with the Office of Minority 
Health of the Department of Health and Human Services. It is 
broad-based, and it includes the goals of increasing research 
on minority health issues, collecting data, improving the data 
base, increasing the recruitment and retention of minority 
students in biomedical science and conducting community 
outreach and public education programs.
    There's a whole host of programs for which we collaborate 
with the Office of Minority Health with AHRQ. The Agency for 
Healthcare Research and Quality supports several programs aimed 
at understanding and eliminating health disparities that focus 
on community outreach, building research capacity and training. 
The Center provides funding for many of these projects, 
particularly the EXCEED program. It is our intent to continue 
to support these efforts and to continue to collaborate with 
our various partners.
    The Center continues to explore and develop future 
initiatives for research activities and programs aimed at 
reducing and eliminating health disparities. We will be meeting 
with our new advisory council in the coming weeks to discuss a 
number of new initiatives that we plan to launch.
    The Center is considering a cultural competency initiative 
which addresses the need for the development of cultural 
competency among health care providers and others who 
participate in health care processes. There is an urgent need, 
Mr. Chairman, for such individuals to have a firm grasp on how 
various belief systems, cultural bias, family structures, 
historical realities and a host of other culturally determined 
factors influence the way people experience illnesses and the 
way they respond to advice and treatment. We understand that 
such differences are real and translate into real differences 
in the outcome of care.
    We will explore with our advisory council the establishment 
of health disparity community centers that will conduct 
research, provide shared resources and provide the formal 
infrastructure to facilitate rapid advances in knowledge about 
communication among health disparity populations. These 
interdisciplinary efforts will result in new theories, methods 
and intervention that will contribute to addressing and 
ultimately eliminating disparities in health status.
    Finally, Mr. Chairman, the Center is grateful to the 
Congress, the administration, the NIH institutes and centers 
and to all of you for the overwhelming support that you have 
provided the Center in transitioning from the Office of 
Research on Minority Health to the National Center on Minority 
Health and Health Disparities. I'm proud of the progress that 
the Center has made over the past year in establishing its 
organizational structure and programs. We will continue to work 
with our many partners to explore new opportunities to reduce 
and eliminate health disparities.
    Through continued and increasing collaborative ventures, 
the Center will work diligently to define the health disparity 
issue for every American and garner support to ensure the 
health of all Americans.
    Health disparity is an issue that transcends minorities and 
other health disparity populations. Clearly, it is everybody's 
concern and it calls for shared responsibilities to effect 
permanent change. Each year we will be providing an annual 
report to the Congress on the result of our activities. We 
would be pleased, Mr. Chairman, to keep your subcommittee 
informed of our progress as well.
    Thank you for the opportunity to speak with you today.
    [The prepared statement of Mr. Ruffin follows:]

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    Mr. Souder. Thank you for your testimony and 
congratulations on being the first Director. There will never 
be another first Director, so it has to be tremendously 
satisfying; and I appreciate your leadership.
    I have a specific question on HIV/AIDS. It is increasingly 
becoming more and more dominant in the African American and 
Hispanic communities. In fact, other groups have stabilized or 
dropped, but the number of black and Hispanic women becoming 
infected continues to increase each year.
    What efforts are you making to address this epidemic, and 
why do you feel that the current efforts are failing, because 
in this area it's actually increasing?
    Mr. Ruffin. Well, as you know, Mr. Chairman, there is an 
office at the National Institutes of Health which deals 
specifically--Congress has mandated an office that deals 
specifically with AIDS research at the National Institutes of 
Health. And that office collaborates with all of the other 
centers at the National Institutes of Health and also 
collaborates with the new center, that is the Center on 
Minority Health and Health Disparities.
    And also if it's--we have been able--there is a report, a 
new report, which I've just seen recently, that has come from 
that particular office that deals specifically with how they 
plan to address those specific issues. Clearly, they recognize 
that this has become of epidemic proportions within those 
communities that you just mentioned. And during a visit to--
their Web site, I noticed recently, clearly points out a number 
of initiatives that go to the core of your question.
    That particular office, as well as the NIH in general, is 
beginning to invest and expand funding in research 
infrastructure at minority institutions to increase capacity 
for support for HIV/AIDS research. We are also increasing a 
number of funded minority investigators, because we know that 
goes to the heart of it as well.
    We need to get more minority investigators trained in those 
fields. I think that the AIDS loan repayment program is a good 
way of doing that, because what we do by supporting those 
individuals is that we're saying to professionals around the 
country that if you go into AIDS research, what we will then do 
is that we will pay back those big loans that individuals have 
incurred in medical school, and other health professionals, to 
deal specifically with that whole issue. And I think as we 
begin more and more to train that cadre of researchers and get 
the word out, we will begin to address those issues, and in a 
major way.
    And there are a number of initiatives that are under way, 
and particularly in the Office of AIDS Research.
    Mr. Souder. So let me see if I understand: In your office, 
would the loan repayment program be under your office even--and 
one of the things your goal would be is to try to address the 
HIV/AIDS question in the minority communities?
    Mr. Ruffin. One of the things that happened at the NIH, and 
specifically with the creation of the new Center--the AIDS loan 
repayment program has been at the NIH for some time, but it was 
an intramural program. Individuals wishing to study and to come 
and do research on AIDS would have to come to the NIH and do 
that research in our intramural program. With the creation of 
the Center, we now have an extramural loan repayment program, 
which means that individuals, minorities as well as 
nonminorities, throughout the country who are doing research in 
these fields can do that research wherever they happen to be.
    Whether those individuals are in Wisconsin or anywhere, 
anywhere else in the country, they can now do research in those 
various areas. So now we have what is called an extramural loan 
repayment program that will help us to address those needs.
    The program sponsored by the Center also does something 
else, it's not just for MDs. It's for MDs, Ph.D.s, individuals 
in dentistry, osteopathic medicine. Because all of those health 
professional fields are going to play a role in our ability to 
eliminate health disparities. That's the new aspect that comes 
with the extramural loan repayment program that did not exist 
when we had the intramural, just the intramural loan repayment 
program at NIH.
    Mr. Souder. Is there a similar overlap in your outreach 
programs?
    Mr. Ruffin. Yes. Also I should add to that now--the loan 
repayment program is a program now that is extended in all of 
the institutes and centers at NIH. All of the institutes and 
centers can participate in the loan repayment program at NIH. 
This is the first year, of course, that we've been able to do 
that.
    Mr. Souder. Thank you.
    Mr. Cummings.
    Mr. Cummings. Thank you very much, Mr. Ruffin, for being 
with us.
    I want to go back to something that Congressman Davis 
talked about in his opening statement, when he was talking 
about the medical schools, African American, black medical 
schools. And it seems like this would be an ideal place, Howard 
and Meharry, to perhaps address these problems and at the same 
time do something for the students there, do something for the 
institutions.
    It's my understanding, for example, that the Howard School 
of Nursing has a program with Yale.
    Mr. Ruffin. Right.
    Mr. Cummings. Apparently, they send 4th year, I guess, 
students from Howard to Yale for a month, about a month, a 
little bit over a month; and they then get introduced to, I 
guess it is, high-level research.
    And it sounds like--when I heard you talking about 
research, I take it--I mean, is that the kind of thing that 
you're talking about also? I mean, these are nurses that would 
normally--in talking to the Dean at Howard, she tells me they 
would at the end of their 4 years just go on and begin to 
practice. But it opens up the door to research.
    Mr. Ruffin. Absolutely. By the way, the funding for that 
program comes out of the Center. So I'm pleased to take credit 
for that.
    Mr. Cummings. Wonderful.
    Mr. Ruffin. I must also say to you that partnering between 
minority and majority institutions is something that is highly 
encouraged.
    But I also mention in my testimony the creation of Centers 
of Excellence, Health Disparity Centers of Excellence. These 
centers would be distrubuted all over the country.
    You know, we have other kinds of disparities. As I listened 
to Congressman Davis talk about some of the situations in 
Arkansas, one of the other kinds of disparities that we have in 
our country is, ``geographical disparities as well.'' So 
getting these centers located to various places throughout the 
country, I think, is going to help.
    Many of the historically black colleges and universities 
will benefit from the creation of these centers because we have 
devised at NIH three different mechanisms to level the playing 
field. All of our programs are competitive programs, but 
institutions have to begin to compete on different levels. So 
we've created three different mechanisms for institutions to 
compete for these Centers of Excellence.
    One is what NIH calls an R-25 mechanism, which is simply a 
planning grant. Institutions which may not be ready for a 
center can compete for the planning grant, 3 years, up to 
$350,000 a year to plan for their centers.
    Other institutions, we have a mechanism which we call a P-
20; those are institutions--essentially an exploratory center. 
It's a corporate agreement. We hold hands with those particular 
centers to say, NIH is here. We're going to help you. We are 
going to be with you. We're going to walk until you are ready 
to go on your own.
    Those centers, individuals will compete on those.
    Then, of course, throughout the country we have 
institutions like Yale and others that we've invested in over 
the years that we want to also get involved in health disparity 
research. These are P-60's, and those institutions will be able 
to compete for health disparity grants as well. And so we are 
going to make those awards this September.
    We have had what we call technical assistance workshops all 
around the country over the last few months to tell people how 
to compete, before the fact to give them the information and to 
let them know what the expectations are. And I know from the 
interest that we're going to get a number of institutions 
around the country competing for these programs.
    Mr. Cummings. I know that you don't have a crystal ball, 
but you are in a position where at some point around 2010 
somebody is going to--a whole lot of people are going to 
probably say, well, back then a few years ago a goal was set 
for us to address these disparities effectively by 2010, and I 
mean, what do you see happening?
    What do you--I mean, what obstacles are in your way from 
what you can see? And talk about money and talk about what we 
can do as the Congress to help you address these issues.
    I just--you know, I couldn't help but just listen, and 
listening to Congressman Davis, I have two relatives, a 
grandfather and a grandmother, who I know died prematurely; and 
I never even got to know them. And so, you know, we talk about 
quality of life, we also talk about the quality of life of 
having that grandparent there for that grandchild. Because, you 
know--and it just--I don't know if a lot of people realize how 
serious this problem is because, going back to my question, 
what do--where do you see us in 2010?
    Mr. Ruffin. Mr. Cummings, I'm encouraged; and one of the 
reasons I'm encouraged is for the very thing that's happening 
here today, that is, your ability and the ability of this 
subcommittee to listen to those of us who have been out in the 
communities and have listened to the individuals who are 
affected most. At the NIH and certainly with the creation of 
the new Center, we've tried to establish a new paradigm. And I 
think this new paradigm is going to lead to some results that 
perhaps we didn't get in the past and we will get by 2010.
