[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
______
86-436 U.S. GOVERNMENT PRINTING OFFICE
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
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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.
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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.]
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