    And that paradigm is this: What we're trying to do is to do 
what you're doing and that is to listen to the community. I 
mention in my statement that we go and we ask the community, 
what is it--and they're the ones after all who know best. We 
ask them, what is it that we should be doing that we're not 
doing. And when you give people a chance to talk, they 
generally tell you what it is that needs to be done.
    What we have to do as professionals is take the 
recommendations that they give to us, bring it back to an 
organization, an agency like the NIH, the premier biomedical 
research facility in the world, and try to take those 
recommendations and convert them to good science. And that's 
what we are trying to do. And think if we do that, I think the 
result this time around is going to be different.
    And so my perspective, looking through my crystal ball, is 
very favorable about what's going to happen as it relates to 
health disparities.
    Mr. Cummings. Just one last question. What's the 
relationship between NIH training programs that you were 
describing and those who--HRSA's Bureau of Health Professionals 
that aim to train minority clinicians; and is it a 
complementary relationship?
    Mr. Ruffin. HRSA has for some years, as you know, had the 
Centers of Excellence program. These are 736 institutions that 
were established in public law. They're not all minority 
institutions, some of them are research-intensive institutions, 
but a great deal of them are minority institutions.
    The law that established the center has allowed us the 
ability to make loans--I'm sorry, endowments to many of those 
institutions; and funds from those endowments can be used for a 
multiplicity of purposes. Not all of those 736 institutions 
would qualify. It is the institutions among the HRSA Centers of 
Excellence that are doing good science, but that have small 
endowments. And we're concentrating on those institutions to 
give them the necessary resources to build a strong biomedical 
emphasis.
    Mr. Cummings. Again, we thank you for--under the 
circumstances, for being with us. And you know our spirit and 
our hearts are with you. And our prayers.
    Mr. Ruffin. Thank you.
    Mr. Souder. Mr. Davis.
    Mr. Davis of Illinois. Thank you very much, Mr. Chairman.
    Dr. Ruffin, let me first of all congratulate you on your 
appointment, and I also would commend the appointing officer 
for making what I would think was a very wise selection.
    Mr. Ruffin. Thank you, sir.
    Mr. Davis of Illinois. Your testimony actually is some of 
the most stimulating that I've heard in a long time in terms of 
possibilities for serious movement.
    I also want to commend you on the program activity that has 
already been generated, especially the loan repayment which 
deals with a real issue and a real problem that people have.
    And then the whole business of trying to train more 
minority researchers. I can tell you, I've participated in so 
many research projects where we first had to train the 
principal investigators until I just got tired of it; you know, 
I'm saying this is ridiculous that these are the people who are 
in charge, and we've got to train them. And so I'm so pleased 
to see that.
    And also I'm pleased to see that there would be some focus 
on trying to engage the historically black colleges and 
universities more into the activity. I think that we've made a 
tremendous amount of progress.
    When we had the old health rights programs when we really 
saw health in a big way in communities, still many of the 
people that we're talking about are poor. I mean, many of the 
people with the greatest amounts of disparity, notwithstanding 
the fact that there are some other people that have some too, 
but poor people. And it seems to me that poor people require 
certain kinds of help and process; and you mentioned outreach, 
and that's my question.
    When there was a great deal of outreach, I thought we were 
making serious progress. But then we killed off that activity 
prematurely, again, I think when we killed off the old OEO 
program and activities.
    And how prominent do you see outreach becoming as a part of 
the focus of the Center as we deal with the disparity question?
    Mr. Ruffin. It's a major part. And not only that, but I 
mentioned to you that we ask people constantly, what is it that 
we ought to be doing that we're not doing. And this is one of 
the issues that come up often. And there are several ways that 
we're going to try and do these kinds of things over time.
    One, of course, is, as I said, trying to develop the 
centers in strategic places around the country. But in addition 
to that, one of the other issues that has been raised 
prominently is the role of community and community-based 
organizations, all in all, of what we do.
    I have to say that at NIH is one of those; that's one of 
those areas where there is a gap, and that is the participation 
of community-based organizations. We've had some activities 
where community-based organizations have participated with 
academic institutions in various partnerships. But there, terms 
of developing a role, a very significant role, for community-
based organizations, I think that would enhance to a great 
extent our ability to do effective outreach. And we're going to 
continue to develop some programs in that area as well.
    The community is demanding that we develop some programs in 
that area. So we have an office in the new Center that is 
devoted exclusively to outreach and a relationship with 
community-based organizations and trying to address that very 
issue that you're mentioning.
    Mr. Davis of Illinois. Let me just thank you very much. 
Your words to my ears are like manna from heaven, because I 
don't believe that you could do a lot of things for people, 
that you have to do things with people. And if you get people 
engaged and involved and have you them moving in concert, then 
I think you can see some progress.
    And so, you give me a great deal of hope. And I certainly 
look forward to working with you and hope that we can move this 
process along.
    And I thank you very much, Mr. Chairman, and yield back.
    Mr. Ruffin. Thank you, sir, and thank you for allowing me 
to testify today.
    Mr. Souder. Thank you, Dr. Ruffin. You're free to leave. We 
appreciate once again that you stayed today.
    Mr. Souder. Next, we move to the testimony from Dr. 
Stinson.
    Dr. Stinson. Good afternoon. I am Nathan Stinson, the 
Deputy Assistant Secretary for Minority Health and the Director 
of the Office of Minority Health in the Department of Health 
and Human Services. I thank you for the opportunity to testify 
before the subcommittee today.
    As has been previously stated, it is very clear that health 
disparities are not a new occurrence. In fact, the 1983 issue 
of Health, United States, which is the annual report card on 
the health status of the American people, documented that, 
although significant progress had been made in the overall 
health picture, there still were persistent and chronic 
disparities experienced by racial and ethnic minority 
populations versus the United States as a whole.
    During the final evaluation of Healthy People 2000, where 
the experts in the different health fields testified about the 
progress made over the past decade, almost without exception 
they talked about how the health in general had improved but 
how disparities among racial and ethnic minorities had either 
persisted or in many cases had gotten worse over the past 
decade.
    This hearing, as Dr. Ruffin said, could not be more timely. 
There are many efforts that are occurring not only within the 
Department of Health and Human Services but also in State and 
local communities to address a problem that we know will not go 
away unless we give it direct and focused attention.
    The Department of Health and Human Services is currently 
involved in a process of developing a comprehensive overall 
plan to address and to marshal the assets that it has in all of 
the different agencies to address the disproportionate burden 
of illness on racial and ethnic minority populations. The 
Office of Minority Health, because of its role as the adviser 
to the Assistant Secretary of Health and the Secretary in 
health-related matters as they affect racial and ethnic 
minority populations, has the opportunity to play a very key 
role in shaping not only the policy aspects on how to address 
these problems but also the implementation of any of the 
particular programmatic activities within the Department.
    I am going to talk very, very quickly about five specific 
areas as ways that the Office of Minority Health implements its 
programs or influences the Department in its programmatic 
development and implementation. The five areas are not in any 
particular order of priority, but I want to start out by 
talking about strategic communication and information 
dissemination.
    It is very, very clear that it is important to develop the 
appropriate health messages, to deliver those messages in a way 
that individuals are receptive to and, as importantly, to gauge 
how effective we have been in producing an enhanced knowledge 
base and sometimes a change in any particular behavior.
    The Office of Minority Health has periodic communications 
that it makes available to over 10,000 organizations and 
individuals. We have a Web site that is available for 
organizations and the public at large, and we have also tried 
to enhance the capacity of the resource center from a science 
and research capability to try to provide the opportunity to 
create a one-stop shopping place for organizations and for 
individuals who have any interest in the areas of minority 
health.
    One of the specific and new activities is a partnership 
that we have at ABC Radio with their urban network radio 
stations around the country where the Department of Health and 
Human Services is providing ABC Radio with the medical content 
and the messages that they then play on their affiliates around 
the country at no cost to the Department, but it is a very 
important way to reach the population at large.
    Clearly, the Department cannot do this by themselves. 
Partnerships are crucial to addressing the problems of health 
disparities around this Nation. We work closely with State 
departments of health. Many of them have offices of minority 
health and have formed a minority health network where we work 
very closely with the efforts that are occurring within 
individual States and minority communities.
    It is very, very important, as Dr. Ruffin said, that the 
recommendations, the program development, the implementation 
are really based on good science. So the Office of Minority 
Health, because it has a direct appropriations, is also able to 
fund some demonstration programs to test some innovative ideas 
and test out some different opportunities, outreach to minority 
communities and then try to help translate some of the lessons 
learned and some of the models that work into the broader 
categorical programs within the Department.
    One of the last two areas I want to talk about is policy 
development. Clearly, it is very crucial, as we look at how 
effective our programs are in attaining the outcome we are 
interested in, is that we make sure that any type of particular 
policies that we have do not create any barriers to what 
happens at the State and local level, but, more importantly, 
that we actually have a systematic way of policy development 
and implementation that actually enables the actions that are 
necessary to address health disparities to occur and, 
therefore, are very proactive in overcoming any perceived 
barriers that are there.
    Last is the collection of racial and ethnic data. This area 
is extremely important. It is important that we understand 
where the potential problems are, but it is also important in 
that we have complete and comprehensive information so that we 
know whether or not we are actually producing the outcome we 
want, we know whether or not it is time to change what we are 
doing because the application of those resources are not going 
to likely deliver the output that we are interested in, and 
that we also know what other areas of disparities are starting 
to develop in any other particular group or any other 
particular condition.
    As Dr. Ruffin said, quite directly and very completely, 
this is a very unique time that we have to step back and really 
look at what is it that we need to do to keep this Nation 
healthy and strong, what do we need to do now as we look at the 
objectives and goals that we have for Healthy People 2010, what 
do we need to do now to assure that the investments that we 
make as a Nation are going to give us and allow us to reach 
that ultimate outcome at the end, which is a healthier Nation.
    Thank you again for the opportunity to testify before the 
subcommittee.
    Mr. Souder. Thank you.
    [The prepared statement of Dr. Stinson follows:]

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    Mr. Souder. Next we will move to Dr. Ruben King-Shaw, 
Deputy Administrator for the Center for Medicare and Medicaid 
Services.
    Mr. King-Shaw. Mr. Chairman, I thank you for the 
opportunity to talk about something for which I have such a 
long-standing compassion. Such a commitment, as expressed by 
the secretary and the President, is quite telling at this 
important time in health care policy.
    Let me first say, for CMS, this is a central issue to who 
we are and what we do, as truly the largest health insurance 
company in the United States, if not the world. When we embrace 
the concepts of eradicating disparities, it has real meaning. 
We spend $1 out of every $3 in the health care system 
nationally, and in many markets we spend 50 percent or more. So 
our activity in this area has an implication far beyond the 70 
million beneficiaries that we serve directly through Medicare, 
Medicaid and SCHIP, but because of some other things that we 
do, such as survey and certification and the market force for 
provider reimbursement and other types of standards of care and 
quality, I would suggest that we have an impact across the 
entire health care finance and delivery system.
    So we approach these issues of health disparity with a 
heartfelt understanding that these issues are not minor, these 
people are not minor, and our efforts must not be minor. So we 
do not conceive of this as a minority health initiative per se. 
We perceive of this as efforts to eliminate disparities among 
ethnic communities. There are issues of fairness and integrity 
and equality and I would submit part of the American promise 
that we make to all Americans and those that come to this 
country. So the strategies that we have pursued at CMS tend to 
fall into a few areas that are logical and natural.
    First, we have embraced evidence-based medicine and 
encourage it in every way. Using clinical practice guidelines 
and standing orders and performance-based measures is one of 
the ways we continue to move forward on these important issues. 
We also focus our efforts on access and delivery. We do have a 
very ambitious research agenda. It is highlighted in the 
testimony. We can talk about what those initiatives are, but to 
a very real extent the difference we make is in adjusting the 
delivery system itself to be more appropriate in delivering 
health care to people of ethnic populations who are underserved 
in the medical community or suffering from adverse outcomes or 
by redirecting our resources to improve access to the existing 
programs in ways that are successful.
    We also are committed to endemic organizational change at 
CMS, so we have a program executive who is full-time dedicated 
to these efforts, Kevin Nash, who is with me here today.
    We have open-door policy forums that allow people from 
across the country who care about the issues of diversity and 
disparity to be part of our discussion, priority setting and 
decisionmaking.
    We have an Equality Council which sees the addressing of 
these disparities as part of its core function.
    It is a quality issue as well. Daily decisionmaking must 
reflect these priorities as we do our job in all of the ways in 
which we do it.
    There are several actions that I can highlight. In the 
interest of time, I will refer to the testimony.
    There are some things which I think are important to note. 
We do have strong existing partnerships with members of the 
communities we serve that can enhance our ability through 
research and delivery and other initiatives to make a 
difference. These include the four historically black colleges 
of medicine: Howard, Meharry, Morehouse and Drew.
    We also include in our efforts ways to have stronger 
relationships with colleges of pharmacy, such as Bayamon, 
Xavier, Hampton and also Southern.
    We also do a number of things called the Hispanic Agenda 
for Action where we partner with leading Hispanic 
organizations, both clinical and communities, as we do with 
Asian American, Pacific Islanders and American Indian 
populations.
    But among the most successful initiatives we have 
established has been the notion of embracing demonstration 
projects to truly improve the outcome of care for the people we 
serve. These have included cancer prevention and treatment 
demonstrations as authorized by BIPA, a number of clinically 
and linguistically appropriate initiatives, as well as disease 
management and case management initiatives that are 
specifically designed to improve outcomes in ethnic populations 
such as HIV, cancer and end stage renal analysis.
    In summary, CMS will continue to do its best efforts in 
this area, whether we are talking about demonstration, 
research, intervention strategies, quality improvement 
organizations who are dedicated in developing best practices to 
improve the health outcomes of all the people we serve, 
including ethnic populations and racial groups, that we will 
continue to do this as a part of our mandate and our mission 
for the centers of Medicaid and Medicare services.
    I look forward to having more discussion in the question 
and answer session on this topic.
    [The prepared statement of Mr. King-Shaw follows:]

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    Mr. Souder. Last we will hear from Dr. Karen Clancy, 
Associate Director, Agency for Healthcare Research and Quality.
    Dr. Clancy. Good afternoon. I am Carolyn Clancy, the Acting 
Director of the Agency for Healthcare Research and Quality, or 
AHRQ. I am very happy to be here today to discuss the 
relationship of the research we support to the issues raised by 
the Institute of Medicine report on unequal treatment. Our 
research provided an important underpinning for the report and 
AHRQ is beginning to respond to the issues raised by that 
report. I would like to leave you with a sense of that.
    I would like to make two observations. First, to make clear 
that we are a research agency but the work that we sponsor 
actually complements the work supported by NIH. Where NIH's 
biomedical agenda focuses on what science is needed to address 
pure prevention and treatment of disease, what treatments can 
work, our research focuses on effectiveness or what does work 
for individual patients in typical or real-world practice 
settings.
    In addition, our research, besides focusing on the content 
of clinical care and the persons with those illnesses--because, 
after all, many persons come with two or three different 
diagnoses--we focus on how that care is organized, the impact 
of health insurance, what sorts of settings people get their 
care in, and so forth.
    The second observation is the issue of poor quality care is 
most marked and severe for members of racial and ethnic 
minority populations, but it is also a problem for all of us. 
We sponsored a study that was cited in the report and was 
published 2 years ago in the New England Journal of Medicine 
which asked: What proportion of Medicare beneficiaries who have 
had a heart attack are receiving an evidence-based, life-saving 
treatment, also known as clot busters, or thrombolysis? What 
the study found was that 59 percent of white men, 56 percent of 
white women, 50 percent of black men and 44 percent of black 
women who met the criteria for these drugs were receiving them.
    So it seems to us that there are two important messages. 
First and foremost, this study confirms the results of far too 
many studies showing that African Americans are significantly 
less likely to receive evidence-based lifesaving treatments, 
and it underscores Dr. King-Shaw's points about the importance 
of evidence-based medicine.
    But the second take-home message is that 59 percent of 
eligible patients, which is the best that we did, is not so 
great and that there is room for quality improvement for all of 
us. We therefore believe and it is a point which has been made 
by Dr. Blend and others, that reducing and eliminating 
disparities in health care is a very critical part of overall 
strategies to improve quality.
    As I noted, many of our studies contributed to the IOM 
report Unequal Treatment. One in particular created a lot of 
attention and as a practicing physician makes me embarrassed to 
tell you about. This was a study that showed that physicians 
are part of the problem, not part of the solution. Well-trained 
actors were trained to portray patients with chest pain. They 
used literally the same wording and language, all of the 
information provided to the doctors and interacted with the 
videotapes of the actors, told them they had the same income, 
occupation, and so forth. What the study found was that the 
physicians were significantly less likely to recommend 
evidence-based treatment for older African American women, and 
this study prompted a great deal of discussion and concern.
    I would like to tell you a little bit about our efforts to 
reduce and eliminate disparities. We have pretty much informed 
our researchers that we have heard enough descriptive 
information and, as IOM study demonstrates, the time to simply 
describe the problem any more fully has probably passed. Now we 
need to focus on understanding why these disparities in health 
care occur and what strategies can be used to reduce and 
eliminate them.
    The centerpiece of our research program is called EXCEED, 
Excellence Centers to Eliminate Ethnic and Racial Disparities 
in Health Care. This is a 5-year grant that began in 2000, and 
it is a collaborative effort with NIH, specifically Dr. Ruffin, 
and HRSA, as well as some other local foundations. Each of 
these focuses on four to seven studies organized around a 
particular problem and organized around the six priority areas 
of reducing racial and ethnic disparities in health initiative.
    In addition, we have supported nearly 200 grants and 
contracts just since 1999 alone.
    In response to the Minority Health and Health Disparity Act 
of 2000, we have also begun this past year to develop a very 
specific focus on community-based participatory research. Too 
often, as many know, minority communities and other communities 
believe that research is something that is done ``to us.'' The 
purpose of this focus on participatory research is to shift 
that framework so, from the community's perspective the 
understanding is that there will be nothing ``about us without 
us.'' We look forward to reporting on our future plans to you 
soon.
    We are also supporting some very important training 
initiatives to make sure the perspectives of the research 
community accurately reflect the diversity of the current 
population.
    Importantly, a unique function of AHRQ is to develop the 
tools to measure and monitor our progress, to help us make sure 
that Mr. Cummings' crystal ball is as clear as possible. We 
support the development of quality measurement tools. In fact, 
the Minority Health and Health Disparity Act has asked us to 
report to Congress on the state of the science for quality 
measurement for disparity populations; and we will be 
submitting that to Congress this year.
    Very importantly, our reauthorization in 1999 directs the 
agency to produce two annual unprecedented reports starting in 
fiscal year 2003. One will report on the overall state of the 
quality of health care and the other is called the National 
Health Care Disparities Report. This will detail prevailing 
disparities in health care delivery as it relates to racial 
factors and socioeconomic factors in minority populations.
    The two reports are closely linked. The disparities report 
will report on quality measures presented by race, ethnicity 
and socioeconomic status. It will also report on consumer and 
patient assessments of health care quality and quality measures 
for priority areas.
    Mr. Chairman, we are very proud of our tradition of 
supporting research to identify and address racial and ethnic 
inequities and the outcomes of health care services in this 
Nation. The findings of the IOM report are very sobering, but 
we believe there is a very important opportunity to establish 
elimination of disparities as a priority. Health care is a core 
component of efforts to improve quality of care for everyone, 
and our current initiatives are designed to reinforce and 
strengthen that opportunity.
    Thank you.
    Mr. Souder. Thank you.
    [The prepared statement of Dr. Clancy follows:]

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    Mr. Souder. I would first like to start with a question for 
Dr. Stinson. First, let me double-check, do you agree that 
married households generally fare better than nonmarried 
households in health care?
    Dr. Stinson. Let me answer it this way. There has certainly 
been some studies that have speculated that married households 
fare better than unmarried households. Most of the research has 
surrounded the health outcomes for individuals which are one 
parent or unmarried households; and they clearly have shown, in 
those types of settings, there may be increased behavioral, 
mental health problems and higher incidence of substance abuse. 
Also, unmarried women at any age have a risk of having a child 
of low birth weight, which has a whole list of potential health 
complications.
    Much of the research has been done looking at one parent or 
unmarried households and have looked at a lot of outcomes which 
have been troubling. There certainly has been an inference that 
in two parent or married households there are some protective 
natures, because it may indeed create a different type of 
environment with certain stabilization around supervision, 
nurturing, et cetera, that may have some beneficial effects on 
health.
    Mr. Souder. I really appreciate your carefulness in 
distinctions. That is my familiarity, is that it is 
predominantly related to children and studies related to child-
bearing mothers. Do you know if you are just single, no 
children? Part of the assumption is, if there are two people 
there, there is a certain amount of commitment and 
responsibility and prodding each other, as my wife particularly 
prods me to get things checked out. Do you know much about 
that?
    Dr. Stinson. I am clearly not an expert on those studies. I 
don't know the answer to your question.
    Mr. Souder. Let me ask, because there actually has been an 
increase in the percent of marriage and minority individuals. 
The bottom line is that we know, freezing insurance and 
freezing income, there are still disparities. Part of the 
question is, in freezing this variable, what would happen? If 
in fact some of the improvement in relative disparities--is 
that improvement partly related to the marriage variable as 
well? Does anybody have any idea regarding that data?
    Dr. Clancy. Our studies have not specifically looked at 
this with regard to race and ethnicity, but there are many 
studies in the literature which support the contention that 
being unmarried is not associated with good health in men in 
particular. Every time it comes up at a meeting and someone 
asks why is that, usually the researcher steps back and says, 
``I am not sure I want to speculate on why that is.'' It 
clearly is a very important factor for men's health.
    Mr. Souder. I was a staffer for Senator Coates for 10 years 
before I became a Congressman, and I worked with Senator Coates 
to try to encourage HHS to have this data in it. It is not 
clear how much we can actually affect that behavior pattern or 
what role it is of government to affect that behavior pattern, 
but we ought to know from a scientific standpoint whether or 
not marriage is one of the variables.
    Let me ask another controversial question, and that is in 
relations to Hispanics, and this would be very difficult to 
find, but is part of the disparity the illegal immigrant 
question and even an unwillingness to respond because of fear 
of the researcher? How much of the disparity is in that 
subgroup?
    Mr. King-Shaw. Mr. Chairman, in southern Florida, clearly 
when you have a population that arrives in this country that is 
formally disconnected from the health care system in any way 
except the emergency room, then you have all of the problems 
that are generated by not having a continuous relationship with 
the health care system. Primary care, diagnostic treatment, 
education, case management, all those things that would 
normally be a part of a connected person to health care would 
not be in an immigrant population or a migrant population. They 
tended to have much of the same characteristics.
    There is also the issue that people can arrive in this 
country not having achieved strong health status before they 
arrived. So there is no connection with the health care system 
going forward to keep them healthy, but it can be very 
difficult to become healthy when you arrive with a situation 
which has already put you behind the eight ball, so to speak.
    That is anecdotal. Most people would agree if you are from 
areas that are high in the population of immigrant individuals, 
I am sure there is some quantifiable data that could bear that 
out. I just can't cite any at this particular time.
    Dr. Stinson. Mr. Chairman, your question points out how 
difficult it is in trying to parse out all of the different 
factors that play a role in health disparities. Some of the 
literature shows in some of the newly arrived immigrants, some 
of the individuals from Asia, some of them actually have better 
rates in some of the diseases, especially in that population in 
cancer, than the individuals who stay here and become U.S. 
citizens. Over the years, that cohort ends up developing some 
of the disparities that we have seen, even though, when they 
first arrived, they did not exhibit any differences in the 
population in general. It makes it difficult to generalize or 
to assume that in every situation, every group, that disparity 
existed prior to immigration to this Nation.
    Mr. Souder. I appreciate that. Often, we do not understand 
the complexity of it, and the research needs to make sure that 
we have all of the variabilities. We all know if you do not 
have access to a provider you are certainly going to be less 
healthy, or if you do not have knowledge of what is available 
you are going to be less healthy. But we are not doing that 
great with any part of the population, as has been pointed out, 
and so some are internal variables.
    I yield to Mr. Cummings, and hopefully we can finish this 
panel before we leave to vote.
    Mr. Cummings. Dr. Clancy, I am concerned about the funding 
for the EXCEED program and other initiatives with regard to 
health disparities. Correct me if I'm wrong, it is my 
understanding that the President has asked that your agency 
budget fall from $300 million to $251 million next year?
    Dr. Clancy. That's correct.
    Mr. Cummings. And I also understand that $192 million of 
the $251 million is protected for specific projects; is that 
correct?
    Dr. Clancy. That's correct.
    Mr. Cummings. That means that $49 million must be cut from 
the remaining $108 million. Does EXCEED fall into the group of 
programs that collectively face that 46 percent cut?
    Dr. Clancy. Yes, it does.
    Mr. Cummings. How do you see that affecting EXCEED? It 
seems like it is getting ready to be--it apparently is going to 
be cut substantially?
    Dr. Clancy. The impact on the Centers for Excellence will 
be less than 46 percent because the core funding for some of 
them comes from the National Center for Minority Health and 
Health Disparities and a little bit from some other 
foundations. So the net impact overall across the nine centers 
I would guess would be somewhere between 25 and 30 percent cut 
in the outyears. The majority of funding does come from AHRQ, 
though.
    Mr. Cummings. I know you have to support the President's 
budget, but when you consider the fact that literally as we sit 
here--and I heard your testimony about how this is a problem 
that does affect a lot of people--but as we sit here, people 
are dying needlessly.
    One of the things that was so painful for me to read this, 
because I had a relative who had an amputation, part of the 
report talks about if you are African American, you have a 3.6 
percentage point times chance of having a lower limb amputated 
if you have diabetes, same stage. For the life of me, there is 
something wrong with this picture. And cutting the EXCEED 
program--and 25 percent is a substantial cut in anybody's 
estimation--I was just wondering how do you feel about that? 
People are literally dying, that is the other piece. People are 
dying, and they are dying early. I was just curious.
    Dr. Clancy. All of the research efforts that you have heard 
about from Dr. Ruffin and from myself, and the others on the 
panel, it is discouraging that it takes time to buildup a 
critical mass of researchers to actually establish 
relationships with communities and local change agents, who can 
take the findings from the work and actually ensure that they 
are translated into practice and institutionalized.
    The timing for the cuts for these centers will be very 
difficult because they will be at a point where they are 
beginning to test and evaluate some potential strategies for 
reducing or eliminating disparities.
    Mr. Cummings. Dr. Stinson, you were talking about the 
various programs that you all have to inform people and what 
have you. If you read the report, it seems like you can get the 
information to the people, but then when they get in the 
doctor's office--and a lot is just getting them to the doctor's 
office. At the doctor's office, they face another hurdle. I was 
just wondering, how do you get to that? Are you following me?
    Dr. Stinson. Yes. It is crucial that we do not blame the 
individual, put all of the burden on the person in that it 
clearly is important for all of us to understand what we need 
to do as far as eating right and exercising, all those things 
that can help us remain healthy.
    But, as importantly, we have to really engage the health 
professionals in a different way, in a more direct way, in a 
way that they understand that the foundation of delivering 
health care that is of the highest quality is that they have to 
communicate effectively with whoever comes through their door. 
That means they have to understand that, just like anybody 
else, we have to be very objective, be very deliberate and very 
focused on how do we address the problems of the patients that 
come through the door.
    The pledge that all health professionals make in delivering 
the best quality of care just does not happen naturally. You 
have to think about your practice, you have to think about how 
you can provide the best care to every patient that comes 
through your door.
    Mr. Cummings. I agree with that. We have to go to a vote, 
so I have to cut you off. I am just saying this as a general 
statement, not directed to any particular person.
    I wish people in government would look at these problems 
with the urgency they would look at them if it was their 
relative, their wife or child, that was involved. Then I think 
people would literally go crazy trying to solve these problems.
    Every human being has value, and I just think that it gets 
so frustrating. When I read that report, I felt like vomiting. 
It was so alarming to think that so many people are dying. A 
cut here, a cut there, it is just a few people. They are going 
to die, suffer, so what? Then when I think about the things 
that we concern ourselves with, it just seems--the unfairness 
continues.
    I thank you all for being here.
    Mr. Souder. I thank you as well and certainly encourage the 
outreach efforts. I have participated in two minority health 
fairs in Fort Wayne, Indiana, where they give free blood 
pressure and other screenings. They do them at community-based 
organizations or a mall where the people actually go, which is 
one of the really important things in the outreach. I think if 
we continue to all be aware of these health disparities and 
work at it, we can all make progress.
    Mr. Waxman also had some questions for this panel, which 
will be submitted for the record.
    We will temporarily recess, and we have a number of votes, 
so we will be a little while.
    The hearing stands in recess.
    [Recess.]
    Mr. Souder. Call the subcommittee back to order. And as 
you've heard our procedure, we need to swear our witnesses in. 
Congresswoman Christensen does not have to be sworn in. It's a 
long-standing protocol but I understand it's because when we 
take our oath of office we already take this oath. So if Dr. 
Rios and Dr. Cooper could stand.
    [Witnesses sworn.]
    Mr. Souder. Let the record show that both witnesses 
responded in the affirmative. Now, if you can summarize your 
testimony and we'll submit your whole statement in the record, 
and I'll be a little liberal with that. I appreciate how long 
you had to wait and I appreciate your willingness to stay for 
this panel and put up with our voting patterns in the House.
    With that, Congresswoman Christensen, we'll let you begin.

STATEMENTS OF HON. DONNA M. CHRISTENSEN, A DELEGATE IN CONGRESS 
 FROM THE TERRITORY OF THE VIRGIN ISLANDS; DR. THOMAS LAVEIST, 
ASSOCIATE PROFESSOR, JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH; DR. 
  LISA COOPER, ASSOCIATE PROFESSOR, JOHNS HOPKINS UNIVERSITY 
  SCHOOL OF MEDICINE; AND DR. ELENA RIOS, PRESIDENT, NATIONAL 
                  HISPANIC MEDICAL ASSOCIATION

    Mrs. Christensen. Thank you. Good afternoon, Chairman 
Souder, Ranking Member Cummings. Thank you for the opportunity 
to testify at what I feel is a very important hearing.
    The IOM report, which is at the center of this hearing, I 
think speaks for itself so I am not going to use my allotted 
time to recount the filings and I will summarize my written 
testimony.
    I particularly appreciate this hearing because this gives 
us an opportunity to have this information on an official 
record. As you know, we in the Congressional Black and Hispanic 
as well as the Asian Pacific Islander Caucuses held a hearing 
earlier this year on the report and the Department's response 
to the presence of health disparities. I am going to focus my 
remarks on issues surrounding the Department of Health and 
Human Services.
    Let me begin with the issue of diversity within the 
Department. We recognize and appreciate the work of Deputy 
Secretary Claude Allen and we have a great respect for his 
knowledge, understanding and his compassion about the health 
care disparities, but we do not feel that the Department's 
diversity goes deep enough. We are not convinced, for example, 
that the Office of Minority Health and the Office of the 
Secretary had direct influence on decisionmaking and policy 
setting across the Department. All of the offices of minority 
health must have their own budget, and their functions need to 
be institutionalized.
    Neither the Office of Minority Health or other programs 
critical to the elimination of disparities of health care, 
including the Agency for Health Care Quality and Research, 
which carries much of the mandate to develop policies to 
eliminate those disparities, have budgets that are reflective 
of a serious commitment.
    The Center for Minority and Disparity Health Research's 
budget has increased but we don't see any evidence that 
convinces us that center has full trans-authority for all 
minority and disparity research dollars at NIH or that it has 
adequate funding to support critical research infrastructure 
development or improvement at our minority health professions 
schools.
    The bottom line is that we are concerned that the 
Department's direction and focus has changed dramatically to 
one primarily of cost containment instead of one of providing 
the resources necessary to promote and restore good health, 
given that inequities exist, which if allowed to continue will 
threaten the very fabric of our Nation, and major investments 
must be a made up front immediately to level the playing field 
or we will never control health care costs, not to mention save 
lives, which is really of primary importance.
    Let me focus on a few issues, other issues. One of the 
important limitations, as you've heard, in the effort to 
eliminate disparities is the lack of data. A study commissioned 
by the Commonwealth Fund and done by the Summit Health 
Institute for Research and Education found that while the 
collection of data by race, ethnicity and language is legal, 
there is no uniform data collection within the Department of 
Health and Human Services. It is critical that the Secretary 
direct the Department to collect this data and, if need be, 
that Congress so direct the Secretary.
    One of the great barriers to appropriate health care is 
that of language differences between that of provider and 
patient. Patients are caught in between providers who are 
experiencing cuts that are driving them to close their offices 
and the need for the interpreters on the other hand. CMS must 
pay for those services, the services of the interpreter as well 
as restore the cuts and provider payments.
    This leads me to work force development. Much of the gap in 
health care for racial, ethnic and linguistic minorities in 
this country would be closed if we had more providers of the 
same language and same background. Yet education and training 
programs are cut in the proposed 2003 budget by more than $200 
million. This needs to be restored, with emphasis on training 
providers of color.
    With regard to physicians of color already in practice, the 
programs of the Center for Medicare and Medicaid Services, 
their denials, their audits and their cuts in funding are 
driving an already marginalized group of practitioners out of 
business. The managed care system just makes the situation 
worse. We need a study to document what is happening to these 
physicians and CMS should require that all managed care 
organizations and group insurances provide services in 
medically underserved and high disparity communities and 
include the providers of those communities who are now 
systematically excluded. Subsidizing malpractice premiums to 
the degree that these providers care for patients covered by 
CMS also should be considered.
    Until the health care landscape is equal for all Americans 
all programs should be directed to place emphasis on areas 
where high disparities exist for the purposes of increased 
funding, for placement of National Health Service Corps 
physicians, and for community health centers, and also within 
the homeland security bioterrorism initiative. All areas of 
this country's public health infrastructure must be strong and 
intact or no one will be safe.
    The need for and the importance of universal coverage to 
reverse the inequities in health care cannot be overemphasized. 
Every year 83,000 people die for the specific reason that they 
lack insurance.
    Three more issues very briefly. A revolution must take 
place in strategies for addressing disease in our communities 
if we are to begin to see change. The most effective way to 
improve the health of our communities is by empowering the 
communities themselves through direct funding and technical 
assistance so that they can be their own agent of wellness. 
That is what we in the Congressional Black Caucus and Hispanic 
Caucus are attempting to do to the Minority HIV/AIDS 
Initiative, but under current departmental directives funding 
that used to be targeted to the community organizations within 
those communities of color just for this relatively small but 
critical program will no longer be so directed. And so we ask 
this committee to consider that the devastation of this tragic 
epidemic in communities of color constitutes a compelling 
government interest which meets the test of Adarand.
    We further request your assistance in restoring language to 
appropriately target the funding to build the capacity of the 
community and faith-based organizations our communities have 
long trusted and responded to so that we can bring this 
epidemic and all of the other disparities under control.
    A central issue is also the need for an effective Office of 
Civil Rights within the Department of Health and Human 
Services. In addition to a permanent director, this office also 
needs a significant funding increase for 2003.
    I would like to cite one important case which was the 
subject of testimony at our hearing which needs to be 
addressed. It's the Sandoval case in which the U.S. Supreme 
Court last year held that private individuals could not sue 
State agencies under Title IV of the 1964 Civil Rights Act for 
unintentional discrimination. Given the lengths to which they 
went, it is felt that the decision may signal a bad omen for 
the future of substantive agency rules condemning disparity 
impact under Title VI. Reversing the Sandoval decision is a 
high priority in eliminating racial and ethnic disparities in 
health care.
    Finally, the health care needs of American citizens in our 
territories whose Medicaid funding is capped and of the Native 
American peoples who suffer some of the greatest disparities in 
several areas must not be overlooked. This testimony just 
represents a few of the important concerns we have concerning 
the Department's policies and operations and the health care 
system nationwide.
    I really welcome and commend the subcommittee's interest 
and concern about this issue that is so vital to the community, 
communities which make up a significant portion of the 
population of this country. African Americans, Native Americans 
and other people of color, like all Americans, have the right 
to good health care but have long been denied. We are working 
with the members of this subcommittee to ensure complete access 
to all Americans for all Americans to quality health care. That 
is the only system that this country is worthy of.
    Thank you.
    [The prepared statement of Mrs. Christensen follows:]

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    Mr. Souder. Thank you, Congresswoman Christensen. Maybe one 
of the things, you can work with Mr. Cummings and if there is 
additional materials from your caucus' hearing that you want to 
see put in this official hearing record, I would be happy to 
work with you.
    Mrs. Christensen. I'd appreciate being able to add for the 
record the testimony that we gave to the Labor-HHS Subcommittee 
of the Committee on Appropriations as well. I have another 
hearing to attend that I have to testify at.
    Mr. Souder. Thank you for taking the time and waiting for 
so long for us to get back.
    Mrs. Christensen. That's OK. Thank you.
    Mr. Souder. Let's see. Dr. Cooper, we'll go with you next. 
You're associate professor, Johns Hopkins School of Medicine, 
is that correct?
    Dr. Cooper. Mr. Chairman, Mr. Cummings, other honorable 
members of this committee, I am Lisa Cooper, M.D., Associate 
Professor of Medicine and of Health Policy and Management at 
Johns Hopkins University. I come before you today as a medical 
researcher, a primary care physician and a medical educator.
    Over the past 10 years with my colleagues I have conducted 
a series of studies investigating the issue of racial and 
ethnic disparities in access and quality of health care 
services. My work has focused on the role of the Patient-
physician relationship in either perpetuating or ameliorating 
these disparities in health care.
    I am familiar with the IOM report, having contributed to 
the study as the author of a chapter on patient-provider 
communication. I would like to address three of the 
recommendations made in the IOM report: First, integrate cross-
cultural education into the training of all current and future 
health professionals; second, increase the number of 
individuals from underrepresented minorities among health 
professionals; and, third, conduct further research to identify 
sources of ongoing racial and ethnic disparities and assess 
promising interventions.
    First, I strongly support the recommendation that the 
medical community integrate cross-cultural education into the 
training of all current and future health professionals. The 
evidence to support this recommendation comes from several 
studies showing that ethnic minority patients experience poorer 
quality technical and interpersonal care from physicians. 
African, Asian, and Hispanic Americans as well as Native 
American patients in the common race discordant relationship 
with their physicians report less involvement and less 
partnership in medical decisionmaking, less respect when 
receiving health care, lower levels of trust in physicians and 
lower levels of satisfaction with care.
    My colleagues and I found in a study of over 1800 managed 
care enrollees in Maryland, Virginia and the District of 
Columbia that ethnic minority patients reported their 
physicians were less likely to involve them in medical 
decisionmaking than white patients. Another recent study showed 
that white physicians are more likely to perceive African 
Americans and lower socioeconomic status patients negatively on 
several dimensions, including intelligence, the likelihood of 
engaging in high risk behavior, likelihood of adhering to 
medical advice, their ratings of affiliation or liking of these 
patients, and several personality attributes.
    While these perceptions are likely to be unconscious and 
unintentional, this study and several others mentioned earlier 
today suggests that the beliefs that physicians hold influence 
their interpretation of patients' symptoms, their interpersonal 
behavior when interacting with patients and ultimately their 
clinical decisionmaking. Therefore, it is essential that 
current and future health professionals at all levels receive 
training in intercultural communication. Legislation that 
mandates the inclusion of such programs into the curricula of 
health professional training programs supported by Federal 
funding such as residency and fellowship training would be 
particularly useful.
    Second, I support the recommendation made by the IOM report 
that we increase the number of individuals from 
underrepresented racial and ethnic minorities among health 
professionals. The evidence to support the need for more ethnic 
minority health professionals comes from several studies 
showing that African American and Hispanic American physicians 
are more likely than their counterparts to provide care for 
underserved populations.
    Additionally, we've heard before that racial and ethnic 
concordance between patients and providers is associated with 
higher levels of perceived quality of care, participation in 
care, and receipt of preventative care and even quality of care 
for some conditions, such as HIV.
    In the same study I mentioned to you earlier, conducted 
here in Maryland, Virginia and the District of Columbia, we 
found that patients who were seeing a race concordant physician 
felt more involved in decisionmaking. The active participation 
by patients in medical decisionmaking with physicians is an 
important marker of the quality of interpersonal care because 
it has been related to satisfaction, longevity of the patient-
provider relationship, and better health outcomes such as 
diabetes and hypertension control.
    The goal of increasing ethnic minority health care 
professionals is to provide patients with more choices and 
access to a more diverse group of health professionals. I 
recommend--ask that you strongly consider supporting the 
continuation of policies in Federal funding to promote the 
training of health professionals from underrepresented 
minorities at all levels, including the provision of loan 
repayment mechanisms for physicians who provide care and 
conduct research to care for underserved populations.
    Finally, I strongly support the recommendation that the 
scientific community conduct additional research to identify 
sources of racial and ethnic disparities and to assess 
promising intervention strategies. Resources from the NIH and 
the AHRQ have allowed medical researchers to identify and 
explain sources of disparity and most recently to design and 
evaluate interventions to eliminate these disparities. These 
two agencies have provided the majority of funding for the 
studies conducted over the past two decades in this field. More 
well-designed interventions with rigorous evaluation are 
needed. As such, the AHRQ and the NIH will need a higher level 
of resources to assure that the research necessary to inform 
health policy as well as clinical practice is done in the most 
effective manner and that future researchers in the field of 
disparities receive appropriate research training.
    Finally, because access to high quality health care is an 
important determinant of health status, this research will 
likely play a pivotal role in improving the health status of 
the entire American public.
    Thank you.
    [The prepared statement of Dr. Cooper follows:]

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    Mr. Souder. Thank you very much. Dr. Cooper, who is 
Associate Professor--no. Dr. Rios, excuse me, I am misreading 
here. You're President of the National Hispanic Medical 
Association. Is that correct?
    Dr. Rios. Yes.
    Mr. Souder. Are you a practicing physician or the Executive 
Director?
    Dr. Rios. Executive Director.
    Mr. Souder. Thank you. Is your mic on?
    Dr. Rios. Is it on?
    Chairman Souder, Congressman, HHS officials and guests, it 
is an honor to be here. The National Hispanic Medical 
Association represents licensed Hispanic physicians in the 
United States. The mission of NHMA is to improve the health of 
Hispanics.
    I also work as the CEO for the Hispanic-Serving Health 
Professions Schools, Inc., that represents 22 medical schools 
and three public health schools. The mission of this 
organization is to develop Hispanic students and faculty and 
research capacity to improve Hispanic health. And I would just 
like to say that I think I have to agree with the Congresswoman 
when she said we really do need universal access and that would 
be--I think that would go a long way to eliminate disparities 
in this country if we had access to health care.
    The Hispanic population right now is 14 percent of the U.S. 
population. By the year 2050 one out of every four Americans 
will be of Hispanic origin. We are the ethnic group in the 
country with the largest rates of uninsured. I know that the 
IOM report, however, discusses disparity not due to access 
related factors so I won't discuss insurance. But in the case 
of Hispanic patients we are challenged by language needs, 
literacy levels, lower levels of poverty and education, 
citizenship status, cultural beliefs and attitudes, family 
group decisionmaking, awareness of public health programs, or 
lack of awareness I should say, lack of awareness of how to 
even follow complex treatment regimens, how to read drug 
labels, where to go for further testing, x-rays or speciality 
care in our complicated health system.
    Our health system is the best in the world, but in order to 
be proud of that system this report challenges all of us to 
develop new strategies to improve the quality of health care 
delivery. And we like to address just some proposed strategies 
for HHS to continue to decrease rates in ethnic disparities in 
health care. And the first area, as has been mentioned, is 
diversity in medicine.
    The U.S. Federal Government has taken the lead to recruit 
and retain minority and disadvantaged health professional 
students since the 1960's, when it was recognized that it is a 
Federal Government role to develop programs that provide health 
care services for all vulnerable population groups in this 
country. Medicare for the elderly and disabled, Medicaid and 
community clinics for poor patients, and the National Health 
Service Corps and the Health Careers Opportunity Program for 
poor, disadvantaged or minority students so that they could 
become health professionals for their communities.
    In the 1980's, HHS further developed these programs by 
addressing the--by calling--by creating the Centers of 
Excellence and the Faculty Development Program for minority 
students at medical schools. Through its curricular efforts, 
the COEs impact cultural competencies of all their graduates. 
In addition, both of these programs have increased the number 
of minority faculty, although small, but they have increased 
the number of minority faculty that address research and 
curricular issues related to minority patients and communities.
    The literature demonstrates many examples of studies on the 
outcomes of minority health professionals serving a major need 
in the United States, mainly that they provide health and 
mental health care services for minority patients of their own 
ethnicity and for those on Medicaid and the uninsured. And 
there's definitely an economic impact by having minority health 
professionals in this country.
    HHS HRSA's Health Careers Opportunity Program and Centers 
of Excellence Program have proven track records of graduating 
two to three times more disadvantaged and minority students 
than the other health professions institutions in this country. 
However, for the second year in a row this administration has 
called for drastic down-sizing of these programs.
    We believe strongly that the IOM is a reminder for us with 
the changing demographics and continued immigration of 
Hispanics and the needs of all minority groups to recognize the 
critical need for minority physicians, and currently Hispanics 
are only 5 percent of America's doctors and only 2 percent of 
America's nurses, and both of these programs should be expanded 
with increased funding at the level requested by Congresswoman 
Donna Christensen at her testimony to the appropriations 
hearing.
    We also propose a new strategy that these programs be 
expanded into public-private partnerships with the medical 
schools, led by HRSA. The medical schools have 
institutionalized recruitment and retention programs. They have 
minority affairs offices. They have staff. But they should be 
required to provide more matching funds and fund-raising 
efforts to increase the support for these programs.
    We support the request from the caucuses again to increase 
the support from the Federal Government, also. And why 
shouldn't a recruitment program be linked to academic 
enrichment in middle schools and grammar schools and colleges 
through scholarship incentive programs, for example, that could 
be privatized? Scholarships could be linked to the students who 
would be linked to programs developed at certain schools and 
regional consortia. Why shouldn't businesses, especially the 
HMOs, hospitals, pharmaceutical companies, medical suppliers 
and medical groups that are employers and business partners who 
directly benefit from their linkages with physicians be fiscal 
partners in the education process of future physicians?
    We also recommend that there should be collection of data 
of the--about the alumni from these programs and link their 
location of practice to medically underserved areas or health 
professional shortage areas, as does the community clinic and 
the National Health Service Corps program.
    Furthermore, Medicare GME funding for teaching hospitals 
should be linked with the policy focus to provide incentives to 
produce minority physicians and minority programming. There 
should be loan repayment for faculty, and I think that 
physicians should be encouraged to sign up for the National 
Health Service Corps more than we are now in terms of minority 
physicians. President Bush's Medical Reserve Corps is another 
example of an effort where we could get more volunteers to work 
through that effort to help recruit younger students in 
doctor's communities.
    Cross-cultural education was mentioned by my colleague. I 
won't go through that, just to say that it is very important 
because we have so few minority doctors in this country that 
the majority of doctors need to have cultural competency 
training in medical schools, and in fact the accreditation body 
for medical schools in this country just mandated that cross-
cultural education be a requirement for medical schools so that 
the future generation of doctors in this country can better 
know how to communicate and understand and respect their 
patients.
    We also recommend the funding for HRSA for the Cultural 
Competence Curriculum Demonstration Grants that were part of 
the Health Care Fairness Act that created the new national 
Center for Minority Health and Health Disparities Committee. 
They were never funded.
    Also, the Agency for Health Care Research and Quality and 
the Centers for Medicare and Medicaid services should also 
include cultural competence training not only of the health 
providers, the doctors, but the health staff, the programs that 
they support.
    Third thing is language services, and I think that it's 
just important to realize that there are so many people that 
speak other languages in this country and they do need and 
deserve to have access to the health care system and they do 
deserve to be able to communicate with their providers. I think 
that we understand the importance especially of Spanish 
speakers in this country, the increasing number of Spanish 
speakers and that we do know that the White House Office of 
Management and Budget just concluded its study on the 
implementation of the Limited English Proficiency Executive 
Order and said that the benefits seem to outweigh the costs 
since language services improve access to and can increase 
effectiveness and distribution of public health programs.
    Moreover, language services will substantially improve the 
health and quality of life of LEP individuals and their 
families. We propose that HHS support demonstration programs in 
language services to develop the reimbursement models needed 
through programs that exist right now at HRSA, the community 
clinics at SAMHSA, the drug treatment centers, the centers for 
Medicare and Medicaid services through Medicare and Medicaid.
    Interpreter services should be developed not only for 
bilingual staff and bilingual providers but for consultant 
interpreters. That should be developed as new auxiliary health 
positions with certification and training programs, and Spanish 
language training for providers through CME programs and for 
medical students should be supported significantly in targeted 
markets through demonstration projects.
    There really is a critical need to do this now to prepare 
for even more Spanish speakers in the future in this country.
    I also think there could be a new program for managed care 
partnerships in targeted States that could be used as 
incentives to get Medicare programs to expand services to the 
Hispanic elderly. All of HHS prevention literature needs to be 
in different languages and media. Both English and Spanish TV, 
radio, Internet and print needs to be partnered by HHS to start 
developing targeted public health messages.
    Now just a couple of systemic strategies that this report 
leads us to think about. The Hispanic-serving health profession 
schools has a project with the CDC to develop its faculty data 
bases. There has never been an attempt to identify doctors in 
this country who are involved in minority research, and I would 
imagine that historically black colleges and universities have 
done a great job in knowing that about their own faculty but I 
think that for the Hispanic community in this country this is 
the first time that we are attempting to identify resources, 
our human capital resources among our own faculty to do 
research on Hispanic health.
    The National Hispanic Medical Association has developed a 
leadership program for doctors, and this is another area that 
this report leads us to believe that HHS needs to start 
thinking about supporting leadership, not only within its ranks 
but the leadership of minority communities so that they 
understand how to access or how to improve access programs, 
outreach programs, enrollment programs and that we have middle 
managers as well as physicians learn how to work hand in hand 
with the government at the Federal and State level in matters 
of leadership development.
    We also have for future data collection and research, and 
this is the last set of recommendations, there is a real need 
for collaboration among the research agencies at HHS on the 
importance of minority research, cultural competence research, 
and I think, as was stated earlier, especially community-based 
research where we include the community in helping to design 
and develop new strategies and interventions and study those 
hand in hand with researchers and academic institutions. I 
think Dr. Ruffin mentioned earlier about that cultural 
competence research in the future and Dr. Clancy talked about 
the EXCEED programs, and these are examples of programs that 
are very much needed to be expanded for research.
    The National Hispanic Medical Association has established a 
foundation, the National Hispanic Health Foundation, and we 
soon will be developing plans to do health services research 
targeted for Hispanic, understanding Hispanic community issues. 
We will be working with the New York University's Wagner 
Graduate School of Public Service, and we look forward to 
helping to develop more knowledge about the Hispanic community, 
and I think that's one of the wakeup calls of this report is 
that we don't know enough about interventions and strategies. 
We know that there's a huge, huge problem and it's ironic that 
on the verge of a huge demographic change in this country where 
everybody is going to realize that minority health is important 
and that main stream America has recognized that minority 
health is important we need to do something about it and we're 
here to help. So we're here to help with again reaching out to 
our communities and being a link to get more information and 
more leaders for the government.
    [The prepared statement of Dr. Rios follows:]

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    Mr. Souder. Thank you for your testimony. We've been joined 
by Dr. Thomas LaVeist. I need to swear you in. If you'll stand. 
The subcommittee as an oversight committee requires it.
    [Witness sworn.]
    Mr. Souder. Let the record show that the witness responded 
in the affirmative. Thank you for joining us and we'll let you 
have 5 minutes for your testimony and we'll insert anything you 
don't get covered into the record or any additional materials.
    Mr. LaVeist. Thank you. I beg your forgiveness for 
returning late from recess.
    Mr. Chairman, honorable members, thank you for inviting me 
to participate in this important hearing. The recently released 
Institute of Medicine's report on racial disparities and health 
care summarizes decades of research that has not always 
received the attention that it deserved.
    I have devoted my career to further understanding the 
issues of racial disparities in health, and I am pleased by the 
response that has come from this report. I am encouraged that 
later this year Johns Hopkins University along with Morgan 
State University will announce the creation of the Center for 
Health Disparities Studies, and the goal of that center will be 
to bring together--bring to bear the resources of both 
institutions to address this very important problem.
    According to the Census Bureau, in the coming decades 
American racial and ethnic minorities will be an increasing 
proportion of the national population and eventually become a 
majority. As such, the health profile of the country will 
increasingly become reflective of its minority population. The 
United States already has a surprisingly low international 
standing with regard to health status. We are already No. 17 in 
female life expectancy and No. 26 in the world in infant 
mortality. This is only one spot above Cuba. Without a 
reduction in and elimination of health disparities our 
international standing in terms of health will most likely be 
even lower in the coming decades. This will have an important 
negative economic impact as well in terms of lost wages and 
productivity due to disability. And the impact on the Federal 
and State budgets is predictable, increasing Medicare and 
Medicaid costs, and we can't ignore the impact that increasing 
health care costs will have on the private sector.
    While the IOM report is important, this is not the first 
published report documenting disparities and even 
discrimination in health care. This is not even the first such 
report written by the IOM. So why am I so hopeful that this 
time the issue will not again lose momentum and exit the 
national agenda? The reason for my optimism is that I believe 
there is the potential to establish a national infrastructure 
to address race disparities in health. Creation of the National 
Center for Minority Health and Health Disparities is among the 
most important improvements to our Nation's health care 
infrastructure in decades.
    As one who has been conducting research on minority health 
and health disparities for many years, I want to take this 
opportunity to thank Congress for its leadership in creating 
this center. This new entity will play a central role in 
ensuring that the issue of minority health and ill health 
remain on the national agenda. But we must not stop there. 
American public health and medical researchers have sustained a 
steady march toward the furtherance of our understanding of the 
causes of premature death, ill health and preventable 
disability. But while we have been leaders in furthering 
knowledge and health status and curing disease, we have been 
less attentive and some might even say accepting of pervasive 
disparities in health.
    Why is it that American minorities live sicker and die 
younger? Certainly the answer is complex and elusive, but there 
are a few things that we do know. We know that it is unlikely 
that the answer lies in biology and is exceedingly unlikely 
that a solution will come from genomics. Likewise, programs 
such as Take a Loved One to the Doctor Day, which was recently 
proposed by the Secretary of Health and Human Services, misses 
the mark and will have little efficacy. Increasing the number 
of minority health care providers is needed, but this alone 
will not solve the problem.
    The weight of the evidence I believe indicates that the 
causes of persistent and pervasive racial disparities in health 
lie in the actions and inactions of individuals and the 
inequitable outcomes within health care organizations and 
health systems. Health care lags behind other government-
regulated industries in that health care has not addressed 
racial discrimination since the desegregation of hospitals. 
Housing, labor, education, criminal justice, these areas all 
have ongoing systems in place to monitor, measure and sanction 
documented discrimination. In contrast, there are many 
hospitals that do not even collect data on patients' race.
    Why? Well, my contribution to the IOM report was to outline 
the basic parameters of the development of a civil rights 
monitoring program in health care. Monitoring systems are not 
unprecedented in health care. There are existing monitoring 
programs for health care quality, patient satisfaction, and 
there are report cards on health systems. A health care 
discrimination monitoring and enforcement system similar to 
efforts in housing will not likely be the solution to 
disparities in health care, nor will it solve all health access 
problems. However, such a system will help us to move toward 
equity in health care equality and likely reduce disparities in 
health care outcomes and improve health status.
    Thank you.
    [The prepared statement of Dr. LaVeist follows:]

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    Mr. Souder. I want to thank each of the witnesses once 
again for your patience. This has been a long afternoon for 
your testimony, and working with it, I would strongly encourage 
each of you as you work with this and as you work with the 
agencies and with Congress to make sure--I don't think any of 
us would deny regardless what political party, maybe some are 
less inclined, that discrimination in fact occurs. But in order 
to address it we need to know where it is discrimination based 
on race or ethnic backgrounds and where it's discrimination 
based on income, cultural, education, language, and to make 
sure that where possible, it may include marriage 
differentials, in trying to figure out how best to address 
where the root problems are in the differentials we have to 
make sure we have the right mix of scientific data.
    One thing is that you have to collect it. I think that 
there are several other things that I want to make sure that I 
put in the record. I know one of the problems with medical 
coverage in a lot of our urban areas has to do with the medical 
malpractice insurance. And we have to address that question 
because the cost disparity in those places for a physician to 
come in is huge, that over the years--I mean there are just 
tremendously underserved and that's one of the cost pressures 
of any doctor looking at coming in. We need to be fair to the 
patients and at the same time not have that be a distraction.
    I think another kind of fundamental thing that I've seen in 
the emergency rooms, in particular, is the bill collection 
process, where the hospital collects different from the doctor, 
which collects different from the other testing procedures, is 
chaotic no matter what your background is. If you're trying to 
manage a limited amount of income to try to figure that out and 
think you paid the bill then another bill comes, just at a gut 
level having gone through different things in the emergency 
room and talking to different individuals, this is a much 
bigger problem than is acknowledged because the bill collection 
percentage is really low in some areas. And it's why hospitals 
financially are moving more toward suburban markets and they 
find a financial disincentive in some of the doctors. We have 
to figure out where those gaps are in the system and how to 
address those gaps, because if we aren't reflecting what is 
actually occurring at the grass roots level it becomes very 
difficult even while we may be able to force someone by saying, 
which I support, if you're going to get a student loan you will 
underwrite a certain portion to go to a low income-served area. 
The second they fill their requirement in 3 years they're gone. 
If we can't make it so they can figure out how to survive long 
term, we need to address those questions.
    I have a couple of specific questions for Dr. Cooper and 
then if any of you want to comment on the remarks that I made. 
I thought it was interesting and logical that primary care 
patients in race concordant relationships rated their 
physicians as being more participatory than those in race 
discordant. Were the statistics at a level enough to be 
statistically reliable?
    Dr. Cooper. Definitely they were. In fact, in the study 
that I mentioned that took place in this area in Maryland, 
Virginia and the District of Columbia the differences between 
patients and race concordant and discordant relationships were 
of a magnitude such that they predicted at least a 10 percent 
increased likelihood that a patient would disenroll from the 
physician's practice over 1 year. So it was statistically 
significant, but also likely to be clinically significant as 
well.
    Mr. Souder. Is that true in African American, Hispanic, 
Asian and all groups?
    Dr. Cooper. That was in all groups that we looked at.
    Mr. Souder. Are you able or were you able to in any way 
separate that statistic to see how much of it was language and 
how much of it was--in other words, let me give you an example 
in veterans hospitals. Veterans prefer to go in many cases to a 
veterans hospital because they perceive that they're treated 
differently, different respect and some of them are what I 
would call maybe psychological variables which are still real. 
Others are actual barriers because of language questions.
    Dr. Cooper. We actually did not ask about language. You 
know, all of these patients were proficient enough in English 
to respond to the survey. So it would suggest that these people 
were not people who were experiencing extreme language 
difficulty. There's been other work that shows that minority 
patients will say that they prefer a physician of their same 
race or ethnic group and that will occur aside from language 
similarity, that language concordance is something that 
contributes to that, but not totally.
    Mr. Souder. Do you find, and I know this an explosive 
question, I'm just asking to see whether the data reflected 
this--is this predominantly an anglo ethnic or would this apply 
to a Hispanic group with a Hispanic--with a black doctor, an 
Asian group with a Hispanic doctor?
    Dr. Cooper. Right. We actually looked at physicians of 
different races to see where the stronger effect was, and we 
found that within each race group the physicians who were 
seeing patients of their same race were rated more highly with 
the exception of Hispanic physicians, where we didn't achieve 
statistical significance but we had a much smaller number of 
Hispanic physicians in the sample. So it seems it's not a 
finding that is limited to one specific ethnic group, but that 
all ethnic groups, patients of all ethnic groups will express 
this increased satisfaction or partnership when there's a 
similar race physician, which leads us to believe that there's 
something about the relationship and the rapport that may have 
something to do with cultural similarities or similar social 
experiences, something else that we haven't quite captured, 
some trust between people that is based on, you know, just 
comfort level and expectations of being understood and treated 
well.
    So what we'd like to do is see what we can learn from this. 
We think it suggests that we need more diversity among health 
professionals, but it also suggests that maybe there's 
something we can learn from these same-race relationships. Is 
there something that goes on in those relationships that we can 
use to teach other people so that when they're relating cross-
culturally and interculturally that they can emulate those same 
behaviors and attitudes.
    Mr. Souder. It's really an important point because I think 
while we'll try to continue and we need to continue to try to 
recruit more minority people into the health care, the truth is 
particularly when you get into a mid-sized city as opposed to 
large city the base of the sub-communities are not big enough 
with which to sustain all the diversity. For example, in Ft. 
Wayne, which is 200,000, 300 in the metro area, in the south 
side of Ft. Wayne in the community health center, which has 
historically been African American--I think it's now down to 
about 25 percent, maybe 40 percent Hispanic, another 15 percent 
Burmese and another 5 to 10 percent Bosnian with hardly any 
Anglo in it, and yet it's not big enough to sustain a doctor in 
each one of those subgroups and a nurse in each of those 
subgroups. So we have to figure out how to cross-train because 
even if we expand it it's not clear that a minority person who 
is in that area will be of the minority, particularly since 
neighborhoods shift. One of the areas that for some reason we 
have whole lot of Bosnians who came into my area and we have 
the largest Burmese population in the United States. It was 
400, now there's over 2000. So when they move that a 
neighborhood it changed substantially who would be providing 
the health care to them. And they don't--many of them don't 
speak that much English. And it is--we've never had a Burmese 
population before, so it's kind of a new phenomena that the 
whole community is working through. The Mexican immigration is 
easier and Central and South American immigration because we're 
dealing with languages but in some of my school districts they 
have 22 languages in rural Indiana. So you know that this 
problem is becoming increasingly challenging all over the 
country.
    Dr. Cooper. I think what we're trying to do is to learn 
exactly what cultural competence is. What does that mean? And 
are there some generic skills that the students and health 
professionals need to have in order to interact effectively 
regardless of who they're interacting with, you know. Because--
and I think we cannot over simplify the fact that a person is 
from the same race or ethnic group doesn't mean that they're 
necessarily going to hold all the same beliefs and values as 
well. So I think we're trying to understand more from our 
research what this cultural competence phenomenon is so that we 
can actually teach it in a more effective way. And we need to 
teach it and also to evaluate how our teaching is impacting on 
care and our outcomes.
    Mr. Souder. Mr. Cummings.
    Mr. Cummings. Dr. LaVeist, do you--how much faith do you 
have in this National Center for Minority Health?
    Mr. LaVeist. I do think it's very important. I do have 
faith in it, because what that center does is tries to cut 
across the various institutions at NIH. NIH is set up in a 
disease specific way. But the issue of race disparity is not 
disease specific, it's not so much cancer or heart disease or 
stroke, it's all that. I think a center that cuts across the 
various health outcome mandates of those institutes I think is 
the right configuration. My faith is I guess entrusted in--my 
faith is operating under the assumption that it will continue 
to be funded at an appropriate level and as such be able to do 
things like develop these research centers and fund these 
centers appropriately so that these centers can continue to do 
the kind of research that needs to be done.
    Mr. Cummings. You were here a little bit earlier and you 
heard the testimony of how certain things were being cut back 
with regard to the----
    Mr. LaVeist. HRQ.
    Mr. Cummings. Yeah. And how that seems to fly in the face 
of all the things that we're talking about here today. Did you 
have a comment on that, Dr. Rios, on what I just said?
    Dr. Rios. Oh, sure. I couldn't agree with you more. I think 
it is a time, a very difficult time right now when the Federal 
Government is committed to healthy people 2010, which is still 
another 8, 9 years away. We've got all the States involved with 
trying to focus in on collecting race data now, collecting 
subgroup data for Hispanics. Now we have a new census, a 2000 
census, that shows us that we've got markets in different 
countries, as the chairman alluded to, markets where we haven't 
seen minority populations live. We have a health care awareness 
of the need for language and culture to make a quality health 
care. And in spite of that, the funding for I think what is 
very important, research and preparing for the future, is being 
targeted for major cuts. And the health professions too, I have 
to throw that in. I think that we need to think about how to 
have a cross-cutting approach to HHS when we talk about 
disparities. And there are things that do work.
    There are programs that are working that have proven 
successful for increasing minority health. Only nobody's ever 
looked at them together. The National Health Service Corps that 
you mentioned, there should be a more targeted approach to 
people that come from certain communities to--and I'm from 
California, and in California there's a State-based, a State 
Health Service Corps Program, So that the doctors would pay 
back their student loans but stay in the same State. And there 
was more of a chance at that time doctors would go working in 
community clinics and certain communities and staying in those 
States because they're from the area.
    Mr. Cummings. Dr. Cooper, when you--you know, I was talking 
about this study on the radio in Baltimore, and I was trying to 
figure out what the listening audience could do themselves 
because the report sounded so bleak. And when I look at the 
funding situation, I mean I'm trying to figure out what do you 
say to a patient or people who--because there are a lot of 
people who are sick and don't even know it. And I mean, do you 
tell them to go and get--I'm not trying to take the weight off 
the government because we're supposed to do what we're supposed 
to do, but in the meantime what do you say to a patient. If you 
had a patient that had read this report and understood it, and 
the patient says, well, what advice do you have for me and for 
my family, I mean, because according to the report you got 
insurance, I mean apparently you know how to get to a doctor, 
these people, and I'm talking about as far as the study is 
concerned, I mean what do you say to them? They can't just go 
up to say, look, are you a racist or what? So what do you say? 
What would you as a doctor say?
    Dr. Cooper. I think what I try to say to my patients is, 
well, first of all, I try to ascertain from them what their 
level of interest is in advocating for their own health and try 
to encourage them to become more active in this, engaging in 
more healthy life-style changes and in healthy behaviors. But I 
also encourage them to become more involved in learning about 
health and encourage them to ask questions when they don't 
understand. I think this is part of what we're talking about 
when we say improving intercultural communication. We're 
talking about cultural sensitivity and reducing stereotyping 
behavior and bias, but we're also talking about just using good 
communication skills, which will allow people to express what 
their concerns are. So just asking people what's your 
understanding of what's wrong with you and trying to assess 
where they are with that and can you tell me why you think you 
have kidney failure and what do you think would help in this 
situation. And so trying to understand what people's own 
understanding of their illness is and what they think would 
work for them and then working with them based on their own 
social and family situation, but trying to get them really 
engaged in the process, because we know that's the only thing 
that's going to allow people to make changes in their behavior.
    Mr. Cummings. Do you say to the person, the African 
American person who this report says has the 3.6 times chance 
of having an amputation if he's got diabetes--I mean what do 
you say to that person when they come to you and say, Doc, I 
read this report, and it's a lady, and she says I love my legs 
but now they're saying I've got it? And this is very real.
    Dr. Cooper. I am concerned about the impact of this report 
on the doctor-patient relationship. I think it's very important 
that we're looking at these problems, but I also am concerned 
that the way that the message is portrayed is not such that it 
causes more distrust between patients and providers. I think 
what I would say to people is that you know, I think the 
majority of health professionals don't go into this field so 
that they can discriminate against people, that a lot of these 
people are well-meaning people that have good intentions, and 
what it is is that people are just not aware of their own 
biases. And so although I believe the burden of responsibility 
is on health professionals first and foremost, I think that 
patients can play a role if they're more informed about what is 
going on and they know what is appropriate for them. So if they 
can get information, ask for someone who is an educator or case 
manager to explain to them what should I be getting if I'm a 
diabetic patient, what kind of treatment should I be receiving 
that I'm not receiving, you know. Am I on the right medication 
that I should be on? Am I on the right dose? What should I be 
asking my doctor to help me do so that I don't end up with an 
amputation? And letting them know that they do have a right to 
ask those questions and to request, you know, certain things.
    Mr. Cummings. But tomorrow my leg is going to be amputated. 
My leg is going to be amputated, Doctor, and I know that as a 
black person I have a four times, almost four times greater 
chance. I mean that's the rest of their life you're talking 
about, quality of life you're talking about, you know, having 
to go around this a wheelchair. See, and that's what make the 
report so--and I agree with you. I'm concerned about the other 
end of it, too. But when these people call me and say what are 
we supposed to do, you know, that kind of stuff is just so 
wrenching. I think government has to, we've got to do more. 
We've got to find ways--I've often said, and I'm sure the 
chairman agrees with me, we've got to spend the people's tax 
dollars effectively and efficiently but we've got to find ways 
in that mode of effective and efficiency, we've got to find 
ways to try to prevent some of the catastrophes that this 
report says are happening every minute of almost every day.
    Dr. Cooper. And I think it's going to have to take place on 
several levels, you know, like the chairman mentioned. 
Financial incentives for providers need to be changed. I think 
from the patient perspective, doing everything they can, having 
them know that they do have a right to question what's being 
done to them and that they can request a second opinion, they 
can bring in a family member, or they can call someone else who 
they know who might be more familiar with the health care 
system and ask their opinion as well, that they're entitled to 
that. I think if there's anything we can do it is to educate 
the public that this is a problem and that you do have a right 
to question this and to ask for the best quality health care 
because it's available here in America. It is here and it's a 
question of actually advocating more actively for it whenever 
possible.
    So, but again I feel like that we can educate and activate 
people up to a point, but really the burden is on the system 
and on the professionals to take the lead in that role.
    Mr. Cummings. Finally, there were three things that you all 
would want us to do, Dr. Rios. What would those three things 
be? I mean top priority. If the Congress said there are three 
things that we're going to do, we may not be able to do all 
this other stuff that is recommended, but the things that come 
under our purview, what would be the three top things off the 
top that you would want to see us do?
    Dr. Rios. No. 1 is universal access. I think if we can have 
public education, and this system may not be the best, public 
schools in certain cities, depending on the teachers and the 
curriculum, but we certainly have an opportunity for education. 
And in this country we don't have an opportunity for health 
care. That's part of the big problem for disadvantaged and 
immigrants and Hispanics and other minorities. That's No. 1.
    No. 2 I think is more research that's community based and 
targeted approaches and intervention so you can measure and 
understand with a small study what works, what doesn't work. 
The interpreter services, right now the Robert Wood Johnson 
Foundation just started the new project of La Muz Huntos to do 
that. They're looking at cities where it's an emerging problem 
to understand how to work with doctors that have never worked 
with Spanish speaking patients before.
    So I think I know we need community based research, 
targeted, demonstration models, with minority consumers and 
minority providers working with the government. And the third 
thing is we need the minority doctors, because what we don't 
have is the minority physicians to document the cultural 
competence and the best practices. For years we've had doctors 
working in small mom and pop private clinics, private offices. 
I am from the East L.A. area, they're still there, volume cash 
paying patients. It's a whole underground market. There's no 
licensing from--I mean there's no data collection from the 
State because the State only collects from licensed clinic, 
licensed hospitals, licensed nursing homes. These are private 
businesses. Managed care doesn't touch the underground that 
exists in our minority communities. Doctors provide care 
because there's a demand. But there's no documentation of what 
are the best practices and how those doctors do get those 
patients, and generations after generations of families after 
families coming back to the same doctors. And that's the 
quality care that we need to understand and meld with our 
academic health centers, where a lot of minority patients go 
there, you know, because there's training going on of young 
residents.
    Mr. Cummings. Thank you very much.
    Mr. Souder. I want to thank you all for participating and 
thank Mr. Cummings for seeking this hearing and working with 
us. I found it very informative, and one of the primary reasons 
we did this is we know we're never going to fully fix our 
health care system and people are always going to complain and 
the hopes and dreams of a perfect health care system outstrip 
our ability to pay for it and the new inventions of everything 
from drugs to facilities that are unimaginable at this point. 
We don't even know what's going to be invented tomorrow, and 
our expectations and the reality of it need to be addressed.
    We also know we have huge immigration questions in this 
country, that we've always had them, but right now they're of 
particular attention and we have to work that through, which is 
a subpart of what you're doing.
    I felt this hearing was also especially important because 
whether or not we get more than 59 percent happy with the 
health care system may or may not be achievable long term, but 
what we do know is there shouldn't be a 20 percent disparity. 
And even in those statistics, 59 to 50 and 40 something to 40, 
between African American and non-African American, for example, 
is not right. And even if the gap is closing we need to be 
concentrating on whatever satisfaction level we can get as a 
society. The gaps inside it should be minimal, and that's 
ultimately one of the goals of Congress. And we appreciate your 
help with that and Mr. Cummings' leadership.
    With that, our hearing stands adjourned.
    [Whereupon, at 3:40 p.m., the subcommittee was adjourned.]
    [Additional information submitted for the hearing record 
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